Exam (elaborations)
NUR257 Exam 2 - Questions And Accurate Answers
NUR257 Exam 2 - Questions And Accurate Answers
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NUR257 Exam 2 - Questions And Accurate AnswersA client with a confirmed DVT is being discharged from the ED. Which
client statement indicates that the client has received proper nursing
instruction and understands how to manage this condition?
"I should try not to drink too much during the daytime."
"I should lie on my side with my knees bent when sleeping."
"I need to ice my leg every 2 hours for about 20 minutes."
"I need to do my leg exercises five times or more every hour." Correct
Ans - "I need to do my leg exercises five times or more every hour."
A nurse is caring for a client who had an aortic balloon valvuloplasty. The
nurse should inspect the surgical insertion site closely for which
complication(s)?
Bleeding and infection
Bleeding and wound dehiscence
Thrombosis and infection
Evisceration Correct Ans - Bleeding and infection
A client who recently had a myocardial infarction develops pericarditis and
complains of chest pain rated 6 (on a scale of 0-10) with deep breathing.
Which ordered pro re nata medications is most appropriate for the nurse to
administer?
Morphine sulfate 6 mg IVP every 2-4 hours
Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours
Acetaminophen 650 mg PO every 4 hours
Ibuprofen 800 mg PO every 8 hours Correct Ans - Ibuprofen 800
mg PO every 8 hours
The nurse instructs a client recovering from mechanical valve replacement
surgery. Which client statement indicates that teaching has been effective?
"I can play soccer in a week or two."
"I will not drive until informed by my health care provider."
"I have a low risk of developing an infection in my heart."
"I will not need to take anticoagulant medication every day." Correct
Ans - "I will not drive until informed by my health care provider."
A nurse is caring for a client receiving warfarin therapy following a
mechanical valve replacement. The client had a prothrombin time and
,International Normalized Ratio (INR) drawn before breakfast. The
laboratory report shows the client's INR reading was 4. What is the nurse's
first priority ?
Assess the client for bleeding and notify the health care provider of the
results.
Notify the next nurse on afternoon shift to hold the evening dose of
warfarin.
Notify the health care provider to request an increase in the warfarin dose.
Be prepared to administer an I.M. vitamin K injection and notify the
healthcare provider of the results. Correct Ans - Assess the client
for bleeding and notify the health care provider of the results.
The nurse suspects a client has developed pericarditis after a week of cold-
like symptoms. Which of the client's signs and symptoms indicate
pericarditis?
low urine output secondary to left ventricular dysfunction
fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
pitting edema, chest discomfort, and nonspecific ST-segment elevation
lethargy, anorexia, and heart failure Correct Ans - fever, chest
discomfort, and elevated erythrocyte sedimentation rate (ESR)
A client is admitted to the hospital with aortic stenosis. What assessment
findings would indicate the development of left ventricular failure?
Orthopnea, nausea, pedal edema
Distended jugular veins, pedal edema, nausea
Dyspnea, orthopnea, pulmonary edema
Dyspnea, distended jugular veins, orthopnea Correct Ans -
Dyspnea, orthopnea, pulmonary edema
Which would the nurse stress as a periodic lifelong necessity for a client
managing infective endocarditis?
Exercise regimen
Antihypertensive medication
Potassium replacement
Antibiotic therapy Correct Ans - Antibiotic therapy
The nurse is caring for a client who has been diagnosed with aortic
stenosis. The client is prescribed digoxin. What is the rationale for the
medication?
,left ventricular dysfunction
angina
dyspnea
edema Correct Ans - left ventricular dysfunction
A client is admitted to the hospital with possible acute pericarditis and
pericardial effusion. The nurse knows to prepare the client for which
diagnostic test to confirm the client's diagnosis?
Computed tomography
Echocardiography
Chest x-ray
Cardiac catheterization Correct Ans - Echocardiography
A client comes to the clinic reporting fever, chills, and sore throat and is
diagnosed with streptococcal pharyngitis. A nurse knows that early
diagnosis and effective treatment is essential to avoid which preventable
disease?
Rheumatic fever
Cardiomyopathy
Pericarditis
Mitral stenosis Correct Ans - Rheumatic fever
The nurse is educating a client about the care related to a new diagnosis of
mitral valve prolapse. What statement made by the client demonstrates
understanding of the teaching?
"I will take antibiotics before getting my teeth cleaned."
"I can get my tongue pierced at a store in the shopping mall."
"I will avoid caffeine, alcohol, and smoking."
"I can get a tattoo at a local parlor." Correct Ans - "I will avoid
caffeine, alcohol, and smoking."
A nurse is caring for a client with aortic stenosis whose compensatory
mechanisms of the heart have begun to fail. The nurse will monitor the
client carefully for which initial symptoms?
Dizziness, nausea, diarrhea
Exertional dyspnea, orthopnea, pulmonary edema
Syncope, fever, vomiting
Nausea, vomiting, exertional fatigue Correct Ans - Exertional
dyspnea, orthopnea, pulmonary edema
, The nurse is assessing a client admitted with infective endocarditis. Which
manifestation would the nurse expect to find?
Bruising on the palms of the hands and soles of the feet
Raised red rash on the trunk and face
Involuntary muscle movements of the extremities
Small painful lesions on the pads of the fingers and toes Correct Ans -
Small painful lesions on the pads of the fingers and toes
During assessment of a client admitted for cardiomyopathy, the nurse notes
the following symptoms: dyspnea on exertion, fatigue, fluid retention, and
nausea. The initial appropriate nursing diagnosis is which of the following?
Ineffective airway clearance
Disturbed sensory perception
Decreased cardiac output
Autonomic dysreflexia Correct Ans - Decreased cardiac output
A nurse and a nursing student are performing a physical assessment of a
client with pericarditis. The client has an audible pericardial friction rub on
auscultation. When leaving the room, the student asks the nurse what
causes the sound. The nurse's best response is which of the following?
"The layers of the heart become loose from each other and rub together
with each heart beat."
"The lung surfaces lose their lubrication and rub against the myocardium
with each heart beat."
"The great vessels rub against the pericardium with each heart beat."
"The pericardial surfaces lose their lubricating fluid because of
inflammation and rub against each other." Correct Ans - "The
pericardial surfaces lose their lubricating fluid because of inflammation
and rub against each other."
The nurse determines that a patient has a characteristic symptom of
pericarditis. What symptom does the nurse recognize as significant for this
diagnosis?
Dyspnea
Fatigue lasting more than 1 month
Uncontrolled restlessness
Constant chest pain Correct Ans - Constant chest pain
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