FINAL EXAM PRACTICE QUESTIONS Flashcards
A client has emergency surgery for a ruptured appendix. While in the postanesthesia care unit, the client manifests signs and symptoms of shock. The nurse should:
1/ Prepare for a blood transfusion
2/ Notify the surgeon immediately
3/ Elevate the head of the bed 30 degrees
4/ Order an electrocardiogram (ECG)
2/ Notify Doc
Peritonitis and shock are potentially life-threatening complications following abdominal surgery; prompt, rigorous treatment is necessary. The surgeon should be notified Fluids, not blood, are needed to expand and maintain the circulating blood volume. The head of the bed should be flat to increase tissue perfusion and oxygenation to the vital organs. An ECG does not treat shock.
When assessing an 85-year-old client’s vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. The finding that is consistent with a pathologic condition rather than the aging process is:
1/ A pulse rate irregularity
2/ Equal apical and radial pulse rates
3/ A pulse rate of 60 beats per minute
4/ An apical rate obtainable at the fifth intercostal space and midclavicular line
1/
Dysrhythmias are abnormal and are associated with acute or chronic pathological conditions.
Prednisone (Meticorten) (Canada: Winpred) is prescribed for a client with an exacerbation of colitis. Before administering the first dose, the nurse teaches the client that:
1/ Symptoms associated with the colitis will decrease slowly over time
2/ The client will be protected from getting an infection
3/ Although the medication causes anorexia, weight loss may not occur
4/ Although the medication decreases intestinal inflammation, it will not cure the colitis
4/ There is Ø cure
Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. The response usually is rapid. The drug suppresses the immune response and increases the potential for infection. Appetite is increased; weight gain may result from this or from fluid retention.
A nurse notes that a client's urine has a sweet fruity odor. Which information is most important to evaluate when performing a further client assessment? 1/ Vital signs 2/ Fluid balance 3/ Serum glucose level 4/ Dietary calorie count
3/
Sweet fruity smelling urine is an indicator of ketoacidosis, which can result from uncontrolled diabetes. Hyperglycemia and hypoglycemia are assessed by serum glucose monitoring. Vital signs, fluid imbalance, and dietary counts have no relation to sweet fruity smelling urine.
The nurse is caring for a client hospitalized with a severe myocardial infarction. Which analgesic is the drug of choice for this client? 1/ Diazepam (Valium) 2/ Meperidine (Demerol) 3/ Flurazepam 4/ Morphine sulfate
4/ Morphine
Which assessment should the nurse obtain before administering digoxin (Lanoxin) (Canada: Toloxin) to a client?
1/ Apical heart rate
2/ Radial pulse on the left side
3/ Radial pulse in both right and left arms
4/ Difference between apical and radial pulses
A/ Apical
Because digoxin slows the heart rate, the apical pulse should be counted for one minute before administration. If the apical rate is below a preset parameter (usually 60 bpm), digoxin should be withheld because its administration may further decrease the heart rate.
A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which patient history item? 1/ Pain that increases after meals 2/ Frequent nausea 3/ Black tarry stools 4/ Joining Alcoholics Anonymous
3/ Black tarry stool
Black (tarry) stools indicate upper gastrointestinal (GI) bleeding; digestive enzymes act on the blood, resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. Investigation of bleeding takes priority; later the nurse should help to identify irritating foods that are to be avoided.
A client in the emergency department is diagnosed with atrial fibrillation. Initially the health care provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm? 1/ Vagus nerve is stimulated. 2/ Glottis closes momentarily. 3/ Thoracic pressure decreases. 4/ Respiratory pattern is interrupted.
1/ Vagus Stimulation
Inhaling and forcing the diaphragm and chest muscles against a closed glottis increase intrathoracic pressure, which affects the vagus nerve and slows the heart.
A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, “I feel nauseated and very weak.” What action should the nurse take?
1/ Call the rapid response team
2/ Perform a nutritional assessment
3/ Discuss possible sources of stress with the client
4/ Provide reassurance while helping the client to focus on pleasant topics
1/ Response team
These are classic symptoms of a myocardial infarction; further medical evaluation and intervention are needed immediately.
On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. The nurse should:
1/ Prepare for blood transfusions
2/ Notify the surgeon immediately
3/ Give the client nothing by mouth (NPO)
4/ Administer the prescribed sedative
2/ Notify Surgeon
Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms.
An 85-year-old client has a serum potassium level of 6.7 mEq/L (Canada: 6.7 mmol/L). Which nursing action is a priority at this time?
1/ Monitor for cardiovascular irregularities.
2/ Inquire about changes in bowel patterns.
3/ Assess client for leg muscle twitching or weakness.
4/ Assess client for signs and symptoms of dehydration
1/
Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns and leg muscle twitching and weakness are signs of hyperkalemia, but are not life threatening. Dehydration may be a cause of hyperkalemia.
A client is found unconscious and unresponsive. What should the nurse do first? 1/ Initiate a code. 2/ Check for a radial pulse. 3/ Compress the lower sternum. 4/ Give four full lung inflations.
1/
or Call Batman.
Additional help and a cardiac defibrillator must be obtained immediately. The carotid, not radial, pulse is used. Compressing the lower sternum is done after the nurse summons help. Two lung inflations are given after 30 chest compressions.
A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client? 1/ Pallor 2/ Ankle edema 3/ Yellowed toenails 4/ Diminished pedal pulses
2/ Ankle Edema
Ankle edema results from venous pooling with increased hydrostatic pressure; fluid moves from intravascular to interstitial spaces. Pigmentation, not pallor, may occur with varicosities. Yellowed toenails occur with arterial, not venous, insufficiency. Diminished pedal pulses occur with arterial, not venous, insufficiency.
The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first?
1/ Obtain the other vital signs.
2/ Recheck the pulse to verify the rate.
3/ Stay with the client until an ambulance arrives.
4/ Alert the health care provider of the client’s status.
1/ Obtain other vitals
The radial pulse of a client with chronic atrial fibrillation may range from 50 to 180 beats per minute. Other vital signs should be assessed before notifying the health care provider. Although rechecking the pulse to verify the rate may be done, it is not necessary because a pulse of 136 beats per minute is not unusual for a client with chronic atrial fibrillation. Staying with the client until the ambulance arrives or alerting the health care provider are not the initial actions.
A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery?
1/ Increasing activity tolerance
2/ Preventing cardiac dysrhythmias
3/ Promoting physical and emotional rest
4/ Maintaining potassium and sodium intake
3/ REST
The major goal is to decrease the workload of the heart; physical and emotional rest reduces cardiac oxygen demand. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. There is no indication that the client has a history of dysrhythmias. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart.
A client appears anxious, with respirations that are shallow and 40 per minute. The client reports feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. What does the nurse determine is the probable cause of these clinical manifestations? 1/ Hyperventilation 2/ Dyspnea 3/ Kussmaul respirations 4/ Carbon dioxide intoxication
1/ Hyperventilation
The client is hyperventilating and is blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted, this can lead to respiratory alkalosis.
When assessing a client with pleural effusion, the nurse expects to identify:
1/ Moist crackles at the posterior of the lungs
2/ Deviation of the trachea toward the involved side
3/ Reduced or absent breath sounds at the base of the lung
4/ Increased resonance with percussion of the involved area
3/ Reduced sounds at the base of the lungs
Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no cracklesare produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.
The nurse is caring for a client with a history of atrial fibrillation and a diagnosis of dehydration. The nurse anticipates that the plan of care will include:
1/ A glass of water every hour until hydrated
2/ Small, frequent intake of juices, broth, or milk
3/ Short-term nasogastric tube for replacement of fluids and nutrients
4/ A rapid intravenous (IV) infusion of an electrolyte and glucose solution
2/
Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. Water does not supply the necessary electrolytes, and hyponatremia may result. No data are present to indicate that the client cannot take fluids orally; a nasogastric tube is not necessary when the client can take fluids by mouth. Rapid correction of a fluid and electrolyte imbalance is dangerous; therapy should promote a gradual correction.
A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority? 1/ Head injury 2/ Fractured femur 3/ Ventricular fibrillation 4/ Penetrating abdominal wound
3/ V-Fib
It’s bad news.
Ventricular fibrillation will cause irreversible brain damage and then death within minutes because the heart is not pumping blood to the brain. Defibrillation or CPR until defibrillation is possible must be initiated immediately. Although head injury, fractured femur, and penetrating abdominal wound require prompt treatment, death is not as imminent as with ventricular fibrillation.
A nurse is providing discharge instructions about digoxin (Lanoxin) (Canada: Toloxin). Which response should a nurse include as a reason for a client to withhold the digoxin? 1/ Chest pain 2/ Blurred vision 3/ Persistent hiccups 4/ Increased urinary output
2/ Blurred Vision
Visual disturbances, such as blurred or yellow vision, may be evidence of digoxin toxicity.
A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. What is the goal of the medical regimen for this client?
1/ Increase left ventricular filling and improve cardiac output.
2/ Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias.
3/ Decrease the workload on the heart and promote maximum coronary artery filling.
4/ Increase venous return to the right atrium and increase pulmonary arterial blood flow.
3/
With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore, the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and, therefore, oxygen to reach cardiac muscle; this increases myocardial efficiency.
A client with a history of cirrhosis of the liver develops heart failure and is experiencing bigeminal premature ventricular complexes. What should the nurse expect about the dose of lidocaine (Xylocaine) prescribed by the health care provider?
1/ Higher to compensate for the impaired liver function
2/ Lower because the drug is metabolized at a diminished rate
3/ Reduced because other organs will compensate for the sluggish liver
4/ Equal to that needed for other clients to provide a loading dose for the myocardium
2/
The client has heart failure, which causes liver congestion, further compromising liver function; therefore, less than the usual adult dose will be prescribed because the liver will not be able to break down lidocaine as effectively as necessary.
A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space? 1/ Cerebral embolism 2/ Pulmonary embolism 3/ Dry gangrene of a limb 4/ Coronary vessel occlusion
2/ Pulmonary Embolism
The pulmonary capillary beds are the first small vessels that the embolus encounters once it is released from the calf veins.
While a pacemaker catheter is being inserted, the client's heart rate drops to 38 beats/min. What medication should the nurse expect the health care provider to prescribe? 1/ Digoxin 2/ Lidocaine 3/ Amiodarone 4/ Atropine
4/ Atropine
Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate.
