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NUR236 Test one
| Question | Answer |
|---|---|
| A nursing assessment that is most important in the care of a patient with a deep vein thrombosis is to assess for | sudden acute pain |
| A secondary cause of peripheral arterial disorders is | diabetes mellitus. |
| An acute sign of inadequate arterial blood supply to the feet is: | pale, cool, mottled skin |
| the patient is taking digoxin and a thiazide diuretic. This combination of medications increases the risk for cardiac dysrhythmias related to: | hypokalemia. |
| The medication cilostazol (Pletal) is used for patients experiencing intermittent claudication to: | relax vessel walls and increase blood flow to the legs. |
| Upon assessment, signs of abdominal aortic aneurysm include: | back pain and possibly a visible pulsation of the abdomen. |
| factors that contribute to the formation of varicose veins include | 1. gaining too much weight. 2. standing regularly for long periods of time. 3. pregnancy. |
| When providing postoperative care for a patient following a carotid endarterectomy, which assessment finding is the priority concern? | increasing hoarseness |
| Teaching for a patient discharged on warfarin (Coumadin) includes keeping appointments for frequent laboratory tests to check the: | International Normalized Ratio value and/or prothrombin time |
| prothrombin time indicates | the time taken by the blood to form a clot |
| Which medication is the most common and effective anti-platelet aggregation agent? | Aspirin |
| Percutaneous transluminal angioplasty (PTA) | done to open an artery to reduce claudication symptoms and improve extremity perfusion |
| The nurse observes an inflamed excoriated area on the patient's right shin. Which intervention should the nurse perform first? | Cover with clear occlusive dressing |
| The nurse is caring for a patient with a deep venous thrombosis (DVT). Which medication would likely be used for intial inpatient treatment? | Heparin |
| The nurse is teaching a patient who takes warfarin (Coumadin) about a coagulation monitoring device. Which blood clotting time should the device monitor? | INR |
| INR | A coagulation monitoring device measures the INR level for clotting time for a person on therapeutic doses of warfarin |
| Which problems are potential complications of uncontrolled hypertension? | 1. Stroke 2. Kidney failure 3. Heart attack 4. Congestive heart failure |
| Which findings characterize peripheral vascular disease | 1. Narrowed arteries 2. Obstructed veins 3. Defective valve function 4. Thrombophlebitis |
| Which words compose part of the "5 P's" of arterial disease? | 5 P's of arterial disease are pain, pulselessness, pallor, paresthesias, and paralysis |
| Intermittent claudication | is inadequate arterial supply to muscles in the lower extremities that results in severe cramping of the muscles with activity. |
| A patient complains of burning and numbness in her hands and states that "they turn really red" if she is in an air-conditioned environment for too long. The nurse would anticipate which diagnosis? | Raynaud disease |
| A patient with varicose veins wears elastic support hose. The nurse knows these stockings serve which purpose? | Promote venous return. |
| The nurse is caring for a patient with peripheral vascular disease (PVD). The nurse understands that which age-related changes may cause PVD? | 1. Loss of elasticity in vessel walls 2. Atherosclerotic changes in vessels 3. Sedentary practices 4. Weakened leg muscles |
| Varicose veins | are enlarged, tortuous veins engorged with pooled blood. Veins that develop varicosities have incompetent valves that allow reflux of blood from the deep to the superficial veins |
| Which intervention(s) is/are important for a patient with venous insufficiency? | 1. Elevate feet to reduce edema 2. Apply elastic compression wraps twice daily |
| Classic signs and symptoms of thrombophlebitis include | swelling, redness, warmth, and considerable tenderness and pain on touching the affected extremity |
| A patient diagnosed with peripheral arterial disease complains of a sudden onset of pain in the right foot. Identify the nursing actions in priority order. | 1. Check for pedal and posterior tibial pulses 2. Note the color, temperature, and capillary refill of the foot 3. Check vital signs 4. Notify the health care provider |
| You are receiving a patient who has angioplasty and stenting of the right femoral artery. Which nursing intervention would take priority in the immediate postoperative period? | Checking right pedal pulses |
| Bleeding gum and petechiae will indicate | (DIC), It is a fatal condition caused by the coagulation inside all the blood vessels. |
| How does long-term alcohol abuse lead to alteration in the immune system? | Alcohol impairs the ability of B lymphocytes to produce antibodies |
| A person has been exposed to an allergen resulting in a hypersensitivity reaction. The nurse correctly recognizes that which immunoglobulin has been triggered? | IgE |
| The nurse is educating a patient about his diagnosis of stage II Hodgkin Disease. Which statement indicates that the nurse's teaching has been successful? | "Two nodes in my left are are affected" |
| The industrial nurse should teach all middle-aged employees to receive a tetanus booster how often? | Every 10 years |
| Which assessment finding indicates that the patient actually may have fibromyalgia | A pain response to non-painful stimuli |
| Which statements about passive immunity are true? | - Passive immunity prevents further tissue damage - Passive immunity provides temporary immunity from the disease |
| A patient with an immune deficiency has been admitted to the medical unit due to a current infection and weight loss of 12% of his body weight. Which nutritional interventions are most appropriate for this patient | increase protein intake |
| The nurse reviewing lab results notes that the C-reactive protein is elevated in the patient who had surgery 2 days ago. The nurse is aware this is an indication of: | Impending infection |
| The nurse has just administered a new antibiotic to a patient. Which manifestation is the early indicator that the patient may be experiencing an anaphylactic reaction? | Angioedema |
| The nurse differentiates the humoral response from the cell-mediated response in that in cell-mediated response | the sensitized lymphocytes attack the cell for which they were sensitized |
| The nurse caring for an immunosuppressed patient would include in the care considerations to: | - Adhere to standard precautions - Avoid bringing potted plants into the patient's room - Employ reverse isolation - Use filters on air conditioner vents |
| The nurse clarifies that the lymphocytes that actually produce either sensitized lymphocytes or antibodies are the: | B lymphocytes |
| What is necessary for a humoral immune response to occur? | Presence of a particular antibody that responds to an antigen |
| The patient sustains trauma to the right lower extremity. To reduce the pain and edema associated with the inflammatory response, which action would the nurse perform first? | Assess the distal pulses and sensation to touch. |
| What is the purpose of giving “booster doses” of an immunizing agent, such as tetanus toxoid? | Stimulates the memory of plasma cells and thereby stimulates synthesis of greater quantities of antibody |
| The nurse is reviewing a patient’s laboratory values. Which laboratory value indicates that the patient is having the desired response to antibiotic therapy? | an increase in WBCs |
| Your patient has had blood drawn to measure the level of several immunoglobulins. What is the most important factor to consider when interpreting the results? | Age of the patient |
| A patient is diagnosed with herpes zoster. What is the drug of choice for herpes? | Acyclovir (Zovirax) |
| The patient comes to the clinic for a physical examination and HIV testing. He tells the nurse that he thinks he may have been recently exposed to HIV. Which assessment item(s) should be included at this point? | 1. Sexual history 2. IV drug use 3. Current medications 4. Vital signs |
| Which group of drugs commonly tends to cause allergies in many people? | Aspirin, barbiturates, anticonvulsants, and antibiotics |
| Which problems are related to the use of antihistamines in aging males? | Hesitancy and urinary retention |
| A patient was recently diagnosed with systemic lupus erythematosus. Which sign(s) and symptom(s) would the nurse expect to find documented in this patient’s medical record? | Painful or swollen joints Red rash usually on the face Fatigue and weakness Unexplained fever Sensitivity to the sun |
| which medications are likely to be prescribed for a patient with systemic lupus erythematosus? | NSAIDs and prednisone |
| The health care provider recommends that a patient be scheduled for a diagnostic test to detect presence of Reed-Sternberg cells in the tissues to rule out lymphatic cancer. Which diagnostic test will detect these cells? | Biopsy of the lymph nodes |
| The patient asks the nurse to explain some of the differences between Hodgkin and non-Hodgkin. What information about Hodgkin is correct? | It is less widespread through the lymphatic tissues. |
| B-cells secrete | immunoglobulins that are called antibodies. |
| The CDC recommends that older adults, people with respiratory impairment, and health care workers acquire | annual influenza immunization |
| produced and mature in the bone marrow and play a significant role in the humoral immune response. | B lymphocytes |
| Bone marrow produces | all types of blood cells |
| Lymph nodes and lymph | contains nutrients such as proteins, glucose, monocytes, and lymphocytes. |
| The lymph system removes | what is left over after the plasma has delivered nutrients to the cells. |
Created by:
snmartin
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