Midterm Practice Questions

Question 1

A nurse is reinforcing teaching for a client who has hypertension and is prescribed hydrochlorothiazide (HydroDIURIL) twice daily. Which of the following instructions should the nurse include in the client’s teaching?
a. “You should avoid foods high in potassium.”
b. “Take the second dose of the day by early afternoon.”
c. “Watch for ankle swelling that may appear late in the evening.”
d. “Limit your daily fluid intake to 1½ L.”

Answer 1

b. “Take the second dose of the day by early afternoon.”

Question 2

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?

A. Suggest that the client use a salt substitute.
B. Advise the client to add citrus juices and bananas to her diet.
C. Obtain a 12-lead ECG
D. Obtain a blood sample for a serum sodium level

Answer 2

C. Obtain a 12-lead ECG

Question 3

A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report?

A. Nasal congestion
B. Swelling of the tongue
C. Dry cough
D. Nausea
C. Dry cough
D. Nausea

Answer 3

B. Swelling of the tongue

Question 4

A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?

A. Bradycardia
B. Tremor
C. Cough
D. Constipation

Answer 4

A. Bradycardia

Question 5

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?

A. Check the client’s vital signs
B. Request an order for an antiemetic
C. Suggest the client rests before eating a meal.
D. Request a dietician consult

Answer 5

A. Check the client’s vital signs

Question 6

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?

Answer 6

Spironolactone

Question 7

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider’s orders and recognizes that clarification is needed for which of the following medications?

A. Carvedilol
B. Fluticasone
C. Captopril
D. Isosorbide denigrate

Answer 7

A. Carvedilol

Question 8

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?

Answer 8

Frothy sputum

Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

Question 9

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?

A.Dyspnea
B. Oliguria
C. Pitting edema
D. Fatigue

Answer 9

D. Fatigue

Question 10

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?

A. Place the tablet under your tongue, and then take a small sip of water
B. The medication can take up to 15 minutes to take effect
C. Avoid taking the medication prior to exercising
D. Stop taking the medication and notify your provider if you develop a headache

Answer 10

A. Place the tablet under your tongue, and then take a small sip of water

Question 11

A nurse is teaching a client about appropriate snacks 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?

A. A slice of cheese
B. A jam sandwich
C. A cup of plain popcorn
D. A small container of applesauce

Answer 11

A. slice of cheese

Question 12

All instructions on applying a nitro patch

Question 13

A nurse is caring for a client who is scheduled for surgery. What is the nurse’s role in regard to informed consent?

Answer 13

Determining the client’s level of understanding about the procedure.

Question 14

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?

A. Cranberry juice
B. Flavored gelatin
C. Skim milk
D. Chicken broth

Answer 14

C. Skim milk

Question 15

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

Answer 15

Generalized urticaria

The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm.

Question 16

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?

a.The client holds his breath for 10 seconds after inhaling the medication.
b.The client exhales as the medication is released from the inhaler.
c.The client takes a quick inhalation while releasing the medication from the inhaler.
d.The client waits 10 min between inhalations.

Answer 16

A. The client holds breath for 10 seconds after inhaling the medication.

Question 17

The nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

A. Nausea
B. Dysphagia
C. Agitation
D. Hypotension

Answer 17

C. Agitation

Question 18

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?

Answer 18

Instructing now to use kitchen tools to prepare a meal.

Question 19

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for chest x-ray?

Answer 19

Have the client wear a mask

Question 20

A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

a. lethargy
b. high-grade fever
c. weight gain
d. dry cough

Answer 20

A. Lethargy

Question 21

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?

A. Auscultate lung fields.
B. Assess pulse and respirations.
C. Assess characteristics of her sputum.
not the first action the nurse should take.
D. Instruct to slowly exhale with pursed lips.

Answer 21

A. Auscultate lung fields.

Question 22

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?

a. Admin another nitroglycerin tablet
b. Initiate a peripheral IV
c. Call the Rapid Response Team
d. Obtain an ECG

Answer 22

A. Admin another nitroglycerin tablet

Question 23

In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions?

A. Apply a heating pad on a low setting to help relieve leg pain.
B. Adjust the thermostat so that the environment is warm.
C. Wear antiembolic stockings during the day.
D. Rest with the legs above heart level.

Answer 23

B. Adjust the thermostat so that the environment is warm.

Question 24

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

A. Pain at Rest
B. Intermittent Claudication
C. Dependent Rubor
D. Foot Pain

Answer 24

B. Intermittent Claudication

Question 25

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?

A) Obtain a pair of slipper socks for the client
B) Rub the clients feet briskly for several minutes
C) Increase the client’s oral fluid intake
D) Place a moist heating pad unde the client’s feet

Answer 25

A) Obtain a pair of slipper socks for the client

Question 26

A nurse is planning care for a client who has DVT of the lower leg. Which of the following interventions should the nurse include in the plan of care?

A. Keep the client’s affected leg elevated while in bed.
B. Have the client ambulate prior to applying antiembolic stockings.
C. Apply ice packs to affected leg.
D. Massage the client’s affected leg twice a day.

Answer 26

A. Keep the client’s affected leg elevated while in bed.

Question 27

A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods?

Answer 27

Red meat and organ meat

This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.

Question 28

The nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse instructs the client that which food item is a good dietary source of iron?

1. Oranges
2. Apricots
3. Egg whites
4. Refined white bread

Answer 28

2. Apricots

Question 29

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?

1. Vitamin B12 injections
2. Iron supplements
3. Blood transfusions
4. Vitamin B6 supplements

Answer 29

1. Vitamin B12 injections

Question 30

The nurse has completed an assessment on the client after the syncopal episode. Complete the following sentence by using the list of options.

The nurse should first address the client’s
A. glossitis
B. oxygen saturation
C. increased fatigue
D. hemoglobin
E. paresthesia of the feet

followed by the client’s
A. heart murmur
B. pale and cool skin
C. wound on heel
D. decreased energy level
E. hypotension

Answer 30

The nurse should first address the client’s

B. Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, circulation approach to client care is client’s oxygen saturation. Anemia is a reduction in the number of RBCs and the amount of hemoglobin or hematocrit. Hemoglobin carries oxygen to the tissues. When a client’s hemoglobin level is low, the delivery of oxygen is decreased, which results in hypoxia.

Followed by the clients

D. Hypotension is correct. After the nurse had addressed the client’s oxygen saturation level, the nurse should address the client’s hypotension. Anemia reduces oxygen delivery causing the heart to work harder to maintain tissue perfusion. Pulses become weak and thready and blood pressure decreases.

Question 31

The nurse has completed an assessment on the client after the syncopal episode. Complete the following sentence by using the list of options.
The nurse should first address the client’s
Glottis
oxygen saturation
increased fatigue
hemoglobin
paresthesia of the feet

followed by the client’s
heart murmur
pale and cool skin
wound on heel
decreased energy level
hypotension

Answer 31

Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, circulation approach to client care is client’s oxygen saturation. Anemia is a reduction in the number of RBCs and the amount of hemoglobin or hematocrit. Hemoglobin carries oxygen to the tissues. When a client’s hemoglobin level is low, the delivery of oxygen is decreased, which results in hypoxia.

Hypotension is correct. After the nurse had addressed the client’s oxygen saturation level, the nurse should address the client’s hypotension. Anemia reduces oxygen delivery causing the heart to work harder to maintain tissue perfusion. Pulses become weak and thready and blood pressure decreases.

Question 32

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? Select all that apply.

a. Lubricate the lips with water-soluble ointment.
b. Brush teeth with a soft toothbrush.
c. Blow nose gently.
d. Limit fruit consumption.
e. Use a straight edge razor to shave.

Answer 32

a. Lubricate the lips with water-soluble ointment.
b. Brush teeth with a soft toothbrush.
c. Blow nose gently.

Question 33

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?

A. Clamp the catheter.
B. Initiate oxygen therapy.
C. Auscultate breath sounds.
D. Position the client in left lateral Trendelenburg.

Answer 33

A. Clamp the catheter.

The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

Question 34

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

A. Dependent rubor
B. Peripheral edema
C. Hair loss
D. Thick, deformed toenails

Answer 34

B. Peripheral edema

Question 35

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?

A. Apply Ice packs to your legs
B. Use elastic Stockings
C. Remain on bed rest
D. Place your legs in a dependent position while in bed

Answer 35

B. Use elastic Stockings

Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic or compression stockings reduce venous stasis and assist in venous return of blood to the heart.

Question 36

A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. The nurse notes the catheter site is warm and painful to touch. Which of the following actions should the nurse take?

a. Place the affected extremity below the level of the client’s heart.
b. Slow the IV infusion
c. Apply a warm compress to the IV site.
d. Place a pressure dressing over the IV site.

Answer 36

C. Apply a warm compress to the IV site

The nurse should apply a warm compress to the IV site to decrease inflammation and promote comfort.

Question 37

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?

A) Impaired tissue perfusion
B) Alteration in body image
C) Alteration in activity intolerance
D) Impaired skin integrity

Answer 37

A) Impaired tissue perfusion

Question 38

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy d/t NPO status. Which of the following solutions should the nurse prepare to infuse?

A. Lactated Ringer’s
B. Dextrose 5% in 0.9% NaCl
C. 0.45% NaCl
D. Dextrose 10% in water

Answer 38

C. 0.45% NaCl

A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.

Question 39

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?

A. Blood in the IV tubing
B. Absence of blanching at the insertion site
C. Edema in the palm of the hand
D. Warmth around the insertion site

Answer 39

C. Edema in the palm of the hand

Edema, pallor, and coolness around the insertion site indicate a collection of fluid leaking into subcutaneous tissue, also known as an infiltration.

Question 40

Which foods will be recommended to a client with iron deficiency anemia

Answer 40

Spinach
Beef
Liver

Question 41

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?

A. WBC
B. RBC
C. Granulocytes
D. Platelets

Answer 41

D. Platelets

The nurse should recognize that ITP results from the destruction of platelets by antibodies, therefore, the nurse should expect a platelet level below the expected reference range. The nurse should not expect a decrease in granulocytes. The nurse should not expect a decrease in the RBC or the WBC.

Question 42

A nurse is preparing an educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?

A. “ use a rectal suppository if constipated.”
B. “ swish with a commercial mouthwash after brushing the teeth.”
C. “ Notify the dentist of your condition prior to invasive procedures.”
D. “Take aspirin for headaches.”

Answer 42

C. “ Notify the dentist of your condition prior to invasive procedures.”

Question 43

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?

A. Increase the oxygen flow to 3 L/min.
B. Assess the client’s respiratory status.
C. Call emergency services for the client.
D. Have the client cough and expectorate secretions.

Answer 43

B. Assess the clients respiratory status

Question 44

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

A. hemolysis
B. fluid overload
C. fever
D. urticaria

Answer 44

D. urticaria

For clients who have previously had allergic reactions to blood transfusions, administering an antihistamine such as Benadryl before transfusion may prevent future reactions.
An antihistamine will not prevent a febrile reaction to a blood transfusion.

Question 45

Clinical manifestations in a patient who has heart failure and fluid overload.

Answer 45

Crackles, edema, SOB, fatigue

Question 46

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?

Answer 46

Temperature

The greatest risk to the client is injury from a blood transfusion reaction. Therefore, the priority action is to take a baseline temperature measurement. The nurse should then monitor the client’s temperature throughout the infusion as an increase in temperature can indicate an adverse reaction.

Question 47

A nurse is preparing to administer blood to a client the unit of blood on hand is type O negative and the client is type a positive blood. Which of the following action should the nurse take?

A. Administer the blood as ordered
B. Contact the provider for further orders
C. Notify the blood bank
D. Complete an incident report

Answer 47

A. Administer the blood as ordered

Question 48

A nurse us preparing to administer 2units of packed RBCs to an older adult client. Which of the following actions should the nurse take?

a. Administer each unit over 3 hr.
b. Use an 18-gauge needle to obtain venous access.
c. Use blood that is less than a month old.
d. Obtain the client’s vital signs every 30min throughout the transfusion.

Answer 48

a. Administer each unit over 3 hr.

The nurse should administer blood to an older adult client at a slower rate. Therefore, each unit should be administered over 2 to 4 hr.

Question 49

Know what to do for a blood transfusion reaction

If they are experiencing: nonhemolytic febrile reaction and has a fever

Answer 49

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.

Question 50

How to use an MDI

Answer 50

1) Inhale deeply and then exhale completely.
2) Place her lips firmly around the mouthpiece.
3) Breathe in deeply over 2 to 3 seconds while pushing down on the canister.
4) Hold her breath for 10 seconds.
5) Exhale slowly through pursed lips.
6) Wait 60 seconds between each puff.

Question 51

Autonomy and beneficence

Answer 51

The client is exercising their right to determine their own care and treatment. The nurse should advocate for the client and support the client’s right of autonomy or self-determination.

Question 52

A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is

a. lung sounds.
b. urinary output.
c. peripheral pulses.
d. peripheral edema.

Answer 52

A. Lung sounds

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

Question 53

A nurse is providing dietary teaching to a client who has history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?

Drink 3 L of fluid every day.
Take 3,000 mg of vitamin C daily.
Restrict calcium intake to one serving per day.
Eat 12 oz of animal protein daily.

Answer 53

Drink 3 L of fluid every day

To decrease the risk for renal calculi, the client would have to increase fluid intake of 3-4L daily.

Question 54

Inadequate magnesium intake or absoprtion can occur from??

Answer 54

Inadequate magnesium intake or absorption
— Alcohol use disorder

Question 55

A client who is 16 hours postoperative rates pain as 7 out of 10, has a respiratory rate of 28 breaths/min, and an arterial blood gas (ABG) result of pH 7.47, CO2 33 mm Hg (4.39 kPa), and HCO3 26 mEq/L (26 mmol/L). Which action should the nurse take?

Answer 55

Administer IV morphine sulfate 4 mg as prescribed

The client is experiencing respiratory alkalosis caused by the increased respiratory rate due to incisional pain and anxiety. The nurse’s first action should be to medicate the client for pain. There is no indication that the client requires oxygen. Teaching proper breathing is not effective if the client is experiencing pain. The ABG results are only slightly abnormal and should correct if pain is adequately treated so there is no indication to notify the health care provider.

Question 56

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 ´ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ´ 103/µL. Which action should the nurse take?

a. Call the surgeon and anesthesiologist immediately.
b. Ask the patient about any symptoms of a recent infection.
c. Discuss the possibility of blood transfusion with the patient.
d. Send the patient to the holding area when the operating room calls.

Answer 56

D. Send the patient to the holding area when the operating room calls

Question 57

The best way to determine the appropriate oxygen flow rate

Answer 57

By monitoring the patient’s oxygenation either by arterial blood gases or pulse oximetry.

An oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive.

Question 58

The nurse is admitting a client with chronic obstructive pulmonary disease (COPD) to the hospital. Which of the following positions should the nurse place the client in to improve gas exchange?

a. Resting in bed with the head elevated to 45–60 degrees
b. Sitting up at the bedside in a chair and leaning slightly forward
c. Resting in bed in a high Fowler’s position with the knees flexed
d. In the Trendelenburg position with several pillows behind the head

Answer 58

b. Sitting up at the bedside in a chair and leaning slightly forward

Clients with COPD improve the mechanics of breathing by sitting up in the “tripod” position. Resting in bed with the head elevated would be an alternative position if the client was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the client’s ability to ventilate well.

Question 59

A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure?

a. Give the rescue medication immediately before testing.
b. Administer oral corticosteroids 2 hours before the procedure.
c. Withhold bronchodilators for 6 to 12 hours before the examination.
d. Ensure that the patient has been NPO for several hours before the test.

Answer 59

C. Withhold the bronchodilators for 6 to 12 hours before the examination

Bronchodilators are held before spirometry so that a baseline assessment of airway function can be determined.

Question 60

What can affect nutritional status for a client

Answer 60

The client relies on the public transit system for transportation is correct.

The client potential mobility impairment because of arthritis is correct.

Question 61

For patients with PAD

Answer 61

Aggressive lipid management is needed for all patients with PAD.

Question 62

Because the edema associated with venous insufficiency increases when the patient has been standing, A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis?

a. I cant get my shoes on at the end of the day.
b. I cant seem to ever get my feet warm enough.
c. I have burning leg pains after I walk two blocks.
d. I wake up during the night because my legs hurt.

Answer 62

a. I cant get my shoes on at the end of the day.

Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD).

Question 63

A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger’s disease). When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient?

a. Cessation of smoking
b. Control of serum lipid levels
c. Maintenance of appropriate weight
d. Demonstration of meticulous foot care

Answer 63

a. Cessation of smoking

Question 64

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

a; Report of right calf pain
b: Erythema of right lower leg
C: New onset shortness of breath
D: Temperature of 100.4° F (38° C)

Answer 64

C: New onset shortness of breath

New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE.

Question 65

Which action by the patient with newly diagnosed Raynaud’s phenomenon best demonstrates that the nurse’s teaching about managing the condition has been effective?

A: The patient exercises indoors during the winter months.
B: The patient immerses hands in hot water when they turn pale.
C: The patient takes pseudoephedrine (Sudafed) for cold symptoms.
D: The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

Answer 65

A: The patient exercises indoors during the winter months.

Question 66

Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be recommended for what

Answer 66

Sickle cell anemia

Question 67

Which assessment finding would the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

a. Bruises on the patient’s back.
b. Difficulty awakening the patient.
c. Purpura on the patient’s oral mucosa.
d. The patient’s platelet count is 52,000/L.

Answer 67

b. Difficulty awakening the patient.

Question 68

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

a. A patient with chronic heart failure
b. A patient who has viral pneumonia
c. A patient who has right leg cellulitis
d. A patient with multiple abdominal drains

Answer 68

a. A patient with chronic heart failure

Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

Question 69

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find

a. dilated superficial veins.
b. swollen, dry, scaly ankles.
c. prolonged capillary refill in all the toes.
d. a serosanguineous drainage from the ulcer.

Answer 69

c. prolonged capillary refill in all the toes.

Question 70

Which nursing intervention is important when providing care for a patient with sickle cell crisis?
a. Limiting the patient’s intake of oral and IV fluids
b. Evaluating the effectiveness of opioid analgesics
c. Encouraging the patient to ambulate as much as tolerated
d. Teaching the patient about high-protein, high-calorie foods

Answer 70

b. Evaluating the effectiveness of opioid analgesics

Question 71

IM or subcutaneous injections should be avoided because of the risk for bleeding.

Question 72

In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says

A. “I will have to buy some loose clothing that does not bind across my legs or waist.”
B. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.”
C. “I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily.”
D. “I will change my position every hour and avoid long periods of sitting with my legs down.”

Answer 72

B. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.”