Page 1 MCA II Exam 2
A 56-yr-old patient who has no previous history of c. diagnosis, treatment, and ongoing monitoring will be needed.
hypertension or other health problems suddenly
develops a blood pressure (BP) of 198/110 mm Hg. A sudden increase in BP in a patient older than age 50 years with no
After reconfirming the BP, it is appropriate for the previous hypertension history or risk factors indicates that the hypertension
nurse to tell the patient that may be secondary to some other problem. The BP will need treatment and
a. a BP recheck should be scheduled in a few weeks. ongoing monitoring. If the patient has no other risk factors, a stroke in the
b. dietary sodium and fat content should be immediate future is unlikely. There is no indication that dietary salt or fat
decreased. intake have contributed to this sudden increase in BP, and reducing intake of
c. diagnosis, treatment, and ongoing monitoring will salt and fat alone will not be adequate to reduce this BP to an acceptable
be needed. level.
d. there is an immediate danger of a stroke, requiring
hospitalization.
After the nurse teaches the patient with stage 1 c. The patient drinks low-fat milk with each meal.
hypertension about diet modifications that should be
implemented, which diet choice indicates that the For the prevention of hypertension, the Dietary Approaches to Stop
teaching has been most effective? Hypertension (DASH) recommendations include increasing the intake of
a. The patient avoids eating nuts or nut butters. calcium-rich foods. Caffeine restriction and decreased protein intake are not
b. The patient restricts intake of chicken and fish. included in the recommendations. Nuts are high in beneficial nutrients and 4
c. The patient drinks low-fat milk with each meal. to 5 servings weekly are recommended in the DASH diet.
d. The patient has two cups of coffee in the morning.
MCA II Exam 2 1
,Page 2 MCA II Exam 2
a client is admitted to the hospital with a long history c. blood urea nitrogen
of uncontrolled hypertension. which laboratory result
will be important for the nurse to review? hypertension leads to changes in renal blood flow and eventually to
a. blood glucose level decreased renal function, which is tested with blood urea nitrogen levels. all
b. white blood cell count of the other results would also be reviewed by the nurse, but they are no
c. blood urea nitrogen associated with complications of hypertension. Changes in blood glucose
d. lactic dehydrogenase level are not associated with hypertension, although if the client also has
diabetes then there will be more risk for kidney disease. White blood cell
count is not affected by hypertension, but it would be assessed for any
possible infectious or inflammatory process. Lactic dehydrogenase is an
enzyme associated with multiple other diagnoses, but it is not affected by
hypertension.
MCA II Exam 2 2
,Page 3 MCA II Exam 2
A client is admitted to the hospital with chronic a. atelectasis
asthma. Which complication should the nurse monitor
in this client? as a result of narrowed airways, adequate ventilation of lung tissue is
a. atelectasis compromised, and alveoli may collapse (atelectasis). pneumothorax is not a
b. pneumothorax common complication of asthma; a collapsed lung is referred to as a
c. pulmonary edema pneumothorax. pulmonary edema is not a common complication of asthma;
d. respiratory alkalosis pulmonary edema is caused by left-sided heart failure. respiratory alkalosis is
not a common complication of asthma; with narrowed air passages, the
client with asthma is at risk for hypoxia and respiratory acidosis.
MCA II Exam 2 3
, Page 4 MCA II Exam 2
During change-of-shift report, the nurse obtains the c. The patient has developed wheezes throughout the lung fields.
following information about a hypertensive patient
who received the first dose of nadolol (Corgard) The most urgent concern for this patient is the wheezes, which indicate that
during the previous shift. Which information indicates bronchospasm (a common adverse effect of the noncardioselective b-
that the patient needs immediate intervention? blockers) is occurring. The nurse should immediately obtain an O2 saturation
a. The patient's pulse has dropped from 68 to 57 measurement, apply supplemental O2, and notify the health care provider.
beats/min. The mild decrease in heart rate and complaint of cold fingers and toes are
b. The patient complains that the fingers and toes feel associated with b receptor blockade but do not require any change in
quite cold. therapy. The BP reading may indicate that a change in medication type or
c. The patient has developed wheezes throughout the dose may be indicated. However, this is not as urgently needed as
lung fields. addressing the bronchospasm.
d. The patient's blood pressure (BP) reading is now
158/91 mm Hg
MCA II Exam 2 4
A 56-yr-old patient who has no previous history of c. diagnosis, treatment, and ongoing monitoring will be needed.
hypertension or other health problems suddenly
develops a blood pressure (BP) of 198/110 mm Hg. A sudden increase in BP in a patient older than age 50 years with no
After reconfirming the BP, it is appropriate for the previous hypertension history or risk factors indicates that the hypertension
nurse to tell the patient that may be secondary to some other problem. The BP will need treatment and
a. a BP recheck should be scheduled in a few weeks. ongoing monitoring. If the patient has no other risk factors, a stroke in the
b. dietary sodium and fat content should be immediate future is unlikely. There is no indication that dietary salt or fat
decreased. intake have contributed to this sudden increase in BP, and reducing intake of
c. diagnosis, treatment, and ongoing monitoring will salt and fat alone will not be adequate to reduce this BP to an acceptable
be needed. level.
d. there is an immediate danger of a stroke, requiring
hospitalization.
After the nurse teaches the patient with stage 1 c. The patient drinks low-fat milk with each meal.
hypertension about diet modifications that should be
implemented, which diet choice indicates that the For the prevention of hypertension, the Dietary Approaches to Stop
teaching has been most effective? Hypertension (DASH) recommendations include increasing the intake of
a. The patient avoids eating nuts or nut butters. calcium-rich foods. Caffeine restriction and decreased protein intake are not
b. The patient restricts intake of chicken and fish. included in the recommendations. Nuts are high in beneficial nutrients and 4
c. The patient drinks low-fat milk with each meal. to 5 servings weekly are recommended in the DASH diet.
d. The patient has two cups of coffee in the morning.
MCA II Exam 2 1
,Page 2 MCA II Exam 2
a client is admitted to the hospital with a long history c. blood urea nitrogen
of uncontrolled hypertension. which laboratory result
will be important for the nurse to review? hypertension leads to changes in renal blood flow and eventually to
a. blood glucose level decreased renal function, which is tested with blood urea nitrogen levels. all
b. white blood cell count of the other results would also be reviewed by the nurse, but they are no
c. blood urea nitrogen associated with complications of hypertension. Changes in blood glucose
d. lactic dehydrogenase level are not associated with hypertension, although if the client also has
diabetes then there will be more risk for kidney disease. White blood cell
count is not affected by hypertension, but it would be assessed for any
possible infectious or inflammatory process. Lactic dehydrogenase is an
enzyme associated with multiple other diagnoses, but it is not affected by
hypertension.
MCA II Exam 2 2
,Page 3 MCA II Exam 2
A client is admitted to the hospital with chronic a. atelectasis
asthma. Which complication should the nurse monitor
in this client? as a result of narrowed airways, adequate ventilation of lung tissue is
a. atelectasis compromised, and alveoli may collapse (atelectasis). pneumothorax is not a
b. pneumothorax common complication of asthma; a collapsed lung is referred to as a
c. pulmonary edema pneumothorax. pulmonary edema is not a common complication of asthma;
d. respiratory alkalosis pulmonary edema is caused by left-sided heart failure. respiratory alkalosis is
not a common complication of asthma; with narrowed air passages, the
client with asthma is at risk for hypoxia and respiratory acidosis.
MCA II Exam 2 3
, Page 4 MCA II Exam 2
During change-of-shift report, the nurse obtains the c. The patient has developed wheezes throughout the lung fields.
following information about a hypertensive patient
who received the first dose of nadolol (Corgard) The most urgent concern for this patient is the wheezes, which indicate that
during the previous shift. Which information indicates bronchospasm (a common adverse effect of the noncardioselective b-
that the patient needs immediate intervention? blockers) is occurring. The nurse should immediately obtain an O2 saturation
a. The patient's pulse has dropped from 68 to 57 measurement, apply supplemental O2, and notify the health care provider.
beats/min. The mild decrease in heart rate and complaint of cold fingers and toes are
b. The patient complains that the fingers and toes feel associated with b receptor blockade but do not require any change in
quite cold. therapy. The BP reading may indicate that a change in medication type or
c. The patient has developed wheezes throughout the dose may be indicated. However, this is not as urgently needed as
lung fields. addressing the bronchospasm.
d. The patient's blood pressure (BP) reading is now
158/91 mm Hg
MCA II Exam 2 4
