Week 4 - HESI/EAQ Flashcards
the most common cause of heart failure is ________________
myocardial infarction
Heart failure results in the inability of the heart to provide sufficient blood flow to meet the _____________ of the body’s tissues and organs
oxygen needs
Heart failure occurs most commonly in clients over the age of ____, and occurs more commonly in _______________
Heart failure occurs most commonly in clients over the age of 60, and occurs more commonly in males than females.
Which assessment finding provides the earliest indication that the client is experiencing right-sided heart failure?
Dyspnea at rest.
Sinus tachycardia.
Peripheral edema.
Lack of energy.
Peripheral edema.
_________sided heart failure results in peripheral congestion due to the inability of the right ventricle to effectively pump blood out of the heart to the lungs, causing edema, JVD, an enlarged liver, abdominal ascites, and weight gain. Edema and weight gain are among the earlier signs.
Right-
After the client’s cardiac rhythm is confirmed, which action should the nurse implement next?
Administer a prescribed stat dose of digoxin.
Notify the HCP of the dysrhythmia.
Transfer the client to the Medical Intensive Care Unit (MICU).
Prepare for synchronized cardioversion.
Administer a prescribed stat dose of digoxin.
If a dose of digoxin has already been prescribed, it should be administered before taking further action. Digoxin slows the heart rate and increases the force of the heart’s contraction, which is very useful in the treatment of the client’s type of cardiac dysrhythmia.
Digoxin ______ the heart rate and increases the force of the heart’s contraction
slows
The client is scheduled for a chest x-ray, 12 lead electrocardiograph (ECG) and an echocardiogram.
When preparing the client for the echocardiogram, which intervention should the nurse implement?
Set-up treadmill for initial test.
Instruct the client to fast for at least 6 hours before the test.
Ensure the client is wearing comfortable clothes and shoes.
Ask the client to lay on their left side during the test.
Ask the client to lay on their left side during the test.
The echocardiogram records direction and flow of blood through the heart and transforms it to audio and graphic data that measure valve abnormalities, congenital heart defects, wall motion, ejection fraction (EF), and heart function. The best results are obtained when the patient is in a left side lying position.
Normal potassium is ______ mEq/L
3.5 - 5.0
The client is concerned about how easily they are bruising since they started taking the warfarin. Which intervention is most important for the nurse to include in the client’s plan of care?
Monitor INR levels every 4-6 weeks.
Use soft toothbrush to minimize bleeding gums.
Use electric razors for shaving.
Avoid contact sports and hobbies.
Monitor INR levels every 4-6 weeks.
The target INR for warfarin is 2.4 - 3.5. INR should be monitored on a regular basis. Changes in the warfarin dosage will be adjusted to keep the INR within a safe range which will decrease the risk of a life-threatening bleed.
[HF] The client asks the nurse why they have to be weighed every day. The nurse explains that weight gain is one of the first signs of retaining fluid. Which intervention is most important for the nurse to include in the client’s plan of care?
Weigh at the same time of day.
Keep a record of daily weights.
Report a gain of 3 pounds in one week.
Inform healthcare provider of ankle swelling.
Report a gain of 3 pounds in one week.
A weight gain of 3 pounds in 2 days or 3-5 pounds in a week should be reported immediately. This may indicate an exacerbation of the heart failure which requires immediate intervention.
Carvedilol works best if you take it with ______.
food
Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?
Blood pressure 180/100.
Anorexia, nausea, and vomiting.
Pitting dependant ankle edema.
Blurred vision and halo vision.
Anorexia, nausea, and vomiting.
Gastrointestinal (GI) symptoms are among the earliest symptoms of digoxin toxicity, along with confusion and fatigue. Additional manifestations include headache, hypotension, and cardiac dysrhythmias.
A precipitous drop in serum ___________ may occur after treatment with digoxin immune FAB .
potassium
Respiratory ___________ is diagnosed with the PaCO2 is high and the pH is low.
acidosis
In an effort to monitor his heart failure, what is the most important intervention that the client can perform at home?
Check radial pulse 6 times a day, upon arising, at each meal, and before bed.
Take weekly ankle measurements to monitor edema.
Weighing every day on the same scale.
Incorporate a regular exercise routine.
Weighing every day on the same scale.
Daily weights are the most important intervention for monitoring heart failure. Clients should be instructed to call the HCP immediately with a weight gain of 2 to 3 lbs in 24 hours.
Which clinical manifestations further support a right-sided stroke? SATA
Visual field deficit on the left side.
Spatial-perceptual deficits.
Paresthesia of the left side.
Increased distractibility.
Global aphasia
Visual field deficit on the left side.
Spatial-perceptual deficits.
Paresthesia of the left side.
Increased distractibility.
The neurologist writes a diagnosis of “suspected stroke” and prescribes a computed tomography (CT) scan without contrast STAT. Which intervention should the nurse implement when preparing client and his son for this procedure?
Determine if the client has any allergies to iodine or shellfish.
Explain that the procedure requires the client to lie completely still.
Offer client an anxiolytic prior to the procedure.
Ensure that client does not have on any material that is metal, this includes metal prosthesis.
Explain that the procedure requires the client to lie completely still.
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test?
Elevated heart rate.
Allergy to iodine.
Left hip replacement.
History of hypertension.
Left hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure.
With a diagnosis of a stroke, which priority interventions should the nurse include in client’s plan of care?
Monitor PTT daily.
Assess neurological status every hour.
Evaluate platelet levels daily.
Keep the head of the bed elevated.
Monitor blood glucose levels daily.
Monitor PTT daily.
Assess neurological status every hour.
Keep the head of the bed elevated.
Monitor blood glucose levels daily.
Homonymous hemianopsia is loss of the visual field blindness in the ______ ______ of each visual field.
same half
The student nurse rechecks the client’s blood pressure now that he has been sitting quietly for a few minutes. His blood pressure is 180/106 mmHg.
According to the assessment of this client, which recommendation is most important for the student nurse to provide?
See the HCP as soon as possible within the next week for a BP recheck.
Limit salt intake and start a weight loss program.
Attend a stress reduction seminar offered in his community.
Learn about high fiber foods and add more fiber to his diet.
See the HCP as soon as possible within the next week for a BP recheck.
The client’s blood pressure is significantly elevated. Since these BP readings were obtained on the same day, the client needs to see his HCP as soon as possible for another BP measurement. The HCP can then determine a diagnosis and initiate treatment.
Often clients with hypertension have no symptoms and ____________ may occur before the client becomes symptomatic.
organ damage
Most cases of hypertension are without an identified ______ and effected by multiple risk factors, so unless there is a health history indicator, the HCP does not look for one.
cause
Use of _________ products is linked with increased risk for cardiovascular disease.
tobacco
“Phantom limb pain is caused by the severing of _________ nerves.”
peripheral
The client tells the nurse that every time he walks a short distance, he gets an aching or cramping pain in his left leg.
How should the nurse correctly document this data?
Paresthesia.
Intermittent claudication.
Deep vein thrombosis (DVT).
Peripheral neuropathy.
Intermittent claudication.
A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment finding would alert the nurse to the possible development of thrombocytopenia? Select all that apply. One, some, or all responses may be correct.
Fever
Diarrhea
Melena
Hematuria
Ecchymosis
Nausea
Alopecia
Mucositis
Melena
Hematuria
Ecchymosis
The nurse reviews the medical record of a client with a grade 2 goiter. Which assessment finding is consistent with this type of goiter?
It is impalpable.
It is asymmetrical.
It moves up when the client swallows.
It is invisible when the client’s neck is in the normal position.
It is asymmetrical.
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery?
Maintain muscle strength
Reduce leg discomfort
Prevent clot formation
Improve wound healing
Prevent clot formation
Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct.
Providing oxygen
Assessing vital signs
Obtaining a 12-lead EKG
Drawing blood for cardiac enzymes
Auscultating heart sounds
Administering nitroglycerin
All of the above
How would the nurse describe heart failure to a client?
A cardiac condition caused by inadequate circulating blood volume
An acute state in which the pulmonary circulation pressure decreases
An inability of the heart to pump blood in proportion to metabolic needs
A chronic state in which the systolic blood pressure drops below 90 mm Hg
An inability of the heart to pump blood in proportion to metabolic needs
Which type of hepatitis virus spreads through contaminated food and water?
Hepatitis A virus
Hepatitis B virus
Hepatitis C virus
Hepatitis D virus
Hepatitis A virus
Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct.
Lopsided smile
Unilateral vision
Incoherent speech
Unable to raise right arm
Symptoms started 2 hours ago
All of the above
Which statement by an older adult client about skincare to prevent pressure ulcers indicates a need for further teaching?
“I should gently pat my skin.”
“I should use mild, heavily fatted soap.”
“I should wash my skin with tepid water, rather than hot water.”
“I should apply powders or talc on a perineum wound.”
“I should apply powders or talc on a perineum wound.”
A client has surgery for the creation of a colostomy. Postoperatively, which color would the nurse expect a viable stoma to be?
Brick red
Pale pink
Light gray
Dark purple
Brick red
Which organism would the nurse identify as causing syphilis?
Treponema pallidum
Campylobacter jejuni
Trichomonas vaginalis
Chlamydia trachomatis
Treponema pallidum
After an above-the-knee amputation for bone cancer, an adolescent male is returned to his room. Which item would the nurse plan to keep at the bedside?
Hemostat
Vitamin K
Protamine sulfate
Pressure dressing
Pressure dressing
Which rationale supports the need for the nurse to contact the client’s primary health care provider when a nurse observes vaginal packing protruding from the client’s vaginal vault after radium implants for cervical cancer were inserted?
The radioactive packing will injure healthy tissue.
Removal of the packing will prevent excessive blood loss.
Radium exposure to the environment diminishes the effectiveness.
Removal of the packing minimizes life-threatening contact with the radiation.
The radioactive packing will injure healthy tissue.
Which information about benign prostatic hyperplasia (BPH) is important for the nurse to consider when caring for a client with that condition?
It is a congenital abnormality.
A malignancy usually results.
It predisposes to hydronephrosis.
Prostate-specific antigen decreases.
It predisposes to hydronephrosis.
The secretion of which hormone is an example of a positive feedback mechanism?
Insulin
Estradiol
Parathormone
Catecholamines
?
The nurse obtains a laboratory report that shows acid-fast rods in a client’s sputum. Which disorder would the nurse consider may be related to these results?
Influenza virus
Diphtheria bacillus
Bordetella pertussis
Mycobacterium tuberculosis
Mycobacterium tuberculosis
A client who is receiving radiation therapy for bone cancer lives alone and works full time. Which client action would the nurse encourage?
Begin to perform regularly scheduled aerobic activity daily.
Take a leave of absence from work when receiving therapy.
Include rest periods during the day while receiving radiation.
Continue the activities usually performed before becoming ill.
Include rest periods during the day while receiving radiation.
Which action transmits the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct.
Multiple mosquito bites
Sharing syringe needles
Breast-feeding a newborn
Dry kissing an infected individual
Anal intercourse
Sharing drinking glasses
Sharing syringe needles
Breast-feeding a newborn
Anal intercourse
The nurse is providing immediate postoperative care to a client who has undergone a total laryngectomy. It is appropriate for the plan of care to include which intervention?
Instructing the client to whisper
Placing the client in the orthopneic position
Removing the outer tracheostomy tube as needed
Suctioning the tracheostomy tube whenever necessary
Suctioning the tracheostomy tube whenever necessary
Which clinical feature is indicative of hypercortisolism?
Loss of weight
Thickening of skin
Enhanced density of bones
Increased pigmentation
Increased pigmentation
Which organism is a common opportunistic infection in a client infected with human immunodeficiency virus (HIV)?
Oropharyngeal candidiasis
Cryptosporidiosis
Toxoplasmosis encephalitis
Pneumocystis jiroveci pneumonia
Oropharyngeal candidiasis
Which explanation for the client’s behavior would be useful to consider in planning care for a client who has been on hemodialysis for 2 years, communicates in an angry, critical manner, and does not adhere to the prescribed medications and diet?
An attempt to punish the nursing staff
A constructive method of accepting reality
A defense against underlying depression and fear
An effort to maintain life and to live it as fully as possible
A defense against underlying depression and fear
Which part of the electrocardiogram (ECG) represents depolarization of the ventricles?
P wave
T wave
PR interval
QRS interval
QRS interval
Which evaluation method is the most effective way for the nurse to evaluate the teachers’ knowledge of hand-washing techniques after a program for teachers about infection-control and hand-washing techniques?
Observe the teachers lecture the children about hand hygiene.
Administer an objectively written final examination to the teachers.
Have the teachers share their knowledge of hand washing.
Watch the teachers demonstrate infection-control techniques.
Which action would the nurse take in caring for a client after surgical placement of an external fixator on the client’s leg?
Cleanse the pin sites with alcohol several times a day.
Perform a neurovascular assessment of the lower extremities.
Ambulate the client with partial weight bearing on the affected leg.
Maintain placement of an abduction pillow between the client’s legs.
Perform a neurovascular assessment of the lower extremities.
Which information in the response of a client receiving peritoneal dialysis indicates understanding of the purpose of the procedure?
Reestablishing normal kidney function
Cleaning the peritoneal membrane
Providing fluid for intracellular spaces
Removing toxins and metabolic wastes
Removing toxins and metabolic wastes
Which answer would a nurse give to a client receiving a hemodialysis treatment who asks which substances are being removed?
Blood
Sodium
Glucose
Bacteria
Sodium
Which statement explains why metabolic acidosis develops with kidney failure?
Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention
Inability of the renal tubules to reabsorb water to dilute the acid contents of blood
Impaired glomerular filtration, causing retention of sodium and metabolic waste products
Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
Which assessment finding indicates hypersecretion of adrenocorticotrophic hormone?
Moon face
Lower jaw protrusion
Heat intolerance
Barrel-shaped chest
Moon face
Which statement by a client with pruritus about personal care interventions indicates understanding of the interventions?
“I will trim my fingernails regularly.”
“I will apply moisturizing lotion before my bath.”
“I will avoid filing the edges of fingernails into oval shapes.”
“I will use baby powder or talc in my groin areas.”
“I will avoid filing the edges of fingernails into oval shapes.”
Which result would the nurse expect to find when reviewing the serum screening tests of a client with acquired immunodeficiency syndrome (AIDS)?
A decrease in CD4 T cells
An increase in thymic hormones
An increase in immunoglobulin E
A decrease in the serum level of glucose-6-phosphate dehydrogenase
A decrease in CD4 T cells
A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up?
“I will leave the skin markings intact.”
“I will protect the skin from sources of heat.”
“I will wear soft clothing over the upper body.”
“I will use an oatmeal-based lotion after each treatment.”
“I will use an oatmeal-based lotion after each treatment.”
Which sexually transmitted infection is managed with antiviral medications as the treatment of choice?
Syphilis
Gonorrhea
Genital herpes
Chlamydial infection
Genital herpes
Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?
Urticaria
A medication reaction
Atopic dermatitis
Contact dermatitis
Contact dermatitis
The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. Which action would the nurse take?
Administer the prescribed oxygen.
Administer the prescribed antianxiety medication.
Notify the health care provider immediately of the findings.
Record the observations and continue to observe the client.
Administer the prescribed oxygen.
Which description would the nurse provide to a client scheduled for a cystoscopy who asks about the procedure?
“It is a computerized scan that outlines the bladder and surrounding tissue.”
“It is an x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye.”
“It is the visualization of the bladder lining with an instrument connected to a source of light.”
“It is the imaging of the urinary tract through ureteral catheterization using radiopaque material.”
“It is the visualization of the bladder lining with an instrument connected to a source of light.”
Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours?
To maintain client comfort
To prevent development of pressure injuries
To prevent flexion contractures of the extremities
To improve venous circulation in the lower extremities
To prevent development of pressure injuries
Which lobe of the brain would the nurse conclude is affected in a client unable to differentiate between heat or cold and sharp or dull sensory stimulation after a cerebrovascular accident (CVA)?
Frontal
Parietal
Occipital
Temporal
Parietal
Which physiological activity is associated with the “proliferative phase” of normal wound healing?
White blood cells migrate into the wound.
Epithelial cells grow over the granulation tissue.
Scar tissue gradually becomes thinner and pale.
Vasodilation occurs with increased capillary permeability.
Epithelial cells grow over the granulation tissue.
Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure?
Sodium
Calcium
Potassium
Magnesium
Sodium
Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit?
Stabilized vital signs and complaints of pain
Pale and alert; remains restless
Increasing temperature and apprehension
Fluctuating vital signs and drowsy, but easily roused
Stabilized vital signs and complaints of pain
Which dietary instruction would be beneficial to a client who has undergone a hypophysectomy and has difficulty passing stools?
“Drink plenty of water.”
“Eat foods rich in protein.”
“Drink a glass of milk daily.”
“Eat foods rich in carbohydrates.”
“Drink plenty of water.”
A client with a chest tube is to be transported via a stretcher. When transporting the client, what would the nurse do?
Keep collection device attached to mechanical suction
Keep chest tube clamped distal to the water-seal chamber
Keep collection device below the level of the client’s chest
Keep chest tube end covered with sterile gauze pads taped to the client
Keep collection device below the level of the client’s chest
Which carcinoma is the most common type of thyroid cancer and is most often found in younger women?
Papillary carcinoma
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma
Papillary carcinoma
Which hormonal imbalance would the nurse suspect in a client who has low serum sodium levels?
Epinephrine
Glucagon
Calcitonin
Aldosterone
Aldosterone
Which technology will be used for the treatment of electrical burns?
Skin substitutes
Electrical stimulation
Topical growth factors
Hyperbaric oxygen therapy
Hyperbaric oxygen therapy
Which action would the nurse take to prevent venous thrombus formation after abdominal surgery?
Keep the client in a gatch bed to elevate the knees.
Have the client dangle the legs off the side of the bed.
Help the client use an incentive spirometer every hour.
Encourage the client to ambulate multiple times daily.
Encourage the client to ambulate multiple times daily.
Which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count?
Increased blood pH
Decreased hematocrit
Increased blood viscosity
Decreased immune response
Increased blood viscosity
A client is admitted to the emergency department with a stab wound of the chest. Which is a priority nursing assessment?
Level of pain
Quality and depth of respirations
Amount of serosanguinous drainage
Blood pressure and pupillary response
Quality and depth of respirations
Which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia?
“I have abnormal platelets.”
“I have abnormal hemoglobin.”
“I have abnormal hematocrit.”
“I have abnormal white blood cells.”
“I have abnormal hemoglobin.”
Which term would the nurse use to document a client experiencing urinary incontinence via involuntary loss of small amounts (25–35 mL) of urine from an overdistended bladder?
Urge incontinence
Stress incontinence
Overflow incontinence
Functional incontinence
Overflow incontinence
Which electrical activity of the cardiac conduction system is reflected in the P wave?
Atrial depolarization
Atrial repolarization
Ventricular depolarization
Ventricular repolarization
Atrial depolarization
