MCA II Exam 2 | Questions and Answers (Complete Solutions)

MCA II Exam 2 | Questions and Answers (Complete Solutions) Which clinical finding would the nurse expect to identify when caring for a client with a left leg venous thrombosis? select all that apply. a. pain in the left calf b. intermittent claudication c. redness in the affected area d. swelling of the lower left leg e. ecchymotic areas at the left ankle f. localized warmth in the lower left leg A, C, D, F pain is related to the edema associated with the inflammatory response. Redness is related to vasodilation and the inflammatory response. Edema distal to the venous thrombosis occurs because of increased venous pressure. Warmth in the affected part of the leg occurs due to the inflammatory response. Intermittent claudication (pain when walking, resulting from tissue ischemia) may occur with peripheral arterial disease. Ecchymosis is a sign of bleeding and would not be seen with venous thrombosis. A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate: a. Venous insufficiency b. Arterial Insufficiency c. Phlebitis d. Lymphedema clients experiencing arterial insufficiency present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. Clients with venous insufficiency often have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result of impaired flow of the lymphatic system. A client is admitted to the hospital with a long history of uncontrolled hypertension. which laboratory result will be important for the nurse to review? a. blood glucose level b. white blood cell count c. blood urea nitrogen d. lactic dehydrogenase hypertension leads to changes in renal blood flow and eventually to decreased renal function, which is tested with blood urea nitrogen levels. all of the other results would also be reviewed by the nurse, but they are no associated with complications of hypertension. Changes in blood glucose level are not associated with hypertension, although if the client also has diabetes then there will be more risk for kidney disease. White blood cell count is not affected by hypertension, but it would be assessed for any possible infectious or inflammatory process. Lactic dehydrogenase is an enzyme associated with multiple other diagnoses, but it is not affected by hypertension. Which clinical finding would the nurse expect for a client with hypertensive emergency? a. increased urine output b. severe pounding headache c. heart rate 110 beats/min d. weak & thready radial pulses hypertensive emergency often causes hypertensive encephalopathy because of increased cerebral capillary permeability, leading to severe headache, nausea, vomiting, and confusion or coma. Increased urine output would not be expected because acute kidney injury can occur with hypertensive emergency. Tachycardia is not typically seen with hypertensive emergency; high blood pressure can lead to bradycardia because of increased pressure on the carotid sinus and bodies. Radial pulses would be bounding with hypertensive emergency. The nurse is teaching pursed-lip breathing to a client with COPD. The client asks about the benefit of the exercises. Which explanation would the nurse give? a. prevents complications that are associated with COPD b. relieves shortness of breath by increasing the breath rate c. increases the amount of air that the client can inhale with each breath d. keeps the airway open longer to decrease the work that goes into breathing pursed-lip breathing keeps the airway open longer to decrease the work that goes into breathing. clients with COPD are taught to breathe out through pursed lips to help keep the air passages open until exhalation is complete. pursed-lip breathing does not prevent COPD complications. pursed-lip breathing may relieve shortness of breath by decreasing the breath rate. pursed-lip breathing does not increase the amount of air taken in during inspiration. Which finding by the nurse will be of most concern when a client has venous insufficiency? a. bilateral brown lower leg discoloration b. calf pain when the feet are dorsiflexed c. severe edema from ankles to calves d. thickened and dry skin on lower legs calf pain when the feet are dorsiflexed, which is referred to as Homans sign, is a symptoms of possible venous thrombosis and would require further diagnostic testing and treatment. bilateral brown lower leg discoloration is a common symptoms of chronic edema caused by venous insufficiency and would be expected in this client. severe edema is a common and expected symptom of venous insufficiency and may require actions such as leg elevation, but is not as concerning as a positive Homans sign. thick and dry skin is common in chronic venous insufficiency and the nurse will plan to use a lubricating ointment, but it is not as big a concern as a possible venous thrombosis. The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient rapidly inhales the medication. c. The patient attaches a spacer to the Diskus. d. The patient performs huff coughing after inhalation. The patient should inhale the medication rapidly. Otherwise the dry particles will stick to the tongue and oral mucosa and not get inhaled into the lungs. Advair Diskus is a dry powder inhaler; shaking is not recommended. Spacers are not used with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient should not huff cough or exhale forcefully after taking Advair in order to keep the medication in the lungs. The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the inhaler. b. The patient coughs vigorously after using the inhaler. c. The patient removes the facial mask when misting stops. d. The patient activates the inhaler at the onset of expiration. A nebulizer is used to administer aerosolized medication. A mist is seen when the medication is aerosolized, and when all of the medication has been used, the misting stops. The other options refer to inhaler use. Coughing vigorously after inhaling and activating the inhaler at the onset of expiration are both incorrect techniques when using an inhaler. Which information will the nurse include in the asthma teaching plan for a patient being discharged? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators. Tremors are a common side effect of short-acting b2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers. The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. No wheezes are audible. b. O2 saturation is 90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute. The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next? a. Increase the dose of the leukotriene inhibitor. b. Teach the patient about the use of oral corticosteroids. c. Administer a bronchodilator and recheck the peak flow. d. Instruct the patient to keep the scheduled follow-up appointment The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symptoms now and use the bronchodilator. A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about: a. a1-antitrypsin testing. b. leukotriene modifiers. c. use of the nicotine patch. d. continuous pulse oximetry When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in a1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD. which clinical manifestation would the nurse expect to find when assessing a client with varicose veins? select all that apply. a. presence of ankle edema b. increased leg fatigue c. diminished peripheral pulses d. report of leg fullness and pruritus e. leg pain with activity that resolves with rest the presence of ankle edema, increased leg fatigue, and a report of leg fullness and pruritus are all signs of varicose veins, due to poor venous return and increased venous pressure. diminished peripheral pulses occur with decreased arterial blood flow. intermittent claudication (as evidenced by leg pain with activity that resolves with rest) occurs with decreased arterial, not venous, perfusion. Which assessment finding will the nurse expect when caring for a client with peripheral arterial disease? select all that apply a. absence of hair on the toes b. pink and moist ankle ulcers c. pitting edema of the lower legs d. reports of pain associated with exercising e. increased pigmentation of the medial malleolus area the absence of hair on the toes occurs because of diminished circulation. reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when the arterial flow is impaired. pink and moist ulcers are associated with venous insufficiency; arterial ulcers are pale and dry because of decreased blood flow. pitting edema of the lower extremities is associated with venous insufficiency. increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency. Which is the best action for the nurse to take when a client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick"? a. educate the client about the complications associated with high blood pressure. b. ask the client questions to determine the current understanding of high blood pressure. c. emphasize the importance of taking blood pressure medications now to continue to feel well. d. show the client the current blood pressure and compare that with normal blood pressure levels. further assessment of the client's understanding of hypertension and treatment is important before the nurse can develop an effective plan to change the client's behavior. education about complications of hypertension may be helpful, but first the nurse needs to know what the client already understands about the long-term effects of high blood pressure. an emphasis on taking medications now to ensure future health may be appropriate for this client, but further assessment is needed before using this strategy. many clients may respond to actually seeing the difference between their blood pressures and the expected normals, but more information about the client's knowledge is needed to know if this will be a useful strategy for this client. Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? a. Report of chest tightness b. Heart rate of 112 beats per minute c. Expiratory wheezes in both lungs d. Markedly decreased breath sounds Markedly decreased breath sounds may indicate very limited airflow and life-threatening asthma exacerbation. The nurse would immediately check oxygen saturation and anticipate possible need for mechanical ventilation. Clients with asthma exacerbation frequently report chest tightness, but this finding does not indicate possible impending respiratory arrest. Tachycardia is common with asthma exacerbation because of stress and increased work of breathing, but a heart rate of 110 beats per minute is not life threatening. Expiratory wheezes are heard early in asthma exacerbation; inspiratory wheezes are a more ominous finding and indicate further progression of airway obstruction. A client is admitted to the hospital with chronic asthma. Which complication should the nurse monitor in this client? a. atelectasis b. pneumothorax c. pulmonary edema d. respiratory alkalosis as a result of narrowed airways, adequate ventilation of lung tissue is compromised, and alveoli may collapse (atelectasis). pneumothorax is not a common complication of asthma; a collapsed lung is referred to as a pneumothorax. pulmonary edema is not a common complication of asthma; pulmonary edema is caused by left-sided heart failure. respiratory alkalosis is not a common complication of asthma; with narrowed air passages, the client with asthma is at risk for hypoxia and respiratory acidosis. When a client with a large abdominal aortic aneurysm is admitted for elective surgery, which clinical finding would the nurse expect when completing the admission assessment? a. Elevated heart rate b. Visible peristaltic waves c. Radiating abdominal pain d. Pulsating abdominal mass With an abdominal aortic aneurysm, a pulsating midline mass can be palpated with each heartbeat. Signs of shock such as tachycardia would not be expected unless the aneurysm ruptures or dissects. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not typical for an abdominal aortic aneurysm, but may be seen with enlargement or rupture of the aneurysm. A pregnant client with severe asthma is admitted for induction of labor. which medication would the nurse question when performing a medication reconciliation during the admission process? a. albuterol inhaler b. epidural anesthesia c. intravenous D 5W with piggyback oxytocin d. prostaglandin E 2 vaginal suppository One side effect of prostaglandin E2 is bronchoconstriction, which may cause a bronchospasm in a client with asthma. An albuterol inhaler may be used as needed. Epidural anesthesia is not contraindicated for pregnant clients with asthma. Intravenous D 5W with piggyback oxytocin is not contraindicated for a pregnant client with asthma. Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%? a. Level of orientation b. Arterial blood gases c. Bilateral lung sounds d. Complete blood count Clients with COPD who have low oxygen levels respond to oxygen administration. However, some clients with COPD have a respiratory drive that stimulates breathing that is dependent on carbon dioxide. The administration of too much oxygen in these clients lowers respiratory drive and decreases breathing. Therefore, the nurse would assess the client's arterial blood gases to determine how much oxygen to administer. Level of orientation shows the amount of hypoxia the client is experiencing. Clients may have abnormal lung sounds that can impede oxygenation, but this is not the basis for determining oxygen administration. A complete blood count assesses red blood cells, hemoglobin, and hematocrit; these values can be diminished in clients with COPD, but they do not determine oxygen needs. Pulmonary function tests are used to diagnose pulmonary disorders. The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? a. The patient reports a recent 15-lb weight gain. b. The patient denies shortness of breath at present. c. The patient takes cimetidine (Tagamet HB) daily. d. The patient complains of coughing up green mucus. Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not affect whether the theophylline should be administered or not. Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue. The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? a. Chest pain b. Finger clubbing c. Peripheral edema d. Elevated temperature Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not indicators of cor pulmonale. Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? a. Schedule the procedure 1 hour after the patient eats. b. Maintain the patient in the lateral position for 20 minutes. c. Give the prescribed albuterol (Ventolin HFA) before the therapy. d. Perform percussion before assisting the patient to the drainage position Bronchodilators are administered before chest physiotherapy. Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is done while the patient is in the postural drainage position. 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 appropriate for the nurse to include in the plan of care? a. Stop exercising when you feel short of breath. b. Walk until pulse rate exceeds 130 beats/minute. c. Limit exercise to activities of daily living (ADLs). d. Walk 15 to 20 minutes a day at least 3 times/week Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise (80% of the maximal heart rate of 150 beats/min A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? a. Change the O2 flow rate to the highest prescribed rate. b. Teach the patient to use the Flutter airway clearance device. c. Reinforce the ongoing use of pursed-lip breathing techniques. d. Teach the patient about consistent use of inhaled corticosteroids. Airway clearance devices assist with moving mucus into larger airways, where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patient's problem of thick mucus secretions. The nurse completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy? a. The patient uses albuterol (Ventolin HFA) before aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases after using the albuterol (Ventolin HFA) inhaler. d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent). Long-acting b2-agonists should be used only in patients who also are using an inhaled corticosteroid for long term control. Salmeterol should not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min Use of accessory muscle indicates that the patient is experiencing respiratory distress, and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required. Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Scattered crackles and wheezes heard bilaterally c. Complaint of sharp chest pain with deep breathing d. Respiratory rate 28 breaths/minute while ambulating Hemoptysis may indicate life-threatening hemorrhage, and should be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications. The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular physical exercise c. Drinks a beer with dinner every night d. Weight is 5 pounds above ideal weight The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake is within guidelines and will not increase the hypertension risk. Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Teach the patient that headaches often occur with this drug. c. Instruct the patient to call for help if heart palpitations occur. d. Ask the patient to request assistance before getting out of bed. Labetalol decreases sympathetic nervous system activity by blocking both a- and b- adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives. After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient drinks low-fat milk with each meal. d. The patient has two cups of coffee in the morning. For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet. Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of: a. daily alcohol use. b. peptic ulcer disease. c. reactive airway disease. d. myocardial infarction (MI). Nonselective b-blockers block b1- and b2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. b-Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. b-Blocker therapy is recommended after MI.