Essential Medical Terms & Definitions for Nursing Students

A client has been receiving normal saline intravenously at 75 ml/hr and is NPO. Which of the following assessment findings indicates a need to contact the health care provider immediately?

A) weight gain of 2 pounds above the preoperative weight

B) an oral temperature of 100.1° F with bibasilar lung crackles

C) gradually decreasing level of consciousness (LOC)

D) serum sodium level of 138 mEg/L (138 mmol/L)

C) gradually decreasing level of consciousness (LOC)

The nurse obtains all of the following assessment data about a patient with a fluid-volume deficit caused by a massive burn injury. The patient has IV NSS running at 50 ml/hr. Which of the following assessment data will be of greatest concern?

a. Oral fluid intake is 100 ml for the last 8 hours with urine output of 320ml

b. The blood pressure change from 110/60 to 80/40 mm Hg

c. Urine output is 30 ml over the last hour with at total of 200 ml

d. There is prolonged skin tenting over the sternum and dry lips

b. The blood pressure change from 110/60 to 80/40 mm Hg

When evaluating the response to treatment for a client admitted for nausea and vomiting with fluid imbalance, a prudent nursing action would be to:

check skin turgor

assess presence of edema

consult the opinion of the charge nurse

obtain further data about the patient

obtain further data about the patient

A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. Symptoms the nurse teaches the patient to report include:

confusion and personality changes

anxiety and muscle twitching

abdominal cramping and diarrhea

fatigue and muscle weakness

fatigue and muscle weakness

A client in a medical surgical unit is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as:

frequent loose stools

facial muscle spasms

sinus bradycardia

personality changes

sinus bradycardia

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a client as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective?

a. "I will have apple juice instead of orange juice during breakfast"

b. *I will drink an extra amount of water every day to prevent dehydration."

c. "I will sure l have my daily serving of fresh lettuce salad every meal"

d. "I can have cottage cheese with my breakfast as long as it is only the size of one portion."

a. "I will have apple juice instead of orange juice during breakfast*

When assessing a client with increased extracellular fluid (ECF) osmolality, the nurse prioritizes assessing for:

capillary refill and skin temperature

skin turgor and tenting

presence of confusion

heart sounds and ECG reading

presence of confusion

While assigned in a medical surgical unit, a newly hired RN recalls that there is a clinical manifestation that supports the concept that filtration is directly related to hydrostatic pressure. Which of these clinical manifestations is the RN recalling?

capillary refill is faster in fingers than in toes

central venous pressure is lowest in the right atrium at 45 degree head elevation

pitting edema is usually detected first in lower extremities while upright

systolic blood pressure is higher than diastolic blood pressure in the left arm

pitting edema is usually detected first in lower extremities while upright

The home health nurse notes that an elderly client has a low serum albumin level. The nurse will plan to assess for:

amount of food intake during breakfast

presence of tactile fremitus at the posterior chest

increase in circumference of the lower extremities

color and temperature of the skin

increase in circumference of the lower extremities

A client is receiving a 3% NaCI solution for correction of hyponatremia. Prior to the administration of the solution, the nurse would like to obtain baseline assessment findings. Which is the most important for the nurse to obtain?

peripheral pulses

urinary output

peripheral edema

lung sounds

lung sounds

The nurse is assigned to take care of a client with decreased albumin in a recent laboratory report. What effect would an infusion of 200 mL of albumin have on this client?

may lead to edema formation

may increase blood pressure

may cause hypoglycemia

may decrease renal output

may increase blood pressure

A 70 year-old client inquires why she has experienced difficulty breathing since she was diagnosed with heart failure. The best rationale the nurse can make is ...

"Fluid will back up to the lungs if the heart is unable to contract effectively"

"There is an increased blood volume in pulmonary vessels in older population"

"Most clients with heart congestion also have pulmonary infection"

"There is increased blood volume in the pulmonary vessels in the older population"

"The lungs are trying to compensate for the lack of heart strength by contracting."

"Fluid will back up to the lungs if the heart is unable to contract effectively"

Which statement made by a 74-year-old client should alert the nurse to the possibility of fluid and electrolyte imbalances?

"My skin is always so dry, especially here in the Southwest."

"I often use a glycerin suppository for constipation."

"I don't drink any liquids at all after 5 PM so I don't have to get up at night"

"In addition to coffee. I drink at least one glass of water with each meal"

"I don't drink any liquids at all after 5 PM so I don't have to get up at night"

A medical surgical nurse is giving a health lesson to a client with CHF. This client has an order for a cardiac diet. Which of these food items should the client choose to indicate the correct understanding of the sodium content of food?

A chicken breast and celery salad with 1⁄2 a cup of steamed carrots

canned tuna salad with fresh tomatoes and low fat milk

A ham and cheddar cheese sandwich on two slices of whole wheat bread

Toasted bread and white cheese and whole milk

A chicken breast and celery salad with 1⁄2 a cup of steamed carrots

A client is receiving 150 mL of 3.0% saline intravenously over the next 2 hours. Which response should the nurse expect to indicate that the goal to improve circulatory volume was objectively met?

blood pressure will increase from 90/60 to 110-120/80-90

leg circumference will increase 3-5 cm in measurement

urine concentration of potassium will be elevated

hematocrit and hemoglobin levels will increase within normal limits

blood pressure will increase from 90/60 to 110-120/80-90

Which assessment finding obtained while taking the history of an older client should alert the nurse to the possibility of fluid or electrolyte imbalance?

"I am often cold and need to wear a sweater, even when other people are warm."

"I seem to urinate more when I drink coffee"

"In the summer, I feel thirsty more often."

"My rings are tighter this week."

"My rings are tighter this week."

A nurse attended an in-service class about assessment of fluid electrolyte imbalances. This nurse wants to demonstrate an understanding of the concepts when prioritizing their clients who are at the greatest risk of dehydration. Which client is at greatest risk for dehydration?

a. 25 year old client with immobility

b. 65 year old client receiving D5NSS IV fluid

c. 35 year old client receiving D5LR IV fluid

d. 70 year old client with cognitive impairment

d. 70 year old client with cognitive impairment

Which is the most important question the nurse should ask a client who has been diagnosed with fluid volume deficit when identifying a possible cause of the fluid imbalance?

"How regular is your bowel movement?"

"How many full meals do you eat a day?"

"Do you take any medication that will make you pee a lot?"

"What are the over the counter medications you take?"

"Do you take any medication that will make you pee a lot?"

Based on the data presented in the situation below, the nurse should:Situation: A nurse is looking up various IV fluids available as floor stock for intravenous therapy. Which doctor's order does the nurse anticipate administering to a client with generalized weakness? (Questions 19-20 pertain to this situation).

Dextrose 5% in water

Dextrose 10% in water

0.45% sodium chloride

0.9% sodium chloride

A) do nothing until enough data is available.

B) call the pharmacist to ask which one to administer.

C) ask the charge nurse which IV fluid is best per protocol.

D) administer the NSS because it's the safest

A) do nothing until enough data is available.

Which doctor's order does the nurse anticipate administering to a client with generalized weakness? Refer to the data in question 19.

A) Review the latest laboratory results available for the client

B) Read the patient's history and admission data found in the chart

C) Verify doctor's progress notes and read all medications ordered

D) Perform all tasks above to understand more about the client

D) Perform all tasks above to understand more about the client

After reading the data on the situation below, which intravenous solution should the nurse be prepared to administer?

Situation: The nurse reviewed the patient chart with the following information:

History and Physical: Diagnosed with Diabetes Mellitus 5 years ago and has been very compliant with the prescribed regimen. She came home last night from a trip and started having diarrhea with nausea and vomiting. She reported to have 3 episodes of watery stools and vomited greenish fluid 4 times before coming to the hospital. Skin is dry with poor skin turgor, heart rate is 110 / beats a min, respiration rate is 28 breaths / min, urine looks dark.

Laboratory Results: Serum Glucose = 250 mg/dl, serum sodium = 147 mEq/L, Hematocrit 55 %.

Doctors Progress Notes: Patient needs to be rehydrated using IV fluid and encouraged oral intake of fluids. Blood sugar to be monitored with sliding scale coverage using regular insulin. Will obtain stool specimen x 3. Please call for result - Dr. Smith M.D.

(Questions 21-22 pertain to this situation)

A) Dextrose 5% in water

B) Dextrose 10% in water

C) D5 0. 45% sodium chloride

D) D5 0.9% sodium chloride

C) D5 0. 45% sodium chloride

Based on the scenario above, which IV solution would prompt the nurse to ask the prescriber for its appropriateness if ordered?

a. Dextrose 5% 3% Na CI

b. Plain LR (lactated ringer)

c. D5LR (lactated ringer)

d. D5 0. 45% sodium chloride

a. Dextrose 5% 3% Na CI

While giving an orientation to a newly hired nurse in the unit, the senior nurse warned about the risk of giving D5W to a patient with potential increase in ICP. The junior nurse asked why dextrose 5% in water is considered to be a hypotonic solution rather than an isotonic solution. The best response the senior nurse will make were based on the following data:

History : Client is non-diabetic

Laboratory Result: Serum osmolarity : 272 mOsm/L

A) An isotonic solution must have an osmolarity greater than 300 mOsm/L.

B) Glucose is not an electrolyte and does not completely dissociate in water.

C) Glucose is immediately metabolized upon administration, leaving pure water in circulation.

D) Intravenous glucose immediately draws water from the interstitial and intracellular spaces, resulting in hemodilution.

C) Glucose is immediately metabolized upon administration, leaving pure water in circulation.

What is the most likely contributing factor for a laboratory result of a 35 year-old woman's iron level being 42 mg/dl?

A) 60 packs per year smoking history

B) Heavy menses for the past 6 months

C) Diet chronically low in vegetables and high in meats and fats

D) Presence of chronic allergies, for which she takes diphenhydramine (Benadryl) daily

B) Heavy menses for the past 6 months

While trying to prioritize the care among the patients assigned to a nurse's care, which client is most at risk for anemia due to a nutritional deficiency of iron?

a. 48-year-old man who had a myocardial infarction 5 years ago

b. 62-year-old woman with diabetes mellitus who is on insulin therapy

c. 55-year-old man with chronic alcoholism

d. 27-year-old woman taking oral contraceptives

c. 55-year-old man with chronic alcoholism

When a person's hemoglobin is deficient in iron, which assessment finding is expected?

Cherry red mucous membranes

Increased respiratory rate

Slow capillary refill

Bradycardia

Increased respiratory rate

A client with a thalassemia trait has a sister with the disease, and a husband with neither the disease nor the trait. She asks her nurse what her children's chances are of having thalassemia. What is the nurse's best response?

"Because you have the trait and your husband does not, only your daughters can have thalassemia"

"Because you have the trait and your husband does not, none of your children will have the disease, but each child will have a 50% risk for having the trait"

"Because your sister actually has thalassemia, the risk for your children having the disease is 50% with each pregnancy."

"None of your children with have the trait or the disease, and would show for the next 3-5 generations of children at all."

"Because you have the trait and your husband does not, none of your children will have the disease, but each child will have a 50% risk for having the trait"

A client has anemia and all of the following clinical manifestations. Which manifestation indicates to the nurse that anemia is a long-standing problem?

Headache

Clubbed fingers

Circumoral pallor

Orthostatic hypotension

Clubbed fingers

Which menu selection made by a client with vitamin B12 deficiency anemia demonstrates an adequate understanding of dietary management for this problem?

Fried liver and onions, orange juice, spinach salad

Baked chicken breast, boiled carrots, glass of white wine

Eggplant Parmesan, cream-style cottage cheese, iced tea

Whole-grain pasta with cheese, apple sauce, glass of red wine

Fried liver and onions, orange juice, spinach salad

A client with chronic gastritis is experiencing "tingling" in his hands. The nurse realizes that this client might be demonstrating signs of:

Iron deficiency anemia

Acute blood loss anemia

Folic acid deficiency anemia

Vitamin B12 deficiency anemia

Vitamin B12 deficiency anemia

A nurse is providing dietary instructions to a vegetarian client with iron deficiency anemia. Which of the following should be included in these instructions?

Consider animal source of protein in the diet

Ensure adequate sources of vitamin C when consuming non animal-based protein

Drink at least 12 glasses of water a day

Avoid exercise at least 30 minutes after completing a meal or snack

Ensure adequate sources of vitamin C when consuming non animal-based protein

When developing a health teaching plan for a 65-year-old patient with all of these risk factors for coronary artery disease (CAD). the nurse will focus the plan on the:

family history of heart disease

increased risk associated with the patient's ethnicity

high incidence of cardiovascular disease in older people

low activity level the patient reports

low activity level the patient reports

Which of these nursing interventions will be the most effective in assisting a patient with CAD to make appropriate dietary changes?

Assist the patient in modifying their favorite high-fat recipes by arranging a meeting with the dietician.

Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

Instruct the patient that a diet containing fat and added sodium will be countered if the patient will engage in at least some kind of activity.

Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.

Assist the patient in modifying their favorite high-fat recipes by arranging a meeting with the dietician.

A nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction?

The pain worsens when the patient raises their arms

The chest pain increases with deep breathing and when coughing

The pain is relieved in less than 3 min. after the patient takes nitroglycerin

The pain has persisted longer than 30 minutes with no relief

The pain has persisted longer than 30 minutes with no relief

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?

The patient rates the pressure pain at a level 6 to 8 (0-10 scale)

The patient states that the pain "wakes me up at night when I am sleeping"

The patient indicates that the pain is resolved after taking one sublingual nitroglycerin tablet

The patient says that the frequency of the pain has increased over the last few weeks

The patient indicates that the pain is resolved after taking one sublingual nitroglycerin tablet

A patient who has had severe chest pain for the last 4 hours is admitted with a diagnosis of possible MI. Several laboratory tests were ordered. Which of these laboratory tests should the nurse monitor to help determine whether the patient has had an MI?

Troponin levels

C-reactive protein

High-density lipoprotein (HDL)

Cholesterol

Homocysteine

Troponin levels

A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of heparin?

Heparin will dissolve the clot that is blocking blood flow to the heart

Coronary artery plaque size and adherence are decreased with heparin

Heparin will prevent the development of clots in the coronary arteries

Platelet aggregation is enhanced by IV heparin infusion

Heparin will prevent the development of clots in the coronary arteries

A nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for:

relief of chest discomfort

a decreased heart rate

an increase in BP

fewer cardiac dysrhythmias

relief of chest discomfort

After a nurse teaches a patient with chronic stable angina about how to use the prescribed nitrates, which statement by the patient indicates that the teaching has been effective?

"I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

"I will put on the nitroglycerin patch as soon as I develop any chest pain."

"I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin."

"I will keep the nitroglycerin in my kitchen window where I can find it quickly"

"I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

Two days after having an MI, a patient tells the nurse, "This heart attack made me feel invalid. I won't be able to do anything now." The most appropriate nursing diagnosis is:

ineffective coping related to depression and anxiety.

situational low self-esteem related to perceived role changes.

impaired adjustment related to unwillingness to alter lifestyle.

ineffective health maintenance related to lack of knowledge.

situational low self-esteem related to perceived role changes.

41. A nurse obtains the following data when caring for a patient who experienced an MI 2 days previously. Which information is most important to report to the health care provider?

a. The oral temperature is 100.8° F (38.2°C) and skin feel warm to touch

b. The lungs have bubbling sound audible upon auscultation

c. The patient denies ever having a heart attack saying, This is not happening to me"

d. The white blood cell count (WBC) is 12,000/ml

b. The lungs have bubbling sound audible upon auscultation

A few days after experiencing an MI, the patient states, "This is not happening to me at all. As soon as I get out of here, I'm going for my vacation as planned." Which nursing intervention is appropriate to include in the nursing care plan?

Have the family members encourage the patient to continue planning for the vacation

Allow expressions of denial as a coping mechanism until the patient begins asking questions

about the MI

Implement reality orientation by reminding the patient several times a day about the MI

Allow expressions of denial as a coping mechanism until the patient begins asking questions about the MI

After having an MI, a 62-year-old patient tells the nurse, "I guess having sex again will be too hard on my heart." The nurse's best response is:

"Sexual intercourse may be too strenuous on your heart, but closeness and intimacy can be maintained with holding and cuddling."

"You should discuss your questions about your sexual activity with your doctor because the activity it requires is a medical concern."

"Sexual activity can be resumed whenever you feel like you are ready."

"Most sexual response is emotional rather than physical."

"Sexual activity can be gradually resumed like other activities. A good comparison of energy expenditure is climbing two flights of stairs."

"Sexual activity can be gradually resumed like other activities. A good comparison of energy expenditure is climbing two flights of stairs."

A nurse has just received a change-of-shift report about these four patients. Which patient should the nurse assess first?

A 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain

A 45-year-old who had an MI 4 days ago and is anxious about the planned discharge

A 51-year-old who has just returned to the unit after an invasive coronary arteriogram and coronary stent placement

A 51-year-old who has just returned to the unit after an invasive coronary arteriogram and coronary stent placement

A patient with a history of angina and hypertension who developed chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations of 28. The most important assessment for the nurse to accomplish next is to:

auscultate the lung sounds

assess the orientation

check the capillary refill

palpate the abdomen

auscultate the lung sounds

A patient with a history of MI has developed chronic heart failure and has been following a low-sodium diet. The patient tells the nurse at the clinic about a 10-pound weight gain in the last 3 days. The nurse's first action will be to:

ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet

instruct the patient how to start a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods

assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring

assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring

A nurse is caring for a patient receiving Aldactone (spironolactone) 25 mg for left sided CHF after having an MI. When evaluating the patient's response to the medication, the best indicator that the treatment has been effective is:

a. weight loss of 5 pounds overnight

b. improvement in hourly urinary output

c. reduction in systolic BP when standing

d. decreased dyspnea when supine using 1 pillow

d. decreased dyspnea when supine using 1 pillow

When a nurse is developing a teaching plan to prevent the development of heart failure in a patient with hypertension, the information that is most likely to improve compliance with antihypertensive therapy is:

hypertensive crisis may lead to development of acute cardiac hypertrophy in some patients

hypertension eventually will lead to heart failure by overworking the heart muscle

high BP increases risk for rheumatic heart disease

high systemic pressure precipitates papillary muscle rupture

hypertension eventually will lead to heart failure by overworking the heart muscle

A client with CHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to:

administer NV/ morphine sulfate 2 mg.

give /V diazepam (Valium) 2 5 mg.

increase dopamine (lutropin) infusion by 2 mcg/kg/min

increase nitroglycerin (Tridil) infusion by 5 mcg min.

administer NV/ morphine sulfate 2 mg.

A client was admitted to the ER. During the history taking, the client tells the nurse, "I need at least 3-4 pillows because I feel like I was suffocating! The nurses, suspect that the patient developed:

a. panic attack

b. congestive heart failure

c. angina pectoris

d. acute myocardial infarction

b. congestive heart failure

A client with CHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of these medications have been ordered for the patient. The first action by the nurse will be to:

administer IV morphine sulfate 2 mg

give IV diazepam (Valium) 2.5 mg

increase dopamine (Intropin) infusion by 2 mcg/kg/min

increase nitroglycerin (Tridil) infusion by 5 mcg/min

administer IV morphine sulfate 2 mg

A nurse working in the heart failure clinic will know that health education given to a 74-year-old client with newly diagnosed heart failure has been effective when the patient:

says that the nitroglycerin patch can be used to help the heart not overwork calls when the patient's weight

increases from 124 to 130 pounds in 2 days.

tells the home care purse that furosemide (Lasid is taken daily in the morning)

makes an appointment to see the doctor at feast once yearly

increases from 124 to 130 pounds in 2 days.

A client has been complaining of chest pain upon ambulation. After walking about 300 ft, he states, "I should have taken my sublingual nitro before I have to walk. " What would be the best action for the nurse to do?

a. administering sedatives to promote rest and decrease myocardial oxygen

b. allow the client to walk back hurriedly to head and position client in a high- Fowlers

c. stop ambulation and administering oxygen per mask or nasal cannula per doctor's order

d. encouraging leg exercises to improve venous return while on a chair

c. stop ambulation and administering oxygen per mask or nasal cannula per doctor's order

When teaching a patient with heart failure about a 2000-mg sodium diet, the nurse explains that high sodium foods which needs to be restricted include:

eggs and other high-cholesterol foods

frozen fruits and vegetables

fresh or frozen vegetables

bread, milk, yogurt, and other dairy products

bread, milk, yogurt, and other dairy products

When a nurse discusses foods high in iron with a patient who has iron-deficiency anemia, the patient tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. An appropriate goal for the patient would be to increase dietary intake of:

eggs and fish

nuts and cornmeal

milk and dairy products

legumes and whole-grain cereals

legumes and whole-grain cereals

A 52-year-old patient has pernicious anemia with long-standing weakness and paresthesia of the feet and hands. Which of these statements by the patient indicates to the nurse that the patient understands the expected outcomes of their therapeutic regimen?

"I will need to have cobalamin injections regularly for the rest of my Life"

"I will increase sources of cobalamin. such as muscle meats and fiver, in my diet"

"The feeling in my hands and feet will return when my hemoglobin level returns to normal"

"I should plan for only part-time employment because of the chronic fatigue that pernicious

anemia causes"

"I will need to have cobalamin injections regularly for the rest of my Life"

During the admission assessment of a patient who has an Hb of 6.6 g/dI (66 8/L and jaundice of the sclera, the nurse suspects a(n):

aplastic anemia

hemolytic anemia

microcytic anemia

megaloblastic anemia

hemolytic anemia

A physician orders a transfusion with packed red blood cells for a patient who has severe anemia resulting from a bleeding peptic ulcer. The most important action by the nurse to prevent hematologic and cardiac complication related to blood transfusion is to:

verify and document patient identification

check and verify the expiration date of the blood

administer the blood at a rate of no more than 2 ml/min

stay with the patient during the first 15 minutes of the transfusion

check and verify the expiration date of the blood

A patient is admitted to the hospital for a splenectomy (for treatment of Thalassemia Major). The patient asks the nurse about the benefits of the splenectomy. The nurse explains that the expected effect of the splenectomy is:

Reduced destruction of RBC by the spleen cell

Promotion of the sequestering of RBC by the liver

Increased production of RBC by the Bone Marrow

Increased RBC production to compensate for the loss of blood

Reduced destruction of RBC by the spleen cell

To assess for jugular vein distention in a patient with congestive heart failure, the nurse should:

ask the patient to perform the Valsalva maneuver while lying in a supine position.

palpate the jugular veins, comparing the volume and pressure of one with those of the other.

measure in centimeters the distance the jugular veins are distended outward from the neck.

observe the vertical distention of the veins as the patient is gradually elevated to an upright

position.

observe the vertical distention of the veins as the patient is gradually elevated to an upright

position.

The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis. Which question by the nurse is most appropriate?

"Do you have a history of a heart attacks"

"Have you any recent immunizations?"

"Have you been to the dentist lately?"

"Is there a family history of endocarditis?"

"Have you been to the dentist lately?"

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with mitral stenosis based on the assessment finding of:

petechiae of the buccal mucosa and conjunctiva.

fever, chills, and diaphoresis.

urine output less than 30 ml/hr.

an increase in pulse rate of 15 beats/min with activity.

urine output less than 30 ml/hr.

Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the health care provider?

A loud systolic murmur is audible along the right sternal border.

The patient complains of chest pain associated with ambulation.

The point of maximum impulse (PMI) is at the left midclavicular line just below the nipple line.

A loud S2 at the 2nd intercostal space, rightternal border.

The patient complains of chest pain associated with ambulation.

When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for:

murmur and syncope.

dyspnea and hemoptysis.

JD and peripheral edema.

hypotension and paroxysmal nocturnal dyspnea.

dyspnea and hemoptysis.

While caring for a client with Mitral Valve Prolapse with mild valvular reabsorption, the nurse determines that discharge teaching has been effective when the patient tells the nurse she will:

Discuss the diagnosis of mitral valve prolapse with the dentist prior to any dental works.

When caring for a patient with mitral valve stenosis, it is most important the the nurse assess for:

Presence of murmur at the PMI

Peripheral Edema

Right Upper Quadrant Tenderness

Complaints of shortness of breath

Complaints of shortness of breath

While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate intervention by the nurse is to:

a. promote rest and decrease myocardial oxygen demand.

b. educate the patient about the need for anticoagulant therapy.

c. teach the patient to use nitroglycerin patch for chest pain.

d. elevate the head of the bed 60 degrees to decrease venous return.

a. promote rest and decrease myocardial oxygen demand.

When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors?

Male gender

Marfan syndrome

Abdominal trauma history

Uncontrolled hypertension

Uncontrolled hypertension

Which nursing action in the care plan for a patient who had an open repair of an abdominal aortic aneurysm 3 days previously is appropriate for the nurse to delegate to experienced nursing assistive personnel (NAP)?

Check the lower extremity strength and movement.

Monitor the quality and presence of the pedal pulses.

Teach the patient the signs of possible wound infection.

Help the patient to use a pillow to splint while coughing.

Help the patient to use a pillow to splint while coughing.

A recently admitted patient has a small-cell carcinoma of the lung, which is causing an increase of antidiuretic hormone secretions. The nurse will monitor carefully for:

decreased serum sodium level.

rapid and unexpected weight loss.

increased total urinary output.

elevation of serum hematocrit.

decreased serum sodium level.

A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as:

a. frequent loose stools

b. facial muscle spasms

c. personality changes

d. generalized weakness

d. generalized weakness

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia?

Cornmeal muffin and orange juice

Strawberry and banana fruit plate

Omelet and whole wheat toast

Cantaloupe and cottage cheese

Omelet and whole wheat toast

A client is seen in the clinic complaining of fatigue with increasing dyspnea only when swimming with a recent diagnosis of Liver impairment. The client also complained of black tarry stools for a while now. Labs drawn indicate low hemoglobin, low hematocrit, and low red blood cell count. The nurse knows that this most likely indicates which condition:

a. Covert prolonged bleeding

b. Increase in White Blood Cell count

c. Increased formation of thromboses in deep veins

d. Elevated blood pressure from hypercellularity

a. Covert prolonged bleeding

What effect would an infusion of 200 mL of albumin have on a healthy client's plasma osmotic and hydrostatic pressures?

Decreased osmotic pressure, decreased hydrostatic pressure.

Decreased osmotic pressure, increased hydrostatic pressure.

Increased osmotic pressure, increased hydrostatic pressure.

Increased osmotic pressure, decreased hydrostatic pressure.

Increased osmotic pressure, increased hydrostatic pressure.

During the admission assessment of a patient with hemolytic anemia, the nurse notes jaundice of the sclerae. The nurse will plan to check the laboratory results for:

the gastric analysis testing

the Schilling test

the bilirubin level

the stool occult blood test

the bilirubin level

After the nurse has finished teaching a patient about taking oral ferrous sulfate, which patient statement indicates that additional instruction is needed?

"I will call the doctor if my stools start to turn black."

"I should increase my fluid and fiber intake while I am taking the iron tablets."

"I will take a stool softener if I feel constipated occasionally."

"I should take the iron with orange juice about an hour before eating."

"I will call the doctor if my stools start to turn black."

The client's serum sodium level is 128 mEq/L and serum potassium level is 2.8 mEq/L. Which hormonal problem is most likely to have caused this clinical situation?

Increased ADH secretion

Decreased aldosterone secretion

Decreased ADH secretion

Increased aldosterone secretion

Increased ADH secretion

A recently admitted patient got diagnosed with small cell carcinoma of the lung. The tumor is causing an inappropriate increase of antidiuretic hormone release. The nurse will monitor carefully for:

increased total urinary output

rapid and unexpected weight loss

elevation of serum hematocrit

decreased serum sodium level

decreased serum sodium level

When caring for a patient with a chronic iron deficiency anemia, the nurse will assess for:

pink-tinged sclera

shiny, smooth tongue

gum bleeding and tenderness

hypersensitivity of the extremities

shiny, smooth tongue

A client is admitted to the hospital with iron deficiency anemia. This client is resting in bed and complains of shortness of breath, palpitations, and a sore tongue. After completing all necessary focused assessments, what is the priority nursing action for this client?

Administer supplemental oxygen as ordered.

Administer pain medication as ordered.

Notify the physician of abnormal findings.

Administer oral iron supplementation as ordered.

Administer supplemental oxygen as ordered.

A patient with a tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. The nurse's first action should be to:

a. attempt to reinsert the tracheostomy tube guided with an obturator.

b. position the patient in an upright position with the neck extended.

c. assess the patient's oxygen saturation and call the health care provider.

d. ventilate the patient with a manual bag mask until the health care provider arrives.

a. attempt to reinsert the tracheostomy tube guided with an obturator.

While auscultating the breath sounds of a client with suspected pneumonia you hear harsh, hollow sounds over the trachea. What is your best action?

Document the finding as the only action

Notify the physician immediately

Ask the client to cough and spit out any collected mucus

request an order for MRI ASAP from the provider.

Document the finding as the only action

In analyzing a client's ECG tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation?

a. Ventricular depolarization is being initiated at a site different from atrial depolarization.

b. One of the chest leads is not making sufficient contact with the skin.

c. The client is in ventricular tachycardia

d. The client has hyperalma

a. Ventricular depolarization is being initiated at a site different from atrial depolarization.

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to:

a. suction the patient's mouth and trachea before deflation of the cuff.

b. measure the amount of air removed from the cuff during deflation

c. deflate the cuff during any phase of the respiratory cycle

d. remove the inner cannula of the tracheostomy tube before deflation.

a. suction the patient's mouth and trachea before deflation of the cuff.

When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will:

use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10

print a 1-minute ECG strip and count the number of QRS complexes

count the number of large squares in the R- interval and divide by 300.

calculate the number of small squares between one ORS complex and the next and divide into

1500

use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10

A client's cardiac status is being observed by telemetry monitoring. A nurse observes a P wave that is distorted rather than the smooth rounded single bump in shape in lead I. What conclusion can the nurse make from this?

The P wave is originating from an ectopic focus in the atria.

The P wave is firing twice from the sinoatrial (SA) node.

There is no real P wave.

The P wave is normal.

The P wave is originating from an ectopic focus in the atria.

The client who has experienced blunt trauma to the chest is at risk for developing a hemothorax. Which would the nurse expect to find in a client with a hemothorax?

a. Thick tenacious sputum

b. Muffled bilateral tactile fremitus

c. Percussion dullness on affected side

d. Hypertympanic sound on affected side

c. Percussion dullness on affected side

Sinus bradycardia (rate 55 beats per minute) is identified in a sleeping patient on telemetry. looking at the ECG tracing you know it is a sinus bradycardia because:

a. P wave precedes every R wave and there are 5 R's in a six second strip.

b. P wave precedes every R wave and there are less than 60 "R"'s in the ECG strip that is

available at the moment

c. There are 55 P waves noted before every "R" wave obtained in the strip

d. There are about less than 60 "p" waves noted paired with every "R" wave observed in a 6-inch

length of ECG strip obtained

a. P wave precedes every R wave and there are 5 R's in a six second strip.

When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient?

Supine with the head of the bed elevated 45 degrees

In the Trendelenburg position with both arms extended

On the left side with the right arm extended above the head

Sitting upright with the arms supported on an over bed table

Sitting upright with the arms supported on an over bed table

A young man is admitted to the emergency department with a stab wound to the right chest. He has moderate bleeding from the site, and his vital signs show symptoms of shock. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should:

position the patient on his injured side.

administer high-flow oxygen using a non-rebreathing mask.

cover the Sucking chest wound with a petrolatum gauze dressing.

apply a nonporous dressing taped on three sides to the chest wound.

apply a nonporous dressing taped on three sides to the chest wound.