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Ati lpn level 3 med surg exam
Ati lpn level 3 med surg exam
Total Questions : 31
Showing 10 questions Sign up for moreA nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?
Explanation
A. Malaise: Malaise is a common symptom of infective endocarditis, indicating generalized discomfort or fatigue. However, it is not an immediate life-threatening condition and does not require urgent intervention.
B. Dyspnea: Dyspnea is the priority because it can indicate heart failure or a pulmonary embolism, both of which are serious complications of infective endocarditis. This requires immediate attention and reporting.
C. Fever: Fever is common in infective endocarditis due to the underlying infection. While important, it is expected and usually managed with antipyretics and antibiotics. It is not as urgent as dyspnea.
D. Anorexia: Anorexia is also a common symptom of infective endocarditis but is not an immediate threat to the client’s health.
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
Explanation
A. Obtain a pair of slipper socks for the client. This is an appropriate action. Slipper socks can provide warmth and help improve circulation, promoting comfort.
B. Increase the client's oral fluid intake. While hydration is important for overall health, it will not directly address the cold feet caused by poor circulation in this scenario.
C. Place a moist heating pad under the client's feet. Heating pads, especially moist ones, can increase the risk of burns and should be avoided in clients with vascular occlusions, as they may have decreased sensation.
D. Rub the client's feet briskly for several minutes. Rubbing the feet briskly could cause skin breakdown and injury due to fragile skin and impaired circulation.
A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?
Explanation
A. The stockings prevent venous stasis. Antiembolism stockings help prevent venous stasis by promoting venous return from the legs to the heart, which helps reduce the risk of deep vein thrombosis (DVT).
B. The stockings prevent varicose veins. Antiembolism stockings are not specifically used to prevent varicose veins. They are primarily used to prevent blood clots and improve circulation after surgery.
C. The stockings replace the need for postoperative leg exercises. Antiembolism stockings do not replace the need for leg exercises. Movement and exercise are still necessary to promote circulation and prevent DVT.
D. The stockings are used to reduce pain. Antiembolism stockings are not designed to reduce pain. Their main purpose is to prevent blood clots and improve circulation.
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
Explanation
A. Soft, pliable calf muscle: A soft and pliable calf muscle is not indicative of a thrombus. Typically, a thrombus leads to swelling and firmness in the affected area.
B. Cool and clammy skin: Cool and clammy skin could indicate poor circulation, but it is not specific to a thrombus.
C. Dull, aching calf pain: Dull, aching calf pain is a key symptom of deep vein thrombosis (DVT) and should prompt further investigation.
D. Temperature > 100°F: A fever could indicate an infection but is not a classic sign of a thrombus.
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?
Explanation
A. "It usually takes at least 2 to 3 days for heparin to dissolve a clot." Heparin does not dissolve clots; it prevents the formation of new clots and stops existing clots from growing.
B. "Heparin prevents new clots from forming rather than dissolving established clots." Heparin's role is to prevent new clots from forming, not to dissolve existing clots. The body's natural fibrinolytic system will eventually break down the clot.
C. "The time it takes for heparin to dissolve a clot depends on the size of the clot." This is incorrect because heparin does not dissolve clots, regardless of their size.
D. "The time it takes heparin to dissolve clots varies between clients." This is incorrect as well, as heparin does not dissolve clots at all.
A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition?
Explanation
A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.
B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.
C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.
D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.
A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?
Explanation
A. Tell the client to take another nitroglycerin tablet in 15 minutes. Nitroglycerin can be taken every 5 minutes, up to three doses, for chest pain. Waiting 15 minutes to take another dose is too long and can delay necessary treatment.
B. Advise the client to take an antacid. Antacids are not appropriate for managing chest pain that may be related to angina or a myocardial infarction. This response may delay critical treatment.
C. Advise the client to come into the office. This would delay care in a potential emergency situation. If the client is experiencing unrelieved chest pain after taking nitroglycerin, immediate emergency care is necessary.
D. Instruct the client to call 911. Chest pain unrelieved by nitroglycerin is a sign of a possible myocardial infarction, which is a medical emergency. The client should call 911 immediately to receive urgent care.
A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?
Explanation
A. Troponin T: Troponin T remains elevated for 10 to 14 days after a myocardial infarction. This protein is highly specific for cardiac muscle injury and is used to confirm myocardial infarction.
B. Creatinine phosphokinase: Creatinine phosphokinase (CPK) typically returns to normal levels within 3 days after a myocardial infarction, so it would no longer be elevated at this point.
C. Myoglobin: Myoglobin rises early after a myocardial infarction but is not specific to heart muscle and returns to normal within 24 hours, so it would not be elevated at this time.
D. Creatinine kinase-MB: Creatinine kinase-MB (CK-MB) usually returns to normal levels within 2 to 3 days after a myocardial infarction, so it is unlikely to still be elevated 6 days later.
A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?
Explanation
A. Nitroglycerin: Nitroglycerin is used to relieve chest pain by dilating coronary arteries and increasing blood flow. However, in the immediate setting of a suspected MI, oxygen is prioritized to ensure adequate oxygenation.
B. Aspirin: Aspirin is essential in the early treatment of MI to prevent further clot formation by inhibiting platelet aggregation, but oxygen would still come first if the client’s oxygenation is compromised.
C. Morphine: Morphine is used for pain relief and to reduce anxiety and oxygen demand on the heart. However, it is administered after ensuring oxygen supply.
D. Oxygen: Oxygen should be administered first in a suspected myocardial infarction to ensure the heart and tissues receive adequate oxygen, especially if the patient is hypoxic.
A nurse is reinforcing teaching with a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions?
Explanation
A. Eggs: Eggs, particularly the yolks, are high in cholesterol and should be limited in a low-cholesterol diet.
B. Milk: Full-fat milk is high in saturated fat and cholesterol. If the client consumes milk, it should be low-fat or non-fat varieties.
C. Beans: Beans are high in fiber and low in fat and cholesterol. They are an excellent choice for a low-cholesterol diet.
D. Liver: Liver is high in cholesterol and should be avoided by clients following a low-cholesterol diet.
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