Exam 3

Question 1

The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance?

Answer 1

Emphysema

Question 2

A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?

Answer 2

Adequate flow of blood through the pulmonary circulation.

Question 3

A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?

Answer 3

Perfusion

Question 4

The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?

Answer 4

An adequate ventilation perfusion ratio

Question 5

A gerontologic nurse is analyzing the data from a patient’s focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change?

Answer 5

Decreased diffusion capacity for oxygen

Question 6

A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state?

Answer 6

The patient’s tissue demands may be met, but she will be unable to respond to physiological stressors.

Question 7

A gerontologic nurse is analyzing the data from a patient’s focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change?

Answer 7

Decreased diffusion capacity for oxygen

Question 8

A medical patient rings her call bell and expresses alarm to the nurse, stating, “I’ve just coughed up this blood. That can’t be good, can it?” How can the nurse best determine whether the source of the blood was the patient’s lungs?

Answer 8

Try to see if the blood is frothy or mixed with mucus.

Question 9

While assessing an acutely ill patient’s respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?

Answer 9

Biot’s respiration

Question 10

The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?

Answer 10

Withhold food and fluids for several hours before the test.

Question 11

The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance?

Answer 11

Emphysema

Question 12

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?

Answer 12

Dyspnea and substernal pain

Question 13

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patient’s high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurse’s best response?

Answer 13

CPAP allows a lower percentage of oxygen to be used with a similar effect.

Question 14

Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?

Answer 14

Chest auscultation

Question 15

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

Answer 15

To remove air from the pleural space

Question 16

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?

Answer 16

Maintaining a patent airway

Question 17

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

Answer 17

Monitor the pressure in the cuff at least every 8 hours

Question 18

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?

Answer 18

When adventitious breath sounds are auscultated

Question 19

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Answer 19

Stable vital signs and ABGs

Question 20

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?

Answer 20

Prior outcomes of weaning

Question 21

The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?

Answer 21

Removal from the ventilator, tube, and then oxygen

Question 22

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient?

Answer 22

How to splint the incision when coughing

Question 23

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient’s respirations. How should the nurse best respond to this assessment finding?

Answer 23

Document that the chest drainage system is operating as it is intended.

Question 24

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?

Answer 24

Removing excess air and fluid

Question 25

The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?

Answer 25

Correct and safe use of oxygen therapy equipment

Question 26

The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication?

Answer 26

It inhibits the release of histamine and other chemicals

Question 27

The nurse is teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions?

Answer 27

Read drug labels carefully before taking OTC medications.

Question 28

The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching?

Answer 28

Overuse of nasal spray may cause rebound congestion.

Question 29

A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication?

Answer 29

Sinus infections

Question 30

A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patient’s midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?

Answer 30

Silver nitrate application

Question 31

The nurse is caring for a patient in the ED for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis?

Answer 31

Humidify the indoor environment.

Question 32

The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis?

Answer 32

Beconase

Question 33

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?

Answer 33

Rapidly assess the patient and notify the surgeon about the patient’s bleeding.

Question 34

A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?

Answer 34

Apply ice and keep the patient’s head elevated.

Question 35

A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, “Does this kind of cancer tend to spread to other parts of the body?” What is the nurse’s best response?

Answer 35

“This cancer usually does not spread to distant sites in the body.”

Question 36

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he “just can’t breathe enough.” The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem?

Answer 36

Acute respiratory failure

Question 37

The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patient’s symptoms from those of a cardiac etiology?

Answer 37

Brain natriuretic peptide (BNP) level

Question 38

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment?

Answer 38

Hypovolemia secondary to leakage of fluid into the interstitial spaces

Question 39

The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client?

Answer 39

Anticoagulant therapy usually lasts between 3 and 6 months.

Question 40

A student nurse is preparing to care for a patient with bronchiectasis. The student nurse should recognize that this patient is likely to experience respiratory difficulties related to what pathophysiologic process?

Answer 40

Dilation of bronchi and bronchioles

Question 41

A nurse is caring for a patient who has been admitted with an exacerbation of chronic bronchiectasis. The nurse should expect to assess the patient for which of the following clinical manifestations?

Answer 41

Copious sputum production

Question 42

A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a new admission. The nurse should identify what characteristic aspects of CF?

Answer 42

Bronchial mucus plugging, inflammation, and eventual bronchiectasis

Question 43

A nurse is documenting the results of assessment of a patient with bronchiectasis. What would the nurse most likely include in documentation?

Answer 43

Clubbing of the fingers

Question 44

A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma?

Answer 44

Anti-inflammatory drugs

Question 45

A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this client’s airflow obstruction?

Answer 45

Administer an inhaled beta-adrenergic agonist

Question 46

A patient’s severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patient’s statements suggests a need for further education?

Answer 46

I’ll make sure to use this each time I feel an asthma attack coming on.

Question 47

A patient is having pulmonary-function studies performed. The patient performs a spirometry test, revealing an FEV1/FVC ratio of 60%. How should the nurse interpret this assessment finding?

Answer 47

Obstructive lung disease

Question 48

The nurse is caring for a patient admitted with angina who is scheduled for cardiac catheterization. The patient is anxious and asks the reason for this test. What is the best response?

Answer 48

Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are.

Question 49

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what?

Answer 49

Myocardial ischemia

Question 50

The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult?

Answer 50

Widening of the aorta

Question 51

A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident’s pain would be most suggestive of angina as the cause?

Answer 51

The pain occurs immediately following physical exertion.

Question 52

The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurse’s most appropriate response?

Answer 52

Stop the test and monitor the patient closely.

Question 53

The critical care nurse is caring for a patient who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the patient’s left ventricular function?

Answer 53

Pulmonary artery pressure monitoring (PAPM)

Question 54

When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a patient who has such a device in place, the nurse should check which of the following components? Select all that apply.

Answer 54

A transducer
A flush system
A pressure bag

Question 55

A critical care nurse is caring for a patient with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply.

Answer 55

Pneumothorax
Infection
Air embolism

Question 56

The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate?

Answer 56

Possible hypovolemia

Question 57

The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patient’s CVP is increasing. Of what may this indicate?

Answer 57

Hypervolemia

Question 58

The nurse is caring for an acutely ill patient who has central venous pressure monitoring in place. What intervention should be included in the care plan of a patient with CVP in place?

Answer 58

Change the site dressing whenever it becomes visibly soiled.

Question 59

The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurse’s most recent assessment reveals that CVP is 7 mm Hg. What is the nurse’s most appropriate action?

Answer 59

Assess the patient for fluid overload and inform the physician.

Question 60

The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function. What is an additional function of pulmonary artery pressure monitoring systems?

Answer 60

To assess the patient’s response to fluid and drug administration

Question 61

The critical care nurse is caring for a patient who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the patient’s left ventricular function?

Answer 61

Pulmonary artery pressure monitoring (PAPM)

Question 62

A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care?

Answer 62

Perfusion distal to the insertion site

Question 63

An adult patient with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?

Answer 63

Fewer QRS complexes than P waves

Question 64

The nurse is caring for a patient on telemetry. The patient’s ECG shows a shortened PR interval, slurring of the initial QRS deflection, and prolonged QRS duration. What does this ECG show?

Answer 64

Wolf-Parkinson-White (WPW) syndrome

Question 65

A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine?

Answer 65

Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg.

Question 66

The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient?

Answer 66

Trancutaneous pacemaker

Question 67

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor’s best response?

Answer 67

“The difference is the timing of the delivery of the electric current.”

Question 68

The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do?

Answer 68

Maintain firm contact between paddles and patient skin.

Question 69

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention?

Answer 69

Defibrillation

Question 70

The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?

Answer 70

Ensure no one is touching the patient at the time shock is delivered.

Question 71

The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class?

Answer 71

Use a conducting medium between the paddles and the skin.

Question 72

A patient the nurse is caring for has a permanent pacemaker implanted with the identification code beginning with VVI. What does this indicate?

Answer 72

Ventricular paced, ventricular sensed, inhibited

Question 73

A patient is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse’s responsibility in the care of the patient’s pacemaker?

Answer 73

Monitoring for pacemaker malfunction or battery failure

Question 74

The nurse is caring for a patient who has had a biventricular pacemaker implanted. When planning the patient’s care, the nurse should recognize what goal of this intervention?

Answer 74

Resynchronization

Question 75

The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?

Answer 75

Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

Question 76

The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified?

Answer 76

Obesity, inactivity, diet, and smoking

Question 77

A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause?

Answer 77

Coronary arteriosclerosis

Question 78

When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena?

Answer 78

Exercise increases the heart’s oxygen demands.

Question 79

A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following?

Answer 79

Reducing the heart’s workload by decreasing heart rate and myocardial contraction

Question 80

A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?

Answer 80

Begin ECG monitoring.

Question 81

The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?

Answer 81

T wave inversion

Question 82

A patient presents to the ED in distress and complaining of “crushing” chest pain. What is the nurse’s priority for assessment?

Answer 82

Prompt initiation of an ECG

Question 83

The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.

Answer 83

Dyspnea
Unusual fatigue
Syncope

Question 84

The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patient’s care plan?

Answer 84

Administer supplementary oxygen, as needed.

Question 85

You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being “distressed” and “shocked” by her new diagnosis. What nursing diagnosis is most clearly suggested by the woman’s statement?

Answer 85

Anxiety related to cardiac symptoms

Question 86

A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient?

Answer 86

A sheath will be placed over the insertion site after the procedure is finished.

Question 87

A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurse’s most appropriate action?

Answer 87

Call for help and apply pressure to the access site.

Question 88

A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient?

Answer 88

Bleeding at insertion site

Question 89

The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply.

Answer 89

Abrupt closure of the coronary artery
Bleeding at the insertion site
Retroperitoneal bleeding
Arterial occlusion

Question 90

A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this?

Answer 90

To prevent bacterial endocarditis

Question 91

Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient have with mitral valve prolapse? Select all that apply.

Answer 91

Anxiety
Fatigue
Palpitations

Question 92

The nurse is caring for a recent immigrant who has been diagnosed with mitral valve regurgitation. The nurse should know that in developing countries the most common cause of mitral valve regurgitation is what?

Answer 92

Rheumatic heart disease and its sequelae

Question 93

A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension. What valvular disorder should the nurse anticipate being diagnosed in this patient?

Answer 93

Mitral stenosis

Question 94

A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse’s interview is most suggestive of this valvular disorder?

Answer 94

Whenever I do any form of exercise I get terribly short of breath.

Question 95

A patient has been diagnosed with a valvular disorder. The patient tells the nurse that he has read about numerous treatment options, including valvuloplasty. What should the nurse teach the patient about valvuloplasty?

Answer 95

For some patients, valvuloplasty can be done in a cardiac catheterization laboratory.

Question 96

The nurse is caring for a patient with acute pericarditis. What nursing management should be instituted to minimize complications?

Answer 96

The nurse helps the patient with activities until the pain and fever subside.

Question 97

The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM?

Answer 97

Dilated ventricles without hypertrophy of the ventricles

The cardiac nurse is caring for a patient who has been diagnosed with dilated cardiomyopathy (DCM).

Question 98

Echocardiography is likely to reveal what pathophysiological finding?

Answer 98

Decreased ejection fraction

Question 99

A patient has been living with dilated cardiomyopathy for several years but has experienced worsening symptoms despite aggressive medical management. The nurse should anticipate what potential treatment?

Answer 99

Heart transplantation

Question 100

The critical care nurse is caring for a patient who is receiving cyclosporine postoperative heart transplant. The patient asks the nurse to remind him what this medication is for. How should the nurse best respond?

Answer 100

Azathioprine minimizes rejection of the transplant.

Question 101

A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patient’s medication regimen, what nursing diagnosis should be prioritized?

Answer 101

Risk for infection

Question 102

The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient?

Answer 102

Improved cardiac output

Question 103

A patient with hypertrophic cardiomyopathy (HCM) has been admitted to the medical unit. During the nurse’s admission interview, the patient states that she takes over-the-counter “water pills” on a regular basis. How should the nurse best respond to the fact that the patient has been taking diuretics?

Answer 103

Inform the care provider because diuretics are contraindicated.

Question 104

A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease?

Answer 104

Recognizing and promptly treating streptococcal infections

Question 105

The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient?

Answer 105

A beta-adrenergic blocker

Question 106

The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics?

Answer 106

Take the diuretic in the morning to avoid interfering with sleep.

Question 107

The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms?

Answer 107

Confusion and bradycardia

Question 108

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?

Answer 108

Potassium level

Question 109

The nurse’s comprehensive assessment of a patient who has HF includes evaluation of the patient’s hepatojugular reflux. What action should the nurse perform during this assessment?

Answer 109

Press the right upper abdomen.

Question 110

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?

Answer 110

Monitor her weight daily

Question 111

The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem?

Answer 111

Pulmonary edema

Question 112

A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?

Answer 112

Acute pulmonary edema

Question 113

A cardiac patient’s resistance to left ventricular filling has caused blood to back up into the patient’s circulatory system. What health problem is likely to result?

Answer 113

Acute pulmonary edema

Question 114

The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?

Answer 114

The patient admitted following an MI

Question 115

The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply.

Answer 115

Fluid status
Cardiac rhythm
Action of medications

Question 116

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication?

Answer 116

Deep vein thrombosis

Question 117

The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient’s warfarin is at therapeutic levels?

Answer 117

International normalized ratio (INR) between 2 and 3

Question 118

The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurse’s rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm?

Answer 118

Asystole

Question 119

When assessing venous disease in a patient’s lower extremities, the nurse knows that what test will most likely be ordered?

Answer 119

Duplex ultrasonography

Question 120

The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient’s subsequent care, the nurse should most likely address what health problem?

Answer 120

Intermittent claudication

Question 121

The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply.

Answer 121

Weight loss
Regular exercise
Smoking cessation

Question 122

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient’s left leg is visibly swollen and reddened. What is the nurse’s most appropriate action?

Answer 122

Inform the physician that the patient has signs and symptoms of VTE.

Question 123

The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient’s renal status affect heparin therapy?

Answer 123

Lower doses of heparin are required for this patient.

Question 124

An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins?

Answer 124

Walk for several minutes every hour to promote circulation.

Question 125

The nurse is assessing a woman who is pregnant at 27 weeks’ gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse’s best response?

Answer 125

Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.

Question 126

A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary rationale behind that advice to the patient?

Answer 126

Tobacco use increases the patient’s concurrent risk of heart disease.

Question 127

A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state?

Answer 127

Exercise on a regular basis.

Question 128

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurse’s health education should include which of the following?

Answer 128

Use of strategies to prevent falls stemming from postural hypotension

Question 129

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which of the following should the nurse integrate into the management of this client’s hypertension?

Answer 129

Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.

Question 130

A 55-year-old patient comes to the clinic for a routine check-up. The patient’s BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurse’s best response?

Answer 130

Hypertension greatly increases your risk of stroke and heart disease.”

Question 131

The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions?

Answer 131

Taking the BP at least 10 minutes after nicotine or coffee ingestion

Question 132

A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patient’s care, what desired outcome should the nurse identify?

Answer 132

Patient takes medication as prescribed and reports any adverse effects.

Question 133

The nurse is providing care for a patient with a new diagnosis of hypertension. How can the nurse best promote the patient’s adherence to the prescribed therapeutic regimen?

Answer 133

Have the patient participate in monitoring his or her own BP.

Question 134

The nurse is assessing a patient new to the clinic. Records brought to the clinic with the patient show the patient has hypertension and that her current BP readings approximate the readings from when she was first diagnosed. What contributing factor should the nurse first explore in an effort to identify the cause of the client’s inadequate BP control?

Answer 134

Lack of adherence to prescribed drug therapy