fashion 2

Case Study: At the end of the day shift, the nurse is checking the chest drainage system to determine the amount of drainage during their shift of care. The last mark made by the nurse on the previous shift is at the 725 mL marking. The level of fluid in the drainage collection chamber is now at the 850 mL marking. The nurse uses a marker to mark the current level and indicates the time and date of the measurement. How much drainage does the nurse document on the patient's intake and output record for the shift?

a. 125 mL.

b. 725 mlL

c. 850 mL

d. 1.575 ml

a. 125 mL.

Case Study (same as previous question): Based upon the findings from the above question, what is the best subsequent action from the nurse?

a. Document the findings.

b. Notify the physician immediately.

c. Recheck the patient's CBC from this morning

d. Prepare the patient for discontinuation of the chest tube.

a. Document the findings.

The healthcare provider inserts a chest tube in a patient with a hemo-pneumothorax. When monitoring the pt a couple hours after the chest tube placement, the nurse will be most concerned about:

a. a some air leak in the water-seal chamber, 02 sat at 90%

b. 700 mL of blood in the collection chamber. BP 90/60

c. complaint of pain with each deep inspiration. Respiratory rate of 22 breaths /min

d. mild subcutaneous emphysema at the insertion site. radial pulse rate at 89/min

b. 700 mL of blood in the collection chamber. BP 90/60

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to:

a. document the presence of a large air leak.

b. obtain and attach a new collection device.

c. notify the surgeon of a possible pneumothorax.

d. take no further action with the collection device.

d. take no further action with the collection device.

A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take?

a. Position the patient so that the right chest is dependent.

b. Keep the head of the patient's bed at no more than 30 degrees elevation.

c. Tape a nonporous dressing on three sides over the chest wound.

d. Cover the sucking chest wound firmly with an occlusive dressing.

c. Tape a nonporous dressing on three sides over the chest wound.

Which of the following findings would suggest pneumothorax in a trauma victim?

a. Pronounced rhonchi.

b. Inspiratory wheezing.

c. Dullness on percussion.

d. Absent breath sounds.

d. Absent breath sounds.

Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider?

a. BP is 150/90 mm Hg.

b. Oxygen saturation is 86%

c. Pain level is 5/10 with a deep breath.

d. Respiratory rate is 24 when ring flat

b. Oxygen saturation is 86%

A patient is undergoing a thoracentesis. The nurse should monitor the patient during and immediately after the procedure for which of the following EXCEPT?

a. Infection.

b. Pneumothorax.

c. Pulmonary edema.

d. Tension pneumothorax.

a. Infection.

Following assessment of a patient with pulmonary TB, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?

a. Resting pulse oximetry (Sp02) of 85%

b. Respiratory rate of 28

c. Large amounts of greenish sputum

d. Weak, nonproductive cough effort

d. Weak, nonproductive cough effort

During assessment of the chest in a patient with lung consolidation, the nurse would expect to find:

a. hyper-resonance on percussion.

b. increased vocal fremitus on palpation.

c. fine crackles in all lobes on auscultation.

d. asymmetric chest expansion on inspection.

b. increased vocal fremitus on palpation.

A 60-year-old homeless man has a cough, late-afternoon fever, and night sweats. The patient's response to a purified protein derivative (PPD) skin test is 12 mm. The nurse recognizes that this response indicates that the patient:

a. has a tubercular infection unless proven otherwise.

b. has clinically active chronic pulmonary disease.

c. has a history of being exposed to microorganisms.

d. has pulmonary disease and abnormal chest x-ray is needed to confirm.

a. has a tubercular infection unless proven otherwise.

A patient has just been started on chemotherapy for TB. The nurse informs the patient that the disease can be transmitted to others until:

a. The night sweats, fever and coughing have subsided.

b. three smears for acid-fast bacilli are negative.

c. The medications have been taken for 6 months.

d. sputum is negative of overt blood.

b. three smears for acid-fast bacilli are negative.

A patient diagnosed with TB is started on initial drug therapy. The nurse plans to teach the patient about the uses and effects of ...

a. isoniazid, rifampin, ethambutol, and amoxicillin.

b. isoniazid, pyrazinamide, and streptomycin.

c. isoniazid, rifampin, pyrazinamide, and ethambutol.

d. para-aminosalicylic acid, ethambutol rifampin, and pyrazinamide.

c. isoniazid, rifampin, pyrazinamide, and ethambutol.

To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to:

a. splint the chest when coughing.

b. maintain fluid restrictions.

c. wear the nasal oxygen cannula.

d. try the pursed-lip breathing technique.

a. splint the chest when coughing.

A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C) , a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is:

a. hyperthermia related to infectious illness.

b. ineffective airway clearance related to thick secretions.

c. impaired transfer ability related to weakness.

d. impaired gas exchange related to respiratory congestion.

d. impaired gas exchange related to respiratory congestion.

The nurse identifies the nursing diagnosis of activity intolerance for a patient with pneumonia. What collected data supports this nursing diagnosis?

a. use of accessory muscles for breathing during ambulation.

b. fear of suffocation related to oxygen mask use.

c. anxiety and restlessness and asking the nurse to call for the priest.

d. dyspnea and respiratory rate of 14 min when upset with a family member.

a. use of accessory muscles for breathing during ambulation.

A patient with TB tells the nurse he wishes he would die because he is so disabled with his disease that he just cannot do anything for himself. Based on this information, the nurse identifies the nursing diagnosis of:

a. hopelessness related to long-term stress.

b. anticipatory grieving related to expectation of death.

c. ineffective coping related to unknown outcome of illness.

d. disturbed self-esteem related to physical and psychological dependence.

d. disturbed self-esteem related to physical and psychological dependence.

Following diagnostic testing, a patient with recurring heartburn and indigestion is diagnosed with a hiatal hernia. The nurse explains to the patient that this condition involves:

a. extension of the esophagus through the diaphragm.

b. displacement of the duodenum through the stomach to the esophagus.

c. twisting of the stomach around the esophagus, occluding the esophagus.

d. protrusion of the stomach into the esophagus through an opening in the diaphragm.

d. protrusion of the stomach into the esophagus through an opening in the diaphragm.

The information that is most important for the nurse to obtain during the initial assessment of a patient admitted to the emergency department with vomiting of bright red blood is:

a. current medical problems.

b. medications the patient is taking.

c. history of prior bleeding episodes.

d. vital signs and symptoms of hypovolemia.

d. vital signs and symptoms of hypovolemia.

A 67 year old male is diagnosed with having acute gastritis secondary to alcoholism. When the nurse is obtaining this patient's history, the nurse should give priority to the patient's statement that:

a. The patient states having frequent pain after meals.

b. The patient states frequent episodes of nausea.

c. The patient states that his stools have a tarry appearance.

d. The patient states that he has joined an alcoholic support group.

c. The patient states that his stools have a tarry appearance.

You are providing discharge instructions to a patient who has been diagnosed with a hiatal hernia. She stands 4'9" in height and weighs 180 lbs. The patient asked how to prevent esophageal reflux. Your best response would be:

a. "You should increase your fat intake with every meal."

b. "You should lie down after eating to help with digestion."

c. "You should monitor your caloric intake to help lose weight."

d. "You should drink plenty of fluids during each of your meals."

c. "You should monitor your caloric intake to help lose weight."

A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug:

a. neutralizes stomach acid and provides relief of symptoms in a few minutes.

b. reduces the reflux of gastric acid by increasing the rate of gastric emptying.

c. coats and protects the lining of the stomach and esophagus from gastric acid.

d. treats acid reflux by decreasing stomach acid production.

d. treats acid reflux by decreasing stomach acid production.

When you are discussing dietary drink options for a patient that has a hiatal hernia, vou instruct the patient that drink that is most appropriate for including in the diet is:

a. Orange juice.

b. Sodas, such as cola.

c. Iced Tea.

d. Apple Juice.

d. Apple Juice.

The physician orders IV ranitidine (Zantac) every 6 hours for a patient with an acute exacerbation of his chronic peptic ulcer disease. As the nurse administers the drug, the patient asks about it, saying that the only ulcer drug he had been given IV before was cimetidine (Tagamet). In responding to the patient, the nurse explains that:

a. both drugs neutralize stomach acid but ranitidine has fewer side effects than does cimetidine.

b. ranitidine and cimetidine work the same way to decrease the effect of histamine and decrease

acidity.

c. ranitidine blocks histamine receptors to decrease acid production but cimetidine acts on the nervous system to decrease gastric motility and secretions.

b. ranitidine and cimetidine work the same way to decrease the effect of histamine and decrease

acidity.

A patient with upper gastrointestinal bleeding is diagnosed with a duodenal ulcer following an endoscopy, and a histology of a mucosal specimen is positive for Helicobacter pylori (H.pylori). When the nurse administers antibiotic therapy for the H. pylori, the patient asks if ulcers are caused by an infection. The best response by the nurse includes the information that:

a. H. pylori is strongly associated with gastric ulcers but it is rarely present in those with duodenal ulcers.

b. although H. pylori is believed to be a cause of gastritis, its role in the development of ulcers is not known.

c. because most of the population is infected with H. pylori, it is believed that other factors are responsible for ulcer development.

d. infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier.

d. infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier.

A patient hospitalized with bleeding of a peptic ulcer develops sudden, severe upper abdominal pain and calls the nurse. She is doubled over in pain and is diaphoretic. An additional sign indicating perforation of the ulcer that the nurse assesses for is:

a. rapid, deep respirations.

b. a rigid, board-like abdomen.

c. vomiting of undigested food.

d. bowel sounds increased in frequency and pitch.

b. a rigid, board-like abdomen.

In teaching a patient with peptic ulcer disease about nutritional management of the disorder, the nurse stresses that the patient should:

a. avoid raw fruits and vegetables.

b. avoid foods that cause discomfort such as spicy foods.

c. eat three full meals a day with bland foods

d. increase fruit intake such as oranges and tangerines in the diet.

b. avoid foods that cause discomfort such as spicy foods.

When teaching a patient with a history of upper gastrointestinal bleeding to check his stools for blood, the nurse informs the patient that:

a. If vomiting of bright red blood occurs, stools will not be black and tarry.

b. blood is never obvious in the stools and must be detected by Hemoccult testing.

c. acute bleeding in the upper gastrointestinal tract will result in bright red blood in the stools.

d. stools that are black and tarry occur with prolonged bleeding from the stomach or small intestine.

d. stools that are black and tarry occur with prolonged bleeding from the stomach or small intestine.

The nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements for a patient who is hospitalized with an acute exacerbation of bleeding peptic ulcer disease, based on the finding of:

a. fatigue and weakness

b. a hemoglobin of 10 g/dl (120 g/L), decreased serum albumin.

c. a weight loss of 0.5 lbs in 2 days.

d. a 24-hour diet history that reveals a 1500-calorie intake.

b. a hemoglobin of 10 g/dl (120 g/L), decreased serum albumin.

The nurse identifies a nursing diagnosis of imbalanced nutrition less than body requirements for a patient who is hospitalized with an acute exacerbation of Crohn's Disease based on the finding of ...

a. dizziness and hunger

b. decrease albumin, decrease hemoglobin and hematocrit levels

c. decrease bipedal edema

d. consumed 40% of food served in a 24- hour diet history

b. decrease albumin, decrease hemoglobin and hematocrit levels

A patient with Cohn's disease is demonstrating the nursing diagnosis Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patient's plan of care?

a. A low-calorie, high-milk diet

b. A low-calorie, low-residue diet

c. The DASH diet

d. A high-calorie, low-residue diet

e. A high-calorie, high-fat diet

d. A high-calorie, low-residue diet

In the patient with Crohn's disease experiencing severe diarrhea, what should the nurse monitor for as the priority assessment?

a. Cardiac dysrhythmias

b. Presence of beefy shiny tongue

c. Anorexia

d. Anemia

a. Cardiac dysrhythmias

A patient with Crohn's disease is recovering from a bowel resection. What information should the nurse provide?

a. "Surgery has ensured that you will never have another recurrence of the disease."

b. "You need close follow-up because there is a possibility of recurrence in another portion of the bowel."

c. "You may develop ulcerative colitis now that your Crohn's is cured."

d. "The surgery increases your risk of developing an intestinal stricture."

b. "You need close follow-up because there is a possibility of recurrence in another portion of the bowel."

After receiving a change-of-shift report, which patient should the nurse assess first?

a. A patient whose new ileostomy has drained 800 ml. over the previous 12 hours.

b. A patient with diverticular disease who is complaining of left lower quadrant abdominal pain.

c. A patient with ulcerative colitis who has a blood pressure of 90/54 mm Hg and an apical heart rate of 110.

c. A patient with ulcerative colitis who has a blood pressure of 90/54 mm Hg and an apical heart rate of 110.

A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated & with the diarrhea. The nurse will plan to ...

a. Place the pt on NPO status

b. Administer IV metoclopramide (reglan)

c. Teach the pt about total colectomy surgery

d. Administer cobalamin (vitamin B12) injections

a. Place the pt on NPO status

When caring for a patient who has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months, the nurse will plan to teach the patient about:

a. medication use.

b. fluid restriction.

c. enteral nutrition.

d. activity restrictions.

a. medication use.

A patient who has ulcerative colitis has a proctocolectomy and ileostomy. Which information will the nurse include in patient teaching?

a. Restrict fluid intake to prevent constant liquid drainage from the ileostomy stoma.

b. Use care when eating high-fiber foods to avoid obstruction of the ileum.

c. Irrigate the ostomy daily to avoid having to wear a drainage appliance.

d. Change the ileostomy bag every shift to prevent leakage of contents onto the skin

b. Use care when eating high-fiber foods to avoid obstruction of the ileum.

The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility with ulcerative colitis; the patient is normally alert and oriented. Which action should the nurse take next?

a. Check the patient's pulse rate.

b. Obtain oxygen saturation.

c. Notify the health care provider.

d. Document the change.

b. Obtain oxygen saturation.

A patient has a large bowel obstruction that occurred as a result of diverticulosis. When assessing the patient, the nurse will plan to monitor for:

a. referred back pain.

b. metabolic alkalosis.

c. projectile vomiting.

d. abdominal distention

d. abdominal distention

During the initial postoperative assessment of a patient's stoma formed from a transverse colostomy, the nurse finds it to be deep pink with moderate edema and a small amount of bleeding. The nurse should:

a. document the stoma assessment.

b. monitor the stoma every 30 minutes.

c. notify the surgeon about the stoma appearance.

d. place an ice pack on the stoma to reduce swelling.

a. document the stoma assessment.

Which of these prescribed interventions will the nurse implement first when caring for a patient who has just been diagnosed with peritonitis caused by a ruptured diverticulum?

a. Administer morphine sulfate 4 mg IV.

b. Infuse metronidazole (Flagyl) 500 mg IV.

c. Send the patient for a computerized tomography scan.

d. Insert a nasogastric (NG) tube and connect it to intermittent low suction.

b. Infuse metronidazole (Flagyl) 500 mg IV.

The nurse is reviewing dietary recommendations with a patient recovering from an acute episode of diverticular disease. The nurse identifies which topics for inclusion in the discussion EXCEPT?

a. Incorporating both soluble and insoluble fiber into the daily diet.

b. Including raisins in the diet as a good source of iron to offset poor iron absorption.

c. Ingesting at least 25 to 30 grams of fiber daily, as recommended for adults.

d. Eating oatmeal-based cereals as breakfast and snack foods.

e. Having frequent small meals with less spices.

b. Including raisins in the diet as a good source of iron to offset poor iron absorption.

A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen?

a. After the patient rinses the mouth with mouthwash

b. As soon as the order is received from the health care provider

c. Right after the patient gets up in the morning

d. After the skin test is administered

c. Right after the patient gets up in the morning

A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan?

a. "Take vitamin B6 daily to prevent peripheral nerve damage."

b. "Read a newspaper daily to check for changes in vision."

c. "Schedule an audiometric examination to monitor for hearing loss."

d. "Avoid wearing soft contact lenses to avoid orange staining."

a. "Take vitamin B6 daily to prevent peripheral nerve damage."

When teaching the patient who is receiving standard multi-drug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops:

a. yellow-tinged skin.

b. changes in hearing.

c. orange-colored urine.

d. thickening of the nails.

a. yellow-tinged skin.

The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask?

a. "How long have you lived in the United States?"

b. "Is there any family history of TB?"

c. "Have you received the BCG vaccine for TB?"

d. "Do you take any over-the-counter (OTC) medications?"

c. "Have you received the BCG vaccine for TB?"

A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure, the nurse will plan to:

a. position the patient sitting upright on the edge of the bed and leaning forward.

b. instruct the patient about the importance of incentive spirometer use after the procedure.

c. start a peripheral intravenous line to administer the necessary sedative drugs.

d. remove the water pitcher and remind the patient not to eat or drink anything for 8 hours.

a. position the patient sitting upright on the edge of the bed and leaning forward.

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy tube in place using a traditional tracheal suction set up. Which action by the student requires the RN to intervene?

a. The student preoxygenate the patient for 2 minutes before suctioning.

b. The student applies suction for 10 seconds while withdrawing the catheter.

c. The student puts on clean gloves and uses a sterile catheter to suction.

d. The student inserts the catheter about 5 inches into the tracheostomy tube or until it meets some resistance of the suction tube.

c. The student puts on clean gloves and uses a sterile catheter to suction.

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

a. assess the patient's oxygen saturation and breath sounds and call the health care provider.

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

c. insert the tracheostomy with the obturator and attempt to reinsert the tracheostomy tube.

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

c. insert the tracheostomy with the obturator and attempt to reinsert the tracheostomy tube.

When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is:

a. skin turgor.

b. daily weight.

c. presence of edema.

d. hourly urine output.

d. hourly urine output.

The long-term care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved?

a. Hematocrit 28%

b. Good skin turgor

c. Absence of peripheral edema

d. Blood pressure 110/72 mm Hg

c. Absence of peripheral edema

A patient with anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include:

a. normal red blood cell (RBC) indices.

b. a hematocrit (Hct) of 38%.

c. a hemoglobin (Hb) of 8.6 g/dL (86 g/L).

d. A RBC count of 4,500,000/mL.

c. a hemoglobin (Hb) of 8.6 g/dL (86 g/L).

A patient is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing action for the patient is to:

a. provide a diet high in vitamin K.

b. place the patient in protective isolation.

c. alternate periods of rest and activity.

d. teach the patient how to avoid injury.

c. alternate periods of rest and activity.

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of heart failure with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is:

a. weight loss of 2 pounds overnight.

b. hourly urine output greater than 60 mL.

c. reduction in patient complaints of chest pain.

d. decreased dyspnea with the head of bed at 30 degrees.

d. decreased dyspnea with the head of bed at 30 degrees.

During a visit to a 72-year-old with a history of MI who developed heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain, and complains of "feeling too tired to do anything." Based on these data, the best nursing diagnosis for the patient is:

a. activity intolerance related to fatigue.

b. disturbed body image related to leg swelling.

c. impaired skin integrity related to peripheral edema.

d. impaired gas exchange related to chronic heart failure.

a. activity intolerance related to fatigue.

When teaching a patient with coronary artery disease about the disease's relationship to elevated serum lipid levels, the nurse explains that:

a. each stage in the development of atherosclerotic lesions involves the presence and effects of fat substances.

b. hyperglycemia increases the adhesiveness of platelets, causing platelet plaque formation in arterial walls.

c. cholesterol and other fatty substances destroy and replace smooth muscle throughout the arteriole wall.

a. each stage in the development of atherosclerotic lesions involves the presence and effects of fat substances.

While caring for a patient with angina, the nurse plans interventions that decrease myocardial oxygen demand and promote coronary blood flow. Appropriate interventions are those that primarily prevent:

a. coronary artery spasms.

b. an increase in heart rate.

c. a decreased blood volume.

d. disruption of circadian rhythms.

b. an increase in heart rate.

While teaching a patient and his wife about the dietary modifications that should be made to reduce the risk of coronary artery disease the nurse should explain that:

a. margarine can be used in any amount but butter should be avoided.

b. fish and skinless chicken are preferable to red meats as sources of protein.

c. all vegetable fats are unsaturated and are preferable to meat and dairy fats.

d. fats should be totally restricted from the total daily calories.

b. fish and skinless chicken are preferable to red meats as sources of protein.

The nurse determines that outcomes for teaching regarding precipitating risk factors of angina have been met when the patient states:

a. "I will stop my sexual activities."

b. "I will rest in bed for 3-4 hours after every meal"

c. "I will avoid outdoor activities when it is very hot or very cold."

d. "I will limit my coffee intake, but I may substitute regular cola products."

c. "I will avoid outdoor activities when it is very hot or very cold."

A patient with a history of chronic congestive heart failure is hospitalized with severe dyspnea and a dry, hacking cough. She has pitting edema in both ankles, and her vital signs are blood pressure 170/100, pulse 92, and respirations 28. The nurse recognizes that the patient's symptoms indicate:

a. The venous return to the heart is impaired, causing a decrease in cardiac output.

b. There is impaired emptying of both the right and left ventricles, with low forward blood flow.

c. The right side of the heart is failing to pump enough blood to the lungs to provide systemic oxygenation.

b. There is impaired emptying of both the right and left ventricles, with low forward blood flow.

During assessment of a 72-year-old man with swelling in his ankles, the nurse finds jugular venous distention on an upright position. The nurse knows this finding indicates:

a. decreased fluid volume.

b. elevated right atrial pressure.

c. incompetent jugular vein valves.

d. atherosclerosis of the jugular veins.

b. elevated right atrial pressure.

To prevent the development of heart failure in a patient with hypertension, the nurse stresses the importance of compliance with antihypertensive therapy, based on the knowledge that:

a. diastolic failure and venous congestion may be caused by decreased preload.

b. systolic failure and low forward blood flow can result from increased afterload.

c. systolic failure and low forward blood flow is caused by impaired contractile force of the heart.

d. mixed systolic and diastolic failure may result from dilated cardiomyopathy

b. systolic failure and low forward blood flow can result from increased afterload.

A client with a history of previous myocardial infarction is admitted with heart failure. What statement made by this client would alert the nurse to suspect the occurrence of heart failure?

a. "It is getting more difficult to climb the stairs, I have difficulty breathing."

b. "I think my dose of digoxin may need to be increased."

c. "I have trouble remembering things recently."

d. "I have noticed a loss of appetite recently."

a. "It is getting more difficult to climb the stairs, I have difficulty breathing."

When obtaining a health history from a patient with newly diagnosed coronary artery disease, the nurse recognizes that a modifiable major risk factor for coronary artery disease is present in the patient's history of:

a. hypertension

b. diabetes mellitus

c. a stressful lifestyle

d. high-density lipoproteins above 60 mg/di (1.6 mmol/L)

a. hypertension

A nurse hears the cardiac monitor alarm and notes that the patient has a cardiac pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious with no pulse or respirations. After calling for assistance, the nurse should:

a. start basic cardiopulmonary resuscitation (CPR)

b. administer an IV bolus dose of epinephrine

c. prepare the patient for endotracheal intubation

a. start basic cardiopulmonary resuscitation (CPR)

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

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

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

c. calculate the number of small squares between one QRS complex and the next and divide by 1500

d. use the 3-second markers to count the number of QR complexes in 6 seconds 69 respondents strip and multiply by 10

d. use the 3-second markers to count the number of QR complexes in 6 seconds 69 respondents strip and multiply by 10