Which dietary restriction will the nurse expect to be included in the plan for a client with left

Adventitious

Rationale - Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheeze, and pleural friction rubs.

Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds.

Bronchial sounds are louder and higher pictched and resemble air blowing through a hollow pipe.

Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.

A nurse reviews the plan of care for a client who is recovering from the acute phase of left ventricular failure. The nurse expects which dietary restriction to be included on the plan?

1. Sodium

2. Calcium

3. Potassium

4. Magnesium

1. Sodium

A primary healthcare provider prescribes atenolol 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to include in the discharge teaching plan for this client?

1. Drink alcoholic beverages in moderation.

2. Avoid abruptly discontinuing the medication.

3. Increase the medication if chest pain develops.

4. Report a pulse rate less than 70 beats per minute.

2. Avoid abruptly discontinuing the medication.

Which pH value of the blood is usually fatal?

1. 7.91

2. 6.91

3. 7.36

4. 7.40

1. 7.91

Which foods rich in vitamin C act as dietary supplement for wound healing? Select all that apply.
1. Broccoli

2. Cabbage

3. Legumes

4. Red meat

5. Strawberries

6. Riboflavin-enriched cereals

1. Broccoli

2. Cabbage

5. Strawberries

When monitoring fluids and electrolytes, the nurse recalls that the major cation regulating intracellular osmolarity is what?

1. Sodium

2. Potassium

3. Calcium

4. Calcitonin

2. Potassium

A client with hypertension is to follow a 2-gram sodium diet. Which client statement provides evidence that the nurse's dietary instructions are understood?

1. "My fluid intake should be restricted."

2. "I should limit the number of daily food servings."

3. "Salt should not be used during cooking but can be used at the table."

4. "Labels on prepackaged food products should be evaluated before purchase."

4. "Labels on prepackaged food products should be evaluated before purchase."

A client with a tentative diagnosis of pernicious anemia is scheduled for a Schilling test. Which body process associated with vitamin B 12 is assessed with the Schilling test?

1. Storage

2. Digestion

3. Production

4. Absorption

4. Absorption

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings?

1. Refer the client to a nutritionist after providing health teaching about a low-sodium diet.

2. Place the client in a recumbent position and call the paramedics for transport to the hospital.

3. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service.

4. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

4. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic?

1. Causes mild perspiration

2. Occurs after moderate exercise

3. Continues after rest and nitroglycerin

4. Precipitates discomfort in the arms and jaw

3. Continues after rest and nitroglycerin

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client?

1. Renin causes a gradual decrease in arterial pressure.

2. Lipid plaque formation occurs within the arterial vessels.

3. Development of atheromas within the myocardium is characteristic.

4. Mobilization of free fatty acid from adipose tissue contributes to plaque formation.

2. Lipid plaque formation occurs within the arterial vessels.

The client is receiving multiple blood transfusions after having extensive abdominal surgery. If the client develops fever, chills, and lower back pain, and seems very nervous, what will be the nurse's first action?

1. Notify the blood bank

2. Notify the health care provider

3. Reduce the rate of the blood transfusion

4. Stop the blood and infuse normal saline

4. Stop the blood and infuse normal saline

Metoprolol (Toprol-XL) is prescribed for a client with hypertension. For which side effect should the nurse monitor the client?

1. Hirsutism

2. Bradycardia

3. Restlessness

4. Hypertension

2. Bradycardia

A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. The nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when what happens?

1. Sublingual tingling is experienced.

2. The tablets are more than three months old.

3. The pain is unrelieved, but facial flushing is increased.

4. Onset of relief is delayed, but the duration of relief is unchanged.

2. The tablets are more than three months old.

A 28-year-old woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the nurse's best response?

1. "Give me your name and address. I am sending an ambulance to your home. You need emergency care."

2. "It sounds as if your cast may be constricting the blood flow in your leg. You probably need a new cast."

3. "It sounds like you are having an allergic response to the medication. Can you drive yourself to the hospital?"

4. "You are experiencing a pulmonary embolism. You need to come to the emergency department now for care."

1. "Give me your name and address. I am sending an ambulance to your home. You need emergency care."

What does a nurse who is caring for a client experiencing anginal pain expect to observe about the pain?

1. Unchanged by rest

2. Precipitated by light activity

3. Described as a knifelike sharpness

4. Relieved by sublingual nitroglycerin

4. Relieved by sublingual nitroglycerin

A client with type 1 diabetes asks what causes the several brown spots that have been noted on the skin.
What is the nurse's best response?

1. "The brown spots reflect the accumulation of blood fats in the skin; they should disappear."

2. "The brown spots indicate a high glucose content in the skin, which may get infected if left untreated."

3. "The brown spots are the result of diseased small vessels in the shins and may spread if not treated soon."

4. "The brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

4. "The brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Which blood types can be used?

1. Type O positive

2. Type AB positive

3. Type A or O negative

4. Type A or AB negative

3. Type A or O negative

Which client is most likely to report experiencing fatigue?

1. A client with peripheral edema

2. A client limiting vigorous activity

3. A client with increased oxygen demand

4. A client with increased body temperature

3. A client with increased oxygen demand

A client is admitted to the emergency department with a blood pressure of 240/150 mm Hg. The client complains of a severe headache, blurred vision, and swelling of the ankles. In response to the clinical manifestations, what should the nurse do?

1. Obtain a glucose blood sample

2. Collect urine and blood samples

3. Assess the client's pulse and respirations

4. Place the client on bed rest in the supine position

3. Assess the client's pulse and respirations

A client experiences fatigue, chest pain, and dyspnea caused by low tissue perfusion after exercise. Which symptom might also occur in this client?

1. Edema

2. Syncope

3. Orthopnea

4. Increased body temperature

2. Syncope

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis?

1. Perform leg exercises

2. Sit with the knees flexed

3. Apply warm soaks to the legs daily

4. Put on elastic stockings before arising

4. Put on elastic stockings before arising

A client is recovering from a myocardial infarction. Before developing the client's teaching plan, it is important for the nurse to do what?

1. Identify the learning needs of the client

2. Determine the nursing goals for the client

3. Evaluate the community resources available to the client

4. Explore the use of group teaching for the client

1. Identify the learning needs of the client

The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement?

1. "Red blood cells appear normal in size and color; however, there is a decreased amount produced."

2. "The red blood cells have an increased life span with a decrease in normal functioning."

3. "Administration of vitamins B 12 and folate will help to treat this type of long-term anemia."

4. "This is the mildest form of anemia and is easily corrected through administration of blood products."

1. "Red blood cells appear normal in size and color; however, there is a decreased amount produced."

The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. The teaching includes that the client will be what?

1. Ambulated shortly after being transferred to the inpatient room after the procedure.

2. Given a general anesthesia and therefore will be asleep during the procedure.

3. In the supine position with the affected leg extended for several hours postprocedure.

4. Given only clear liquids for the remainder of the procedure day.

3. In the supine position with the affected leg extended for several hours postprocedure.

What should the nurse suggest for a client with right ventricular failure?

1. "Take a hot bath before bedtime."

2. "Avoid emotionally stressful situations."

3. "Avoid sleeping in an air-conditioned room."

4. "Exercise daily until the pulse rate exceeds 100 beats per minute."

2. "Avoid emotionally stressful situations."

What is the priority nursing action when caring for a client with disseminated intravascular coagulation?

1. Monitor for Homan sign.

2. Avoid giving intramuscular injections.

3. Take temperatures via the rectal route.

4. Apply sequential compression stockings.

2. Avoid giving intramuscular injections.

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? Select all that apply.

1. Anxiety

2. Chest pain

3. Irregular pulse

4. Fear of losing control

5. Feelings of depersonalization

1. Anxiety

2. Chest pain

3. Irregular pulse

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client?

1. Warm, flushed skin

2. Increased pulse pressure

3. Lethargy with confusion

4. Reduced peripheral pulses

...

A nurse is caring for a client with the diagnosis of right ventricular failure. Which condition unrelated to cardiac disease is the major cause of right ventricular failure?

1. Renal disease

2. Hypovolemic shock

3. Severe systemic infection

4. Chronic obstructive pulmonary disease (COPD)

4. Chronic obstructive pulmonary disease (COPD)

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? Select all that apply.

1. Decreased urine

2. Hypotension

3. Dyspnea

4. Dry mucous membranes

5. Pulmonary edema

6. Poor skin turgor

1. Decreased urine

2. Hypotension

4. Dry mucous membranes

6. Poor skin turgor

Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? Select all that apply.

1. Increase the client's intravenous (IV) flow rate

2. Massage the client's extremities with lotion

3. Place the client's legs in pneumatic stockings

4. Instruct the client to avoid crossing the legs

5. Instruct the client to dorsiflex the feet routinely

4. Instruct the client to avoid crossing the legs

5. Instruct the client to dorsiflex the feet routinely

A nurse is monitoring a child for toxicity precipitated by digoxin. For what sign of digoxin toxicity will the nurse assess the child?

1. Oliguria

2. Vomiting

3. Tachypnea

4. Splenomegaly

2. Vomiting

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect?

1. Decreased cardiac output

2. Decreased stroke volume of the heart

3. Increased contractile force of the myocardium

4. Increased electrical conduction through the atrioventricular (AV) node

3. Increased contractile force of the myocardium

A client with stage III-B Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the health care provider to seek treatment for which response to chemotherapy?

1. Fever of 100°F

2. Sores in the mouth

3. Moderate diarrhea after treatment

4. Nausea for six hours after treatment

2. Sores in the mouth

A client with heart failure is digitalized and placed on a maintenance dose of digoxin (Lanoxin) 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved?

1. Diuresis and decreased pulse rate

2. Increased blood pressure and weight loss

3. Regular pulse rhythm and stable fluid balance

4. Corrected heart murmur and decreased pulse pressure

1. Diuresis and decreased pulse rate

Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricle failure?

Which foods will the nurse discuss when teaching a client who has a new prescription for warfarin?

What should the nurse teach a client who is taking antihypertensives?

Which substance would the nurse expect to be deficient in a client with hemophilia A?