Question 1

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The physician states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that the consequence of insufficient surfactant is:

Accepted Answer

Surfactant reduces surface tension within the alveoli, preventing their collapse and maintaining lung compliance. Insufficient surfactant leads to alveolar collapse (atelectasis) and decreased lung compliance, making it harder to breathe.

Question 2

The nurse caring for a client with chronic obstructive pulmonary disease ( COPD) anticipates which of the following arterial blood gas (ABG) findings?

Accepted Answer

Chronic obstructive pulmonary disease (COPD) often leads to a state of chronic respiratory acidosis, which is reflected by a lower pH (indicating acidity), elevated PaCO2 (indicating hypoventilation), and compensated by an elevated bicarbonate level (HCO3-) as the body attempts to neutralize the acid. Option B shows these characteristics.

Question 3

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope:

Accepted Answer

A pneumothorax refers to air in the pleural space, which can cause lung collapse. An apical pneumothorax is located at the apex of the lung, near the top. Therefore, to monitor breath sounds in the area of a left apical pneumothorax, the stethoscope should be placed just under the left-sided clavicle, which is closest to the apex of the lung.

Question 4

The nurse would determine that tracheal suctioning is needed if which of the following is noted?

Accepted Answer

Congested breath sounds in the lung fields indicate that there may be secretions obstructing the airways, which can be relieved through tracheal suctioning.

Question 5

The client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which of the following documented in the client's record is an expected finding with this client?

Accepted Answer

Hyperinflation of the lungs is a common finding in clients with COPD, as documented by chest x-ray. This occurs due to the trapping of air in the lungs, leading to their overexpansion.

Question 6

The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which of the following assessment findings would be indicative of further fluid volume deficit?

Accepted Answer

An increase in pulse rate from 100 beats/min to 136 beats/min can indicate a compensatory mechanism for fluid volume deficit, as the heart tries to maintain adequate circulation despite the reduced blood volume.

Question 7

The nurse is preparing to take an apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope at which cardiac site?

Accepted Answer

The mitral area, also known as the apex of the heart, is the recommended location for taking an apical pulse. This area allows for the best auscultation of the heart's apical beat, which is located in the 5th intercostal space at the midclavicular line.

Question 8

The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which of the following conclusions?

Accepted Answer

The normal range for cardiac output is approximately 4 to 8 liters per minute for an average adult. A cardiac output of 3.2 L/min is below this normal range, indicating reduced cardiac efficiency or potential complications post-surgery.

Question 9

The nurse is listening to a 56-year-old client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/min. Which of the following would be an appropriate course of action taken by the nurse?

Accepted Answer

The nurse should withhold the digoxin because a heart rate of 48 beats/min is below the safe threshold for administering the medication. Additionally, the nurse should assess for signs of decreased cardiac output and digoxin toxicity, as digoxin can cause bradycardia and other symptoms of toxicity.

Question 10

The nurse is assisting in admitting a client who has a diagnosis of hypothermia. The nurse anticipates that this client will exhibit which of the following vital signs?

Accepted Answer

Hypothermia, a condition where the body temperature drops below the normal range, leads to a decreased heart rate and decreased blood pressure as the body's metabolic rate slows down in an attempt to conserve heat and energy.

Question 11

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused around reduction of which specific problem associated with this type of heart failure?

Accepted Answer

Left-sided heart failure primarily affects the lungs, leading to pulmonary congestion and resulting in symptoms such as bilateral lung crackles. This is due to the inability of the left side of the heart to effectively pump blood out to the systemic circulation, causing fluid to back up into the lungs.

Question 12

A client with angina complains that the anginal pain is prolonged, severe, and occurs at the same time each day, most often in the morning. On further assessment, a nurse notes that the pain occurs in the absence of precipitating factors. How would the nurse best describe this type of anginal pain?

Accepted Answer

Variant angina, also known as Prinzmetal's angina, is characterized by severe pain that occurs spontaneously, often at rest, and without any obvious precipitating factors. It tends to occur in cycles, often at the same time of day, typically in the early morning hours. This type of angina is caused by a spasm in the coronary arteries.

Question 13

A client's total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching?

Accepted Answer

The client's total cholesterol and LDL-C levels are high, and the HDL-C level is low, all of which are risk factors for cardiovascular disease. Therefore, measures to modify these risk factors should be taught.

Question 14

The ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which of the following areas is unnecessary to emphasize when providing client education for blood pressure control?

Accepted Answer

Limiting protein intake is not specifically related to controlling high blood pressure. Instead, dietary recommendations often focus on reducing salt intake, maintaining a healthy weight, and regular physical activity.

Question 15

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which of the following results would be consistent with the observation?

Accepted Answer

PVCs (Premature Ventricular Contractions) can be associated with electrolyte imbalances, particularly hypokalemia. A serum potassium level of 2.8 mEq/L is low (normal range is approximately 3.5 to 5.0 mEq/L), indicating hypokalemia, which can cause PVCs.

Question 16

The client who has had intracranial surgery is experiencing diabetes insipidus. The nurse understands that the client is experiencing which of the following problems?

Accepted Answer

Diabetes insipidus is characterized by the insufficient production of antidiuretic hormone (ADH), which leads to excessive urination and thirst due to the body's inability to conserve water.

Question 17

The client is admitted to the hospital with a tentative diagnosis of bladder cancer. The nurse expects the client history to reveal which of the following earliest manifestations of the disease?

Accepted Answer

Hematuria (blood in the urine) without pain is often the earliest sign of bladder cancer. Other symptoms like painful urination, proteinuria, and pyuria typically occur later or may be indicative of other conditions.

Question 18

The client with glomerulonephritis has developed acute renal failure (ARF) as a complication. The nurse would expect to note which of the following abnormal findings documented on the client's medical record?

Accepted Answer

Glomerulonephritis can lead to acute renal failure (ARF), which often results in fluid retention and volume overload. This can cause hypertension due to the increased fluid volume the heart has to pump against.

Question 19

The client has been diagnosed with pyelonephritis. The nurse interprets that which of the following health problems has placed the client at risk for this disorder?

Accepted Answer

Diabetes mellitus increases the risk for pyelonephritis due to the higher glucose levels in the urine, which can promote bacterial growth and infection in the urinary tract extending to the kidneys.

Question 20

The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse should avoid which of the following errors in technique when implementing this procedure?

Accepted Answer

The nurse should ask the client to void and discard the first specimen, not save it, and then note the start time for the 24-hour collection.

Quiz 1: Adult Health