Mid Term Flashcards
A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide?
Take med early in the day
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Obtain a 12 lead ECG
A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report?
Swelling of the tongue
A nurse is teaching a pt who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?
Bradycardia
The nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions will the nurse take first?
Check the clients vital signs
A nurse is giving a presentation about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts the clients at risk for both hyperkalemia and hyponatremia?
Spironolactone
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider’s orders, the nurse recognizes that clarification is needed for which of the following medications?
Propranolol (carvedilo)
A nurse is caring for an older
Adult client who has left sided heart failure which of the following assessment findings should the nurse expect
Frothy sputum
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?
Fatigue
A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin to treat angina pectoral. Which of the following instructions should the nurse include?
Place the tablet under your tongue, and then take a small sip of water
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
Slice of cheese
A nurse is caring for a client who is scheduled for surgery. What is the nurse’s role in regard to informed consent?
Determining the client’s level of understanding about the procedure.
A client who is 2 days postoperative following abdominal surgery is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?
Skim milk
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Urticaria
A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?
The client holds his breath for 10 seconds after inhaling the medication.
The nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
Agitation
A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance?
How to use kitchen tools to prepare meals
A nurse is teaching a newly hired group of assistive personnel about infection control measures on the unit. It is crucial for the nurse to remind the AP that which of the following is the most effective way to prevent the spread of pathogens during client care?
Have the client wear a mask
combination drug therapy for tb
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
Lethargy
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?
Auscultate lung sounds
A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
Admin another nitroglycerin tablet
In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions?
Adjust the thermostat so that the environment is warm.
A nurse is caring for a client who has Peripheral Arterial Disease (PAD), which of the following symptoms should the nurse expect to find in the early stage of the disease?
Intermittent claudication
All instructions on applying a nitro patch
A nitroglycerin patch should be applied to a clean, residue-free, hairless, nonirritated area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and if headache occurs, the patient should not change the patch removal schedule to avoid these headaches.
A nurse is caring for a client who has peripheral vascular disease. What should be given by the nurse for cold feet that causes the patients difficulty sleeping?
A pair of extra socks
‘A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Keep the client’s affected leg elevated while in bed.
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?
‘vitamin B12 injections
The nurse should first address the client’s ________ , followed by the clients ________.
‘Oxygen saturation, hypotension
A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?
clamp the catheter.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
-edema
, A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?
Elastic stockings
A nurse is planning to insert a short-peripheral IV device into the arm of a client who has a bleeding disorder. Which of the following actions should the nurse plan to take?
apply a warm compress
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnosis should the nurse identify as being the priority in the client’s care?
impaired tissue perfusion
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy d/t NPO status. What solutions should the nurse prepare to infuse?
0.45% sodium chloride
-A nurse is assessing an IV infusion site on an infant’s left hand. Which of the following findings should the nurse identify as an indication of an indication of an infiltration?
Edema
A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect to be decreased?
platelets
A nurse is preparing an educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?
” Notify the dentist of your condition prior to invasive procedures
A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?
: assess the client’s respiratory status
A provider prescribes a transfusion of one unit packed RBC for a client who has a low hemoglobin level. The provider also prescribes diphenhydramine (Benadryl) for administration before the transfusion to prevent
urticaria
Clinical manifestations in a patient who has heart failure and fluid overload.
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
temperature
‘A nurse is preparing to administer blood to a client. The unit of blood on hand is type O negative, and the client has type A positive blood. Which of the following actions should the nurse take?
administer the blood as ordered
A nurse us preparing to administer 2units of packed RBCs to an older adult client. Which of the ff. actions should the nurse take
‘Administer each unit over 3 hr.
Know what to do for a blood transfusion reaction
Stop the client’s blood transfusion is correct. The nurse should identify the client is experiencing a nonhemolytic febrile reaction to the donor blood and should stop the transfusion immediately / Request a prescription for an antipyretic medication is correct. The nurse should identify the client is experiencing a nonhemolytic febrile reaction to the donor blood, which is causing the client to experience fever. Therefore, the nurse should request a prescription for an antipyretic medication for the client. / Begin infusing 0.9% sodium chloride solution is correct. The nurse should identify the client is experiencing a nonhemolytic febrile reaction to the donor blood. The nurse should stop the transfusion immediately and begin infusing 0.9% sodium chloride solution to keep the client’s vein open.
. Which of the following actions should the nurse take? (Select all that apply
’, Stop the client’s blood transfusion / Request a prescription for an antipyretic medication / Begin infusing 0.9% sodium chloride solution
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
temperature
A nurse is preparing an educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?
Notify the dentist of your condition prior to invasive procedures.”
A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?
assess the client’s respiratory status
A patient is receiving 3% naci solution for correction of hyponatremia. During administration on of the solution the most important assessment for the nurse to monitor is?
Lung sounds
A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make
Daily alcohol intake
A patient who had a transverse colectomy for diverticulosis 18 hours ago has a nasogastric suction and is complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths per minute and the arterial blood gases indicate respiratory alkalosis. Which action should the nurse take first
Give the patient the PRN IV morphine sulfate 4mg
The outpatient surgery nurse reviews the complete blood cell count results for a patient who is schedules for surgery in a few days. The results are white blood cells count 10.2 103/uL hemoglobin 15 g/dl hematocrit 45% platelets 150. Which action should the nurse take
Send the patient to the holding are when the operating room calls
The nurse is admitting a patient diagnosed with an acute exacerbation of cCOPD. How should the nurse determine the appropriate 02 flow rate
Maintain the pulse oximetry level at 90% or greater
The nurse is admitting a client with COPD to the hospital. Which of the following positions should the nurse place the client in to improve gas exchange
Sitting up at the bedside in a chair and leaning slightly forward “tripod position”
A patient is scheduled for a spirometer. Which action should the nurse take to prepare the patient for this procedure
Withhold bronchodilators 6-12 hours before examination
A 67 year old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnoses
I can’t get my shoes on at the end of the day
The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans ( Buerger disease). Which expected outcome has the highest priority for this patient ?
Cessation of all tobacco use
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (vte) require immediate action by the nurse ?
New onset of shortness of breath
After teaching a patient with newly diagnosed Raynaud’s phenomenon about how to manage the condition which action by the patient demonstrates that the teaching has been effective
The patient exercises indoors during the winter months
Which statement by a patient indicates good understanding of the nurses teaching about preventing sickle cell crisis
Risk for a crisis is decreased by having an annual influenza vaccination
Which assessment finding would the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider
Difficulty awakening the patient
Which patient should the nurse assign as the roommate for a patient with aplastic anemia
A patient with chronic heart failure
The nurse performing an assessment with a patient who has chronic peripheral artery disease of the legs and an ulcer on the right second toe would expect to find what
Prolonged capillary refill in all the toes
A patient is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis is it important for the nurse to ?
Encourage the patient to rest as much as possible
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenia purpura (ITP)?
Avoid intramuscular injections (IM)
The nurse evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD) Which patient statement indicates a need for further instruction
I will use a heating pad on my feet at night to increase the circulation
