PN2 EXAM 2 QUESTIONS AND ANSWERS & STUDY GUIDE 2 Rasmussen College

PN2 EXAM 2 QUESTIONS AND ANSWERS & STUDY GUIDE 2 Risk factors for the development of pneumonia include which of the following? • advanced age and immobility Which of these presenting complaints is associated with the client who has pneumonia? • a high fever with sudden onset Which tests confirm a diagnosis of TB? • chest X-ray and sputum culture Pharmacological treatment of active TB consists of: • a 6-month regime of isoniazid, rifampin, and pyrazinamide Which of the following factors may cause an episode of extrinsic asthma? • food additives Which asthma patient would the nurse assess first? • A 27-year-old patient with a heart rate of 120 beats/min Which patient with COPD would the nurse assess first? • A 52-year-old in a tripod position using accessory muscles to breathe A patient has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? • Educating the patient on adherence to the med regimen What outcome demonstrates that goals for a pneumonia patient type have been met? • Antibiotics started before admission A pt. is being discharged on long-term therapy for (TB). What referral by the nurse is most appropriate? • Visiting nurses for directly observed therapy The nurse has a positive PPD during the last testing cycle for tb Which of the following is indicated for this nurse? • Pharmacological treatment A client is being treated for exacerbation of copd. Which of the following nursing interventions should be done? • Initiate oxygen at 1 L/min via nasal cannula Which of the following medications should the client be instructed not to use during an acute asthma attack? • Serevent The client should be aware that albuterol may cause: • nervousness What is the MOST common source of chemical pneumonia? • inhalation of irritating substances What is the main goal for the treatment of a client with pneumonia? • clearing of exudate from the airway and adequate oxygenation If a client has a positive skin test for tuberculosis (TB), the nurse knows this result indicates that the client: • has been infected with and has formed antibodies against tuberculosis Which of these terms describes an asthma attack that persists and does not respond to treatment? • status asthmaticus The sac that surrounds and protects the heart is called the: • Pericardium When listening to heart sounds, the valve closures that heard at the base of the heart are: • Aortic and pulmonic The pacemaker: • SA Node Pt. getting up multiple times at night with dib. What might you ask? • Do you have any history of problems with your heart?” Baby sleeps right after feeding and anything strenuous. What should you ask? • Presence of dyspnea or diaphoresis when sucking What does a swooshing blowing sound indicate? • Blood flow turbulence During an assessment of a healthy adult, where would the nurse palpate the apical impulse? • Fifth left intercostal space at the midclavicular line Major blood supply to arm: • Brachial Where to palpate dorsalis pedis. • Lateral to the extensor tendon of the great toe Which vein(s) is(are) responsible for most of the venous return in the arm? • Superficial Which of these people are highest at risk for venous disease? • Person who has been on bed rest for 4 days Pain that comes when walking and stops with rest. • Claudication Pain that gets worse with elevation and better when dangling the legs. • Problems related to arterial insufficiency What kind of pulse would you assess with hyperthyroidism? • Bounding What skin might look like with venous stasis. • Brownish discoloration to the skin of the lower leg What bruits represent: • Occur with turbulent blood flow, possible occlusion The nurse sees that the patient has dilated, tortuous veins in her lower legs and is pregnant: • Varicose veins What does a doppler sound like? • Swishing whooshing Fingers turn red, white and blue: • Reynaud phenomena What does a 2+ pulse mean? • Normal What is essential hypertension? • “It is hypertension that has no cause" Which nonpharmacologic comfort measure should the nurse implement for pericarditis? • Provide a pillow for client to lean forward on What to teach a heart failure patient about energy conservation: • Gather all supplies before doing a task Which question should the nurse ask to assess the extent of the client’s heart failure when a pt. has a hx of HF? • “Are you able to walk upstairs without fatigue?” Which assessment finding should the nurse expect to find with pericarditis? • Friction rub at the left lower sternal border Which infection control precautions should the nurse use for infective endocarditis? • Standard Precautions A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? • Assess the client’s respiratory status Which statement by the client alerts the nurse to the possibility of right-sided heart failure? • My shoes fit really tight lately Best meal for high cholesterol: • Baked chicken breast, broccoli, tomatoes A nursing student is caring for a pt with an abdominal aneurysm. What action by the student requires the RN to intervene? • Palpates the abdomen in four quadrants A nurse is caring for a client with a (DVT). What nursing assessment indicates a priority outcome has been met: • Oxygen saturation of 98% A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the UAP • Apply a warm moist pack. A patient has peripheral arterial disease (PAD). What statement by the patient shows need for further teaching? • I can use a heating pad on my legs if it’s set on low Which finding is most concerning for a patient with Atherosclerosis? • Triglycerides: 198 mg/dL How can a pt get rheumatic heart disease? • streptococcal infection Nursing interventions for a client in the acute stage of bacterial endocarditis? • Administration of analgesics as needed The client with a recent diagnosis of cardiomyopathy asks the nurse, “What contributed to my getting this illness: • unknown cause The nurse assesses the foot of a pt that has become suddenly cold, painful, and pulseless. What should he/she do next? (if you’ve already assessed you not gonna assess again!) • Call the physician During a routine physical examination, a client reports recent occipital headaches, blurred vision, fatigue? • Hypertension Name this rhythm: • A-Fib Quizzes 1. Following an acute myocardial infarction, a previously healthy 63-yr-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about Angiotensin- converting enzyme (ACE) inhibitors 2. A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take first? Assess the patient's respiratory status 3. A nurse assesses a patient after administering isosorbide mononitrate (Imdur). The patient reports a headache. What action would the nurse take? Administer PRN acetaminophen 4. A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? "I must stop halfway up the stairs to catch my breath." 5. A nurse assesses patients on a cardiac unit. Which patient would the nurse identify as being at greatest risk for the development of left-sided heart failure? A 36-year-old woman with aortic stenosis 6. The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? "I can expect some swelling around my lips and face." 7. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? Reduced dyspnea with the head of bed at 30 degrees 8. A nurse is caring for a patient with a deep vein thrombosis (DVT). What nursing assessment indicates that a priority outcome has been met? Oxygen saturation of 98% 9. The nurse is evaluating a 3-day diet history with a patient who has an elevated lipid panel. What meal selection indicates that the patient is managing this condition well with diet? Baked chicken breast, broccoli, tomatoes 10. The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning? Triglycerides: 198 mg/dL 11. A nurse is teaching a patient with heart failure who has been prescribed enalapril (Vasotec). Which statement would the nurse include in this patient's teaching? "Avoid using salt substitutes." 12. The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? No regular physical exercise 13. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include notify the health care provider if nausea develops 14. A nurse teaches a patient who has a history of heart failure. Which statement would the nurse include in this patient's discharge teaching? "Weigh yourself daily while wearing the same amount of clothing." 15. A nurse teaches a patient who is prescribed digoxin (Lanoxin) therapy. Which statement would the nurse include in this patient's teaching? "Do not take this medication within 1 hour of taking an antacid." 16. The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that she will call the clinic if her weight goes up 3 pounds in 1 week 17. A nursing student is caring for a patient with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? Palpates the abdomen in four quadrants 18. A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? "Most people with hypertension do not have symptoms." 19. A patient has just been diagnosed with hypertension and has been started on captopril. Which information is most important to include when teaching the patient about this drug? Change position slowly to help prevent dizziness and falls. 20. A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of drugs will the nurse plan to include when teaching about PAD management? Statins 21. A patient is 4 hours postoperative after a femoral-popliteal bypass. The patient reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? Assess distal pulses and skin color. 22. A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as paroxysmal nocturnal dyspnea 23. A patient with chronic heart failure who is taking a diuretic and an angiotensin- converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. The nurse's priority action will be to assess the patient for clinical manifestations of acute heart failure 24. A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? "It is hypertension with no specific cause." 25. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? Palpating both carotid arteries at the same time 26. When discussing risk factor modification for a patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus teaching on which patient risk factor? Uncontrolled hypertension 27. When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will “use a heating pad on my feet at night to increase the circulation." 28. Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension? Ask the patient to request assistance before getting out of bed. 29. While assessing a 65-year-old with ascites, the nurse also notes (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates increased right atrial pressure. 30. While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? Assess for symptoms of left- sided heart failure 31. The nurse is assisting the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client? Skim milk, oatmeal, banana, OJ, coffee 32. Which statement indicates that the client understands teaching about the use of long-acting beta2 agonist medications? “I will take this medication daily to prevent an acute attack” 33. A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? Potassium of 2.9 mEq/L 34. The nurse is caring for four clients with asthma. Which client does the nurse assess first Client whose heart rate is 120 beats/min 35. The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? Middle-aged woman with aortic stenosis 36. The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective? Increasing fluids to 2 L/day if tolerated 37. A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? Decrease in tissue perfusion 38. The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client’s right foot. What condition do these findings correlate with? Peripheral arterial disease 39. What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.) Avoid drinking fluids just before and during meals. Rest before meals if you have dyspnea. Have about six small meals a day. 40. The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions? “I will give my canned soups to the food pantry.” 41. A nurse assesses a patient who reports waking up feeling very tired, even after 8 hours of good sleep. What action would the nurse take first? Ask the patient if he or she has ever been evaluated for sleep apnea. 42. A nurse assesses patients on the medical-surgical unit. Which patient is at greatest risk for development of obstructive sleep apnea? A 55-year-old woman who is 50 lbs (23 kg) overweight 43. While assessing a patient who has facial trauma, the nurse auscultates stridor. The patient is anxious and restless. What action would the nurse take first? Contact the provider and prepare for intubation. 44. A nurse is caring for a patient who has sleep apnea and is prescribed modafinil (Provigil). The patient asks, “How will this medication help me?” How would the nurse respond? “This medication will promote daytime wakefulness.” 45. A patient is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? Visiting nurses for directly observed therapy 46. A nurse admits a patient from the emergency department. Patient data are listed below: History Physical Assessment Laboratory Values 70 years of age Crackles and rhonchi heard WBC: 5,200/mm3 (5.2 ´ History of diabetes throughout the lungs 109/L) On insulin twice a day Dullness to percussion LLL PaO2 on room air 85 Reports new-onset dyspnea and Afebrile mm Hg productive cough Oriented to person only What action by the nurse is priority? Administer oxygen at 4L per nasal cannula 47. A nurse assesses a patient with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions would the nurse take? (Select all that apply.) Administer prescribed albuterol (Proventil) inhaler. Administer oxygen to keep saturations greater than 94%. 48. A nurse assesses a patient who has a mediastinal chest tube. Which symptoms require the nurse’s immediate intervention? (Select all that apply.) Tracheal deviation Sudden onset of SOB Drainage greater than 70 mL/hr Disconnection at Y site 49. A nurse assesses a patient with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the patient’s activity tolerance? (Select all that apply.) “Have you lost any weight lately?” “Do you have any difficulty sleeping?” “How long does it take to perform your morning routine?” 50. A nurse plans care for a patient who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this patient’s plan of care? (Select all that apply.) Ask the patient to drink 2 L of fluids daily Use a vibrating positive expiratory pressure device Add humidity to the prescribed oxygen 51. A nurse cares for a patient who is prescribed an intravenous prostacyclin agent. What actions would the nurse take to ensure the patient’s safety while on this medication? (Select all that apply.) Use strict aseptic technique when using the drug delivery system. Ensure that there is always a backup drug cassette available. Keep an intravenous line dedicated strictly to the infusion Use strict aseptic technique when using the drug delivery system. 52. A home health nurse evaluates a patient who has chronic obstructive pulmonary disease. Which assessments would the nurse include in the patient’s evaluation? (Select all that apply) Examination of mucous membranes and nail beds Measurement of rate, depth, rhythm of respirations Determine the patient’s need and use of oxygen 53. A nurse is teaching a patient how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.) “Breath out slowly without puffing your cheeks” “Use your abdominal muscles to squeeze air out of your lungs” “Exhale at least twice the amount of time it took to breathe in” 54. A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What patients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) Patient who is taking medication for hypertension 22-year-old patient with asthma Healthy 72-year-old patient Patient with well-controlled diabetes Patient who is taking medication for hypertension 55. A hospital nurse is participating in a drill during which many patients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) Doxycycline (Vibramycin) Amoxicillin (Amoxil) Ciprofloxacin (Cipro) 56. A patient in the emergency department is taking rifampin (Rifadin) for tuberculosis. The patient reports of yellowing of the sclera and skin and bleedings after minor trauma. What laboratory results correlate to this condition? (Select all that apply) Prothrombin time: 35 seconds International normalized ratio (INR): 6.3 57. A patient has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this patient? Assisting with chest tube insertion Providing antipyretics as needed Performing frequent respiratory assessment Facilitating pleural fluid sampling 58. The emergency department nurse is participating in a bioterrorism drill in which several patients are suspected to have inhalation anthrax. Which patients should the nurse see as the priorities? (Select all that apply.) Stridor Oxygen saturation of 91% Diaphoresis Cardiac Heart failure causes: hypertension is #1 cause- more volume, more pressure; valvular heart disease Left sided heart failure: blood not moving forward into the aorta and out to the body, it will backwards into the (lungs?) Can be acute/chronic, mild/severe. Further broken into two more categories: systolic HF or diastolic HF L Ventricular systolic dysfunction: cardiac output diminished- leading to impaired tissue perfusion, anerobic metabolism and unusual fatigue. Assess activity tolerance: perform ADLs or climb stairs without fatigue or dyspnea? Causes: Hypertension, coronary artery disease, and valvular disease s/s: pulmonary congestion, dyspnea, cough, blood tinged frothy sputum, restlessness, tachycardia *S3, *orthopnea, *nocturnal dyspnea. Chest discomfort, palpitations. Oliguria during day, nocturia at night. Confusion, pallor, weak pulses. Cool extremities. **Decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels indicate left ventricular failure (LVF). Tx: ace inhibitors (preferred as first tx but can cause a dry cough so prescribe ARBs) , ARBs Diet: low sodium, DASH diet! Increase fruits, vegetables, low fat dairy foods pt. teaching: Right sided heart failure: blood not moving forward into the lungs, goes backward into the venous system Right sided heart failure in the absence of left sided HF is usually result of pulmonary probs such as COPD or pulmonary hypertension Causes: Left ventricular HF, Right ventricular MI, or pulmonary hypertension s/s: *Jugular (neck vein) distention, enlarged liver/spleen, edema, distended abdomen, polyuria at night, weight gain, increased BP from fluid excess or decreased BP due to failure **Increased volume and pressure develop in the venous system, and peripheral edema results. Shoes may fit tighter; socks may leave indentations. Nausea/Anorexia may result from liver engorgement resulting from fluid retention. An adult may retain 4-7 liters of fluid before pitting edema occurs Weigh daily! Best indicator of increased fluid. Report weight over 2lbs. Tx: diuretics and venous vasodilators. Furosemide, torsemide, bumetanide most effective for treating fluid volume overload pt. teaching: Infective (Bacterial) Endocarditis Caused by rheumatic fever, tooth extractions, street drugs Precautions: antibiotics before dental cleaning/dental sx, S&S: low grade fever, anorexia, chills, petechia on face; mimics the flu!! Diagnosing: Labs- **blood culture or Echo Pericarditis