Final

Front 1

2. A 54-year-old male client was recently diagnosed with subacute bacterial endocarditis (SBE). The nurse determines that the client understands the discharge teaching when he makes which statement?

Back 1

You answered correctly: "I have to call my doctor so I can get antibiotics before seeing the dentist."

Front 2

4. A client is scheduled for coronary angiography. In reviewing the client's record, what significant finding would the nurse report to the healthcare provider before the diagnostic procedure?

Back 2

You answered correctly: Client reported an allergy to shrimp

Front 3

5. The nurse is implementing a discharge teaching plan for a client newly diagnosed with heart failure. When discussing fluid status with the client, the nurse would explain the importance of doing which of the following?

Back 3

You answered correctly: Recording body weight every day before breakfast and report a weight gain of 3 or more pounds in a week

Front 4

7. A client is getting ready to go home after acute myocardial infarction (AMI). The client is asking questions about the prescribed medications, and wants to know why metoprolol (Lopressor) was prescribed. The nurse's best response would be which of the following?

Back 4

You answered correctly: "Lopressor slows your heart rate and decreases the amount of work it has to do so it can heal."

Front 5

8. A client is taking digoxin (Lanoxin) and furosemide (Lasix) for heart failure. The nurse approves of which of the following client selections that is the best menu choice for this client?

Back 5

You answered correctly: Chicken with baked potato and cantaloupe

Front 6

1. A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. The nurse concludes that what response from the client indicates understanding of this medication?

Back 6

"I have a small metal labeled case for a few nitroglycerine tablets that I carry with me when I go out."

Front 7

3. The nurse is caring for a client who has just returned from the cardiac catheterization lab following a percutaneous transluminal coronary angioplasty (PTCA). The client is receiving a continuous infusion of heparin. The urine is now tea colored. What action should the nurse take next?

Back 7

Assess the insertion site for bleeding and measure pulse and blood pressure.

Front 8

4. The nurse is caring for a client being discharged after valve replacement surgery using a St. Jude mechanical valve. The nurse is reviewing the instructions for the client's follow-up care and determines that the client understands the instructions when the client states:

Back 8

"I will need to take anticoagulant medication for the rest of my life."

Front 9

5. The nurse is caring for a client on the second postoperative day after coronary artery bypass (CABG) surgery. The client has a nursing diagnosis of Impaired gas exchange. Which action would the nurse take to best assist the client with this diagnosis?

Back 9

Ensure that client uses the incentive spirometer every hour.

Front 10

6. A client who just underwent cardiac catheterization insists on getting up to go to the bathroom to urinate immediately after returning to his room. Which of the following would be the nurse's best response?

Back 10

"If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications."

Front 11

7. The nurse is caring for a client admitted to the Emergency Department (ED) with chest pain. He reports that chest pain developed while mowing the lawn and he stopped and rested on the sofa, as is typical for him. This time the pain was not relieved by rest so he came to the ED. The chest pain is relieved following administration of 2 sublingual nitroglycerine tablets. The nurse draws which conclusion about this client's status?

Back 11

Client most likely has unstable angina.

Front 12

8. The nurse is assessing a client at 07:30 in the morning on a day when the client has a cardiac stress test scheduled for 11:30. The client reports that no breakfast was delivered this morning and the client is hungry. Which of the following is the nurse's best action?

Back 12

Have nursing assistant get the client cereal with milk and orange juice.

Front 13

9. A hospitalized client has continuous electrocardiographic (ECG) monitoring, and the monitor shows that the rhythm has suddenly changed to ventricular tachycardia (VT). What is the first action that the nurse should take?

Back 13

Quickly assess the client's level of consciousness, blood pressure, and pulse.

Front 14

10. The physician has diagnosed acute myocardial infarction (AMI) on the basis of electrocardiogram (ECG) changes for a client in the Emergency Department (ED). The nurse assesses the client frequently, and notes that the client seems forgetful, and periodically asks the nurse to explain the ECG and noninvasive blood pressure monitors. The nurse concludes that the client's response is most likely due to which of the following reasons?

Back 14

Client is showing signs of fear and anxiety.

Front 15

1. A client with hypertension has a blood pressure of 160/96 after six months of intensive exercise and diet modifications. The nurse makes which appropriate statement to the client at this time?

Back 15

"Medication therapy will likely need to be started along with continuing your exercise and diet program."

Front 16

2. The nurse has been caring for a client with peripheral arterial disease. The nurse would assess for which outcome as evidence of increased arterial blood supply to the extremity?

Back 16

: Reduced muscle pain

Front 17

3. In teaching a hypertensive client about the side effects of propranolol (Inderal) the nurse plans to include which side effect of this medication therapy?

Back 17

Bronchospasm

Front 18

4. The nurse is doing an assessment on a client during the first postoperative day after abdominal surgery. Which of the following manifestations does the nurse report immediately?

Back 18

Leg swelling and calf pain

Front 19

5. The nurse concludes that the hypertensive client taking furosemide (Lasix) demonstrates understanding of the drug when the client states the importance of increasing intake of which beverage?

Back 19

Orange juice

Front 20

6. The nurse is caring for a preoperative client diagnosed with abdominal aortic aneurysm (AAA). The client reports the onset of severe back pain. What action should the nurse take next?

Back 20

Call the healthcare provider immediately.

Front 21

7. The nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT) who is being treated with a continuous infusion of heparin. Which of the following must the nurse report immediately?

Back 21

Partial thromboplastin time (PTT) of 50

Front 22

8. The nurse is preparing an assignment for a nurse orientee. Because the new nurse has not cared for a client having a Greenfield filter inserted, which clients may be selected for the new nurse's assignment as possible candidates for a Greenfield filter? Select all that apply.

Back 22

60-year-old male with pelvic fractures, compound femur fracture, and unknown history; 54-year-old just admitted with ARDS who previously had deep vein thrombosis (DVT) following an extended plane flight

Front 23

9. The nurse is caring for a client diagnosed with hypertension who is being treated with a bumetanide (Bumex) and enalapril (Prinivil). Which of the following should the nurse include in this client's discharge instructions?

Back 23

: Sit up and get out of bed slowly to prevent dizziness.

Front 24

10. When educating the client with essential hypertension, the nurse instructs the client to do which of the following?

Back 24

Have regular eye exams.

Front 25

1. When caring for a client diagnosed with end-stage renal failure, which of the following diets should the nurse recommend?

Back 25

Restricted protein, increased carbohydrates

Front 26

3. The nurse is caring for a client who has developed urinary incontinence. During the intake assessment, the nurse performs an assessment of cognitive functioning. When questioned by the family, the nurse explains that this assessment will help to determine whether the client has:

Back 26

Functional incontinence.

Front 27

4. The nurse is caring for an elderly male who reports difficulty starting urination and voiding several times during the night. The nurse suspects that this client has:

Back 27

Benign prostatic hyperplasia (BPH).

Front 28

6. Which of the following nursing actions is most appropriate when caring for a client with a nursing diagnosis of excess fluid volume related to renal insufficiency?

Back 28

Teaching clients about sodium content of foods

Front 29

7. The nurse is caring for a client with recurrent cystitis. Which of the following instructions should be included prior to discharge?

Back 29

Void at least every four hours even if the urge is absent.

Front 30

8. A client has undergone creation of an ileal conduit. Which of the following instructions to the client about urostomy care would be appropriate to include in the teaching plan?

Back 30

Cleanse the skin around the stoma using gentle soap and water, rinse and dry well.

Front 31

10. A client underwent cystectomy for cancer of the bladder and had a Kock pouch created for urinary diversion. The home care nurse would follow up with the client about which of the following instructions for self-care?

Back 31

Technique for catheterizing the Kock pouch