Adult Heath Exam 2 - Evolve Book Questions
Terms in this set (21)
The nurse is providing education to help reduce cardiovascular risks for a women's book club. Which statement made by a participant indicates a need for further teaching?
A. "We are more likely to die from cardiovascular disease than men."
B. "We need to walk or do other exercise every day for 30 minutes."
C. "We need to stay away from people who smoke."
D. "We should take hormones for menopause to decrease the risk for heart attack."
Rationale: Medications used in hormone therapy can cause an increased incidence of myocardial infarction or stroke in women.
A client is admitted to the telemetry unit after a right-sided cardiac catheterization. What is the nurse's priority when caring for this client?
A. Assess the intensity and quality of the client's pain.
B. Position the client in a sitting position to improve breathing.
C. Check the client's arterial insertion site.
D. Apply oxygen at 2 L/min via nasal cannula.
Rationale: Patients who have had cardiac catheterization should be restricted to short-term bedrest, and the insertion site extremity should be kept straight. The nurse should assess the insertion site for bloody drainage or hematoma formation because complications with vascular closure devices are not common but can be very serious.
A client who had open abdominal surgery 4 hours ago reports feeling weak and dizzy. The client's current blood pressure has decreased to 98/50, and pulse rate is 108. What is the nurse's best action at this time?
A. Document the vital signs, and continue to monitor the client.
B. Remind the client to stay in bed if feeling weak and dizzy.
C. Call the health care provider immediately.
D. Increase the client's IV rate to restore fluid volume.
Rationale: Surgery or trauma may cause ventricular fibrillation. Symptoms may include faintness, loss of consciousness, and then apnea with pulselessness. The nurse should contact the health care provider immediately.
The health care provider prescribes warfarin (Coumadin) for a client with atrial fibrillation. Which foods will the nurse teach the client taking this drug to avoid? Select all that apply.
D. Brussels sprouts
Answer: A, D
Rationale: Patients taking warfarin (Coumadin) should be taught to avoid foods that are high in vitamin K, as well as herbs such as ginger, ginseng, goldenseal, Ginkgo biloba, and St. John's wort, because all of these may interfere with the drug's action. Spinach and Brussels sprouts are high in vitamin K.
A client is prescribed to take rivaroxaban (Xarelto) 20 mg orally every day. What is the nurse's priority when teaching the client about this drug?
A. "Be sure to keep laboratory appointments to check your clotting times."
B. "Take the medication every morning before breakfast."
C. "Report any signs of bleeding to your health care provider."
D. "Have vitamin K available in case you need it."
Rationale: Reversal agents are not available for this medication. Prothrombin time and international normalized ratio are not accurate predictors of bleeding time. Therefore, the patient should report any signs of bleeding to their health care provide immediately.
A client in the telemetry unit is on a cardiac monitor. The monitor technician notices there are no ECG complexes and the alarm sounds. What is the first action by the nurse?
A. Begin CPR immediately.
B. Call the emergency response team.
C. Press the record button to get an ECG strip.
D. Assess the client and check lead placement.
Rationale: The nurse should first assess the client and check for lead placement to be sure that the leads are intact. If leads are not intact, the rhythm displayed on the monitor may be inaccurate. If all leads are intact, the nurse should implement all other actions immediately thereafter.
A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply.
A. Peripheral edema
B. Crackles in both lungs
Answer: B, C, E
Rationale: Clients with left-sided heart failure will exhibit symptoms such as fatigue, dyspnea or breathlessness, and crackles on auscultation of breath sounds. Peripheral edema and ascites are associated with right-sided heart failure.
A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time?
A. Assess the client's oxygen saturation level.
B. Ask the laboratory to retest the potassium level.
C. Give potassium as an IV infusion.
D. Check the client's serum creatinine.
Rationale: Clients who are hyperkalemic (those with an elevated serum potassium level) may also be in renal failure. The client's serum creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time the health care provider should be notified before administering any supplemental potassium.
An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action?
A. Call the ED physician immediately.
B. Draw a serum digoxin level.
C. Assess for signs of hypokalemia.
D. Establish the client's airway.
Rationale: The clinical manifestations of digoxin toxicity are often vague and nonspecific and include anorexia, fatigue, blurred vision, and changes in mental status, especially in older adults. Older adults are more likely than other patients to become toxic because of decreased renal excretion.
A client who recently had a heart valve replacement is taking warfarin (Coumadin) as prescribed. What statement by the client indicates that the nurse will need to do additional health teaching?
A. "I will take my pulse every day, and call my doctor if it is below 60."
B. "I will eat foods that are high in vitamin K, such as kale and spinach."
C. "I will weigh myself every day in the morning using the same scale."
D. "I will take my blood pressure every day and call if it is too high or low."
Rationale: Patients taking warfarin (Coumadin) should be taught to avoid foods that are high in vitamin K, as well as herbs such as ginger, ginseng, goldenseal, Ginkgo biloba, and St. John's wort, because all of these may interfere with the drug's action. Spinach and kale are high in vitamin K.
A client diagnosed with atherosclerosis has been prescribed lovastatin (Mevacor). Which statement by the client indicates a need for further teaching?
A. "I won't need to change my diet because now I'm taking a pill."
B. "I'll follow up with my nurse practitioner on a regular basis."
C. "I need to quit smoking as soon as I possibly can."
D. "I shouldn't drink grapefruit juice while on this drug."
Rationale: Clients should engage in lifestyle modifications to lower cholesterol and decrease their risk for atherosclerosis. Drug therapy alone is not enough. The client should appropriately continue to follow up with the health care provider; quit smoking; and avoid grapefruit juice, which can interfere with drug efficacy.
A client is prescribed enalapril (Vasotec) for control of hypertension. What health teaching will the nurse provide before the client begins therapy?
A. "You may develop a higher pulse rate."
B. "You may notice some swelling in your feet."
C. "You may develop a nagging cough."
D. "Your diet should include foods high in sodium."
Rationale: The most common side effect of angiotensin-converting enzyme inhibitors such as enalapril (Vasotec) is a nagging, dry cough. Teach clients to report this problem to their health care provider as soon as possible. If a cough develops, the drug is usually discontinued.
The nurse is caring for a client with lower extremity peripheral arterial disease. Which statement made by the client regarding self-management requires further health teaching?
A. "I need to quit smoking as soon as I can."
B. "I will elevate my legs above the level of my heart."
C. "I will use a heating pad to promote circulation."
D. "I will avoid crossing my legs at all times."
Rationale: This patient should avoid raising his or her legs above the heart level because extreme elevation slows arterial blood flow to the feet. Smoking cessation, gently warming the extremity, and avoiding crossing the legs (which interferes with blood flow) can assist in management of peripheral arterial disease.
The nurse is providing care to a client who has started warfarin after being diagnosed with a deep vein thrombosis. What health teaching will the nurse provide to the client related to self-management of warfarin therapy?
A. "You must have your partial thromboplastin time checked every 2 weeks."
B. "Massage the injection site after the warfarin is injected."
C. "Eat plenty of dark green leafy vegetables while taking warfarin."
D. "Report any signs of bleeding to your primary care provider."
Rationale: Any signs of bleeding should be immediately reported to the primary care provider. The client's international normalized ratio will be monitored while the patient is taking warfarin. Injection sites should not be massaged because this could dislodge a clot. Clients who are on warfarin therapy should avoid foods with high concentrations of vitamin K, especially dark, green, leafy vegetables, because they can interfere with the action of warfarin
The nurse is caring for a client with chronic venous stasis ulcers. Which statement by the client indicates a need for further health teaching?
A. "I'll wear compression stockings at night."
B. "I'll keep my affected leg above my heart."
C. "I'll eat protein and vitamin C foods to help heal the ulcer"
D. "I'll change my dressing every 3 to 5 days as needed."
Rationale: Compression stockings should be worn during the day and the evening rather than just at night. Teach the patient to elevate his or her legs for at least 20 minutes four or five times per day. When the patient is in bed, remind him or her to elevate the legs above the level of the heart. Food rich in protein and vitamin C can assist with healing processes. Hydrocolloid dressings are left in place for a minimum of 3 to 5 days for best effect.
An older client has a history of coronary artery disease. Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply.
A. Older age
B. Tobacco use
D. High-fat diet
E. Family history
Answer: B, D, F
Rationale: Modifiable risk factors are those in which the patient can actively make changes to control. The patient can modify tobacco use, dietary selection, and obesity. Being an older adult, being female, and having a family history are nonmodifiable risks.
A client weighing 174 pounds had thrombolytic therapy followed by a one-time dose of IV Lovenox 30 mg. The physician prescribes Lovenox 1 mg/kg subcutaneously after the IV administration. The nurse will give ____ mg of Lovenox to the client.
Rationale: 174 lb = 79 kg (1 lb = 2.2 kg; 174 divided by 2.2 = 79)
The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will the nurse report to the surgeon immediately?
A. Incisional pain
B. Blood pressure of 136/76
C. Decreased level of consciousness
D. Apical pulse of 88
Rationale: A change in level of consciousness should be reported to the surgeon immediately. Incisional pain is to be expected. The blood pressure is only slightly elevated, which can indicate a response to pain; the apical pulse is normal.
Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume?
A. Edema and weight gain
B. Confusion and lethargy
C. Decreased urine output and thirst
D. Increased pulse and respiratory rates
Rationale: Both reduced urine output and thirst are stimulated by a decreasing circulating blood volume. When people can respond to thirst by drinking, the action compensates temporarily by increasing circulating fluid volume. Decreased or absent urine output compensates by preventing a greater fluid loss. The fluid that would have been lost from the body as urine is retained. This is why hourly urine output measurements are such a sensitive indicator for whether shock is improving or progressing. Edema and weight gain are not compensations for circulating blood volume. Confusion and lethargy are responses to circulating blood volume, not compensation to improve it. Increasing pulse and respiratory rates compensate for hypoxia, not for reduced volume.
Which change in laboratory value or clinical manifestations in a client with hypovolemic shock indicates to the nurse that current therapy may need to be changed?
A. Urine output increases from 5 mL/hour to 6 mL/hour
B. Pulse pressure decreases from 28 mm Hg to 22 mm Hg
C. Serum potassium level increases from 3.6 mEq/L to 3.9 mEq/L
D. Core body temperature increases from 98.2° F (36.8° C) to 98.8° F (37.1° C)
Rationale: A compensatory response to shock is vasoconstriction. Initially, the diastolic pressure increases but systolic pressure remains the same. As a result, the difference between the systolic and diastolic pressures (pulse pressure), is smaller or "narrower." When interventions are inadequate and shock worsens, systolic pressure decreases as cardiac output decreases. This causes the pulse pressure to narrow even further, indicating that shock is progressing. Although an increase in urine output usually signals improvement, a change of 1 mL/hr is within the margin of measurement error and is meaningless in this situation.
Which clinical manifestation in a client alerts the nurse to the probability of septic shock instead of hypovolemic shock?
B. Pale, clammy skin
C. Decreased urine output
D. Oozing of blood at the IV site
Rationale: The manifestations of hypotension, pale and clammy skin, and decreased urine output are associated with any type of shock, including hypovolemic shock and septic shock. Sepsis and septic shock, however, are associated with disseminated intravascular coagulation, which consumes clotting factors and leaves the client at high risk for hemorrhage. One of the earliest manifestations of septic shock is bleeding from any area of nonintact skin, including IV insertion sites.