Missed from Exams Flashcards
(23 cards)
Your patient, Carlos Adams, 18 years old was in evolved in a car accident and suffered blunt trauma to the abdomen. An hour later his vital signs are now: HR 140/min, RR 28, SaO2 94%. For Carlos, which order should you question?
A. IV of ringer’s lactate at 75 mL/hr
B. Monitor urine hourly
C. Oxygen by non-rebreather mask
D. Draw a STAT HGB and HCT
A. IV of ringer’s lactate at 75 mL/hr
Which patient is at high risk for developing hyponatremia?
A. Elderly male with COPD
B. Female with partial drowning in salt water
C. Young female with bulimia
D. Adult male on Digoxin
C. Young female with bulimia
Which of the following is the most appropriate nursing intervention for a patient with ABG of: pH 7.50, Pa02 94, PaCO2 26, and HCO3 of 24?
A. Administer the prescribed nebulizer treatment
B. Use a rebreather mask
C. Offer the patient fluids frequently
D. Administer the prescribed supplemental oxygen
B. Use a rebreather mask
Your patient has hyperkalemia. The priority nursing intervention you, as the nurse, should do is:
A. Monitor the electrocardiogram
B. Weigh the patient daily
C. Hold the next dose of Lasix
D. Increase fluid intake
A. Monitor the electrocardiogram
Your patient is confused and weak. BP is 88/64, HR is 100, and her skin is dry. The most appropriate nursing diagnosis is:
A. Ineffective tissue perfusion
B. Ineffective gas exchange
C. Fluid volume deficit
D. Decreased urinary output
C. Fluid volume deficit
Your patient has diarrhea. You assess him for the following early indication of fluid volume deficit:
A. Hypotension
B. Hypernatremia
C. Thirst
D. Bradycardia
C. Thirst
A 22 year old male is admitted after taking a full bottle of acetylsalicylic acid (aspirin). He is diagnosed with salicylate poisoning. One hour after taking the aspirin, his RR is 42 and his BP is 60/40. What would you expect his bicarbonate level to be?
A. 12 mEq/L
B. 24 mEq/L
C. 38 mEq/L
D. 45 mEq/L
B. 24
Your patient is a well-controlled asthmatic. Today, during her exercise class, she begins wheezing. The best medication for her to use is a:
A. Short acting Beta 2 agonist, Proventil
B. Corticosteroid, Flovent
C. Mast cell stabilizer, Intal
D. Leukotriene inhibitor, Singulair
A. Short acting Beta 2 agonist, Proventil
In severe hyperkalemia, Calcium Gluconate is administered intravenously to the patient to:
A. Immediately lower the K
B. Prevent transient renal failure
C. Antagonize the action of K on the heart
D. All of the above
C. Antagonize the action of K on the heart
In the stress response from the stimulation of the sympathetic nervous system, you would expect the patient to exhibit which of the following effects?
A. Bradycardia
B. Increased urine output
C. Diaphoresis
D. Bronchoconstriction
C. Diaphoresis
As nurses we educate our patients to control their HTN to avoid and/or delay damage to which four “target organs”?
A. Heart, lungs, liver, brain
B. Brain, eyes, adrenals and lungs
C. Kidneys, heart, eyes, brain
D. Liver, brain, lungs, eyes
C. Kidneys, heart, eyes, brain
The type of vessel insufficiency associated with an assessment of ankle ulcers is:
A. Arterial insufficiency
B. Venous insufficiency
C. All of the above
D. None of the above
B. Venous insufficiency
In caring for a patient having an acute myocardial infarction, you assess for ____, the leading cause of death from MIs.
A. Cardiogenic shock
B. Dysrhythmias
C. Pulmonary edema
D. Congestive heart failure
B. Dysrhythmias
Your nursing interventions for the patient with pulmonary edema will include the following:
A. Oxygen, Morphine, Lasix
B. Aspirin, Aldactone, Inderal
C. Tridil, Heparin, Aggrastat
D. Inderal, Lipitor, Calan
A. Oxygen, Morphine, Lasix
What is the first intervention for a nurse to implement for a patient experiencing a myocardial infarction?
A. Morphine
B. Nitroglycerin
C. Oxygen
D. Aspirin
C. Oxygen
In starting nitroglycerine (Tridil) IV, the adverse effect you need to assess the patient for is
A. Oliguria
B. Hypotension
C. Hypertension
D. Bradycardia
B. Hypotension
When you first suspect your patient is in the early stage of pulmonary edema, the best position to place him in is:
A. Prone to encourage maximum rest
B. Semi-Fowler’s to facilitate breathing
C. Trendelenburg to drain the upper airways
D. Sitting upright with the legs dependent
D. Sitting upright with the legs dependent
Your patient had a myocardial infarction 5 days ago and is ready to go home. Discharge planning began:
A. On admission
B. After the first 48 hours when you were sure she would live
C. When discharge orders were written
D. When she was transferred from the CCU to the med-surg floor
A. On admission
The type of vessel insufficiency associated with an assessment of a cool, pale extremity is:
A. Arterial
B. Venous
C. All of the above
D. None of the above
A. Arterial
Your patient is scheduled for cardiac catheterization. As a nurse, you explain that this procedure is primarily to:
A. Evaluate the electrical conduction
B. Assess for coronary artery blockage
C. Determine how large the MI is
D. Assess the function of the valves
B. Assess for coronary artery blockage
The nursing assessment of dependent edema is associated with the pathophysiology of:
- Right-sided heart failure
- Left-sided heart failure
- None of the above
Right sided heart failure
Your patient has peripheral arterial insufficiency. The best nursing intervention to decrease her leg pain during rest is to:
A. Elevate the leg above heart level
B. Lower the leg so that it is dependent
C. Massage the leg
D. Place the leg on a plane horizontal to the body
B. Lower the leg so that it is dependent
The type of vessel insufficiency associated with an assessment of diminished pedal pulses is:
A. Arterial
B. Venous
C. All of the above
D. None of the above
C. All of the above
