theory final exam

A nurse is providing discharge teaching to a client who has hyperkalemia. Which of the following foods should the nurse teach the client to avoid? (Select all that apply.)

apples

cabbage

spinach

carrots

tomatoes

bananas

bananas, tomatoes, spinach

A nurse is providing discharge education to a client who has hypokalemia. Which statement by the client indicates to the nurse the client understands the teaching?

i will report if i experience muscle weakness to my provider

i will continue to take my laxatives as needed for my constipation

i should replace my salt substitute with table sakt

i should avoid consuming green veggies

i will report if i experience muscle weakness to my provider

Following surgery to repair a tear in a client's shoulder, the client is prescribed physical therapy. During physical therapy the client has an exacerbation of their chronic back pain which is treated by another provider. Which of the following interventions would be priority to ensure the client receives holistic care?

1. The nurse should educate the client about the medication that will be required during the recovery process.

2. The nurse should note the surgical error that occurred during the initial procedure in the client's records.

3. The nurse should educate the client about potential health-care-associated infections that could hinder the postoperative recovery.

4. The nurse should facilitate contact between the client's surgical team, physical therapist, and primary care physician.

4. The nurse should facilitate contact between the client's surgical team, physical therapist, and primary care physician.

A nurse is planning care for a client who has hyponatremia. Which of the following actions is the priority to include in the plan of care?

1. Monitor serum osmolality

2. Monitor neurologic status

3. Monitor urine output

4. Monitor serial serum sodium levels every 4-6 hr

2. Monitor neurologic status

Which of the following risk factors is associated with a client having a higher risk of experiencing status asthmaticus?

1. Bronchial pneumonia

2. Previous stroke

3. Irritants and and hypersensitivity to medications

4. Previous intubation due to status asthmaticus episode

4. Previous intubation due to status asthmaticus episode

A nurse is providing care to a client that has end-stage colon cancer. A family member states to the nurse, "Why is my loved one losing weight?" Which of the following statements made by the nurse is the most accurate and appropriate?

1. "A significant weight loss is a cause to be concerned."

2. "Your loved one has a decrease in their desire to eat."

3. "Losing some weight is natural; it's probably just fluid."

4. "Your loved one has cancer and is being stubborn."

2."Your loved one has a decrease in their desire to eat."

A nurse is providing care to a client at the end stages of the dying process. The client's family member asks the nurse if their family member is brain dead. Which of the following statements is the appropriate therapeutic response for the nurse to make?

1. "Your family member is at the end-stage of death but is not considered to be brain dead."

2. "Why would you think your family member is brain dead?"

3. "You don't need to be concerned about that right now."

4. "It will take a long time before your family member is brain dead.

"Your family member is at the end-stage of death but is not considered to be brain dead."

A nurse is presenting a poster on burnout to a group of newly licensed nurses. Which of the following points should the nurse include in their presentation?

1. Burnout is usually recognizable within the first few days.

2. Lack of sleep is a risk factor for burnout.

3. Burnout has similar manifestations in all nurses.

4. The nurse should transfer to another unit if they experience burnout.

2. Lack of sleep is a risk factor for burnout.

A nurse is caring for a group of clients. Which of the following clients is most susceptible to keloid scar formation?

 1. A client who is Black

2. A female client

3. A client who takes opiate medications

4. A pediatric client

1. A client who is black

A nurse is discussing spiritual wishes with a client receiving comfort care. Which of the following statement(s) should the nurse use to begin the conversation?

1. "Do you want to have your dog with you?"

2. "How do you see your last days transpiring?"

3. "What are your expectations for end-of-life care?"

4. "Can I have my rosary with me?"

3. "What are your expectations for end-of-life care?"

A nurse is discussing the impact of social determinants of health and their impact on the spread of communicable diseases and infections. Which of the following factors should the nurse identify as a social determinant that increases the risk of infection among individuals who are living at a lower income level?

1. Occupation and work conditions

2. Family history and genetic background

3. Citizenship status

4. Comorbidities

1. Occupation and work conditions

Which of the following is the most common risk factor for emphysema?

1. Pollution

2. Asthma

3. Smoking tobacco

4. Between 20 to 30 years of age

3. Smoking tobacco

A nurse is caring for a client experiencing acute asthma manifestations. The medication ordered is one that will provide immediate relief for the client having an asthma flare-up. Which of the following is the class of medication likely ordered for the client?

1. Inhaled corticosteroid

2. Long-acting beta-agonist (LABAs)

3. Short-acting beta-2 agonist (SABA)

4. Long-acting anti-cholinergic (mucarinic) agents

3. Short-acting beta-2 agonist (SABA)

A nurse performs an initial interview for a client who presents with manifestations consistent with Parkinson's disease. The nurse also interviews the client's family. Which of the following steps of the nursing process is the nurse completing?

1. Evaluation

2. Assessment

3. Diagnosis

4. Planning

2. Assessment

A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation?

(Select all that apply.)

Blood pressure

Bowel sounds

Level of consciousness

Urine output

Platelet count

blood pressure, LOC, and urine output

The nurse is educating the client's family about the changes occurring during the early stage of the dying process. The family member tells the nurse, "My parent is really confused at times." Which of the following is the nurse's best response?

1. "Your parent has their days and nights mixed up."

2. "Your parent is suffering from sundowners."

3. "This is a normal cognitive change that is occurring."

4. "Showing any emotion near death is always positive."

3. "This is a normal cognitive change that is occurring."

A nurse leader is discussing possible continuing education opportunities with other staff members. Which of the following actions should the nurse leader recommend to maintain clinical competence?

1. Removing expired supplies from the storage area

2. Joining a nurses' union

3. Attending a professional conference

4. Discussing facility policies with coworkers

3. Attending a professional conference

A nurse is providing care to a client with end-stage breast cancer. The nurse should determine which of the following assessment findings are evidence of death?

1. Cessation of palpable blood pressure.

2. Oxygen saturation less than 88%.

3. Cessation of any bodily movement.

4. Cessation of breathing and cessation of the pulse.

4. Cessation of breathing and cessation of the pulse.

A nurse at a same-day surgery facility meets with a client postoperatively treated for a torn meniscus in the left knee. The client requires a recovery plan to rehabilitate. Which of the following steps should the nurse take to advocate for the client?

1. Provide the client with a referral to a facility that offers physical therapy.

2. Note the client's preinjury manifestations to help plan the client's care needs. 

3. Provide instructions on emergency care for the client's condition.

4. Provide a nutrition plan to adjust the client's eating habits.

1. Provide the client with a referral to a facility that offers physical therapy.

A nurse is caring for a client who has a serum brain natriuretic peptide (BNP) of 1200 pg/mL (< 100pg/mL). Which of the following findings should the nurse anticipate with this client? (Select all that apply.)

(Select All that Apply.)

Weight loss of 1.4 kg (3 lbs)

Tetany

Rales in lung fields

Dyspnea

Dry mucous membranes

rales in the lungs, dyspnea

A nurse is providing culturally competent care to a client who is terminally ill. Which of the following should the nurse perform when providing care to clients with diverse backgrounds?

1. Instruct the client to complete all their treatments.

2. Implement multiple specialty care providers.

3. Be nonjudgmental in their health care practices.

4. Encourage the client to be placed in the nursing home.

3. Be nonjudgmental in their health care practices.

A nurse is providing care to a client with end-stage renal disease. When the nurse assists the client to set goals, which of the following should be the focus for end-of-life care?

1. Extend life as long as possible.

2. Maximize time with family.

3. Increase physical activity.

4. Maintain quality of life.

4. Maintain quality of life

A nurse is teaching a client who has hyponatremia. Which of the following statements should the nruse include in the teaching?

1. "You will need to restrict fluids to prevent hyponatreia from recurring."

2. "You will need to be on a 2 grams sodium diet."

3. "You will need to have a brain natriuretic peptide drawn every 3 months."

4. "You will need to wear a Holter monitor for 3 days after discharge."

1. "You will need to restrict fluids to prevent hyponatreia from recurring."

A nurse is caring for a client in an acute care setting who states, "The nurses here have been awful to me." Which of the following statements by the nurse demonstrates professional communication with the client?

1. "The provider can discharge you if you are not happy with your care."

2. "Tell me what happened to make you feel that way."

3. "The nurses are doing the best that they can."

4. "This hospital does have some pretty bad nurses."

2. "Tell me what happened to make you feel that way."

A nurse is caring for a client who has a wound. Which of the following actions can the nurse take to promote their own safety?

1. Eat a full meal prior to a wound dressing change.

2. Sedate the client before performing a home care wound dressing.

3. Utilize appropriate standard precautions or isolation procedures.

4. Choose a dressing that will add moisture to the wound bed.

3. Utilize appropriate standard precautions or isolation procedures.

A nurse is working with a postoperative client to develop mobility goals. Which of the following steps of the nursing process is the nurse completing?

1. Assessment

2. Planning

3. Diagnosis

4. Implementation

2. Planning

A nurse is caring for a client who practices Catholicism. The client has just received word from the physician that their condition is terminal and there is nothing else that can be added to their treatment plan. The client is visibly upset and requesting to speak with a priest and have their last rites administered. Which of the following interventions should the nurse perform?

1. Pray with the family.

2. Notify the charge nurse.

3. Contact the chaplain.

4. Complete discharge teaching.

3. Contact the chaplain

A nurse is caring for a client with pneumonia. Which of the following is true regarding the pathophysiology of pneumonia?

1. Pathogens causing pneumonia are transmitted only by aerosol.

2. Pneumonia is caused by bacterial or viral respiratory pathogens.

3. Transmitted pathogens colonize the trachea.

4. Infection results when the pathogen amount is overloaded.

2. Pneumonia is caused by bacterial or viral respiratory pathogens.

A nurse is providing care to a client with end-stage throat cancer who is unresponsive and unable to eat. The client has been receiving total parenteral nutrition (TPN) to meet their nutritional needs. The family has requested the nurse to withdraw the TPN and stop all further treatments. What should the nurse perform first?

1. Withdraw the feedings.

2. Notify the physician of the family's request.

3. Discuss the request with the chaplain.

4. Change the plan of care after meeting with the social worker.

2. Notify the physician of the family's request.

A nurse is providing care for a client who has a new diagnosis of anxiety. The client's heart rate is 100/min, respiratory rate is 34/min, and the client reports numbness and tingling of the hands. Which of the following acid-base imbalances should the nurse suspect?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory alkalosis

4. Respiratory acidosis

3. Respiratory alkalosis

A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? Select all that apply.

(Select All that Apply.)

Decreased plasma volume

Capillary leak

Diuresis

Hypermagnesemia

Loss of protein

loss of protein, capillary leak, and decreased plasma volume

A nurse is caring for a client who is receiving home hospice care. The family states, "We are exhausted. We do not want to admit our parent to a long-term care unit, but what alternatives do we have?" Which of the following statements should the nurse include when speaking to the family?

1. "You can take them to the emergency room and get them admitted to the hospital for a while."

2. "I think you should admit your parent to the long-term care unit so your family can get some rest."

3. "Respite care is available for caregivers of terminally ill clients."

4. "You can do this for a little longer. You should just rest when they rest."

3."Respite care is available for caregivers of terminally ill clients."

A nurse is caring for a client admitted with pneumonia caused by Streptococcus pneumoniae. Which of the following types of pneumonia is Streptococcus pneumoniae?

1. Aspiration pneumonia  

2. Chemical pneumonitis

3. Typical pneumonia

4. Atypical pneumonia

3. Typical pneumonia

A nurse is preparing to discharge a client who has several new prescriptions. The client states, "I don't think I can afford to buy all of these medications." Which of the following responses by the nurse demonstrates advocacy to promote the client's health?

1. "I will be sure to involve the social worker in your discharge planning."

2. "You might be able to negotiate prices of the medications with your insurance company."

3. "There are lots of pharmacies in the city that have competative pricing."

4. "I'm sure you will find a way to get the medications."

1. "I will be sure to involve the social worker in your discharge planning."

A nurse is providing care to a client who is unable to participate in the decision-making process. Which of the following demonstrates how the Patient's Bill of Rights supports a client-based approach?

1. It provides the client the right to be informed of billing and payment methods.

2. It allows a designated surrogate, such as a health care proxy, to make decisions for them. 

3. It provides the client the right to review their medical records and have them explained or interpreted as needed. 

4. It gives the client the right to consent or decline participation in medical research.

2. It allows a designated surrogate, such as a health care proxy, to make decisions for them. 

A nurse is caring for a client who has a potassium level of 5.2 mEq/L (3.5 to 5 mEq/L). Which of the following findings from a client's medical history should the nurse identify as a potential contributor to the client's potassium level?

1. Nephrotic syndrome

2. Heart failure

3. IV insulin administration

4. Use of ACE inhibitors

4. Use of ACE inhibitors

A nurse is assessing clients for skin problems on the medical surgical floor. Which option is most likely to result in chronic wounds?

1. Cluster of oral herpes sores

2. Abdominal surgical incision

3. Posterior scalp wound

4. Diabetic foot ulcer

4. Diabetic foot ulcer

A nurse is caring for a client who is scheduled to have negative pressure wound therapy (NPWT). The client asks why this type of therapy would be needed on the wound. Which of the following is the nurse's best response?

1. "NPWT puts antibiotics up against the wound to fight off infection."

2. "NPWT infusing oxygen into the wound to promote wound healing."

3. "NPWT cleans most of the bacteria off from the body to prevent future infections."

4. "NPWT removes moisture and helps new skin cells to fill in the wound."

4. "NPWT removes moisture and helps new skin cells to fill in the wound."

A nurse is caring for the client who has pulmonary edema and a chronic condition known as renal vascular disease. Clients with renal cascualr diseae have a higher risk of developing pulmonary edema due to which of the following?

1. Occurs prior to myocardial infarction (MI).

2. Chronic hypertension.

3. Decreased cardiac filling pressure.

4. Buildup of fluid in the lungs.

2. Chronic hypertension

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

1. Temperature of 100.4F (68C).

2. Report of right calf pain.

3. New onset of shortness of breath.

4. Erythema of right lower leg.

3. new onset of shortness of breath

A nurse is assessing risk factors for atherosclerotic cardiovascular disease with a client. The nurse should encourage which of the following lifestyle habits to help the client prevent this disease? 

(Select All that Apply.)

Eating fruits and vegetables every day

Following a high-fiber diet

Maintaining a blood sugar level within normal ranges

 Consuming 3 to 4 glasses of red wine per day

Exercising every day

Taking a medication for hyperlipidemia as prescribed

fruits and vegetables, fiber, and exercise

A nurse is caring for a client who has coronary artery disease that has progressed to an ST elevation myocardial infarction (STEMI). Which of the following procedures should the nurse anticipate for this client?

1. Administration of pentoxifylline.

2. Balloon valvuloplasty. 

3. Heart catheterization and percutaneous intervention.

4. Heparin bolus followed by a continuous infusion. 

3. Heart catheterization and percutaneous intervention.

A nurse is caring for a client who has hypomagnesemia following a myocardial infarction. The nurse should understand the client is at risk for which of the following findings?

1. Decreased urine output

2. Hypocalcemia

3. Polydipsia

4. Ventricular fibrillation

4. Ventricular fibrillation

A nurse on the telemetry unit is caring for a patient who has unstable angina and is reporting chest pain with a severity of 6 out of 10. The nurse administers one (1) sublingual nitroglycerin tablet. After five (5) minutes, the client states that his chest pain is now a severity of four (4). Which of the following actions would the nurse take?

1. Call a Rapid Response.

2. Administer another nitroglycerin tablet.

3. Obtain a repeat electrocardiogram (ECG).

4. Prepare for synchronized cardioversion.

2. Administer another nitroglycerin tablet.

A client presents to the clinic with suspected peripheral artery disease in their right lower limb. Which of the following assessment findings should suggest to the nurse the impaired circulation to the limb?

(Select All that Apply.)

The skin tone of the client's right lower extremity is different than the remainder of the skin.

The client's left lower leg is warm to the touch.

The client reports pain in their left lower limb.

The client's right dorsalis pedal pulse is absent by doppler.

There is a foul odor near the client's right foot.

There is a necrotic area on the sole of the client's right foot.

Peripheral artery disease is a primary cause of loss of circulation to a limb. Clinical manifestations include a pale or necrotic limb, absent pulse, non-blanchable, and there might be a foul odor present.

A nurse is presenting an in-service to nursing staff on heart failure. Which of the following risk factors for heart disease should the nurse identify as the result of structural changes to the heart?

1. Hypertension

2. Excessive levels of thyroid hormone

3. Anemia

4. Thiamine deficiency

1. Hypertension

A nurse is teaching a group of clients about risk factors for developing peripheral artery disease. Which of the following risk factors should the nurse include in the teaching?

1. Body mass index of 35

2. Rheumatic fever

 3. Chronic pulmonary disease

4. History of venous thrombosis

1. BMI of 35

A nurse is teaching a cient about reducing risk factors for coronary artery disease (CAD). Which of the following client statements indicates to the nurse understanding of the teaching?

1. "I will drink whole milk with my meals."

2. "Coronary artery disease is an unavoidable part of aging."

3. "I will only smoke cigars."

4. "I will follow a moderate exercise regimen."

4. "I will follow a moderate exercise regimen."

A nurse is reviewing diagnostic tests for a client who has peripheral artery disease. Which of the following ankle-brachial index results (ABI) should the nurse understand indicates peripheral artery disease?

1. ABI ratio of 0.9

2. ABI ratio of 0.7

3. ABI ratio of 1.0

4. ABI ratio of 1.2

2. ABI ratio of 0.7

A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

1. "It makes me sad that I can't keep up with my grandchildren."

2. "I need to walk slowly as I lose my balance often.

 3. "I don't go out much because of the pain in my legs."

4. "I have a small-healed area on my spine that is painful."

2. "I need to walk slowly as I lose my balance often.

2. A nurse is caring for a client who has been prescribed a DASH diet. Which of the following is the best protein source for the nurse to instruct the client to eat?

   1. Beef

   2. Pork

   3. Lamb

   4. Turkey

4. Turkey

4. A nurse is providing care for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

   1. Creatine kinase (CK) test

   2. Creatine kinase-myocardial band (CK-MB) test

   3. Troponin T test

   4. Brain natriuretic peptide (BNP) test

3. Troponin T test

A charge nurse is teaching a newly licensed nurse about deep vein thrombosis (DVT). Which of the following should the charge nurse include as risk factors for developing DVTs?

(Select All that Apply.)

Immobility

Fracture

Atrial fibrillation

Anticoagulant therapy

Estrogen therapy

Immobility, fractures, afib, estrogen therapy

A nurse is providing discharge teaching to a client who has been diagnosed with left-sided heart failure and is going home with a prescription for 2 liters of oxygen via nasal cannula. Which of the following instructions should the nurse include in the teaching?

1. Increase fluid intake to prevent constipation. 

2. Ambulate frequently to prevent development of venous ulcers. 

3. Perform foot care to prevent wounds and gangrene.

4. Maintain six feet between oxygen and an open flame.

4. Maintain six feet between oxygen and an open flame.

A nurse is providing discharge teaching to a client who has atrial fibrillation (A-fib) about prevention of complications. Which of the following should the nurse include in the teaching?

1. Avoid taking over-the-counter decongestants.

2. Decrease dietary intake of sodium. 

3. Reduce fluids to 2 liters each day.

4. Refrain from sexual activities.

1. Avoid taking over-the-counter decongestants.

A nurse is caring for a client with peripheral artery disease who has an arterial ulcer. Which of the following best describes the mechanism for developing the clinical problem?

1. Lower extremity compression stockings likely caused the wound to occur.

2. Decreased blood flow to the area can cause the wound and decrease the healing.

3. Increased blood sugar associated with the condition is likely the cause of the wound not healing.

4. Swelling of the lower extremity can create a wound that is difficult to heal.

2. Decreased blood flow to the area can cause the wound and decrease the healing.

A nurse in the emergency department is caring for a client who took three (3) nitroglycerin tablets sublingually for chest pain. The patient reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

1. "A headache indicates tolerance to the medication."

2. "A headache is an expected adverse affect of the medication."

3. "A headache is an indication of an allergy to the medication."

4. "A headache is likely due ot the anxiety about the chest pain."

2. "A headache is an expected adverse affect of the medication."

A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?

1. Pericardiocentesis

2. Synchronized electrical cardioversion

3. Septal myectomy

4. Pericardial window

2. Synchronized electrical cardioversion

A nurse is educating a client who has a chronic illness about a DASH diet. Which of the following meals best fits the DASH diet?

1. Pork sausage and baked beans

2. Hamburger, steak fries, and an orange

3. Enriched cereal in whole milk

4. Turkey sandwich on whole wheat bread, green beans, and banana

4. Turkey sandwich on whole wheat bread, green beans, and banana

A nurse is analyzing a client's electrocardiogram (ECG) strip and identifies the following information: HR 145 bpm, Rhythm regular, P wave indiscernible, and QRS duration 0.06 seconds. Based upon this information, the nurse will interpret the client's rhythm as which of the following?

1. Normal sinus rhythm (NSR)

2. Atrial fibrillation (A-fib)

3. Sinus bradycardia (SB)

4. Supraventricular tachycardia (SVT)

4. Supraventricular tachycardia (SVT)

A nurse is reviewing laboratory results for a client who has heart failure. Which of the following blood tests should the nurse understand will evaluate the severity of heart failure and risk of death?

1. Troponin I

2. B-type natrikuretic peptide (BNP

3. Homocysteine level

4. C-reactive protein (CRP)

2. B-type natrikuretic peptide (BNP

Which client statement is consistent with venous insufficiency?

1. "I wake up during the night because my legs hurt."

2. "I have burning leg pain after I walk two blocks."

3. "I can't ever seem to get my feet warm enough."

4. "I can't get my shoes on at the end of the day."

4. "I can't get my shoes on at the end of the day."

A nurse is caring for a client who is receiving an intravenous (IV) dose of furosemide (Lasix) and morphine sulfate for the treatment of acute heart failure with severe orthopnea. Which clinical finding is the best indicator that the treatment is effective?

1. Patient denies experiencing chest pain or pressure. 

2. Hourly urine output greater than 60 mL.

3. Weight loss of 2 pounds in 24 hours.

4. Reduced orthopnea with the head of the bed at 30 degrees.

4. Reduced orthopnea with the head of the bed at 30 degrees.

A nurse is teaching a group of clients about risk factors for developing atrial flutter. Which of the following clients should the nurse understand is at highest risk for developing atrial flutter?

1. The client who is recovering from a recent illness that caused vomiting and diarrhea.

2. The client whose mother and uncle were diagnosed with this same condition.

3. The client who had a myocardial infarction and required stent placement.

4. The client who is out of work and has been experiencing increased stress.

3. The client who had a myocardial infarction and required stent placement.

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?

1. The heart’s electrical signals are rapid, chaotic, and irregular.

2. The heart’s electrical transmission through the atrioventricular (AV) node is unusually slow.

3. An early electrical signal occurs before the expected sinoatrial (SA) node signal.

4. The SA node sends an electrical signal greater than 100/min.

1. The heart’s electrical signals are rapid, chaotic, and irregular.

A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?

1. Clopidogrel

2. Enoxaparin

3. Alteplase (tPA)

4.  Warfarin

2. Enoxaparin

A nurse is reviewing the electronic medical record of a middle-aged client who was admitted following a stroke. Which of the following findings should the nurse identify as a modifiable risk factor for stroke?

1. Hypertension

2. Client’s age

3. Parent who has cardiovascular disease

4. History of sickle cell disease

1. Hypertension

A nurse is teaching a client who has peripheral arterial disease. Which of the following statements should the nurse include in the teaching to explain peripheral arterial disease?

1. "Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract."

2. "Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood."

3. "Blood flow is altered due to incompetent valves causing increased venous pressure."

4. "Blood flow is altered and causes blood to pool in the legs."

2. "Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood."

While performing an admission assessment on a client, you note vericose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

1. Alteration in activity tolerance.

2. Failure to thrive.

3. Impaired tissue perfusion.

4. Alteration in body image.

3. Impaired tissue perfusion.

A client has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. What should the nurse expect to find during the assessment?

1. Prolonged capillary refill.

2. Swollen, scaley ankles.

3. Dilated superficial veins.

4. Serosanguinous drainage from the ulcer. 

1. Prolonged capillary refill.

A nurse is teaching a cient who has coronary artery disease (CAD) about prevention of progression of the disease. Which of the following lifestyle modifications should the nurse include in the teaching?

1. Cessation of intravenous (IV) drug use.

2. Controlling of hypertension. 

3. Prevention of injury to lower extremities. 

4. Restricting fluid to 2 liter per day.

2. Controlling of hypertension. 

A nurse is preparing to administer medications to a client with peripheral artery disease (PAD). Which of the following medications should the nurse anticipate administering? (Select all that apply.)

(Select All that Apply.)

Captopril

Cilostazol

Pentoxifylline

Verapamil

Colchicine

Cilostazol and pentoxifylline

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include to explain the correlation between changes in the coronary arteries and manifestations that occur?

1. "Coronary arteries become more elastic, causing the arteries to stretch as individuals age and the heart not to receive enough oxygen."

2. "Manifestations occur due to dilation of coronary arteries with increased blood flow, causing increased pressure."

3. "The heart and the coronary arteries weaken, leading to poor perfusion and resulting in angina."

4. "Coronary arteries decrease in diameter, leading to insufficient blood, oxygen, and nutrients reaching the heart muscle."

4. "Coronary arteries decrease in diameter, leading to insufficient blood, oxygen, and nutrients reaching the heart muscle."

A nurse is teaching a client who has a new prescription for hydrochlorothiazide (HTZ) for management of hypertension. Which of the following instructions should the nurse include?

1. "Reduce intake of potassium-rich foods."

2. "Monitor for muscle cramps."

3. "Avoid grapefruit juice."

4. "Take the medication before bedtime."

2. "Monitor for muscle cramps."

A nurse is educating a client about the DASH diet. Which of the following would be the best choice for the dairy requirement?

1. 1 oz of hard cheese

2. 8 oz of skim milk

3. 1 oz of cream cheese

4. 6 oz of cola

2. 8 oz of skim milk

A nurse is assessing a client who has peripheral artery disease. Which of the following findings should the nurse recognize as requiring immediate intervention?

1. Pain, pallor, and paresthesia in the foot

2. Lower extremities edematous with decreased pulses and cool to the touch

3. Murmur auscultated at the left 5^th midclavicular line, slight dyspnea, and lower extremity edema

4. Presence of an open wound near the ankle with serous drainage and pruritus

1. Pain, pallor, and paresthesia in the foot

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

1. Thick, deformed toenails.

2. Dependent rubor.

3. Hair loss.

4. Edema.

4. Edema

The health care provider prescribes an infusion of heparin and daily partial thromboplastic time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should the nurse include in the plan of care?

1. Decrease the infusion rate when the PTT value decreases.

2. Avoid administering intramuscular (IM) injections to prevent localized bleeding. 

3. Obtain a doppler for monitoring bilateral pedal pulses.

4. Have vitamin K available in case reversal of heparin is needed.

2. Avoid administering intramuscular (IM) injections to prevent localized bleeding. 

A nurse is caring for a client who was diagnosed with type 2 diabetes mellitus 2 years ago. The client reports following the recommended diet and exercising four times per week. Which of the following findings indicates that the client's beta cells are restoring normal function?

1. Weight gain of 5 lb

2. Client reports smoking cessation

3. Fasting blood glucose of 140 mg/dL

4. HbA1c = 5.6 %

4. HbA1c = 5.6 %

A nurse is providing education to a client who has type 1 diabetes mellitus and has been experiencing hypoglycemic episodes. Which of the following statements by the nurse is appropriate?

1. "Clients with hypoglycemia cannot participate in religious/cultural fasting."

2. "Increasing exercise can help with hypoglycemia."

3.  "Keeping supplies on hand to treat hypoglycemic episodes is important."

4. "Clients will usually have obvious manifestations of hypoglycemia."

3. "Keeping supplies on hand to treat hypoglycemic episodes is important."

What is not a sign of acute glomerulonephritis? 

1. Bilateral Fine Crackles in Lungs

2. Urine Dark and Cloudy

3. Heart Rate 92/min

4. Temperature of 37.1*C (98.8*F)

4. Temperature of 37.1*C (98.8*F)

You are caring for a client who is postoperative following a thyroidectomy. Which of the following complications do you need to monitor the client for within the first 24 hours of surgery? 

1. Hypoglycemia 

2. Kussmaul Respirations

3. Airway Obstruction

4. Hypercalcemia

3. Airway Obstruction

A nurse is caring for a 20-year-old male patient diagnosed with bacterial meningitis who is receiving gentamicin. Morning lab results include the following: BUN 31 mg/dL, creatinine 1.8mg/dL, and glomerular filtration rate 55 mL/min. Which of the following conditions is likely?

1. A prerenal AKI 

2. A postrenal AKI 

3. CKD

4. An intrarenal AKI

4. An intrarenal AKI

A nurse is caring for a client who reports to the clinic for laboratory tests. The client has an acute kidney injury caused by acute tubular necrosis and asks why their glomerular filtration rate keeps decreasing. Which of the following pathophysiological changes occurring in the kidney should the nurse explain as the cause of decrease?

1. The glomerular filtration rate decreases because inflammatory cells invade the already damaged kidneys.

2. The glomerular filtration rate decreases because there is obstruction leading to the filtration system backing up and eventually shutting the kidneys down.

3. The glomerular filtration rate decreases because there is injury to the renal tubular cells.

4. The glomerular filtration rate decreases because there is a reduction of blood flow to the kidneys.

3. The glomerular filtration rate decreases because there is injury to the renal tubular cells.

Our guest speaker told his story and stated that he had: 

1. Hypothyroidism

2. Cushing's Syndrome

3. DMII

4. Addison's Disease 

4. Addison's Disease 

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients is at the highest risk for developing an acute kidney injury?

1. A pt with HF receiving PO metoprolol 

2. A pt with bacterial meningitis receiving IV vancomycin

3. A pt with uncontrolled afib receiving IV diltiazem

4. A patient admitted for PNA receiving IV cefazolin

2. A pt with bacterial meningitis receiving IV vancomycin

A nurse is providing teaching to a client who has hypothyroidism and has been prescribed levothyroxine. Which of the following medication instructions would the nurse include in the teaching?

1. "Take this medication before a meal or several hours after a meal."

2. "Take this medication during your morning meal."

3. "Take this medication with a full glass of water or fruit juice."

4. "Take this medication with high-protein foods."

1. "Take this medication before a meal or several hours after a meal."

A nurse is caring for a client who has metabolic syndrome. Which of the following should the nurse expect to see in this client?

1. Decreased HbA1c

2. Low T3 levels

3. High HDL cholesterol 

4. Insulin resistance 

4. Insulin resistance 

A nurse is caring for a client who has progressing chronic kidney disease (CKD). Which of the following laboratory results would the nurse expect to find in the client's electronic health record?

1. Urine albumin increasing

2. Proteinuria decreasing, or decreased protein in the urine

3. Creatinine decreasing

4. Glomerular filtration rate (GFR) increasing

1. Urine albumin increasing

A nurse is caring for a patient admitted to the urology unit with reports of shortness of breath and a diagnosis of ckd. Which of the following pathophysiological changes in the renal system led to the diagnosis of ckd?

1.  Fibrosis and destruction of normal kidney structure/function

2. Reduction of blood flow to the kidneys

3. ATN

4. Obstruction leading to backup and kidney shutdown

1.  Fibrosis and destruction of normal kidney structure/function

All of the following are risks of dialysis except: 

1. Peritonitis

2. Bleeding

3. Infection 

4. Vision Changes 

4. Vision Changes 

A nurse is reviewing laboratory results and notes that a client has an elevated thyroid-stimulating hormone (TSH) level. Which of the following assessment findings would the nurse expect?

1. Shakiness, sweating, nausea

2. Fatigue, constipation, weight gain

3. Anxiety, unintended weight loss, palpitations

4. Increased thirst, increased urine output, and weight loss

2. Fatigue, constipation, weight gain

A nurse is completing discharge teaching for a client on home intermittent peritoneal dialysis. Which statement indicates that more teaching is needed?

1. I will follow the prescribed fluid restriction

2. I will call my provider if I feel short of breath

3. I will weigh myself every other day

4. I will follow the prescribed diet 

3. I will weigh myself every other day

A nurse is gathering medical history from a client admitted for pyelonephritis. Which of the following should the nurse expect the client to report when asked about their medical history?

1. The client states that they consume a high calcium diet and have had high calcium in their blood.

2. The client reports that they took a lot of ibuprofen for arthritis for many years.

3. The client reports that they had two urinary tract infections (UTI) in the past 10 months.

4. The client states that they remember their mother saying their grandma had this same genetic disease.

3. The client reports that they had two urinary tract infections (UTI) in the past 10 months.

A nurse is caring for a client who reports increased anxiety and nervousness, heat intolerance, and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH), elevated thyroxine (T4), and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?

1. Tachycardia

2. Slow respiratory rate

3. Decreased body temperature

4. Hypotension

1. Tachycardia

A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?

1. "Your blood sugar is too high after meals."

2. "Your blood sugar is very unstable."

3. "You have many dangerously low blood sugar levels."

4. "Your average blood sugar is  high."

4. "Your average blood sugar is  high."

A nurse in the emergency department is caring for a client who appears shaky, pale, clammy, and is tachycardic. The client states, "I think I'm having an anxiety attack and need some medication." Which of the following is an appropriate action for the nurse to take?

1. Check a fingerstick blood glucose level.

2. Activate the Rapid Response Team.

3. Establish IV access.

4. Administer an anti-anxiety medication.

1. Check a fingerstick blood glucose level.

You are caring for clients at an urgent care clinic. Which of the following clients is most at risk for a thyroid storm?

1. A client who had DKA 

2. A client who has type I DM and accidently took too much insulin

3. A client who has uncontrolled hyperthyroidism

4. A client who has had their thyroid removed

3. A client who has uncontrolled hyperthyroidism