practice q Flashcards
(39 cards)
Which one of the following statement about visitation in the clinical care unit is true?
Individualized visitation based on client and family needs.
A critically ill client with cancer shows asystole on the monitor and does not have a DNR on the chart. What should the nurse do?
Initiate CPR and call a code.
What are the two priority needs recognized by the nurse staff for family members of a critically ill client?
Have flexible time to visit the client and have personal comfort needs for meds.
What is the core concept of the synergy model of practice?
Meet the needs of client, family, and influence nursing competency.
A client admitted to the cardiac care unit with the diagnosis of acute MI. What is the highest priority in the nursing management of this client?
Provide adequate pain control and reduce myocardial oxygen demand.
During a health promotion program, a participant mentions taking aspirin for arthritis. How does this help with chest pain?
Helps the blood move freely to the vessels.
What is the expected outcome that indicates therapy for a client with acute MI is successful?
Relief of pain, decrease in ST segment, and a narrowed Q wave.
A nurse assists a client with acute MI to get out of bed for the first time, and the client appears dizzy and diaphoretic. What should the nurse do first?
Patient back to sit.
A client is being admitted to the telemetry unit post administration of aTpa. What is a priority for the nurse?
Telemonitor.
In a client with a history of renal failure and diagnosis of MI, which lab data requires immediate attention?
Potassium of 5.8.
What lab data should the nurse report to the health provider for a client newly diagnosed with MI, type 2 diabetes, and renal insufficiency?
Potassium, calcium, and digoxin.
What is the nursing care priority for a client post cardiac catheterization?
Monitor peripheral pulse and catheterization site.
Which trauma therapeutic agent should the nurse anticipate will be recommended for platelet aggregation?
Aspirin.
A patient who had an MI 4 days ago complains of dyspnea. What are the signs and symptoms conclusive with?
Left-sided heart failure.
What should the nurse do first for a client with a syncopal episode who is confused and disoriented?
Assess vital signs.
What is the goal of Cardizem for a client with normal A-fib and a ventricular response of 164?
Control ventricular rate.
A nurse enters a client’s room and finds the client in cardiac arrest. What is the priority action when the code team arrives?
Defibrillate.
A client with heart failure complains of anorexia and nausea. What should the nurse do first?
Check serum digoxin lab levels.
During discharge teaching for a client with CHF, what is an expected outcome for this client?
The client will verbalize: Monitor daily weight.
For a client diagnosed with acute exacerbation of CHF under natrecor, what is the priority action to evaluate the effectiveness of this medication?
Monitor urine output.
What causes gastrointestinal distress associated with right-sided heart failure?
Venous stasis and venous engorgement within abdominal organs.
A client with multiple trauma and extended blood loss has very low BP and pulmonary pressure. What is the most appropriate treatment?
Blood and fluid administration.
If the pulmonary artery movement pressure is 20, what do you suspect?
Fluid overload.
An adult senior with influenza presents with severe weakness. Where is the distal tip of the central line inserted into the subclavian vein placed?
Right atrium.
