Exam 1 Flashcards by Nhi Trieu

As a member of the healthcare team that is caring for a client in the refractory stage of shock, which of the following would be your best nursing intervention?
a. Provide opportunities for the family to spend time with the client and help them to understand this stage of shock
b. Inform the client’s family that the patient is terminal and encourage them to make funeral plans
c. Closely monitor fluid replacement therapy and inform the family that the client should make a full recovery
d. Protect the client’s airway, optimize intravascular volume, and support the pumping action of the heart

a. Provide opportunities for the family to spend time with the client and help them to understand this stage of shock

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When caring for a client with mitral valve stenosis, it is most important that the nurse assess for
a. Abdominal tenderness
b. Peripheral edema
c. Right upper quadrant tenderness
d. Complaints of shortness of breath

d. Complaints of shortness of breath

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Which of these findings is the best indicator that the fluid resuscitation for a client with hypovolemic shock has been successful?
a. Hemoglobin 11 gm/dL
b. Heart rate = 115 beats/min
c. Respiratory rate = 28 breaths/min
d. Mean arterial pressure (MAP) is 75 mmHg

d. Mean arterial pressure (MAP) is 75 mmHg

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A nurse in the emergency department is caring for a client who has anaphylaxis after taking her third dose of Augmentin. Which of the following is the priority intervention?
a. Observe for periorbital edema
b. Evaluate for itching
c. Auscultate for wheezing
d. Monitor for nausea

c. Auscultate for wheezing

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A client is admitted with a urinary tract infection that is rapidly progressing to urosepsis. Which of the following would alert the nurse to a complication of sepsis?
a. Increasing fatigue, blood pressure 121/78, pulse 88, O2 stats 95%
b. ABGs reported as pH 7.45, CO 38, HCO3 21
c. Capillary refill <3 sec, lungs clear to auscultation, bowel sounds present
d. Oliguria, patient repeatedly requests water to drink

d. Oliguria, patient repeatedly requests water to drink

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Three days after a myocardial infarction (MI), the client develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which actions should the nurse take next?
a. Palpate the radial pulses bilaterally
b. Assess the feet for peripheral edema
c. Auscultate for a pericardial friction rub
d. Assess the client’s urine output

c. Auscultate for a pericardial friction rub

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A client admitted with a gastrointestinal ulcer is NPO and has a nasogastric tube connected to low suction. The nurse monitors the client for which type of shock?
a. Anaphylactic shock
b. Septic shock
c. Cardiogenic shock
d. Hypovolemic shock

d. Hypovolemic shock

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The nurse will plan discharge teaching about the need for prophylactic antibodies when having dental procedures for the client who
a. Was admitted with a large acute myocardial infarction
b. Is being discharged after an exacerbation of heart failure
c. Has had a mitral valve replacement with a mechanical valve
d. Has been treated for rheumatic fever after a streptococcal infection

c. Has had a mitral valve replacement with a mechanical valve

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The client who has had a mechanical valve replacement asks the nurse why he must take anticoagulants for the rest of this life. How will the nurse respond?
a. “You are at greater risk for a heart attack, and the anticoagulants can reduce that risk.”
b. “You are at greater risk of forming blood clots with a mechanical replacement valve.”
c. “The vein taken from your leg reduces circulation in the leg, making blood return to the heart much slower.”
d. “The surgery left a lot of small clots in your heart and lungs. The anticoagulants will slowly dissolve these.”

b. “You are at greater risk of forming blood clots with a mechanical replacement valve.”

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The nurse has identified an approved NANDA diagnosis of acute pain related to inflammatory process for a client with acute pericarditis. The most appropriate intervention by the nurse for this problem is to
a. Force fluids to 3000 mL/day to decrease fever and inflammation
b. Instruct the patient to remain supine to decrease complaints of pain
c. Administer nitroglycerin PRN to improve myocardial perfusion
d. Position the patient in Fowler’s position, placing them in a tripod position

d. Position the patient in Fowler’s position, placing them in a tripod position

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The nurse obtains a health history from a client with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?
a. “Have you been to the dentist lately?”
b. “Do you have a history of a heart attack?”
c. “Is there a family history of pericarditis?”
d. “Have you had a flu vaccine?”

a. “Have you been to the dentist lately?”

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What pulse change might a nurse expect in the presence of cardiac tamponade?
a. Bounding pulse
b. Pulse deficit
c. Irregularly irregular pulse
d. Pulsus paradoxus

d. Pulsus paradoxus

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After receiving information about four clients during change-of-shift report, which clients should the nurse assess first?
a. Client with pericardium who has positional chest pain
b. Client who has just returned to the unit after balloon valvuloplasty
c. Client who has heart failure and a heart rate of 85
d. Client with a mitral valve replacement who has an anticoagulant scheduled

b. Client who has just returned to the unit after balloon valvuloplasty

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The home care nurse is assessing the client has been receiving long term antibiotic therapy in the home for infective endocarditis. Which of the following clinical manifestations requires re-evaluation of the treatment regimen?
a. Temperature 101.6F
b. Sphincter hemorrhages present to nail beds
c. Petechiae
d. Mean arterial pressure 78 mm Hg

a. Temperature 101.6F

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A nurse is caring for a postoperative client that has lost a significant amount of blood during surgery. Which set of vital signs suggest that the client has hypovolemic shock?
a. HR 122, BP 145/89, RR 18
b. HR 115, BP 89/60, RR 24
c. HR 50, BP 92/60, RR 16
d. HR 62, BP 139/80, RR 12

b. HR 115, BP 89/60, RR 24

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Important teaching for a patient with paroxysmal arterial fibrillation scheduled for radiofrequency catheter ablation procedure included explaining that
a. Ventricular bradycardia may be induced and treated during the procedure
b. A catheter will be placed in both femoral arteries to allow double-catheter use
c. The procedure will destroy areas of the conduction system that are causing rapid heart rhythms
d. A general anesthetic will be given to prevent the awareness of any sudden cardiac death experiences

c. The procedure will destroy areas of the conduction system that are causing rapid heart rhythms

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When planning care for a client hospitalized with a streptococcal infective endocarditis (IE), which interventions will the nurse include?
a. Monitor WBC count, activity tolerance, and neurologic status
b. Arrange for a dietary consult
c. Encourage the patient to get regular aerobic exercise
d. Teach the importance of maintaining a normal blood pressure and cholesterol

a. Monitor WBC count, activity tolerance, and neurologic status

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A nurse just received a client from the emergency room with the diagnosis of septic shock from bilateral pneumonia. The client’s vital signs are: blood pressure 78/54 mm Hg, pulse 130 beats/minute, RR 30 breaths/minute. What would be the nurse’s first step in managing this client?
a. Perform sputum culture to identify the sensitivity for accurate choice of antibiotics
b. Obtain a 12-lead ECG and arterial blood gases
c. Administer norepinephrine by intravenous infusion
d. Rapidly administer 1000 mL normal saline solution IV

d. Rapidly administer 1000 mL normal saline solution IV

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Which information obtained by the nurse when assessing a client admitted with mitral valve regurgitation should be communicated to the health care provider immediately?
a. The patient has 4+ peripheral edema in both legs
b. The patient has crackles audible to the lung apices
c. The patient has a palpable thrill felt over the left anterior chest
d. The patient has a new onset nausea and vomiting

b. The patient has crackles audible to the lung apices

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Which assessment is most important for the nurse to make in order to evaluate whether treatment of a client with anaphylactic shock has been effective?
a. PERRLA
b. Orientation
c. Bowel sounds
d. Oxygen saturation

d. Oxygen saturation

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Which clinical finding would most likely indicate decreased cardiac output in a client with aortic valve regurgitation?
a. Reduction in peripheral edema and weight
b. Jugular venous distention
c. Dizziness and diminished peripheral pulses
d. Increased preload and abdominal distention

c. Dizziness and diminished peripheral pulses

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Which of these orders written by the health care provider for a client admitted with infective endocarditis (IE) and a fever should the nurse implement first?
a. Obtain blood cultures drawn from two sites
b. Give acetaminophen (Tylenol) PRN for fever
c. Administer ceftriaxone (Rocephin) 1 g IV
d. Obtain a transesophageal echocardiogram

a. Obtain blood cultures drawn from two sites

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Which assessment information obtained by the nurse for a client with aortic stenosis would be most important to report to the health care provider?
a. The patient complains of chest pain associated with ambulation
b. A systolic murmur is audible along the right sternal border
c. The auscultated heart rate = 100 beats/min
d. The point of maximum impulse (PMI) is at the left midclavicular line

a. The patient complains of chest pain associated with ambulation

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The nurse is caring for the client who has aortic valve replacement. To decrease the risk of deep vein thrombosis and pulmonary emboli, which interventions should the nurse plan to include? Select all that apply a. Apply a pneumatic compression device b. Administer a continuous heparin infusion intravenously c. Encourage coughing and deep breathing hourly d. Teach patient how to perform isometric leg exercises e. Avoid the use of graded compression elastic stockings

a. Apply a pneumatic compression device b. Administer a continuous heparin infusion intravenously d. Teach patient how to perform isometric leg exercises

A client has just undergone a balloon valvuloplasty. Which of the following assessment findings suggest the presence of a life-threatening post operative complication? a. Decrease in blood pressure of 20 mm hg with inspiration b. Lower extremity weakness and stiffness c. Short-term memory loss and fatigue d. Clear breath sounds bilaterally

a. Decrease in blood pressure of 20 mm hg with inspiration

A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first? a. Notify the charge nurse immediately b. Administer the medication to the correct patient c. Check the patient’s vital signs d. Complete an incident report to disclose a medication error

c. Check the patient’s vital signs

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the client with infective endocarditis (IE) based on the assessment finding of a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae of the buccal mucosa and conjunctiva d. Increase in pulse rate of 15 beats/minute with activity

b. Urine output less than 30 mL/hr

The nurse is caring for several clients on the acute care cardiac unit. Which client is at highest risk for the development of atrial fibrillation? a. A middle-aged client who takes an aspirin daily b. A client with end stage heart failure c. An older adult client with iron deficiency anemia d. An older adult with diabetes mellitus e. A client with a recent colonoscopy

b. A client with end stage heart failure

The nurse finds the client unresponsive with the following ECG rhythm, what is the first action that the nurse will take?

Defibrillate

A client's ECG tracing shows the above rhythm. What is the first action that the nurse will take?

Assess the client's pulse, breathing, and LOC

The nurse is teaching a class on dysrhythmias and associated therapy. The nurse asks the class, “Which cardiac dysrhythmias would result in the lowest cardiac output, and what treatment would be effect?” The class best demonstrates understanding by responding that _____ results in the lowest cardiac output, and treatment includes _____. a. Atrial flutter, lidocaine b. Tachycardiac, atropine c. First-degree heart block, verapamil d. Ventricular fibrillation; defibrillation

d. Ventricular fibrillation; defibrillation

A client who is complaining of a racing heart and nervousness comes to the emergency department. The nurse places the client on a cardiac monitor (HR 183) and obtains the following ECG tracing (13 QRS)

Obtain the client's blood pressure and oxygen saturation

A client with a history of endocarditis and mitral valve regurgitation develops the following cardiac rhythm on telemetry ECG. The client has the following vital signs, HR 32, BP 80/36. The client reports feeling faint. Which actions should the nurse take?

Apply the transcutaneous pacemaker

Which physiologic alteration would be consistent with the ECG strip HR 232

Decreased cardiac output

A nurse is auscultating a client’s heart sounds and hears an extra heart sound before what should be considered the first heart sound (S1). The nurse should document this finding as which of the following heart sounds? a. S4 b. Friction rub c. S3 d. Split S2

a. S4

The nurse caring for a client with the following ECG. What is the correct interpretation of this rhythm?

ST depression

A 21-year-old student arrives at the student health center at the end of the semester complaining that, “My heart is skipping beats.” An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take first? a. Have the patient transported to the hospital emergency department (ED) b. Administer O2 at 2 to 3 L/min using nasal prongs c. Ask the client about any history of coronary artery disease d. Question the client about current stress level and coffee use

d. Question the client about current stress level and coffee use

A client experiences dizziness and SOB for several days, HR 52 beats. During cardiac monitoring in the ED the nurse obtains the following ECG tracing. The nurse interprets this cardiac rhythm as

Afib

How will the nurse prioritize care for the patient with cardiac rhythms? (1 QRS spiked and wide)

Assess the patient for SOB and obtain vital signs

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The following rhythm is seen via EKG. Which of the labs is the most important for the nurse to address first?

INR 1.5

Which information will the nurse include when teaching a client who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response? a. The pacemaker prevents or minimizes ventricular contraction b. The pacemaker paces the atria at rates up to 150 impulses/minutes c. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur d. The pacemaker stimulates a heartbeat if the patient’s heart rate drops too low

d. The pacemaker stimulates a heartbeat if the patient’s heart rate drops too low

The nurse is reviewing the EKG strip of a client with prolonged vomiting. Which abnormality on the client’s EKG should the nurse interpret as a sign of hypokalemia? a. U wave b. Elevated ST segment c. Wide QRS d. Inverted P wave e. Peaked T waves

a. U wave

The nurse identifies the above rhythm and called the healthcare provider to report?

STEMI

The nurse is planning care for clients on the medical surgical unit. For which client should the nurse remail alert for the possible development of septic shock? a. 22-year-old man with history of pneumonia b. 52-year-old man taking beta blockers for hypertension c. 47-year-old woman who has iron deficiency anemia d. 68-year-old woman with a UTI and body temperature of 97.1 e. 90-year-old woman with a cough and normal lab values

d. 68-year-old woman with a UTI and body temperature of 97.1

A nurse is caring for a client who has rhythm below HR 40. Which of the following assessment findings should concern the nurse?

Client's creatinine is 2.8 Client is unsteady when out of bed Client reports SOB Client potassium is 2.9

Nursing students are studying the cardiovascular system. One student asks the instructor about cardiac tamponade. What should the instructor tell the students? a. Pressure in the pericardial sac increases, causing fluid to leak through b. Pressure in the pericardial sac increases, compressing the lungs c. Pressure in the pericardial sac increases, compressing the heart d. Pressure in the pericardial sac increases, causing it to rupture

c. Pressure in the pericardial sac increases, compressing the heart

A nurse is caring for a client with ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? a. The pacemaker spikes after each QRS complex b. The pacemaker spikes on each P wave c. The pacemaker spikes before each QRS complex d. The pacemaker spikes with each T wave

c. The pacemaker spikes before each QRS complex

A patient with a mechanical mitral valve who is taking warfarin (Coumadin) has an international normalized ratio (INR) value of 5.2. The nurse’s initial response to this lab value is to: a. Administer an additional dose of warfarin (Coumadin) b. Request that the physician place the patient on heparin c. Hold the dose of warfarin and contact the provider d. Prepare the patient for possible thrombolytic therapy

c. Hold the dose of warfarin and contact the provider

Which clinical finding would most likely indicate decreased cardiac output in a patient with some aortic valve regurgitation? a. Reduction in peripheral edema and weight b. Carotid venous distention and new onset atrial fibrillation c. Significant pulses paradoxus and diminished peripheral pulses d. Shortness of breath in minimal exertion and a diastolic murmur

d. Shortness of breath in minimal exertion and a diastolic murmur

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessment data should indicated to the nurse that the client may have development atrial fibrillation? a. Differing blood pressure measurements in bilateral upper extremities greater than 10 mm Hg b. Differing radial and apical pulses c. Different oral and axillary temperatures d. Differences in upper and lower lobe lung fields

b. Differing radial and apical pulses

An ICU nurse is caring for a patient who had an open-heart surgery (CABG) 3 days ago but now is acutely demonstrating symptoms of cardiogenic shock. Which clinical manifestation would be of most concern to the nurse? a. Mean arterial pressure of 58 mm Hg, and cold, clammy skin b. Agitation, respiratory rate of 30 breaths/minute, and serum creatinine level of 2.6 mg/dL c. PaO2 of 45 mm Hg, serum lactate of level of 46 mcg/dL, and bleeding from the chest incision d. Restlessness, heart rate of 128 beats/minute, and hypoactive bowel sounds

c. PaO2 of 45 mm Hg, serum lactate of level of 46 mcg/dL, and bleeding from the chest incision

A patient in the medical surgical unit develops eye swelling, itching, and trouble breathing after receiving a new medication. The nurse’s best response is: a. Call the physician or health care provider b. Assess the patient’s skin for the presence of hives c. Assess the patient’s airway and respirations d. Document the patient’s symptoms in the medical record

c. Assess the patient’s airway and respirations

A client with a newly inserted pacemakers is given cefazolin for the first time. The client becomes restless, tachycardic, hypotensive, and develops a raised itchy rash on the chest. Which of the following is the nurse’s priority intervention? a. Administer metoprolol b. Create a calm environment to alleviate the client’s anxiety c. Obtain stat blood cultures d. Administer epinephrine

d. Administer epinephrine

The nurse is assessing the lung sounds of a client with an anaphylactic reaction to CT contrast. The nurse recognizes that the client’s respiratory status has worsened based on which of the following? a. Wheezing in the apices b. Noticeably diminished breath sounds in the bilateral bases c. Cough and running nose d. Mild wheezing on expiration

a. Wheezing in the apices

Assessment of a client with a current history of IV drug use with acute infective endocarditis should focus on which of the follow signs & symptoms (select all that apply)? a. Retinal hemorrhages b. Splinter hemorrhages c. Painful erythematous macular lesions to tips of fingers and toes d. Painless nodules over bony prominences e. Painless erythematous macules on the palms and soles

a. Retinal hemorrhages b. Splinter hemorrhages c. Painful erythematous macular lesions to tips of fingers and toes e. Painless erythematous macules on the palms and soles

A client has been admitted for septic shock due to pneumonia. The nurse continually assesses the client to prevent complications. The nurse recognizes which of the following assessment findings as an indicator of worsening perfusions? a. Heart rate 90 beats per minute b. Muscle weakness c. Confusion and lethargy d. Increased mobility e. Hyperactive bowel sounds

c. Confusion and lethargy

The registered nurse (RN) is caring for several hospitalized clients. The RN may safely delegate care of which of the following clients to the LVN/LPN? a. A client with ventricular tachycardia b. A client with sinus bradycardia c. A client with ventricular fibrillation that coded and was just successfully resuscitated d. A client with a new third-degree heart block

b. A client with sinus bradycardia

The nurse monitors the client with a newly implanted pacemaker. The nurse assesses the cardiac rhythm on the telemetry monitor and notes several spikes on the rhythm but the spikes are not followed by any waveforms. The nurse recognizes this as: a. An indication that the pacemaker is working correctly b. A normal finding for a new pacemaker c. A problem with the client’s medications d. An abnormal finding that must be reported to the provider

d. An abnormal finding that must be reported to the provider

A diabetic client with purulent drainage from his right heel is admitted to the medical surgical unit. The nurse identifies which of the following assessment findings as potentially indicative of septic shock (select all that apply)? a. Blood pressure 115/78 mmHg b. Temperature 104 F (40 C) c. MAP 59 mmHg d. Respiratory rate 18 e. Heart rate 119 beats/min

b. Temperature 104 F (40 C) c. MAP 59 mmHg e. Heart rate 119 beats/min

You are the nurse caring for a patient with hypovolemic shock. What signs or symptoms would indicate that the shock is progressing? (select all that apply) a. Heart rate 122 beats/min b. Hypotension that does not respond to IV fluid administration c. Respiratory rate 18 breaths/min d. Mean arterial pressure (MAP) of 50 mmHg e. Warm, moist skin, capillary refill <2sec

a. Heart rate 122 beats/min b. Hypotension that does not respond to IV fluid d. Mean arterial pressure (MAP) of 50 mmHg

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (select all that apply) a. Notify healthcare providers before any MRI b. Count your respiratory rate for 4 minutes each morning and evening c. Wear a medical alert ID device d. Avoid direct contact with handheld metal detectors e. Limit activity and lifting on the affected side until your follow up appointment f. Avoid the use of all microwaves

a. Notify healthcare providers before any MRI c. Wear a medical alert ID device d. Avoid direct contact with handheld metal detectors e. Limit activity and lifting on the affected side until your follow up appointment

You are caring for a patient with shock. What signs or symptoms would indicate acute organ dysfunction (select all that apply)? a. Drop in systolic blood pressure greater than 40 mm Hg from baseline blood pressure b. Hypotension that responds to fluid resuscitation c. Vasopressor support is not needed d. Serum lactate greater than 4 mmol/L e. Mean arterial pressure (MAP) less than 60 mm Hg f. Acute confusion and disorientation

a. Drop in systolic blood pressure greater than 40 mm Hg from baseline blood pressure d. Serum lactate greater than 4 mmol/L e. Mean arterial pressure (MAP) less than 60 mm Hg f. Acute confusion and disorientation

A client has been admitted with acute bacterial endocarditis. The nurse completes which of the following orders first? a. Initiate activity as tolerates b. Start normal saline IV infusion c. Administer the vitamin K d. Administer morphine 1mg IVP e. Administer the Vancomycin IV infusion

e. Administer the Vancomycin IV infusion

The nurse should monitor the client with pericarditis for which of the following clinical manifestation(s) of cardiac tamponade? (select all that apply) a. Muffled heart sounds b. Hypotension c. Blurred vision d. Tachycardia e. Jugular venous distension

a. Muffled heart sounds b. Hypotension d. Tachycardia e. Jugular venous distension

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? a. Confusion and altered Mental Status b. Blood pressure 84/50 mm Hg and pulse 132 c. Anuria and elevated Creatinine d. Petechiae

b. Blood pressure 84/50 mm Hg and pulse 132

After a patient who has septic shock receives 2 L of normal saline intravenously, the heart rate is 109 beats/min and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate will be administered next? a. Sodium nitroprusside b. Norepinephrine c. Furosemide d. Nitroglycerin e. Metoprolol

b. Norepinephrine

A nurse is caring for a client who has endocarditis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clots. Which of the following responses should the nurse give? a. “It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level.” b. “I will ask the pharmacist to answer that question.” c. “Heparin will not dissolve the clots, it keeps new clots from forming.” d. “The oral medication you will take after the IV will dissolve the clot.”

c. “Heparin will not dissolve the clots, it keeps new clots from forming.”

A nurse is assessing a client who is receiving dopamine IV to treat cardiogenic shock. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? a. Systolic blood pressure is increased b. Cardiac output is reduced c. Apical heart rate is increased d. Urine output is reduced

a. Systolic blood pressure is increased

A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine? a. Client reports decreased pain of 3 on a 1 to 10 scale b. The client’s blood pressure decreases when rising from resting position c. The client has 2+ peripheral edema d. The client’s respirations are unlabored.

d. The client’s respirations are unlabored.

A nurse in a medical surgical unit is assessing a client with mitral stenosis who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? a. Asthma from pulmonary constriction b. Heart failure from decreased cardiac output c. Aortic valve regurgitation from hypertension d. Hyperkalemia from ace inhibitors

b. Heart failure from decreased cardiac output

A 76-year-old female was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem include (select all that apply) a. Weight loss b. Dry oral mucosa c. Full bounding pulse d. Engorged neck veins e. Decreased venous pressure

a. Weight loss b. Dry oral mucosa e. Decreased venous pressure

A nurse is caring for a 21-year-old client with pancreatitis has a pericardiocentesis scheduled. The client’s parents have asked to view the lab results and see the medications list for the client. Which of the following statements by the nurse indicates a need for further teaching? a. “I cannot disclose any client information to family members at any time.” b. “HIPPA is a federal law, not a state law that protects client confidentiality.” c. “I can show you the information about the client’s medications only.” d. “Client information cannot be shared with family members, but it can be shared with family members that are nurses.”

d. “Client information cannot be shared with family members, but it can be shared with family members that are nurses.”

A nurse is assessing a client who has heart failure and aortic stenosis and is prescribed furosemide. Which of the following findings is an adverse effect of this medication? a. Hypoglycemia b. Muscle cramps c. Hypertension and tachycardia d. Hyperkalemia and hypernatremia

b. Muscle cramps

The nurse monitoring an older adult female client with endocarditis for the development of complications. Which of the following findings should the nurse identify as a potential complication of endocarditis? (select all that apply) a. Client reports sudden onset shortness of breath b. Magnesium 2.0 mEg/L c. Potassium 4.8 mmol/L d. Serum creatinine 1.9 mg/dL e. Client’s right pupil is fixed and dilated f. Client has S1, S2 and regular rhythm

a. Client reports sudden onset shortness of breath d. Serum creatinine 1.9 mg/dL

A nurse is assessing a client post myocardial infarction for pericarditis. Which of the following client assessment findings would alert the nurse about the complication of pericarditis and should be reported to the healthcare provider? a. Apical pulse rate is different than the radial pulse rate b. Increase in heart rate by 20% when moving from sitting to standing c. Drop in systolic BP by 20 mm Hg when changing positions d. Decreases in systolic pressure by more than 10 mm Hg during inspiration

d. Decreases in systolic pressure by more than 10 mm Hg during inspiration

A nurse is caring for a client with a mechanical mitral valve who is on warfarin therapy. The client’s INR is 5.2. Which of the following medications should the nurse prepare to administer? a. Epinephrine b. Atropine c. Protamine sulfate d. Vitamin K

d. Vitamin K

The nurse is caring for a client with cardiogenic shock that is receiving IV fluids. Which of the following assessment finding(s) indicate that the client is experiencing hypervolemic from fluid overload? (select all that apply) a. Nausea and vomiting b. Headache c. Dyspnea d. Hypertension e. Fever f. Coughing

c. Dyspnea d. Hypertension f. Coughing

A nurse is reviewing the laboratory values of a client experiencing a progressive stage of shock and is in respiratory acidosis. Which of the following findings should the nurse expect? a. HCO3 30 mEq/L b. PaCO2 50 mmHg c. pH 7.45 d. K+ 3.3 mEq

b. PaCO2 50 mmHg

While auscultating a client’s heart sounds, the nurse hears a loud turbulence between the S1 and S2 heart sounds. The nurse should recognize this finding as which of the following? a. The third heart sound (S3), the client is in heart failure b. A systolic murmur, the client has a cardiac valvular issue c. An expected heart sound in a client with hypertension d. The fourth heart sound (S4), the client is in ventricular fibrillation

b. A systolic murmur, the client has a cardiac valvular issue

A nurse is assessing with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (select all that apply) a. Administer an analgesic prior to the procedure b. Wash the skin with plain water before placing the electrodes c. Keep the client NPO after midnight d. Inspect the electrode pads e. Instruct the client not talk during the test

d. Inspect the electrode pads e. Instruct the client not talk during the test

An RN on a behavioral health unit is assessing a client. The RN plans to delegate part of the nursing process to a licensed practice nurse (LPN). Which of the following statements by the RN indicated appropriate delegation to the LPN? a. “Please use these client assessment findings to draw a conclusion so that a plan can be developed.” b. “Please document the admission assessment in the chart.” c. “Please perform a complete assessment of the client.” d. “Please verify with the client which of the following medications they are taking.”

d. “Please verify with the client which of the following medications they are taking.”

A nurse caring for a client who has coronary artery disease in history of MI and asked the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? a. Glaucoma and cataracts b. Depression related to chronic fatigue c. Asthma related to seasonal allergies d. Migraines are more frequent with increased stress

c. Asthma related to seasonal allergies

An experienced nurse supervises a new nurse during oral medication administration with a client with hypovolemic shock and intermittent confusion. Which practices by the new nurse should concern the experienced nurse? Select all that apply. a. The new nurse leaves the medication at the bedside while the client is in the bathroom b. The new nurse uses the barcoding mechanisms so to ensure safe administration of the medication c. The new nurse uses a single method to verify the client's identity d. The new nurse checks the picture on the identification band to verify the client's identity e. The new nurse checks the picture on the identification band to verify the client's identity f. The new nurse provides milk for the client to drink and swallow their medications

a. The new nurse leaves the medication at the bedside while the client is in the bathroom c. The new nurse uses a single method to verify the client's identity f. The new nurse provides milk for the client to drink and swallow their medications

The client is most likely experiencing _____. The most common medication for the treatment of this situation is ____. Before administrating this medication, the nurse should assess the client’s ____ and ____.

Anaphylaxis, Epinephrine, Allergies, Respiratory status

The nurse is caring for a client with aortic stenosis. Which client assessment data indicates that the aortic stenosis is progressing and cardiac output is decreasing. Select all that apply. a. Decreased urinary output b. Crackles in bilateral lungs c. Oxygen requirements decreasing d. Tachycardia e. Hypertension f. Bradypnea g. Dyspnea at rest h. New-onset generalized edema i. Confusion j. Bounding peripheral pulses

a. Decreased urinary output b. Crackles in bilateral lungs d. Tachycardia g. Dyspnea at rest h. New-onset generalized edema i. Confusion

The nurse is caring for a client with aortic stenosis that has developed pulmonary edema. Which of the following acid base results does the nurse identify as a complication of pulmonary edema? a. pH 7.55, PCO2 31, HCO3 22, PaO2 67 b. pH 7.49, PCO2 52, HCO3 32, PaO2 76 c. pH 7.42, PCO2 45, HCO3 18, PaO2 80 d. pH 7.3, PCO2 50, HCO3 34, PaO2 56

d. pH 7.3, PCO2 50, HCO3 34, PaO2 56

A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report? a. Nasal congestion b. Nausea and vomiting c. Dry cough d. Swelling of the tongue

d. Swelling of the tongue

When assessing the need for psychologic support after the patient has been diagnosed with mitral valve regurgitation, which question by the nurse will provide the most information? a. “How long ago were you diagnosed with this cancer?” b. “Do you have any concerns about body image changes?” c. “Can you tell me what has been helpful to you in the past when coping with stressful events?” d. “Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?”

c. “Can you tell me what has been helpful to you in the past when coping with stressful events?”

Click the case to review the information in the electronic health record. Determine which actions by the nurse are indicated and which are not indicated. RN Actions: 1. Assess the client's pulse and respirations 2. Interpret rhythm as ventricular tachycardia 3. Initiate cardiopulmonary resuscitation 4. Interpret rhythm as pulseless electrical activity 5. Activity administer adenosine as planned

1. Indicated 2. Indicated 3. Indicated 4. Not indicated 5. Not indicated

A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication? a. Bradycardia b. Tremor c. Constipation d. Cough

a. Bradycardia

Review the case study utilizing all of the tabs. Which of the following findings requires the nurse to follow up? (Select all that apply) a. Electrocardiogram ECG b. Blood pressure c. Heart rate d. Chest X-ray e. Breath sounds f. Neurological status

a. Electrocardiogram ECG b. Blood pressure c. Heart rate f. Neurological status

A nurse is caring for a client who has depression after a STEMI and is discussing activities of daily living (ADLs) with his family. The nurse should identify that the client can perform which of the following activities prior to discharge? a. Driving b. Hygiene c. House cleaning d. Grocery shopping

b. Hygiene

A nurse is caring for a client who requires a crisis intervention for acute anxiety due to a recent diagnosis on mitral valve stenosis and need for surgical intervention. Which of the following actions is the highest priority? a. Protecting the client from injury b. Determining the cause of the client's anxiety c. Ensuring that the client feels safe d. Identifying the clients coping skills

a. Protecting the client from injury

86. A nurse is caring for a client with septic shock who has the following arterial blood gas results: HCO3 24 mEq PaCO2 58 mm Hg and pH 7.32. The nurse recognizes the client is experiencing which of the following acid base imbalance? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic alkalosis d. Respiratory acidosis

d. Respiratory acidosis

Complete the diagram by selecting the choices below to specify the conditions that the client is most likely experiencing.

Action To Take -> Elevate the head of the bed, Administer oxygen via nasal cannula; Potential Condition -> Heart failure; Parameter to Monitor -> Daily weight, lung sounds

A nurse is caring for a client who has heart failure and a potassium level of 2.4mEq/L. The nurse should identify which of the following as the highest potential risk to the client as a result of the client's potassium level? a. Ventricular tachycardia b. Premature ventricular contractions c. Low blood pressure and slowed pulse rate d. Sinus tachycardia

a. Ventricular tachycardia

A nurse is admitting a client with risk for hypovolemic shock has a history of heart failure following myocardial infarction (MI). The nurse recognizes that which of the following orders by the provider presents their highest risk of complications? a. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain b. Laboratory testing of serum potassium upon admission c. Furosemide 40 mg IV bolus every 12 hr d. 0.9% normal saline IV at 75 mL/hr continuous

d. 0.9% normal saline IV at 75 mL/hr continuous

A nurse is preparing to administer fluconazole 400 mg by intermittent IV bolus daily. Available is fluconazole 400 mg in 0.9% sodium chloride (NaCl) 200 mL to infuse over 2 hr. The nurse should set the IV pump to deliver how many mL/hr?

100 mL/hr

A nurse is preparing to infuse a 250 mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute?

31 drops/min

Exam 1 Flashcards

(100 cards)