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User Christine Ellen Behm Course (2015 Fall, Term C) NU 216-KEN/W/1: Adult Health I Test Exam 3(1) Started 11/18/15 1:11 PM Submitted 11/18/15 1:52 PM Status Completed Attempt Score 147.5 out of 150 points Time Elapsed 40 minutes out of 2 hours Instructions You will have 75 minutes to complete this exam. The exam is worth 170 point total. Please make sure you read the question carefully and in its entirety. This exam contains questions that are multiple choice, select all that apply, matching, and math dosage calculations. For multiple choice questions choose the best response to each question. For all that apply questions choose all that apply. Results Displayed All Answers, Submitted Answers, Correct Answers, Feedback, Incorrectly Answered Questions Question 1 2.5 out of 2.5 points Which nursing action would be highest priority when suctioning a patient with a tracheostomy? Selected Answer: b. Assessing the patient's oxygenation saturation before, during and after suctioning. Answers: a. Providing a means of communication for the patient during the procedure. b. Assessing the patient's oxygenation saturation before, during and after suctioning. c. Administering pain and/or antianxiety mecdication 30 minutes before suctioning. d. Auscutating lung sounds after suctioning is complete. Question 2 2.5 out of 2.5 points A client has an upper respiratory infection. Which of the following complementary therapies is more likely to help promote comfort as well as diminish the length of the illlness? Selected Answer: a. Use a warm humidifier with eucalyptus vapors Answers: a. Use a warm humidifier with eucalyptus vapors b. Use over the counter antihistamines and decongestants c. Identify and avoid triggers of allergic reaction d. Increase intake of vitamin C Question 3 2.5 out of 2.5 points A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. On inspection, the throat is reddened and edematous with patchy yellow exudates. The nurse anticipates that collaborative management will include: Selected Answer: d. a throat culture or rapid strep antigen test. Answers: a. treatment with antifungal agents. b. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. c. treatment with antibiotics. d. a throat culture or rapid strep antigen test. Question 4 2.5 out of 2.5 points During an assessment of the patient with viral upper respiratory infection the nurse recognizes that antibiotics may be indicated based on what finding? Selected Answer: d. Dyspnea and severe sinus pain Answers: a. Copious nasal discharge b. Temperature of 99.9 degree farenheit Heart Rate 82 Respirations 22 B/P 144/86 c. Cough and sore throat. d. Dyspnea and severe sinus pain Question 5 2.5 out of 2.5 points Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? Selected Answer: d. Suction the using a Yankauer tonsililar tip catheter PRN Answers: a. Determine the need for replacement of the tracheostomy tube. b. Teach the patient about self-care of the tracheostomy. c. Assess the patient's risk for aspiration. d. Suction the using a Yankauer tonsililar tip catheter PRN Question 6 2.5 out of 2.5 points A client is beign treated for an acute upper respiratory infection. The nurse should instruct the nursing assistants working with the paitent to report which of the following? Selected Answer: b. Excessive nasal discharge , headcahe and muscle aches Answers: a. Pain with inspiration b. Excessive nasal discharge , headcahe and muscle aches c. Night time sweats accompined by elevated temperature d. Blood tinged sputum Question 7 2.5 out of 2.5 points When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which is the first action the nurse willl anticipate taking? Selected Answer: c. Use a swab to obtain a sample for a rapid strep antigen test. Answers: a. Teach the patient about the use of expectorants b. Administer nonsteroidal antiinflammatory drugs (NSAIDs) for throat pain c. Use a swab to obtain a sample for a rapid strep antigen test. d. Discuss the need to rinse the mouth out after using any inhalers. Question 8 2.5 out of 2.5 points Which of the following patients would be the most at risk for aspiration pneumonia (select all that apply)? Selected Answers: a. Patient who is receiving nasogastric tube feeding. c. Patient with seizures. d. Patient with head injury. Answers: a. Patient who is receiving nasogastric tube feeding. b. Patient who had a myocardial infarction. c. Patient with seizures. d. Patient with head injury. e. Patient who had thoracic surgery. Question 9 2.5 out of 2.5 points A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's immediate action to promote airway clearance? Selected Answer: b. Assist the patient to splint the chest when coughing. Answers: a. Instruct the patient on the pursed lip breathing technique. b. Assist the patient to splint the chest when coughing. c. Encourage the patient to wear the nasal oxygen cannula. d. Teach the patient about the need for fluid restrictions. Question 10 2.5 out of 2.5 points A patient suffered a gunshot wound to the left chest. As a result the physician has placed a chest tube attached to a closed chest tube drainage systme. The nurse notes gentle fluctuations, called tidaling, in the water-seal chamber as they inhale and exhale. The nurse should: Selected Answer: b. continue to monitor the patient. Answers: a. lower the dainage collector further from the chest. b. continue to monitor the patient. c. clamp the tubing at progressively distal points away from the patient until the tidaling stops. d. check all connections for a leak in the system. Question 11 2.5 out of 2.5 points A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? Selected Answer: d. Three sputum smears for acid-fast bacilli are negative Answers: a. Chest x-ray shows no upper lobe infiltrates b. Mantoux TB skin test shows an induration less than 10 mm c. TB medications have been taken for 6 months. d. Three sputum smears for acid-fast bacilli are negative Question 12 2.5 out of 2.5 points An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be mosthelpful in reducing the incidence of lung disease? Selected Answer: c. Require the use of protective equipment. Answers: a. Teach about symptoms of lung disease. b. Treat workers with pulmonary fibrosis. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing. Question 13 2.5 out of 2.5 points The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? Selected Answer: d. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath Answers: a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 101.1° F d. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath Question 14 2.5 out of 2.5 points The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? Selected Answer: c. The patient removes the facial mask when misting has ceased. Answers: a. The patient activates the inhaler at the onset of expiration. b. The patient coughs vigorously after using the inhaler. c. The patient removes the facial mask when misting has ceased. d. The patient attaches a spacer before using the inhaler. Question 15 2.5 out of 2.5 points While a nurse is teaching a religious group in a refugee camp about managing tuberculosis, one participant asks why several medications are prescribed. Which of the following repsonses is most appropriate? Selected Answer: b. Ethambutaol (Myambutol) amd Isoniazid (INH) are given at the same time becasue TB is likely to become resistant to one drug Answers: a. Tetracycline and Thioridazine has synergistic efffects b. Ethambutaol (Myambutol) amd Isoniazid (INH) are given at the same time becasue TB is likely to become resistant to one drug c. Streptomycin and Penicillin G potentiate the action of each other d. Pyridoxine and Tetracycline used synergistally prevent the mutation of TB Question 16 2.5 out of 2.5 points Which of the following clients is most likely to develop influenza? Selected Answer: b. A 54 year old with CHF Answers: a. A 44 year old female patient with type 1 diabetes who unerwent a total knee replacement yesturday b. A 54 year old with CHF c. A 72 year old male currently being treated for DVT d. A 68 year old African American patient with a history of CAD and a B/P of 172/94 Question 17 2.5 out of 2.5 points The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? Selected Answer: a. The patient puffs up the cheeks while exhaling. Answers: a. The patient puffs up the cheeks while exhaling. b. The patient practices by blowing through a straw. c. The patient inhales slowly through the nose. d. The patient practices by blowing through a straw. Question 18 2.5 out of 2.5 points The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? Selected Answer: c. Walk 15 to 20 minutes daily at least 3 times/week. Answers: a. Limit exercise to activities of daily living (ADLs). b. Walk until pulse rate exceeds 130 beats/minute. c. Walk 15 to 20 minutes daily at least 3 times/week. d. Stop exercising when short of breath. Question 19 2.5 out of 2.5 points Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced certified nursing assistant (CNA)? Selected Answer: a. Obtain oxygen saturation using pulse oximetry. Answers: a. Obtain oxygen saturation using pulse oximetry. b. Teach the patient about safe use of oxygen at home. c. Adjust oxygen to keep saturation in prescribed parameters. d. Monitor for increased oxygen need with exercise. Question 20 2.5 out of 2.5 points A patient’s blood pressure has not responded to the prescribed drugs for hypertension. Which of the following should the nurse assess first? Selected Answer: c. Patient's compliance to medications therapy. Answers: a. Progressive target organ damage. b. Possible use of recreational drugs. c. Patient's compliance to medications therapy. d. Potential for drug interactions. Question 21 2.5 out of 2.5 points The nurse determines that which of the following blood pressures would meet the criteria for a diagnosis of stage 2 hypertension? Selected Answer: a. 182/94 mmHg Answers: a. 182/94 mmHg b. 126/72 mmHg c. 184/70 mm Hg d. 118/84 mmHg Question 22 2.5 out of 2.5 points What are nonmodifiable risk factors for primary hypertension (select all that apply)? Selected Answers: a. Age b. Genetic Link c. Ethnicity e. Gender Answers: a. Age b. Genetic Link c. Ethnicity d. Obesity e. Gender Question 23 2.5 out of 2.5 points A 64 year old is being treated by his primary care physician for hypertension. His blood pressure is 182/90. He has been complaining of fatigue and headaches. He has been taking metropolol. What action by the patient demonstrates that teaching has been successful? Selected Answer: c. The patient checks his pulse and states,"If I pulse is less than 60 beats in one minute , I will not take my medication." Answers: a. Stops taking his medication because he experineced chest pain b. The patient states , " I will take my blood pressure medication in the morning becasue it will cause me to urinate more." c. The patient checks his pulse and states,"If I pulse is less than 60 beats in one minute , I will not take my medication." d. Take the medication with a glass of orange juice so that it is better absorbed Question 24 2.5 out of 2.5 points The unit is very busy and short staffed. What could be delegated to the certified nursing assistant (CNA)? Selected Answer: c. Obtain orthostatic blood pressure (BP) readings for older patients. Answers: a. Administer antihypertensive medications to stable patients. b. Check BP readings for the patient receiving IV enlapril (Vasotec). c. Obtain orthostatic blood pressure (BP) readings for older patients. d. Teach about home BP monitoring and use of automatic BP monitoring equipment. Question 25 2.5 out of 2.5 points A patient has just been started on a treatment regimen for hypertension which includes an ACE inhibitor, Captopril 50 mg BID. In order to prevent first dose dizziness what will the nurse (RN) need to assess? Selected Answer: d. Orthostatic Blood Pressures Answers: a. A systolic BP>200 mmHg and a diastolic BP>120 mmHg. b. Apical Heart Rate c. Bradycardia d. Orthostatic Blood Pressures Question 26 2.5 out of 2.5 points What is the correct way for the nurse to assess for orthostatic hypotension? Obtain a blood pressure and pule rate with the patient lying down, followed by a B/P and pulse measurement sitting up, and finally both B/P and pulse standing up Answers: Obtain three blood pressure readings beginning with the patient lying down, followed by them sitting , then standing Obtain a blood pressure and pulse rate with the patient standing up , followed by the B/P and pulse sitting down, finally a B/P and pulse lying down Obtain a blood pressure and pule rate with the patient lying down, followed by a B/P and pulse measurement sitting up, and finally both B/P and pulse standing up Obtain both B/P and pulse readings from a patient lying down after they have taken their antihypertensive medications Question 27 2.5 out of 2.5 points Which of the following vital signs demonstrate that a patient is experiencing orthostatic hypotension? B/P 124/86 HR 72 RR 16 Supine B/P 100/72 HR 96 RR18 Sitting B/P 96/56 HR 102 RR 18 Standing Answers: B/P 84/50 HR 120 RR 22 Supine B/P 82/50 HR 122 RR26 Sitting B/P 80/56 HR 120 RR 26 Standing B/P 124/86 HR 72 RR 16 Supine B/P 100/72 HR 96 RR18 Sitting B/P 96/56 HR 102 RR 18 Standing B/P 124/86 HR 50 RR 16 Supine B/P 142/94 HR 50 RR 16 Sitting B/P 158/98 HR 50 RR 15 Standing Question 28 2.5 out of 2.5 points While obtaining patient histories, which patient does the nurse identify as having the highest risk for CAD? Selected Answer: d. A white man, age 54, who is a smoker and has a stressful lifestyle current B/P 184/98. Answers: a. An obese African American man, age 65, with a cholesterol level of 195 mg/dL and a BP of 128/76 mmHg. b. An Asian woman, age 45, with a cholesterol level of 240 mg/dL and a BP of 130/74 mmHg. c. A nonsmoking , white woman, age 48, with a BP of 170/84 mmHg and who is physically inactive. d. A white man, age 54, who is a smoker and has a stressful lifestyle current B/P 184/98. Question 29 2.5 out of 2.5 points What are the manifestations associated with cardiovascular disease (select all that apply)? b. Angina c. Shortness of breath d. Palpitations f. Dysrhythmia Answers: a. Mood swings b. Angina c. Shortness of breath d. Palpitations e. ST-segment-elevation myocardial infarction (STEMI) f. Dysrhythmia Question 30 2.5 out of 2.5 points What causes the pain termed angina? Selected Answer: a. Myocardial oxygen demand exceeds oxygen supply Answers: a. Myocardial oxygen demand exceeds oxygen supply b. Elevated pressure in the ventricles and pulmonary vessels. c. Death of myocardial tissue. d. Dysrhythmias caused by cellular irritability. Question 31 2.5 out of 2.5 points A 52-year-old man is admitted to the emergency department with severe chest pain. On what basis would the nurse suspect an MI as opposed to angina? Selected Answer: c. He reports he has had no relief of the pain with rest or position change Answers: a. He reports nausea and vomited once at home. b. He has a history of hypertension c. He reports he has had no relief of the pain with rest or position change d. He says he is anxious and has a feeling of impending doom. Question 32 0 out of 2.5 points Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? Selected Answer: b. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. Answers: a. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. b. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary. Question 33 2.5 out of 2.5 points A patient with a history of coronary artery disease and angina complains of aching substernal pain as she ambulates to the bathroom. Which of th efollowing is the best action ny the nurse? Selected Answer: c. Administer a dose of PRN Nitroglycerin sublingually per MD orders Answers: a. Call a code 4 if the client is still having pain after taking 3 nitroglycerin 5 minutes apart. b. Administer 2L of O2 per nasal canula c. Administer a dose of PRN Nitroglycerin sublingually per MD orders d. Administer a dose of Tylenol per MD orders Question 34 2.5 out of 2.5 points The acronym FACES is used to help educate patients to identify symptoms of heart failure. What does this acronym mean? Selected Answer: b. Fatigue, limitation of activities, chest congestion/cough, edema, shortness of breath. Answers: a. Factors of risk: activity, cough, emotional upsets, salt intake b. Fatigue, limitation of activities, chest congestion/cough, edema, shortness of breath. c. Frequent activity leads to cough in the elderly and swelling. d. Follow activity plan, continue exercise, and know signs of problems. Question 35 2.5 out of 2.5 points Which initial physical assessment finding would the nurse expect to be present in a patient with acute left sided heart failure? Selected Answer: c. Crackles and tachycardia Answers: a. Frothy blood-tinged sputum and distended jugular veins b. Peripheral edema and cool, diaphoretic skin c. Crackles and tachycardia d. Hepatosplenomegaly and tachypnea Question 36 2.5 out of 2.5 points A patient with chronic heart failure is treated with hydrochlorothiazide, Digoxin, and lisinopril. To prevent the risk of difitalis toxicity with these drugs, what is mostimportant that the nurse monitor for this patient? Selected Answer: b. Potassium levels Answers: a. Blood pressure (BP) b. Potassium levels c. Urinary Output d. Gastrointestinal function Question 37 2.5 out of 2.5 points The nurse determines that treatment of heart failure has been successful when the patient experiences: Selected Answer: c. Clear lung sounds,decreased HR, decrease in edema Answers: a. Improved blood pressure, increase in HR and decrease in fatigue b. Weight loss and diuresis. c. Clear lung sounds,decreased HR, decrease in edema d. Absence of chest pain and improved level of consciousness (LOC). Question 38 2.5 out of 2.5 points Which statement by the patient with chronic heart failure should cause the nurse to determine that additional discharge teaching is needed? Selected Answer: c. "I should weigh myself every morning and go on a diet if I gain more than 2 or 3 pounds in two days." Answers: a. "I will call my health clinic if I wake up breathless at night." b. "I will look for sodium content on labels of foods and over the counter medications." c. "I should weigh myself every morning and go on a diet if I gain more than 2 or 3 pounds in two days." d. "I plan to organize my household tasks so I don't have to constantly go up and down the stairs." Question 39 2.5 out of 2.5 points A patient with a history of left sided heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? Selected Answer: a. Auscultate the breath sounds. Answers: a. Auscultate the breath sounds. b. Check the capillary refill. c. Auscultate the abdomen. d. Assess the level of orientation. Question 40 2.5 out of 2.5 points A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? Selected Answer: d. Monitor the patient's blood pressure and heart rate every hour. Answers: a. Assess the IV insertion site for signs of extravasation. b. Teach the patient the reasons for remaining on bed rest. c. Titrate the rate to keep the systolic blood pressure >90 mm Hg. d. Monitor the patient's blood pressure and heart rate every hour. Question 41 2.5 out of 2.5 points Which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? Selected Answers: a. How to take and record daily weight c. Actions and side effects of prescribed medications d. Date and time of follow-up appointment e. Symptoms indicating worsening heart failure Answers: a. How to take and record daily weight b. Importance of limiting aerobic exercise c. Actions and side effects of prescribed medications d. Date and time of follow-up appointment e. Symptoms indicating worsening heart failure Question 42 2.5 out of 2.5 points A 36 year old patient with type I diabetes mellitus asks the nurse whether an influenze vaccine is necessary every year. What is the best response by the nurse? Selected Answer: c. "You should get the inactivated influenze vaccine that is injected every year." Answers: a. "Only health care workers in contact with high risk patients should be immunized each year." b. "An annual vaccination is not necessary because previous immunity will protect you for several years." c. "You should get the inactivated influenze vaccine that is injected every year." d. "Antiviral drugs, such as zanamivir (Relenze), eliminate the need for vaccine except in the older adult." Question 43 2.5 out of 2.5 points When obtaining a health history form a patient suspected of having early TB, what manifestation should the nurse ask the patient about? Selected Answer: d. Weight loss, night sweats, bloody sputum Answers: a. Pleuritic pain, nonproductive cough, and temperature elevation at night. b. Chest pain, hemoptysis, fatigue c. Cough with purulent mucus and fever with chills. d. Weight loss, night sweats, bloody sputum Question 44 2.5 out of 2.5 points A patient with stage 2 hypertension who is taking hydrochlorothiazide (HydroDiuril) and lisinopril (Prinivil) has prazosin (Minipress) added to the medication regimen. What is most important fo the nurse to teach the patient to do? Selected Answer: c. Change position slowly and avoid prolonged standing. Answers: a. Weight every morning to monitor for fluid retention. b. Take the pulse daily to note any slowing of the heart rate. c. Change position slowly and avoid prolonged standing. d. Use sugarless gum or candy to help relieve dry mouth. Question 45 2.5 out of 2.5 points 1 L of D5W is to be infused in 8 hours by infusion pump. At what hourly rate will the nurse set the infusion pump? Selected Answer: 125 Correct Answer: 125 Answer range +/- 0 (125.0 - 125.0) Question 46 2.5 out of 2.5 points The nurse has available 125 mL of D5W with Heparin 20,000 units infusing at 60 mL/hr. How many units are there per mL? Selected Answer: 160 Correct Answer: 160 Answer range +/- 5 (155.0 - 165.0) Question 47 2.5 out of 2.5 points The nurse (RN) is caring for an adult patient being treated for a myocardial infarction. Oxygen is ordered by the physician. What is the actual problem and rationale for providing the patient with supplemental oxygen? Ineffective Myocardial Perfusion Answers: Anxiety Chest pain Ineffective Myocardial Perfusion Alteration in heart rate, rhythm, and cardiac conduction Question 48 2.5 out of 2.5 points The nurse is planning care for a patient in heart failure. Which of the following goals are appropriate in care planning? (select all that apply) Selected Answers: The patient will demonstrate increased cardiac output The patient will demonstrate increase renal perfusion There will be a decrease in the workload of the heart Answers: The patient will demonstrate increased cardiac output The patient will demonstrate increase renal perfusion There will be a decrease in the workload of the heart There will be a decrease in myocardial contractility Question 49 2.5 out of 2.5 points A 64 year old male patient with a history of chronic CHF is being discharged after being treated for an exacerbation involving SOB and lower extremity edema. To help control the swelling , what intervention should the nurse teach the patient to perform? Selected Answer: Elevate the legs above the level of the heart to promote gravity drainage Answers: Eat a low fat, high protein and low salt diet Elevate the legs above the level of the heart to promote gravity drainage Exercise vigorously three times a week Restrict intake of fluids Question 50 2.5 out of 2.5 points A female patient is admitted to the cardiac unit with the diagnosis of myocadial infarction. The day after admission she tells the nurse that she must go home tonight to care for her two children when her husband goes to work. What nursing diagnosis best describes the problem described? Knowledge deficit r/t disease process Answers: Anxiety related to physical limitations Alteration in cardiac output Imparied home maintenance Knowledge deficit r/t disease process Question 51 2.5 out of 2.5 points In order to prevent possible complications, which of the questions should a nurse ask a client prior to a scheduled cardiac catheterization procedure? Selected Answer: " Do you have any allergies to shellfish?" Answers: " Do you have any allergies to shellfish?" "Have you you ever had a catheterization before?" "Have you ever had a heart attack?" "Do you have a pacermaker?" Question 52 2.5 out of 2.5 points Which of the following cardiac rhythms requires chest compressions? Selected Answer: Ventricular Fibrillation Answers: Atrial Fibrillation Ventricular Fibrillation Ventricular Tachycardia Atrial Flutter Question 53 2.5 out of 2.5 points What is the priority intervention in the plan of care for a patient returning from a cardiac catheterization ? Selected Answer: Assess pedal pulses Answers: Ambulate the client Dangle the client at the edge of the bed Have the client cough and deep breathe Assess pedal pulses Question 54 2.5 out of 2.5 points Which of the following statements made by a client indicates a risk factor for coronary artery disease? Selected Answer: "I smoke 1 1/2 packs of cigareetes per day." Answers: "I exercise four times a week." "I smoke 1 1/2 packs of cigareetes per day." "No one in my family has heart disease." "My cholesterol level is 175." Question 55 2.5 out of 2.5 points A nitroglycrein transdermal patch is prescribed for an adult patient to treat angina. How will the nurse evaluate the effectivness of the medication? Selected Answer: Client reports no episodes of chest pain Answers: Cholesterol levels decrease Blood pressure is maintained WNL Client reports no episodes of chest pain Pulse oximetry is improved Question 56 2.5 out of 2.5 points Which of the following is a manifestation of right-sided heart failure? Selected Answer: Pitting edema Answers: Blood tinged sputum Crackles in both bases of the lungs Cyanosis Pitting edema Question 57 2.5 out of 2.5 points The nurse is caring for a patient who has just had a chest tube inserted which is attached to a portable water-seal drainage system. What should the first action of the nurse be? Selected Answer: Observe the water seal chamber for intermittent bubbling Answers: Flush the chest tubes with normal saline Strip the chest tubes in the direction of the client Maitain the client in a supine position at all times Observe the water seal chamber for intermittent bubbling Question 58 2.5 out of 2.5 points The nurse is ambulating a client who has a chest tube connected to a portable water-seal drainage system. While ambulating the tube disconnects from the collection device. What is the priority action of the nurse? Selected Answer: Insert the distal end of the tube into a glass of water Answers: Insert the distal end of the tube into a glass of water Clamp the tube Assist the client into a sitting position and call the physician Obtain a set of vitals Question 59 2.5 out of 2.5 points Supplemental low-flow oxygen is ordered for a patient with an excaerbation of COPD. Which is the most important action for th enurse to inititate in the care of this client? Selected Answer: Schedule frequent pulse oximetry checks Answers: Schedule frequent pulse oximetry checks Anticpate the need for humidification Notify the physician that this order is contraindicated Keep the client in a High-Folwers position Question 60 2.5 out of 2.5 points A 65 year old client has been smoking since he was 12 years old. He has a history of emphysema amd is admitted to a cardiopulmonary unit due to an acute respiratory infection. Which finding would the nurse expect to observe in the respiratory assessment of this client? Selected Answer: Barrel chest Answers: Abnormal S1 and S2 sounds Barrel chest Labored breathing Obesity
