Respiratory 20,21,23,24/Cardiac 28,29,30,31/Electrolyte-Acid Base 13

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1

4.

The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patient’s chest and hears wheezing throughout the lung fields. What might this indicate?

A)

The patient has a narrowed airway.

B)

The patient has pneumonia.

C)

The patient needs physiotherapy.

D)

The patient has a hemothorax.

Ans:

A

Feedback:

Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.

2

5.

The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patient’s blood?

A)

A capillary blood sample

B)

Pulse oximetry

C)

An arterial blood gas (ABG) study

D)

A complete blood count (CBC)

Ans:

C

Feedback:

The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.

3

6.

The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids?

A)

Presence of a cough and gag reflex

B)

Absence of nausea

C)

Ability to demonstrate deep inspiration

D)

Oxygen saturation of ³92%

Ans:

A

Feedback:

After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.

4

8.

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patient’s arterial oxygen saturation (SaO2). What procedure will best accomplish this?

A)

Incentive spirometry

B)

Arterial blood gas (ABG) measurement

C)

Peak flow measurement

D)

Pulse oximetry

Ans:

D

Feedback:

Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the patient no discomfort. An incentive spirometer is used to assist the patient with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some patients with asthma use peak flow meters to measure levels of expired air.

5

11.

A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse’s respiratory assessment findings would be most consistent with this diagnosis?

A)

Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall

B)

Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall

C)

Lung fields dull to percussion, absent breath sounds, and a pleural friction rub

D)

Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall

C

Feedback:

Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion.

6

12.

The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patient’s room. The nurse asks the patient when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take?

A)

Immediately take the sputum specimen to the laboratory.

B)

Discard the specimen and assist the patient in obtaining another specimen.

C)

Refrigerate the sputum specimen and submit it once it is chilled.

D)

Add a small amount of normal saline to moisten the specimen.

Ans:

B

Feedback:

Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions.

7

15.

A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patient’s physician because these symptoms are suggestive of what?

A)

Pneumothorax

B)

Lung tumors

C)

Infection

D)

Pulmonary edema

Ans:

C

Feedback:

The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.

8

19.

The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess?

A)

Decreased urine output and hypertension

B)

Headache and vision changes

C)

Confusion and lethargy

D)

Jaundice and elevated liver enzymes

Ans:

C

Feedback:

Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine administered during the procedure. The other listed signs and symptoms are not specific to this problem.

9

21.

The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, “What exactly is this test for?” What would be the nurse’s best response?

A)

“A PFT measures how much air moves in and out of your lungs when you breathe.”

B)

“A PFT measures how much energy you get from the oxygen you breathe.”

C)

“A PFT measures how elastic your lungs are.”

D)

“A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.”

Ans:

A

Feedback:

PFTs are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.

10

22.

A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?

A)

Maintenance of constant osmotic pressure in the alveoli

B)

Maintenance of muscle tone in the diaphragm

C)

pH balance in the pulmonary veins and arteries

D)

Adequate flow of blood through the pulmonary circulation.

Ans:

D

Feedback:

Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.

11

25.

A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe?

A)

It allows for full expansion of the lungs within the thoracic cavity.

B)

It prevents the lungs from collapsing within the thoracic cavity.

C)

It limits lung expansion within the thoracic cavity.

D)

It lubricates the movement of the thorax and lungs.

Ans:

D

Feedback:

The visceral pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura do not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.

12

26.

The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?

A)

Impaired gas exchange

B)

Collapsed bronchial structures

C)

Necrosis of the alveoli

D)

Closed bronchial tree

Ans:

A

Feedback:

The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues.

13

27.

The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?

A)

An appropriate perfusion–diffusion ratio

B)

An adequate ventilation–perfusion ratio

C)

Adequate diffusion of gas in shunted blood

D)

Appropriate blood nitrogen concentration

Ans:

B

Feedback:

Adequate gas exchange depends on an adequate ventilation–perfusion ratio. There is no perfusion–diffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen.

14

28.

The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse’s postprocedure care?

A)

Assisting with pulmonary function testing (PFT)

B)

Maintaining the patient’s chest tube

C)

Administering oral suction as needed

D)

Performing chest physiotherapy

Ans:

B

Feedback:

Chest tube drainage is required after mediastinotomy. PFT, chest physiotherapy, and oral suctioning would all be contraindicated because of the patient’s unstable health status.

15

29.

The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?

A)

Sputum production

B)

Shortness of breath

C)

Throat discomfort

D)

Epistaxis

Ans:

B

Feedback:

Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication.

16

32.

The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this patient?

A)

Alveolar dysfunction

B)

Forced vital capacity

C)

Tidal volume

D)

Chest wall invasion

Ans:

D

Feedback:

MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. Imaging would not focus on the alveoli since the problem in the bronchi. A static image such as MRI cannot inform PFT.

17

33.

A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?

A)

Immediately after a meal

B)

First thing in the morning

C)

At bedtime

D)

After a period of exercise

Ans:

B

Feedback:

Sputum samples ideally are obtained early in the morning before the patient has had anything to eat or drink.

18

35.

The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?

A)

Administer a bolus of IV fluids.

B)

Arrange for the insertion of a peripherally inserted central catheter.

C)

Administer nebulized bronchodilators every 2 hours until the test.

D)

Withhold food and fluids for several hours before the test.

Ans:

D

Feedback:

Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.

19

37.

A medical patient rings her call bell and expresses alarm to the nurse, stating, “I’ve just coughed up this blood. That can’t be good, can it?” How can the nurse best determine whether the source of the blood was the patient’s lungs?

A)

Obtain a sample and test the pH of the blood, if possible.

B)

Try to see if the blood is frothy or mixed with mucus.

C)

Perform oral suctioning to see if blood is obtained.

D)

Swab the back of the patient’s throat to see if blood is present.

Ans:

B

Feedback:

Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum. Testing the pH of nonarterial blood samples is not common practice and would not provide important data. Similarly, oral suctioning and swabbing the patient’s mouth would not reveal the source.

20

38.

The nurse is completing a patient’s health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?

A)

“Have you ever been employed in a factory, smelter, or mill?”

B)

“Does anyone in your family have any form of lung disease?”

C)

“Do you currently smoke, or have you ever smoked?”

D)

“Have you ever lived in an area that has high levels of air pollution?”

Ans:

C

Feedback:

Smoking the single most important contributor to lung disease, exceeds the significance of environmental, occupational, and genetic factors.

21

1.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?

A)

Bradycardia and frontal headache

B)

Dyspnea and substernal pain

C)

Peripheral cyanosis and restlessness

D)

Hypotension and tachycardia

Ans:

B

Feedback:

Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.

22

6.

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?

A)

Maintaining positive chest-wall pressure

B)

Monitoring pleural fluid osmolarity

C)

Providing positive intrathoracic pressure

D)

Removing excess air and fluid

Ans:

D

Feedback:

Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.

23

7.

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

A)

To remove air from the pleural space

B)

To drain copious sputum secretions

C)

To monitor bleeding around the lungs

D)

To assist with mechanical ventilation

Ans:

A

Feedback:

Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

24

10.

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?

A)

Fluid intake for the last 24 hours

B)

Baseline arterial blood gas (ABG) levels

C)

Prior outcomes of weaning

D)

Electrocardiogram (ECG) results

Ans:

B

Feedback:

Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patient’s record, and the nurse can refer to them before the weaning process begins.

25

11.

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient’s closed chest-drainage system. What should the nurse conclude?

A)

The system is functioning normally.

B)

The patient has a pneumothorax.

C)

The system has an air leak.

D)

The chest tube is obstructed.

Ans:

C

Feedback:

Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

26

18.

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge?

A)

Walk 1 mile 3 to 4 times a week.

B)

Use weights daily to increase arm strength.

C)

Walk on a treadmill 30 minutes daily.

D)

Perform shoulder exercises five times daily.

Ans:

D

Feedback:

The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

27

24.

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?

A)

20 cm H2O

B)

15 cm H2O

C)

10 cm H2O

D)

5 cm H2O

Ans:

A

Feedback:

The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.

28

25.

The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?

A)

Safe technique for self-suctioning of secretions

B)

Technique for performing postural drainage

C)

Correct and safe use of oxygen therapy equipment

D)

How to provide safe and effective tracheostomy care

Ans:

C

Feedback:

Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The scenario does not indicate the patient needs help with suctioning, postural drainage, or tracheostomy care.

29

29.

The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client?

A)

Teach him postural drainage.

B)

Teach him how to perform huffing.

C)

Teach him to use a mini-nebulizer.

D)

Teach him how to use a metered dose inhaler.

Ans:

B

Feedback:

The technique of “huffing” may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

30

30.

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply.

A)

Post thoracotomy

B)

Spontaneous pneumothorax

C)

Need for postural drainage

D)

Chest trauma resulting in pneumothorax

E)

Pleurisy

Ans:

A, B, D

Feedback:

Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.

31

33.

A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?

A)

Correct use of a ventilator

B)

Correct use of incentive spirometry

C)

Correct use of a mini-nebulizer

D)

Correct technique for rhythmic breathing

Ans:

B

Feedback:

Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

32

38.

Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?

A)

Chest auscultation

B)

Pulmonary function testing

C)

Chest percussion

D)

Thoracic palpation

Ans:

A

Feedback:

Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately before postural drainage.

33

39.

A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?

A)

“Hold the spirometer at your lips and breathe in and out like you normally would.”

B)

“When you’re ready, blow hard into the spirometer for as long as you can.”

C)

“Take a deep breath and then blow short, forceful breaths into the spirometer.”

D)

“Breathe in deeply through the spirometer, hold your breath briefly, and then exhale.”

Ans:

D

Feedback:

The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece.

34

40.

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient’s respirations. How should the nurse best respond to this assessment finding?

A)

Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes.

B)

Inform the physician promptly that there is in imminent leak in the drainage system.

C)

Encourage the patient to do deep breathing and coughing exercises.

D)

Document that the chest drainage system is operating as it is intended.

Ans:

D

Feedback:

Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

35

1.

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient’s increased risk for what complication?

A)

Acute respiratory distress syndrome (ARDS)

B)

Atelectasis

C)

Aspiration

D)

Pulmonary embolism

Ans:

B

Feedback:

A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

36

4.

The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurse’s assessment findings would best corroborate this diagnosis?

A)

The patient is experiencing painless hemoptysis.

B)

The patient’s arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing.

C)

The patient’s oxygen saturation level is below 88%, but he denies shortness of breath.

D)

The patient’s pain intensifies when he coughs or takes a deep breath.

Ans:

D

Feedback:

The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The patient’s ABGs would most likely be abnormal and shortness of breath would be expected.

37

6.

A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?

A)

Preparing to assist with intubating the patient

B)

Setting up oxygen at 5 L/minute by nasal cannula

C)

Performing deep suctioning

D)

Setting up a nebulizer to administer corticosteroids

Ans:

A

Feedback:

A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.

38

7.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client’s oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what?

A)

Diminished or absent breath sounds on the affected side

B)

Paradoxical chest wall movement with respirations

C)

Sudden loss of consciousness

D)

Muffled heart sounds

Ans:

A

Feedback:

In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

39

8.

The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client?

A)

Coumadin will continue to break up the clot over a period of weeks

B)

Coumadin must be taken concurrent with ASA to achieve anticoagulation.

C)

Anticoagulant therapy usually lasts between 3 and 6 months.

D)

He should take a vitamin supplement containing vitamin K

Ans:

C

Feedback:

Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.

40

12.

An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize?

A)

The importance of adhering closely to the prescribed medication regimen

B)

The fact that the disease is a lifelong, chronic condition that will affect ADLs

C)

The fact that TB is self-limiting, but can take up to 2 years to resolve

D)

The need to work closely with the occupational and physical therapists

Ans:

A

Feedback:

Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.

41

13.

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?

A)

Pneumothorax

B)

Anxiety

C)

Acute bronchitis

D)

Aspiration

Ans:

A

Feedback:

If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patient’s recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.

42

15.

The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patient’s symptoms from those of a cardiac etiology?

A)

Carboxyhemoglobin level

B)

Brain natriuretic peptide (BNP) level

C)

C-reactive protein (CRP) level

D)

Complete blood count

Ans:

B

Feedback:

Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

43

16.

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?

A)

Incentive spirometry

B)

Intermittent positive-pressure breathing (IPPB)

C)

Positive end-expiratory pressure (PEEP)

D)

Bronchoscopy

Ans:

A

Feedback:

Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

44

17.

While planning a patient’s care, the nurse identifies nursing actions to minimize the patient’s pleuritic pain. Which intervention should the nurse include in the plan of care?

A)

Avoid actions that will cause the patient to breathe deeply.

B)

Ambulate the patient at least three times daily.

C)

Arrange for a soft-textured diet and increased fluid intake.

D)

Encourage the patient to speak as little as possible

Ans:

A

Feedback:

The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. A soft diet is not necessarily indicated and there is no need for the patient to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.

45

18.

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patient’s risk of developing pulmonary emboli (PE)?

A)

Early ambulation

B)

Increased dietary intake of protein

C)

Maintaining the patient in a supine position

D)

Administering aspirin with warfarin

Ans:

A

Feedback:

For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stocking are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patient’s risk for bleeding.

46

19.

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate?

A)

“The younger you are when you start smoking, the higher your risk of lung cancer.”

B)

“The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays.”

C)

“The risk for lung cancer is determined mostly by what type of cigarettes you smoke.”

D)

“The risk for lung cancer depends primarily on the other risk factors for cancer that you have.”

Ans:

A

Feedback:

Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor.

47

20.

The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment?

A)

“Lately, I have this cough that just never seems to go away.”

B)

“I find that I don’t have nearly the stamina that I used to.”

C)

“I seem to get nearly every cold and flu that goes around my workplace.”

D)

“I never used to have any allergies, but now I think I’m developing allergies to dust and pet hair.”

Ans:

A

Feedback:

The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections and fatigue are not characteristic early signs of lung cancer.

48

25.

The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with non–small cell tumors is what?

A)

Chemotherapy

B)

Radiation

C)

Surgical resection

D)

Bronchoscopic opening of the airway

Ans:

C

Feedback:

Surgical resection is the preferred method of treating patients with localized non–small cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.

49

26.

A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patient’s oxygenation status at the bedside?

A)

Obtain serial ABG samples.

B)

Monitor pulse oximetry readings.

C)

Test pulmonary function.

D)

Monitor incentive spirometry volumes.

Ans:

B

Feedback:

The nurse assesses the patient with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status.

50

27.

The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing?

A)

Traumatic pneumothorax

B)

Empyema

C)

Pleuritic pain

D)

Myocardial infarction

Ans:

C

Feedback:

The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. The scenario does not indicate any trauma to the patient, so a traumatic pneumothorax is implausible. Empyema is unlikely as there is no fever indicative of infection. Myocardial infarction would affect the patient’s vital signs profoundly.

51

29.

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment?

A)

Pulmonary hypotension due to decreased cardiac output

B)

Severe and progressive pulmonary hypertension

C)

Hypovolemia secondary to leakage of fluid into the interstitial spaces

D)

Increased cardiac output from high levels of PEEP therapy

Ans:

C

Feedback:

Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.

52

30.

The home care nurse is monitoring a patient discharged home after resolution of a pulmonary embolus. For what potential complication would the home care nurse be most closely monitoring this patient?

A)

Signs and symptoms of pulmonary infection

B)

Swallowing ability and signs of aspiration

C)

Activity level and role performance

D)

Residual effects of compromised oxygenation

Ans:

D

Feedback:

The home care nurse should monitor the patient for residual effects of the PE, which involved a severe disruption in respiration and oxygenation. PE has a noninfectious etiology; pneumonia is not impossible, but it is a less likely sequela. Swallowing ability is unlikely to be affected; activity level is important, but secondary to the effects of deoxygenation.

53

32.

A 54-year-old man has just been diagnosed with small cell lung cancer. The patient asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurse’s response?

A)

The cells in small cell cancer of the lung are not large enough to visualize in surgery.

B)

Small cell lung cancer is self-limiting in many patients and surgery should be delayed.

C)

Patients with small cell lung cancer are not normally stable enough to survive surgery.

D)

Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

Ans:

D

Feedback:

Surgery is primarily used for NSCLCs, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult visualization and a patient’s medical instability are not the limiting factors. Lung cancer is not a self-limiting disease.

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36.

A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurse’s best response?

A)

“The type of treatment depends on the patient’s age and health status.”

B)

“The type of treatment depends on what the patient wants when given the options.”

C)

“The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient’s health status.”

D)

“The type of treatment depends on the discussion between the patient and the physician of which treatment is best.”

36.

A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurse’s best response?

A)

“The type of treatment depends on the patient’s age and health status.”

B)

“The type of treatment depends on what the patient wants when given the options.”

C)

“The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient’s health status.”

D)

“The type of treatment depends on the discussion between the patient and the physician of which treatment is best.”

Ans:

C

Feedback:

Treatment of lung cancer depends on the cell type, the stage of the disease, and the patient’s physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the patient’s age or the patient’s preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the patient and the physician of which treatment is best, though this discussion will take place.

55

37.

A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy?

A)

Pupillary response

B)

Pressure in the vena cava

C)

White blood cell differential

D)

Pulmonary arterial pressure

Ans:

D

Feedback:

If the patient has undergone surgical embolectomy, the nurse measures the patient’s pulmonary arterial pressure and urinary output. Pressure is not monitored in a patient’s vena cava. White cell levels and pupillary responses would be monitored, but not to the extent of the patient’s pulmonary arterial pressure.

56

39.

The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patient’s history is most likely to have caused the empyema?

A)

Smoking

B)

Asbestosis

C)

Pneumonia

D)

Lung cancer

Ans:

C

Feedback:

Most empyemas occur as complications of bacterial pneumonia or lung abscess. Cancer, smoking, and asbestosis are not noted to be common causes.

57

5.

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?

A)

Anxiety related to diagnosis of cancer

B)

Altered nutrition related to swallowing difficulties

C)

Ineffective airway clearance related to airway alterations

D)

Impaired verbal communication related to removal of the larynx

Ans:

C

Feedback:

Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.

58

7.

The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?

A)

Hoarseness

B)

Dyspnea

C)

Dysphagia

D)

Frequent nosebleeds

Ans:

A

Feedback:

Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.

59

2.

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient’s most recent laboratory reports, you note that the patient’s magnesium levels are high. You should prioritize assessment for which of the following health problems?

A)

Diminished deep tendon reflexes

B)

Tachycardia

C)

Cool, clammy skin

D)

Acute flank pain

Ans:

A

Feedback:

To gauge a patient’s magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

60

3.

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

A)

Metabolic alkalosis

B)

Hypermagnesemia

C)

Hypercalcemia

D)

Hypovolemia

Ans:

D

Feedback:

Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

61

4.

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid–base imbalance?

A)

Respiratory acidosis

B)

Respiratory alkalosis

C)

Increased PaCO2

D)

CNS disturbances

B)

Respiratory alkalosis

62

5.

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

A)

Respiratory acidosis with no compensation

B)

Metabolic alkalosis with a compensatory alkalosis

C)

Metabolic acidosis with no compensation

D)

Metabolic acidosis with a compensatory respiratory alkalosis

Ans:

D

Feedback:

A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

63

10.

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

A)

Hypophosphatemia

B)

Hypocalcemia

C)

Hypermagnesemia

D)

Hyperkalemia

Ans:

B

Feedback:

Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

64

11.

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, “A patient in renal failure partially loses the ability to regulate changes in pH.” What is the cause of this partial inability?

A)

The kidneys regulate and reabsorb carbonic acid to change and maintain pH.

B)

The kidneys buffer acids through electrolyte changes.

C)

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

D)

The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

Ans:

C

Feedback:

The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.

65

12.

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning’s blood work, you notice that the patient’s potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?

A)

Hypercalcemia

B)

Metabolic acidosis

C)

Metabolic alkalosis

D)

Respiratory acidosis

Ans:

C

Feedback:

Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patient’s respiratory status.

66

14.

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

A)

Respiratory acidosis

B)

Metabolic alkalosis

C)

Respiratory alkalosis

D)

Metabolic acidosis

Ans:

A

Feedback:

The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

67

19.

You are the nurse evaluating a newly admitted patient’s laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?

A)

Increased serum sodium

B)

Decreased serum potassium

C)

Decreased hemoglobin

D)

Increased platelets

Ans:

A

Feedback:

Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.

68

20.

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurse’s preceptor is going over the patient’s past lab reports with the new nurse. The nurse takes note that the patient’s PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurse’s best response?

A)

The patient’s calcium will rise dramatically due to pituitary stimulation.

B)

Oxygen will increase the patient’s intracranial pressure and create confusion.

C)

Oxygen may cause the patient to hyperventilate and become acidotic.

D)

Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Ans:

D

Feedback:

When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patient’s calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patient’s intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.

69

24.

You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patient’s labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults?

A)

Substantially reduced renal function

B)

Acute kidney injury

C)

Decreased cardiac output

D)

Alterations in ratio of body fluids to muscle mass

Ans:

A

Feedback:

Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acid–base disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine.

70

26.

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit?

A)

Diarrhea

B)

Dilute urine

C)

Increased muscle tone

D)

Joint pain

Ans:

B

Feedback:

Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia.

71

27.

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

A)

Hypernatremia

B)

Hypomagnesemia

C)

Hypophosphatemia

D)

Hypercalcemia

Ans:

D

Feedback:

The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The patient’s presentation is inconsistent with hypophosphatemia.

72

28.

A medical nurse educator is reviewing a patient’s recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

A)

The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.

B)

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

C)

The kidneys react rapidly to compensate for imbalances in the body.

D)

The kidneys regulate the bicarbonate level in the intracellular fluid.

Ans:

B

Feedback:

The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by renal failure. Renal compensation for imbalances is relatively slow (a matter of hours or days).

73

29.

The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?

A)

Endocarditis

B)

Multiple myeloma

C)

Guillain-Barré syndrome

D)

Overdose of amphetamines

Ans:

C

Feedback:

Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome. The other listed diagnoses are not associated with respiratory acidosis.

74

30.

The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3– 23 mEq/L. The nurse should recognize the likelihood of what acid–base disorder?

A)

Respiratory acidosis

B)

Metabolic alkalosis

C)

Respiratory alkalosis

D)

Mixed acid–base disorder

Ans:

D

Feedback:

Patients can simultaneously experience two or more independent acid–base disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3– concentration immediately suggests a mixed disorder, making the other options incorrect

75

32.

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply.

A)

Decreased kidney mass

B)

Increased conservation of sodium

C)

Increased total body water

D)

Decreased renal blood flow

E)

Decreased excretion of potassium

Ans:

A, D, E

Feedback:

Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

76

39.

A patient’s most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patient’s dietary intake of potassium. Which of the following would be a good source of potassium?

A)

Apples

B)

Asparagus

C)

Carrots

D)

Bananas

Ans:

D

Feedback:

Bananas are high in potassium. Apples, carrots, and asparagus are not high in potassium.

77

40.

The nurse is assessing the patient for the presence of a Chvostek’s sign. What electrolyte imbalance would a positive Chvostek’s sign indicate?

A)

Hypermagnesemia

B)

Hyponatremia

C)

Hypocalcemia

D)

Hyperkalemia

Ans:

C

Feedback:

You can induce Chvostek’s sign by tapping the patient’s facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek’s sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek’s sign.

78

A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following?

A)

The need for regularly scheduled testing of the patient’s International Normalized Ratio (INR)

B)

The need to learn to sleep in a semi-Fowler’s position for the first 6 to 8 weeks to prevent emboli

C)

The need to avoid foods that contain vitamin K

D)

The need to take enteric-coated ASA on a daily basis

Ans:

A

Feedback:

Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.

79

The nurse is teaching a patient diagnosed with aortic stenosis appropriate strategies for attempting to relieve the symptom of angina without drugs. What should the nurse teach the patient?

A)

To eat a small meal before taking nitroglycerin

B)

To drink a glass of milk before taking nitroglycerin

C)

To engage in 15 minutes of light exercise before taking nitroglycerin

D)

To rest and relax before taking nitroglycerin

D

Feedback:

The venous dilation that results from nitroglycerin decreases blood return to the heart, thus decreasing cardiac output and increasing the risk of syncope and decreased coronary artery blood flow. The nurse teaches the patient about the importance of attempting to relieve the symptoms of angina with rest and relaxation before taking nitroglycerin and to anticipate the potential adverse effects. Exercising, eating, and drinking are not recommended prior to using nitroglycerin.

80

The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem?

A)

Pericarditis

B)

Cardiomyopathy

C)

Pulmonary edema

D)

Right ventricular hypertrophy

C

Feedback:

As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patient’s hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.

81

The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patient’s risk for heart failure (HF)?

A)

The patient takes Lasix (furosemide) 20 mg/day.

B)

The patient’s potassium level is 4.7 mEq/L.

C)

The patient is an African American man.

D)

The patient’s age is greater than 65.

Feedback:

HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physician’s office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for HF. The fact that the patient takes Lasix 20 mg/day does not indicate an increased risk for HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate an increased risk for HF.

82

The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patient’s medical history, what is a potential primary cause of the patient’s heart failure?

A)

Endocarditis

B)

Pleural effusion

C)

Atherosclerosis

D)

Atrial-septal defect

C

Feedback:

Atherosclerosis of the coronary arteries is the primary cause of HF. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of HF.

83

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?

A)

Monitor liver function studies

B)

Monitor for hypotension

C)

Assess the patient’s vitamin D intake

D)

Assess the patient for hyperkalemia

B

Feedback:

Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.

84

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient’s diagnosis?

A)

Pulmonary edema

B)

Distended neck veins

C)

Dry cough

D)

Orthopnea

B

Feedback:

Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.

85

The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms?

A)

Confusion and bradycardia

B)

Uncontrolled diuresis and tachycardia

C)

Numbness and tingling in the extremities

D)

Chest pain and shortness of breath

A

Feedback:

A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.

86

A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela?

A)

Stroke

B)

Myocardial infarction (MI)

C)

Hemorrhage

D)

Peripheral edema

A

Feedback:

Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.

87

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?

A)

Skin turgor

B)

Potassium level

C)

White blood cell count

D)

Peripheral pulses

B

Feedback:

The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.

88

A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?

A)

Right-sided heart failure

B)

Acute pulmonary edema

C)

Pneumonia

D)

Cardiogenic shock

B

Feedback:

Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.

89

A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient?

A)

In a high Fowler’s position

B)

On the left side-lying position

C)

In a flat, supine position

D)

In the Trendelenburg position

A

Feedback:

Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.

90

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?

A)

Monitor her blood pressure daily

B)

Assess her radial pulses daily

C)

Monitor her weight daily

D)

Monitor her bowel movements

C

Feedback:

To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.

91

The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?

A)

Jugular vein distention

B)

Right upper quadrant pain

C)

Bibasilar fine crackles

D)

Dependent edema

C

Feedback:

Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

92

The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient’s care?

A)

Improve functional status

B)

Prevent endocarditis.

C)

Extend survival.

D)

Limit physical activity.

E)

Relieve patient symptoms.

A, C, E

Feedback:

The overall goals of management of HF are to relieve the patient’s symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.

93

A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?

A)

Blood pressure

B)

Level of consciousness (LOC)

C)

Assessment for nausea

D)

Oxygen saturation

A

Feedback:

Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.

94

The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient?

A)

A beta-adrenergic blocker

B)

An antiplatelet aggregator

C)

A calcium channel blocker

D)

A nonsteroidal anti-inflammatory drug (NSAID)

A

Feedback:

Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.

95

The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs?

A)

Loop diuretic and antiplatelet aggregator

B)

Loop diuretic and calcium channel blocker

C)

Combination of hydralazine and isosorbide dinitrate

D)

Combination of digoxin and normal saline

C

Feedback:

A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.

96

A patient with a diagnosis of HF is started on a beta-blocker. What is the nurse’s priority role during gradual increases in the patient’s dose?

A)

Educating the patient that symptom relief may not occur for several weeks

B)

Stressing that symptom relief may take up to 4 months to occur

C)

Making adjustments to each day’s dose based on the blood pressure trends

D)

Educating the patient about the potential changes in LOC that may result from the drug

A

Feedback:

An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.

97

The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF?

A)

An S3 heart sound

B)

Pleural friction rub

C)

Faint breath sounds

D)

A heart murmur

A

Feedback:

The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.

98

An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patient’s most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient’s subsequent care, what nursing diagnosis should be identified?

A)

Risk for ineffective tissue perfusion related to dysrhythmia

B)

Risk for fluid volume excess related to medication regimen

C)

Risk for ineffective breathing pattern related to hypoxia

D)

Risk for falls related to hypotension

D

Feedback:

The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patient’s medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.

99

The nurse is providing patient education prior to a patient’s discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?

A)

Know how to recognize and prevent orthostatic hypotension.

B)

Weigh yourself weekly at a consistent time of day.

C)

Measure everything you eat and drink until otherwise instructed.

D)

Limit physical activity to only those tasks that are absolutely necessary.

A

Feedback:

Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.

100

The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics?

A)

Avoid drinking fluids for 2 hours after taking the diuretic.

B)

Take the diuretic in the morning to avoid interfering with sleep.

C)

Avoid taking the medication within 2 hours consuming dairy products.

D)

Take the diuretic only on days when experiencing shortness of breath.

B

Feedback:

Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient’s nighttime rest. Discussing the timing of medication administration is especially important for elderly patients who may have urinary urgency or incontinence. The nurse would not teach the patient about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.

101

The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise?

A)

“Do not exercise unsupervised.”

B)

“Eventually aim to work up to 30 minutes of exercise each day.”

C)

“Slow down if you get dizzy or short of breath.”

D)

“Start your exercise program with high-impact activities.”

B

Feedback:

Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms should prompt the patient to stop exercising, not simply to slow the pace. Low-impact activities should be prioritized.

102

The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.

A)

Facilitate the presence of friends and family whenever possible.

B)

Teach the patient about the harmful effects of anxiety on cardiac function.

C)

Provide supplemental oxygen, as needed.

D)

Provide validation of the patient’s expressions of anxiety.

E)

Administer benzodiazepines two to three times daily.

The nurse should empathically validate the patient’s sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.

103

A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurse’s best action?

A)

Rapidly assess the patient’s cardiopulmonary status.

B)

Arrange for an ECG.

C)

Increase the height of the patient’s bed.

D)

Manage the patient’s anxiety.

A

Feedback:

Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions may be appropriate and necessary.

104

A cardiac patient’s resistance to left ventricular filling has caused blood to back up into the patient’s circulatory system. What health problem is likely to result?

A)

Acute pulmonary edema

B)

Right-sided HF

C)

Right ventricular hypertrophy

D)

Left-sided HF

A

Feedback:

With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.

105

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse’s postoperative plan of care should include what intervention?

A)

Early ambulation and leg exercises

B)

Cessation of the oral contraceptives until 3 weeks postoperative

C)

Doppler ultrasound of peripheral circulation twice daily

D)

Dependent positioning of the patient’s extremities when at rest

A

Feedback:

Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.

106

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication?

A)

Aoritis

B)

Deep vein thrombosis

C)

Thoracic aortic aneurysm

D)

Raynaud’s disease

B

Feedback:

Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow’s triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman’s case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud’s disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.

107

The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient’s renal status affect heparin therapy?

A)

Heparin is contraindicated in the treatment of this patient.

B)

Heparin may be administered subcutaneously, but not IV.

C)

Lower doses of heparin are required for this patient.

D)

Coumadin will be substituted for heparin.

C

Feedback:

If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.

108

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient’s aneurysm?

A)

Sudden increase in blood pressure and a decrease in heart rate

B)

Cessation of pulsating in an aneurysm that has previously been pulsating visibly

C)

Sudden onset of severe back or abdominal pain

D)

New onset of hemoptysis

C

Feedback:

Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.

109

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurse’s health education should include which of the following?

A)

Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker

B)

Maintaining a diet high in dairy to increase protein necessary to prevent organ damage

C)

Use of strategies to prevent falls stemming from postural hypotension

D)

Limiting exercise to avoid injury that can be caused by increased intracranial pressure

C

Feedback:

Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.

110

A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem?

A)

Renal failure

B)

Right ventricular hypertrophy

C)

Glaucoma

D)

Anemia

A

Feedback:

When uncontrolled hypertension is prolonged, it can result in renal failure, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension.

111

A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize?

A)

Rising slowly from a lying or sitting position

B)

Increasing fluids to maintain BP

C)

Stopping medication if dizziness persists

D)

Taking medication first thing in the morning

A

Feedback:

Patients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these patients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Patient should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse’s scope of practice.

112

The nurse is planning the care of a patient who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment?

A)

156/96 mm Hg or lower

B)

140/90 mm Hg or lower

C)

Average of 2 BP readings of 150/80 mm Hg

D)

120/80 mm Hg or lower

B

Feedback:

The goal of antihypertensive drug therapy is a BP of 140/90 mm Hg or lower. A pressure of 130/80 mm Hg is the goal for patients with diabetes or chronic kidney disease.

113

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which of the following should the nurse integrate into the management of this client’s hypertension?

A)

Ensure that the patient receives a larger initial dose of antihypertensive medication due to impaired absorption.

B)

Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.

C)

Recognize that an older adult is less likely to adhere to his or her medication regimen than a younger patient.

D)

Carefully assess for weight loss because of impaired kidney function resulting from normal aging.

B

Feedback:

Elderly people have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline.

114

A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the difference between primary hypertension and secondary hypertension is which of the following?

A)

Secondary hypertension has a specific cause.

B)

Secondary hypertension has a more gradual onset than primary hypertension.

C)

Secondary hypertension does not cause target organ damage.

D)

Secondary hypertension does not normally respond to antihypertensive drug therapy.

A

Feedback:

Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta. Secondary hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated.

115

The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a measurable patient outcome that the nurse should include?

A)

Patient will reduce Na+ intake to no more than 2.4 g daily.

B)

Patient will have a stable BUN and serum creatinine levels.

C)

Patient will abstain from fat intake and reduce calorie intake.

D)

Patient will maintain a normal body weight.

A

Feedback:

Dietary sodium intake of no more than 2.4 g sodium is recommended as a dietary lifestyle modification to prevent and manage hypertension. Giving a specific amount of allowable sodium intake makes this a measurable goal. None of the other listed goals is quantifiable and measurable.


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