Exam practice 1

49. The nurse provides pre-procedure education to a patient scheduled to have a cardiac catheterization. Which statement does the nurse include? a. "The procedure is performed at the bedside." b. "You may feel flushing, warmth, or palpitations during the procedure." c. There may at first be some intense pain that resolves quickly." d. "You may develop a headache, but this is normal."

b. "You may feel flushing, warmth, or palpitations during the procedure."

2. When increasing the level of PEEP, you should monitor for which of the following adverse effects? a. Increased lactate level b. Hypotension c. Worsening acidosis d. Hypercapnia

b. Hypotension

21. What is the name of the valve that allows blood flow into the pulmonary artery? a. Mitral valve b. Pulmonic valve c. Tricuspid d. Aortic

b. Pulmonic valve

43. A new graduate nurse is taking care of a patient with a chest tube. What are correct interventions when caring for a patient with a chest tube? (SATA) a. The patient should not encourage to ambulate b. The patient should be encouraged to turn, cough, deep breath with a chest tube c. If an air leak is observed clamp closest to the chest tube collection chamber d. Patient should regularly be assessed for pain e. Tidaling observed in the water seal chamber

b. The patient should be encouraged to turn, cough, deep breath with a chest tube d. Patient should regularly be assessed for pain e. Tidaling observed in the water seal chamber

34. The main purpose of critical care certification is to a. prepare for graduate school b. Assure the consumer that you will c. Validate knowledge of critical care nursing d. Promote magnet status for your facility

c. Validate knowledge of critical care nursing

39. Heparin is ordered for a patient with a non-ST segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient? a. "Heparin dissolve clot that are blocking blood flow in the coronary arteries" b. "Heparin enhances platelet aggregation at the plaque site." c. "Heparin decreases the size of the coronary artery plaque." d. "Heparin prevents development of new clot in the coronary artery."

d. "Heparin prevents development of new clot in the coronary artery."

4. The nurse is caring for four patients in the telemetry unit. Which patient should the nurse assess first? a. A patient with echocardiogram report that notes severe aortic stenosis b. A patient with a diagnosis of stable angina who calls with a report of chest pain 4/10 c. A patient who has a normal sinus rhythm admitted for intermittent tachycardia d. A patient with a rhythm change from sinus rhythm to ventricular fibrillation (V-fib and V-tach is deadly!!)

d. A patient with a rhythm change from sinus rhythm to ventricular fibrillation (V-fib and V-tach is deadly!!)

24. Positive end-respiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following conditions: a. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure. b. Each time the patient initiates a breath, the ventilator delivers a full present tidal volume c. The patient must have a respiratory drive, or no breaths will be delivered. d. There is pressure remaining in the lungs at the end of the expiration that is measured in cm H2O.

d. There is pressure remaining in the lungs at the end of the expiration that is measured in cm H2O.

1. The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holdings the endotracheal tube (ET) in the hand. Which action should the nurse take next? A. Provide reassurance to the patient B. Manually ventilate the patient with 100% oxygen → Quizlet C. Call the health care provider to reinsert the tube D. Activate the rapid response team.

B. Manually ventilate the patient with 100% oxygen → Quizlet

4. ST segment monitoring for ischemia has gained increasing importance with the advent of thrombolytic therapy. What is the most accurate method for monitoring the existence of true ischemic changes? a. 12-lead ECG (quizlet) b. Biomarkers c. Echocardiogram d. S-lead ECG

a. 12-lead ECG (quizlet)

A patient in the hospital two days after an acute myocardial infarction when he suddenly develops the attached rhythm. His blood pressure is 85/40 mm hg. He is complaining of shortness of breath and his capillary refill is delated. Which is the most appropriate initial action? a. Administer atropine 0.5 mg ivp b. Initiate transcutaneous pacing c. Direct the patient to perform valsalva maneuvers d. Give the ordered dose of propranolol

a. Administer atropine 0.5 mg ivp

30. The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Blood pressure of 132/98 mm Hg b. Absent bowel sounds c. 25 mL of urine output over the past hour d. Weak pedal pulses

a. Blood pressure of 132/98 mm Hg

39. The nurse is caring for a patient with a descending aortic aneurysm. Which assessment finding is most important to report to the health care provider? a. Blood pressure of 158/98 mm hg (quizlet) b. Weak pedal pulses c. 25 ml of urine output over the past hour d. absent bowel sounds

a. Blood pressure of 158/98 mm hg (quizlet)

16. During the patient's acute postoperative period following repair of an AAA, the nurse would ensure that which goal is achieved? a. Bp and all peripheral pulses are evaluated at least every hour b. Hypothermia is maintained to decrease oxygen need c. The patient's bp is kept lower than baseline to prevent leaking at the incision site d. Iv fluids are administered at a rate to maintain urine output of 100 ml/hr

a. Bp and all peripheral pulses are evaluated at least every hour

30. An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while skating. Which assessment will the nurse obtain first? a. Breath sounds (quizlet) b. Heart rhythm c. Pulse d. Body temperature

a. Breath sounds (quizlet)

8. An Intra Aortic balloon pump (IABP) is being used for a patient who is cardiogenic shock. Which data indicate to the nurse that the goals of treatment with the IABP are being met? a. Cardiac output (CO) of 5 L/min b. Urine output of 25 mL/hr c. Stroke volume (SV) of 40 mL/beat d. Heart rate of 110 beats/min

a. Cardiac output (CO) of 5 L/min

9. An intra aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data indicate to the nurse that the goals of treatment with the IABP are being met? a. Cardiac output (CO) of 5 L/min (Normal: 4-8 L) b. Urine output of 25 mL/hr c. Stroke volume (SV) of 40 mL/beat d. Heart rate of 110 beats/min

a. Cardiac output (CO) of 5 L/min (Normal: 4-8 L)

39. A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 60% to 70%, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's blood pressure drops from 120/70 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Oxygen toxicity c. Hypovolemia d. Increase in venous return

a. Decrease in cardiac output

45. The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreased PaO2 levels despite increased FiO2 administration b. Respiratory acidosis associated with hyperventilation c. Elevated alveolar surfactant levels d. Increased lung compliance with increased FiO2 administration

a. Decreased PaO2 levels despite increased FiO2 administration

5. Which of the following statements is true about central venous pressure (CVP) (SATA). a. Decreases in cases of hypovolemia b. Increases in cases in hypervolemia c. Is a measure of preload d. Increases in patients with left ventricular failure e. Decreases in patients with right ventricular failure

a. Decreases in cases of hypovolemia b. Increases in cases in hypervolemia c. Is a measure of preload

18. A nurse cares for a patient for 4 hours of post-percutaneous coronary intervention (PCI). The nurse includes which assessments to best identify the most common complication at PCI? (SATA) → needs to be double check!! (Lewis pg. 715) a. Discomfort or pain report b. Electrocardiogram tracing c. Current WBC count d. Observation of the access site e. Pulse oximetry levels

a. Discomfort or pain report b. Electrocardiogram tracing c. Current WBC count d. Observation of the access site e. Pulse oximetry levels

5. When developing a teaching plan for a 61 year old patient with multiple risk factors for coronary artery disease. The nurse should focus primarily on the a. Elevated low density lipid protein level b. Increased risk of cardiovascular disease as people age c. Increased risk associated with the patient's gender d. Family history of coronary artery disease

a. Elevated low density lipid protein level

24. A patient reports that he has been having indigestion for the last few hours. Upon further review the nurse suspects the patient is having chest pain. Cardiac biomarkers and a 12 lead ecg are done. what finding is most significant in diagnosing an acute coronary syndrome within the first 3 hrs? a. Elevated troponin i b. Inverted t waves c. Elevated b type natriuretic peptide d. Indigestion and chest pain

a. Elevated troponin i

27. A patient has cardiac catheterization using the femoral insertion site and returns to the recovery room. Which action by the new nurse demonstrates lack of understanding of the post-op care if this patient? a. Elevating the head of the bed b. Assessing the motor function of the patient's foot c. Resuming the pre procedure medications as prescribed d. Providing fluids by mouth

a. Elevating the head of the bed

16. A patient becomes apneic and pulseless. CPR has been initiated and the monitor shows asystole in two leads. Which of the following drugs would be used initially? a. Epinephrine b. Atropine c. Amiodarone d. Calcium gluconate

a. Epinephrine

An 82 year old woman with a history of cad and mitral stenosis is being prepared to be discharged home. Based on the rhythm attached, which discharge teaching should the nurse discuss with the patient? a. Explain to the patient that long term anticoagulation therapy is required b. Teach the patient about potential pacemaker insertion c. Explain to the patient the procedure for synchronized cardioversion d. Teach the patient about long term magnesium replacement

a. Explain to the patient that long term anticoagulation therapy is required

28. A nurse cares for a patient with a pulmonary embolism. Which assessment findings does the nurse associate with this condition? (SATA) a. Hemoptysis b. Anxiety c. Sudden chest pain d. Sudden headaches e. New onset dyspnea

a. Hemoptysis b. Anxiety c. Sudden chest pain e. New onset dyspnea

49. A patient with an non-ST segment elevation MI (NSTEMI) is receiving heparin. What is the purpose of heparin? a. Heparin will prevent the development of new clots in the coronary arteries b. Platelet aggregation is enhanced by iv heparin infusion c. Coronary artery plaque size and adherence are decreased with heparin d. Heparin will dissolve the clot that is blocking blood flow to the heart

a. Heparin will prevent the development of new clots in the coronary arteries

46. The nurse is caring for a client with fluid overload. The nurse assesses for which clinical manifestation of fluid overload? (SATA) a. Increased central venous pressure b. Edema to bilateral ankles c. Crackles upon auscultation d. Weight loss of five pounds overnight e. Decreased blood pressure

a. Increased central venous pressure b. Edema to bilateral ankles c. Crackles upon auscultation

4. Onset atrial fibrillation can be serious for which reason? a. It increases the risk of stroke and pulmonary embolism from atrial clots b. It indicated that the patient is about to have an MI c. It increases the patient's risk of deep venous thrombosis d. It may increase cardiac output to dangerous levels

a. It increases the risk of stroke and pulmonary embolism from atrial clots

4. A nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of skin breakdown and nerve damage c. Prevention of gastric aspiration d. Psychological support to patient and family

a. Management and protection of the airway

1. A patient reports to the nurse that his anginal pain is worse after activity. To help the patient understand this, the nurse explains that angina pectoris is a sign of which of the following? a. Myocardial Ischemia b. Coronary embolism c. Mitral insufficiency d. Myocardial Infarction

a. Myocardial Ischemia

6. Which of the following situations may result in a low cardiac output? (SATA) a. Myocardial infarction b. Fever c. Hypovolemia d. Exercise e. Shock

a. Myocardial infarction c. Hypovolemia e. Shock

12. A nurse is developing a discharged plan for a patient who has had a myocardial infarction. Planning for discharge for this patient should begin: a. On admission to the hospital b. 4 weeks after the onset of illness c. On discharge from the cardiac care unit d. On discharge from the hospital

a. On admission to the hospital

12. What is the preferred initial treatment of an acute myocardial infarction? a. Percutaneous coronary intervention (PCI) b. Implanted cardioverter defibrillator (ICD) c. Fibrinolytic therapy d. Coronary artery bypass surgery (CABG)

a. Percutaneous coronary intervention (PCI)

48. What is the preferred initial treatment of an acute myocardial infarction? a. Percutaneous coronary intervention (PCI) b. Coronary artery bypass graft (CABG) c. Fibrinolytic therapy (ICD) d. Implanted cardioverter defibrillator

a. Percutaneous coronary intervention (PCI)

10. The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which of the following (SATA). a. Positive detection of carbon dioxide (CO2) through CO2 detection devices → Quizlet b. Equal bilateral breath sounds upon auscultation c. Fogging of the endotracheal tube d. Auscultation of air over the epigastrium e. Position above the carina verified by chest x-ray

a. Positive detection of carbon dioxide (CO2) through CO2 detection devices → Quizlet b. Equal bilateral breath sounds upon auscultation e. Position above the carina verified by chest x-ray

12. The nurse on the unit notes the following rhythm on the heart monitor. The patient is unresponsive and not breathing. The nurse should a. Provide cardiopulmonary resuscitations b. Treat with intravenous amiodarone or lidocaine c. Ignore the rhythm because it is benign d. Provide electrocardioversion

a. Provide cardiopulmonary resuscitations

28. The provider orders the following mechanical ventilation settings for a patient on simv who weighs 70 kg. The patient's spontaneous respiratory rate is 10 breaths/min. Which arterial blood gas abnormality may occur if the patient continues to breathe at these ventilatory settings? Tidal volume 600 ml (8ml per kg) fio2 0.5 respiratory rate 8 breaths/min mode assist/control positive end expiratory pressure 10 cm h20 a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis

a. Respiratory alkalosis

1. A patient with chest pain that is unrelieved by nitroglycerin is admitted to the coronary care unit (CCU) for observation and diagnosis. While the patient has continuous ECG monitoring what finding would most concern the nurse? a. ST segment elevation b. QRS complex changes c. Occasional PVCs d. A PR interval of 0.18 seconds

a. ST segment elevation

26. A patient with pneumonia is reporting shortness of breath, the nurse suspects the patient is hypoxemix and may need additional oxygen therapy. Which arterial blood gas would validate the nurse's suspicions? a. Sao2 of 87% b. Hco3- of 24 c. Pao2 of 80 mm hg d. Paco2 of 35 mm hg

a. Sao2 of 87%

3. Which patient situation would the nurse anticipate possible Neuromuscular blockade medication to be ordered? (SATA) → needs to be double check!! a. Sedation b. Acute Respiratory Distress Syndrome (ARDS) c. Asynchronous Respirations on the ventilator d. Rapid Sequence Intubation e. Pain

a. Sedation b. Acute Respiratory Distress Syndrome (ARDS) c. Asynchronous Respirations on the ventilator d. Rapid Sequence Intubation

24. A patient with chest pain that is unrelieved by nitroglycerin is admitted to the coronary care unit (CCU) for observation and diagnosis. While the patient has continuous ecg monitoring what finding would most concern the nurse? a. St segment elevation b. Qrs complex changes c. Occasional PVCs d. A pr interval of 0.18 seconds

a. St segment elevation

28. Which statement regarding the difference between stable and unstable angina is accurate? a. Stable angina responds predictably well to nitrates. b. Stable angina is not precipitated by activity. c. Stable angina is a result of coronary artery spasm. d. Stable angina has a low correlation to coronary artery disease (CAD).

a. Stable angina responds predictably well to nitrates.

13. When assessing the patient for hypoxemia, the nurse recognize that an early sign of the effect of hypoxemia on the cardiovascular system is a. Tachycardia b. Tachypnea c. Restlessness d. Heart block

a. Tachycardia

14. The nurse is admitting a patient for whom a diagnosis of pulmonary embolism must be ruled out. The patient's history and assessment reveal all of these findings. Which findings support the diagnosis of pulmonary embolism? a. The patient was on bed rest for 4 hours after a diagnostic procedure b. The patient gave birth to her youngest child 1 year ago c. The patient participated in an anaerobic program for 6 months d. The patient was recently in a motor vehicle crash

a. The patient was on bed rest for 4 hours after a diagnostic procedure

15. Which risk factor should the nurse focus on when teaching a patient who has a 5 cm abdominal aortic aneurysm? a. Uncontrolled hypertension b. Abdominal trauma history c. Male gender d. Turner syndrome

a. Uncontrolled hypertension

22. Which risk factor should the nurse focus on when teaching a patient with a 5 cm abdominal aortic aneurysm? a. Uncontrolled hypertension b. Male gender c. Turner syndrome d. Abdominal trauma history

a. Uncontrolled hypertension

9. Which risk factor should the nurse focus on when teaching a patient who has a 5 cm abdominal aortic aneurysm? a. Uncontrolled hypertension b. Abdominal trauma history c. Male gender d. Turner syndrome

a. Uncontrolled hypertension

38. What are manifestations of acute coronary syndrome (ACS)? (SATA) a. Unstable angina b. Dysrhythmia c. ST-segment elevation myocardial infarction (STEMI) d. Stable angina e. Non-ST segment elevation myocardial infarction

a. Unstable angina c. ST-segment elevation myocardial infarction (STEMI) e. Non-ST segment elevation myocardial infarction

5. What is an ability that is a primary difference in the skills of a certified critical care nurse compared with nurses certified in medical-surgical nursing? a. Use advanced technology to assess and maintain physiology function b. Detect and manage early complication of health problems c. Provide intensive psychological support to the patient and family d. Diagnose and treat-life threatening disease

a. Use advanced technology to assess and maintain physiology function

36. A nurse understand the use of the invasive arterial line is helpful in care by assisting? a. Useful determine the CVP b. Another peripheral line to give medications c. ___ the patient pain from frequent ABG sampling d. High risk of infection due to being inserted into an artery

a. Useful determine the CVP

34. A nurse reviews the patient ECG and notes narrow QRS waves. With regards to the cardiac cycle, what does the QRS waveform indicate? a. Ventricular depolarization b. Atrial depolarization c. Ventricular repolarization d. Atrial repolarization

a. Ventricular depolarization

30. The code blue nurse is responding to a patient in cardiac arrest. The nurse evaluates the rhythm and prepares to defibrillate the patient. Which one of the following rhythms did the nurse observe on the monitor? a. Ventricular fibrillation b. Ventricular tachycardia with a pulse c. Atrial fibrillation d. Third degree heart block

a. Ventricular fibrillation

14. A nurse is caring for a patient who has a thoracic abdominal aneurysm repaired 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? a. Weakness and numbness in the lower extremities b. Abdominal pain at 5/10 on the numeric scale for the past two days c. Heart rate of 100 bpm after ambulating 200 feet d. Urine output of 2,000 mL in 24 hours

a. Weakness and numbness in the lower extremities

11. Which clinical manifestation most suggests a pneumothorax in a trauma victim? a. Inspiratory crackles b. Absent breath sounds c. Pronounced crackles d. Dullness on percussion

b. Absent breath sounds

7. Which clinical manifestation most suggests a pneumothorax in a trauma victim? a. Inspiratory crackles b. Absent breath sounds c. Pronounced crackles d. Dullness on percussion

b. Absent breath sounds

37. The nurse is reviewing emergency management protocols for patients in asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? a. Administer IV amiodarone b. Administer IV epinephrine c. Perform defibrillation d. Prepare for transcutaneous pacing

b. Administer IV epinephrine

31. A patient has just returned to the nursing unit following a cardiac catheterization. What nursing intervention does the nurse perform first? a. Evaluate for urticaria and shortness of breath b. Assess insertion site for hematoma formation c. Administer pain medication d. Administer iv normal saline

b. Assess insertion site for hematoma formation

3. The nurse is caring for a patient on the unit and notices the rhythms attached. Identify the rhythm (EKG Strip) a. Unifocal premature ventricular contractions b. Atrial fibrillation c. Premature atrial contractions d. Ventricular tachycardia

b. Atrial fibrillation

15. A patient with a sinus node dysfunction has a permanent pacemaker inserted. Before discharge, what should the nurse include when teaching the patient? a. Avoid cooking with microwave ovens b. Avoid standing near anti theft device in doorways (it will turn off their pacemaker & die) c. Use mild analgesic to control the chest spasms caused by the pacing current d. Start lifting arm above that shoulder right away to prevent a "frozen shoulder"

b. Avoid standing near anti theft device in doorways (it will turn off their pacemaker & die)

38. Why should the critical care nurse include caregivers of the patient in the ICU as part of the healthcare team? a. Caregivers who are ignited are more likely to question the patient's quality of care b. Caregivers play a valuable role in the patient's recovery c. Caregivers are responsible for making health care decisions for the patients d. The cost of critical care will affect the entire family

b. Caregivers play a valuable role in the patient's recovery

16. The nurse is caring for a patient who is intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal suctioning? (Select all that apply). a. Low-pressure alarm beeping b. Coarse rhonchi bilaterally c. Increased incident of coughing d. Increased oxygen requirements e. heart rate of 64 beat/min

b. Coarse rhonchi bilaterally c. Increased incident of coughing d. Increased oxygen requirements

7. The nurse is caring for a patient who intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal suctioning? (SATA) a. Heart rate of 64 bpm b. Coarse rhonchi bilaterally c. Increased oxygen requirements d. Low pressure alarm beeping e. Increased incident of cough

b. Coarse rhonchi bilaterally c. Increased oxygen requirements e. Increased incident of cough

29. A patient with an acute MI is having multifocal PVCs. He is alert and has a BP of 118/78 mm HG and a regular pulse of 86 bpm. What is the priority of the nurse? a. Ask the patient to perform Valsalva maneuver b. Continue to assess the patient c. Prepare to administer antidysrhythmic drugs per protocol d. Be prepared to administer cardiopulmonary resuscitation (CPR)

b. Continue to assess the patient

18. A patient who has a right sided chest tube after thoracotomy has continuous bubbling in the suction control chamber of the collection device. Which action by the nurse is appropriate? a. Notify the surgeon of a possible pneumothorax b. Continue to monitor the collection device (continuous bubbling is expected) c. Adjust the dial on the wall regulator d. Document the presence of a large air leak

b. Continue to monitor the collection device (continuous bubbling is expected)

17. A patient in acute respiratory failure is receiving acv and is spontaneously breathing. The nurse notices the mechanical ventilator is displaying an auto peep of 14 cm h20. What signs alerts the nurse to undesirable effects of increased airway and thoracic pressure from auto peep? a. Increased crackles b. Decreased bp c. Increased work of breathing d. Decreased pao2

b. Decreased bp

12. The patient with acute respiratory distress syndrome would exhibit which of the following symptoms? a. Respiratory acidosis associated with hyperventilation b. Decreasing pao2 levels despite increase fio2 administration c. Increased lung compliance with increase fio2 administration d. Elevated alveolar surfactant levels

b. Decreasing pao2 levels despite increase fio2 administration

9. The nurse is caring for a client who suddenly develops the following rhythm on the monitor. Which of the following is the most appropriate initial action? (EKG Strip) a. Amiodarosone administration b. Defibrillation c. Cardioversion d. Epinephrine administration

b. Defibrillation

3. A patient reports that he has been having "indigestion" for the last few hours. Upon further review the nurse suspects the patient is having chest pain. Cardiac biomarkers and a 12-lead electrocardiogram (ECG) are done. What finding is most significant in diagnosing an acute coronary syndrome (ACS) within the first 3 hours? a. Elevated B-type natriuretic peptide (BNP) b. Elevated troponin I c. Inserted T waves d. Indigestion and chest pain

b. Elevated troponin I

32. A patient reports that he has been having "indigestion" for the last few hours. Upon further review, the nurse suspects the patient is having chest pain. Cardiac biomarkers and a 12 lead electrocardiogram (ECG) are done. What finding is most significant in diagnosing an acute coronary syndrome (ACE) within the first 3 hours? a. Indigestion and chest pain b. Elevated troponin I c. Inversed T waves d. Elevated BNP

b. Elevated troponin I

28. A patient has a cardiac catheterization using the femoral insertion site and returns to the recovery room. Which action by a new nurse demonstrates lack of the understanding of the post-op care of this patient? a. Provide fluids by mouth b. Elevating the head on the bed c. Resuming pre-procedure medications as prescribed. d. Assessing the motor function of the patient's foot.

b. Elevating the head on the bed

25. The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which the following? (SATA) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Symmetrical chest rest and fall d. Positive Instruction of carbon dioxide (CO2) through detector devices e. Fogging of the endotracheal tube

b. Equal bilateral breath sounds upon auscultation c. Symmetrical chest rest and fall d. Positive Instruction of carbon dioxide (CO2) through detector

9. Which actions should the nurse start to reduce the risk for Ventilator Associated Pneumonia (VAP)? (SATA) a. Obtain arterial blood gases daily b. Give prescribed enoxaparin (Lovenox) c. Elevate the head of the bed to at least 60 degrees (should be 30-45) d. Provide aggressive antibiotic therapy daily e. Provide oral care with chlorhexidine (0.12%) solution

b. Give prescribed enoxaparin (Lovenox) e. Provide oral care with chlorhexidine (0.12%) solution

31. Which nursing intervention for a patient who has open repair of an abdominal aortic aneurysm (AAA) 2 days previously is appropriate for the nurse to delegate to the UAP? a. Monitor the quality and presence of the pedal pulses b. Help the patient to use a pillow to splint while coughing c. Teach the patient the sign of possible wound infection d. Check lower extremities for strength and movement.

b. Help the patient to use a pillow to splint while coughing

36. A nurse is preparing a client for transfer to the icu for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? a. Intracranial pressure b. Hemodynamic status c. Renal function d. Spinal cord perfusion

b. Hemodynamic status

43. A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Heparin c. Atropine d. Dexamethasone

b. Heparin

49. Heparin is ordered for the patient with a non st segment elevation myocardial infarction. How should the nurse explain the purpose of the heparin to the patient? a. Heparin dissolves clots that are blocking blood flow in the coronary arteries b. Heparin prevents the development of new clots in the coronary arteries c. Heparin decreases the size of the coronary artery plaque d. Heparin enhances platelet aggregation at the plaque site

b. Heparin prevents the development of new clots in the coronary arteries

41. A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is a. Administration of two aspirin tablets b. Insertion of a vena cava filter c. Infusion of thrombolytics d. Subcutaneous heparin administration every 12 hours.

b. Insertion of a vena cava filter

8. A strategy for preventing pulmonary embolism in patient at risk who cannot take anticoagulants is a. Subcutaneous heparin administration every 12 hours b. Insertion of a vena cava filter c. Infusion of thrombolytics d. Administration of two aspirin tablets every 4 hours

b. Insertion of a vena cava filter

27. A nurse is caring for a patient in the emergency department. The nurse observes the monitor and notes the rhythm (image attached). The patient has a BP of 80/42 mm Hg and reports dyspnea, chest pain, and feeling faint. Which actions should the nurse prepare to take? (SATA) (Ventricular Tachycardia below) a. Rapid defibrillation b. Instruct the patient to valsalva c. Administer adenosine 6 mg intravenously d. Initiate cardiopulmonary resuscitation and chest compressions e. Administer amiodarone 150 mg intravenously

b. Instruct the patient to valsalva c. Administer adenosine 6 mg intravenously e. Administer amiodarone 150 mg intravenously

29. A patient was admitted following an aspiration event on the medical surgical floor. The patient is receiving 40% oxygen via a simple face mask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Orders for a sedative b. Intubation and mechanical ventilation c. Suction and reposition the patient d. Change in antibiotics orders

b. Intubation and mechanical ventilation

44. Which of the following statements is true about central venous pressure? Sata a. Decreases in patients with right ventricular failure b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia e. Increases in patients with left ventricular failure

b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia

7. Which of the following statements is true about central venous pressure? Sata a. Decreases in patients with right ventricular failure b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia e. Increases in patients with left ventricular failure

b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia

34. Which statement describes the synchronized intermittent mandatory ventilation mode of ventilation? a. It applies positive pressure during both ventilator breaths and spontaneous breaths b. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or or her own volume c. It delivers gas at preset volume and at a set rate d. It delivers gas at preset pressure regardless of the patient's inspiratory efforts

b. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or or her

25. The nurse understands that ventilator associated pneumonia (VAP) protocols include? (Select all that apply) a. Scheduled suctioning b. Keeping head of bed between 30-35 degrees c. Perform regular oral care with antiseptic solution d. Daily assessment for readiness to extubate e. Deep vein thrombosis (DVT) prophylaxis

b. Keeping head of bed between 30-35 degrees c. Perform regular oral care with antiseptic solution d. Daily assessment for readiness to extubate e. Deep vein thrombosis (DVT) prophylaxis

13. The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome (ARDS). The nurse understands that the priority nursing concern for this patient is which of the following? a. Psychological support to patient and family b. Management and protection of the airway c. Prevention of gastric aspiration d. Prevention of skin breakdown and nerve damage

b. Management and protection of the airway

14. A patient reports to the nurse that his anginal pain is worse after activity. To help the patient understand this, the nurse explains that angina pectoris is a sign of which of the following? a. Mitral insufficiency b. Myocardial ischemia c. Myocardial infarction d. coronary embolism

b. Myocardial ischemia

18. The nurse is caring for mechanically ventilated patient and responds to a low inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (SATA) a. Kink on the tubing b. Partial extubation c. ETT cuff leak d. Disconnection from the ventilator e. Cough or attempting to talk

b. Partial extubation c. ETT cuff leak d. Disconnection from the ventilator

47. A patient with an acute lung injury has refractory hypoxemia and severe intrapulmonary shunting. What mechanical ventilation setting can be used to assist this patient with this condition? a. Aspiration b. Positive end expiratory pressure (PEEP) c. SMV d. Tracheostomy

b. Positive end expiratory pressure (PEEP)

A nurse is viewing the cardiac monitor in the patient's room and notes that the patient has just gone into the rhythm attached. The patient is unresponsive and does not have a pulse. CPR and chest compressions are initiated at this time. The nurse would prepare to do which of the following? (VTACH) a. Prepare for a pacemaker insertion b. Prepare for defibrillation c. Prepare for synchronized cardioversion d. Administer atropine intravenously

b. Prepare for defibrillation

33. A mode of pressure targeted ventilation that provide positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is a. T piece adaptor b. Pressure support ventilation c. Positive end expiratory pressure d. Continuous positive airway pressure

b. Pressure support ventilation

5. In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit? a. Bronchial breath sounds b. Refractory hypoxemia c. Increased pulmonary artery wedge pressure (PAWP) d. Progressive hypercapnia

b. Refractory hypoxemia

7. In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit? a. Progressive hypercapnia b. Refractory hypoxemia c. Increased pulmonary artery wedge pressure (PAWP) d. Bronchial breath sounds

b. Refractory hypoxemia

35. Which assessment finding would lead the nurse to suspect the early onset of hypoxemia? a. Dysrhythmia b. Restlessness c. Central cyanosis d. Hypotension

b. Restlessness

43. A nurse provides oral care for a patient who is mechanically ventilated.What is the best rationale for providing this care? a. Routine oral care may reduce the risk of tooth decay b. Routine oral care may reduce the risk of pneumonia c. The patient's cavity requires regular moisture d. The patient is fully dependent on the nurse's actions

b. Routine oral care may reduce the risk of pneumonia

27. Which AV block image attached can be described as a gradually lengthening PR interval until ultimately the final P wave in the group fails to conduct? → needs to be double check!! a. Third degree block ( b. Second degree AV block, type I (PR interval it get short and longer not the same) c. Second degree AV block type II (PR interval is the same basically identical) d. First degree AV block (when the P is longer than it should be)

b. Second degree AV block, type I (PR interval it get short and longer not the same)

25. To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. Dull percussion sounds on the injured site b. Severe respiratory distress and tracheal deviation c. decreased movement and diminished breath sounds of the affected side d. Muffled and distant heart sounds with decreased blood pressure

b. Severe respiratory distress and tracheal deviation

44. When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is a. Tachypnea b. Tachycardia c. Restlessness d. Heart block

b. Tachycardia

29. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care? a. Warfarin (Coumadin) b. Tadalafil c. Furosemide (Lasik) d. Diltiazem (Cardizem)

b. Tadalafil

11. A patient is scheduled to have CABG surgery. What should the nurse should explain is involved with the procedure? a. Reversed segments of a saphenous artery from the aorta will be anastomosed to the coronary artery distal to an obstruction b. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis c. A systemic graft will be used as a tube for blood flow from the aorta to a coronary artery distal to an obstruction d. A stenosis coronary artery will be resected and a synthetic arterial tube graft will be inserted to replace the diseased artery

b. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis

2. A patient is scheduled to have CABG surgery. What should the nurse should explain is involved with the procedure? a. Reversed segments of a saphenous artery from the aorta will be anastomosed to the coronary artery distal to an obstruction b. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis c. A systemic graft will be used as a tube for blood flow from the aorta to a coronary artery distal to an obstruction d. A stenosis coronary artery will be resected and a synthetic arterial tube graft will be inserted to replace the diseased artery

b. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis

45. A patient is scheduled to have cabg surgery. What should the nurse explain is involved with the procedure? a. Reversed segments of a saphenous artery from the aorta will be anastomosed to the coronary artery distal to an obstruction b. The internal mammary artery will be detached from the chest wall and attached to the coronary artery distal to the stenosis c. The stenosed coronary artery will be resected and a synthetic arterial tube graft will be inserted to replace the diseased artery d. A synthetic graft will be sued as a tube for blood flow from the aorta to a coronary artery distal to an obstruction

b. The internal mammary artery will be detached from the chest wall and attached to the coronary artery distal to the stenosis

26. The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patient PaCO2 is 45 mm Hg b. The patient's PaO2 is 33 mm Hg c. The patient's respirations are shallow d. The patient's respiratory rate is 32 breaths/min

b. The patient's PaO2 is 33 mm Hg

5.Which of the following lab values is most concerning to the nurse? a. Triglycerides 170 mg/dL (normal <200) b. Troponin I 1.1 (0-0.4) c. HDL 60 mg/dL (normal >40) d. LDL 120 mg/dL (normal <130)

b. Troponin I 1.1 (0-0.4)

8. Which risk factor should the nurse focus on when teaching a patient who has 5 cm aortic aneurysm? a. Male gender b. Uncontrolled hypertension c. Turner syndrome d. Abdominal trauma history

b. Uncontrolled hypertension

48. The nurse cares for a patient with atrial fibrillation and a heart rate of 123 beats/ min. How does the heart rate affect cardiac output for this patient? a. Ventricular filling time increases b. Ventricular filling time decreases (Heart beat is not letting filling up correctly) c. Oxygen demand decreases d. Stroke volume increases

b. Ventricular filling time decreases (Heart beat is not letting filling up correctly)

38. A nurse is caring for a patient who had thoracic-abdominal aneurysm repaired 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physical immediately? a. Urine output of 2,000 mL in 24 hours b. Weakness and numbness in the lower extremities c. Abdominal pain at 5/10 on the numeric scale for the past two days d. Heart rate of 100 bpm after ambulating 200 feet

b. Weakness and numbness in the lower extremities

4. The nurse provides pre procedure education to a patient scheduled to have a cardiac catheterization. Which statement does the nurse include? a. The procedure is performed at the bedside b. You may feel flushing, warmth, or palpitations during the procedure c. There may at first be some intense pain that resolves quickly d. You may develop a headache but this is normal

b. You may feel flushing, warmth, or palpitations during the procedure

1. When developing a teaching plan for a 61-year-old patient with multiple risk factors for (CAD), the nurse should focus primarily on the a. increased risk of cardiovascular disease as people age b. evaluate low-density lipoprotein (LDL) level c. Increased risk associated with the patient's gender. d. family history of coronary artery disease

b. evaluate low-density lipoprotein (LDL) level

33. The nurse provides pre-procedure education to a patient scheduled to have cardiac catheterization. Which statement does the nurse include? a. "This procedure is performed at the bedside." b. "You may develop a headache but this is normal" c. "You may feel flushing, warmth, or palpitation during the procedure." d. "There may at first be some intense pain that resolves quickly."

c. "You may feel flushing, warmth, or palpitation during the procedure."

10. After receiving the change-end of the shift report on the medical unit, Which patient should the nurse assess first? a. A patient with pneumonia who has crackles bilaterally in the lung bases b. A patient with emphysema who has an oxygen saturation of 90% to 92% c. A patient with septicemia who has intercostal and suprasternal retractions d. A patient with cystic fibrosis who has thick green-colored sputum

c. A patient with septicemia who has intercostal and suprasternal retractions

49. A patient with which disorder would benefit from the use of the intra aortic balloon pump (IABP)? a. A dissecting thoracic aortic aneurysm b. An insufficient aortic valve c. Acute myocardial infarction with cardiogenic shock d. Generalized peripheral vascular disease

c. Acute myocardial infarction with cardiogenic shock

13. The nurse is reviewing emergency management protocols for patients in asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? a. Prepare for transcutaneous pacing b. Administer IV amiodarone c. Administer IV epinephrine d. Perform defibrillation

c. Administer IV epinephrine

6. The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a BP 85/40 mm Hg, HR of 125 bpm, RR 35 bpm, and arterial SpO2 of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac output of 1.0 L/min and a central venous pressure of 1 mm Hg. The nurse questions which of the following physician's orders? a. Obtain arterial blood gas and serum electrolytes b. Infuse 500 mL 0.9% normal saline over 1 hour c. Administer furosemide (Lasix) 20 mg IV (quizlet) d. Tirate supplementary oxygen to achieve a SpO2 94%

c. Administer furosemide (Lasix) 20 mg IV (quizlet)

46. A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? a. Initiate cardiac monitoring b. Start an IV infusion of Lactated Ringers c. Administer oxygen therapy d. Give Morphine IVP

c. Administer oxygen therapy

3. A blood pressure difference of 25 mmHg between the left and right arm indicates which of the following? a. Normal finding b. Myocardial infarction c. Aortic dissection d. Subclavian thrombosis

c. Aortic dissection

18. The nurse is caring for a patient with descending aortic aneurysm. Which assessment finding is most important to report to the health care provider? a. Absent bowel sounds b. Weak pedal pulses c. Blood pressure of 180/106 mm Hg d. 35 mL of urine output over the past hour

c. Blood pressure of 180/106 mm Hg

47. The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the healthcare provider? a. Absent bowel sounds b. 25 ml of urine output over the past hr c. Bp of 152/98 mm hg ( >120 greater) d. Weak pedal pulses

c. Bp of 152/98 mm hg ( >120 greater)

33. An older patient with a history of abdominal aortic aneurysm arrives at the ed with severe back pain and absent pedal pulses. Which action should the nurse take first? a. Determine family history of heart disease b. Draw blood for laboratory testing c. Check the patient's blood pressure d. Assess patient for abdominal bruit

c. Check the patient's blood pressure

20. A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32 breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate? a. Pericardiocentesis b. Thoracentesis c. Chest tube insertion d. Emergent intubation

c. Chest tube insertion

47. A patient present to the walk in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that anginal is most often attributable to what cause? a. Decreased cardiac contractility b. Infarction of the myocardium c. Coronary arteriosclerosis d. Decreased cardiac output

c. Coronary arteriosclerosis

42. A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of the inspired oxygen is increased from 0.6 to 0.7 and positive end-expiratory pressure (PEEP) is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's BP drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in BP? a. Oxygen toxicity b. Hypovolemia c. Decrease in cardiac output d. Increase in venous return

c. Decrease in cardiac output

7. Four hours after mechanical ventilation is initiated, a patient's ABG results include a PH of 7.51, PaO2 82 mmHg, PaCO2 of 26 mmHg and HCO3- of 23 mmol/L. The nurse will make what recommendation to the physician to change the setting? a. Increase the tidal volume b. Increase the respiratory rate c. Decrease the respiratory rate

c. Decrease the respiratory rate →

24. A patient admitted to the coronary care unit (CCU) with a stemi is restless and anxious. The blood pressure is 86/40 mm hg and the heart rate is 132 beats/min. Based on this information, which patient problem is the priority? a. Anxiety b. Acute pain c. Decreased cardiac output d. Stress management

c. Decreased cardiac output

47. A patient admitted to the coronary care unit (CCU) with a stemi is restless and anxious. The blood pressure is 86/40 mm hg and the heart rate is 132 beats/min. Based on this information, which patient problem is the priority? a. Anxiety b. Acute pain c. Decreased cardiac output d. Stress management

c. Decreased cardiac output

43. The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Respiratory acidosis with hyperventilation b. Increased lung compliance with increased fio2 administration c. Decreasing pao2 levels despite increased fio2 administration d. Elevated alveolar surfactant levels

c. Decreasing pao2 levels despite increased fio2 administration

17. A patient has a cardiac catheterization using the femoral insertion site and returns to the recovery room. Which action by a new nurse demonstrates the lack of understanding of the post op care of this patient? a. Resuming pre procedure meds as prescribed b. Providing fluids by mouth c. Elevating head of the bed d. Assessing the motor function of the patient's foot

c. Elevating head of the bed

31. A patient has a cardiac catheterization using the femoral insertion site and returns to the recovery room. Which action by a new nurse demonstrates the lack of understanding of the post op care of this patient? a. Resuming pre procedure meds as prescribed b. Providing fluids by mouth c. Elevating head of the bed d. Assessing the motor function of the patient's foot

c. Elevating head of the bed

10. Which nursing interventions is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? a. Give the patient a list of low sodium, low cholesterol foods that should be included in the diet. b. Inform the patient about a diet containing no saturated fat and minimal salt c. Help the patient modify favorite high-fat recipes using monounsaturated oils d. Emphasize the increased risk for heart problems unless the patient makes dietary changes

c. Help the patient modify favorite high-fat recipes using monounsaturated oils

10. A nurse is evaluating the central venous pressure of a client who has sustained multiple traumas. Which of the following interpretations of a low cvp pressure should the nurse make? a. Fluid overload b. Intracardiac shunt c. Hypovolemia d. Left ventricular failure

c. Hypovolemia

29. The nurse is caring for a patient who is intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal suctioning? SATA a. Low pressure alarm beeping b. Heart rate of 64 beats/min c. Increased oxygen requirements d. Increased incidence of coughing e. Coarse rhonchi bilaterally

c. Increased oxygen requirements d. Increased incidence of coughing e. Coarse rhonchi bilaterally

40. The patient is 72 hours postoperative for cabg. The patient's vital signs include t 103f, hr 112 rr 22 bp 101/58 mm hg, and o2 sat 94% on 3l nasal cannula. The nurse suspects that the patient has developed what problem? a. Infection, which is commonly postoperatively and monitors the patient's condition b. Delirium caused by the elevated temperature c. Infection and notifies the physician immediately d. Cardiac tamponade and notifies the physician immediately

c. Infection and notifies the physician immediately

19. New onset atrial fibrillation can be serious for which reason? a. It indicates that the patient is about to have an MI b. It may increase cardiac output to dangerous levels c. It increases the risk of stroke and pulmonary embolism from atrial clots d. It increases the patient's risk of deep venous thrombosis

c. It increases the risk of stroke and pulmonary embolism from atrial clots

41. New onset atrial fibrillation can be serious for which reason? a. It indicates that the patient is about to have an MI b. It may increase cardiac output to dangerous levels c. It increases the risk of stroke and pulmonary embolism from atrial clots d. It increases the patient's risk of deep venous thrombosis

c. It increases the risk of stroke and pulmonary embolism from atrial clots

13. The nurse is questioning the accuracy of the arterial catheter readings, which two actions should the nurse perform to ensure the accuracy of the transducer? a. Obtain a cuff blood pressure and adjust the monitor to match b. Have the patient laid flat and closing the transducer to air c. Level the transducer to the phlebostatic axis and zero the transducer d. Obtain blood return on the arterial line and closing all the stopcocks

c. Level the transducer to the phlebostatic axis and zero the transducer

46. The nurse is questioning the accuracy of the arterial catheter readings, which two actions should the nurse perform to ensure the accuracy of the transducer? a. Obtain a cuff blood pressure and adjust the monitor to match b. Have the patient laid flat and closing the transducer to air c. Level the transducer to the phlebostatic axis and zero the transducer d. Obtain blood return on the arterial line and closing all the stopcocks

c. Level the transducer to the phlebostatic axis and zero the transducer

40. The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's priority action is to a. Ask the respiratory therapist to get a new ventilator b. Call the rapid response team to assess the patient c. Manually ventilate the patient while calling for the respiratory therapist d. Continue to find the cause of the alarm and fix it

c. Manually ventilate the patient while calling for the respiratory therapist

50. The nurse is concerned that a patient is at an increased risk of developing a pulmonary embolism and develops a plan of care for prevention to include which of the following? a. Oral care b. Bed rest with head of bed elevated c. Mobility d. Coughing and deep breathing

c. Mobility

35. An adult patient is admitted to the ed with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. to minimize cardiac damage, the nurse should expect to administer which of the following interventions? a. Thrombolytics, oxygen administration, and nonsteriodial anti inflammatories b. Best rest, albuterol nebulizer treatments, and oxygen c. Morphine sulphate, oxygen, and bed rest d. Oxygen and beta adrenergic blockers

c. Morphine sulphate, oxygen, and bed rest

6. The nurse is caring for a patient immediately after the repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Wrap both the legs in a warming blanket b. Compare findings to the preoperative assessment of the pulses c. Notify the surgeon and anesthesiologist d. Document the findings and recheck in 15 minutes

c. Notify the surgeon and anesthesiologist

8. A nurse working in the ICU sees the following rhythm on the monitor. The nurse goes into the room and finds the patient cool, clammy, and in and out of consciousness. What is priority action by the nurse? (STRIP PIC) a. Prepare for defibrillation b. Begin chest compressions c. Prepare to administer atropine d. Document the finding and continue to monitor

c. Prepare to administer atropine

26. A surgical repair is planned for a patient who has 5.5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, what should the nurse expect to find. a. Weakness in the lower extremities progressing to paraplegia b. Severe back pain with flank ecchymosis c. Presence of a bruit in the periumbilical area d. Hoarseness and dysphagia

c. Presence of a bruit in the periumbilical area

26. A surgical repair is planned for a patient who has 5.5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, what should the nurse expect to find. a. Weakness in the lower extremities progressing to paraplegia b. Severe back pain with flank ecchymosis c. Presence of a bruit in the periumbilical area d. Hoarseness and dysphagia

c. Presence of a bruit in the periumbilical area

50. A definitive diagnosis of pulmonary embolism can be made by a. Arterial blood gas (ABG) analysis b. C-reactive protein c. Pulmonary angiogram d. Chest x-ray examination

c. Pulmonary angiogram

38. What should the nurse measure to determine whether there is a delay in impulse conduction through the patient's ventricles? a. P wave b. Q wave c. Qrs complex d. Pr interval

c. Qrs complex

31. Which statement regarding the difference between stable and unstable angina is accurate? a. Stable angina is a result of coronary artery spasm b. Stable angina is not precipitated by activity c. Stable angina responds predictable well to nitrates d. Stable angina has a low correlation to coronary artery

c. Stable angina responds predictable well to nitrates

32. Which statement regarding the difference between stable and unstable angina is accurate? a. Stable angina has a low correlation to coronary artery disease (CAD) b. Stable angina is not precipitated by activity c. Stable angina responds predictably well to nitrates d. Stable angina is the result of coronary artery spasm.

c. Stable angina responds predictably well to nitrates

41. A 62 year old patient has been suffering from alcohol abuse and has developed severe hypokalemia with a potassium level of 2.9 mEq/L. An hour after admission to the hospital, of the potassium levels. The monitor shows the rhythm attached. The nurse does not feel a pulse. Which action should the nurse perform next? a. Prepare for immediate defibrillation b. Provide 2 rescue breaths and prepare for intubation c. Start CPR using chest compression d. Administer atropine 0.5 mg IV

c. Start CPR using chest compression

21. A patient has an oral et tube inserted to relieve an upper airway obstruction adn to facilitate secretion removal. What is the first responsibility of the nurse immediately following placement of the tube? a. Assess for bilateral breath sounds and symmetrical chest movement b. Secure the tube to the face with an adhesive tape c. Suction the tube to remove secretions d. Place an end tidal co2 detector on the et tube

c. Suction the tube to remove secretions

22. A patient's status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilation but wants to encourage the patient to breathe spontaneously between the mechanical breaths and his own tidal volume. This mode of ventilation is called a. assist/control ventilation b. Controlled ventilation c. Synchronized intermittent mandatory ventilation d. Positive end expiratory pressure

c. Synchronized intermittent mandatory ventilation

50. A patient's status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously between the mechanical breaths at his own tidal volume. This mode of ventilation is called a. assist/control ventilation b. Controlled ventilation c. Synchronized intermittent mandatory ventilation d. Positive end expiratory pressure

c. Synchronized intermittent mandatory ventilation

33. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Pulmonary artery wedge pressure (PAWP) b. Pulmonary vascular resistance (PVR) c. Systemic vascular resistance (SVR) d. Mean arterial pressure (MAP)

c. Systemic vascular resistance (SVR)

6. A nurse is caring for a patient with a pneumothorax. A chest tube has been placed by the physician and is attached to a traditional water-seal drainage system. The nurse suspects possible leaks in the chest tube and pleural drainage system if they observe which of the following? a. Fluid in the water-seal chamber fluctuates with the patient's breathing b. The water level in the water-seal suction control chamber are decreased c. There is continuous bubbling in the water-seal chamber d. There is constant bubbling of water in the suction control chamber

c. There is continuous bubbling in the water-seal chamber

22. A nurse is caring for a patient with a pneumothorax. A chest tube has been placed by the physician and is attached to a traditional water-seal drainage system. The nurse suspects possible leaks in the chest tube and pleural drainage system if they observe which of the following? a. Fluid in the water-seal chamber fluctuates with the patient's breathing b. The water level in the water-seal suction control chamber are decreased c. There is continuous bubbling in the water-seal chamber - Intermittent Bubble (Normal); Continuous Bubble (Abnormal) in a water-seal chamber d. There is constant bubbling of water in the suction control chamber

c. There is continuous bubbling in the water-seal chamber - Intermittent Bubble (Normal);

35. Which explanation is accurate when teaching the patient with an intrapulmonary shunt about what is happening? a. Gas exchange across the alveolar capillary interface is decreased by thickened or damaged alveolar membrane. b. The occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung. c. This occurs when blood flows through the capillaries in the lungs without taking part in gas exchange. d. This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs.

c. This occurs when blood flows through the capillaries in the lungs without taking part in gas exchange.

40. The patient is admitted with a fever and rapid heart rate. The patient's temperature is 103f (39.4c). The nurse places the patient on a cardiac monitor and notices the patient...(cut off) → needs to be double check!! a. Medications to lower heart rate b. Treatment to reduce the blood pressure c. Treatment to lower temperature d. Treatment to lower cardiac output

c. Treatment to lower temperature

19. A patient's ventilator alarm reads "Low Pressure," but after checking the ventilator and endotracheal tube, the nurse cannot determine the cause of the alarm. Which action does the nurse perform next? Low -pressure (broken seal in the vent due to leaking) High-pressure (need to suction) a. Administer additional oxygen b. Reset the ventilator c. Ventilate the patient manually d. Connect the patient to pulse oximetry

c. Ventilate the patient manually

50. A patient's ventilatory alarm reads low pressure but after checking the ventilator and endotracheal tube, the nurse cannot determine the cause of the alarm. Which action does the nurse perform next? a. Administer additional oxygen b. Reset the ventilator c. Ventilate the patient manually d. Connect the patient to pulse oximetry

c. Ventilate the patient manually

17. The nurse reviews a patient's ECG and notes narrow QRS waves. With regards to the cardiac cycle, what does the QRS waveform indicate? a. Atrial repolarization b. Atrial depolarization c. Ventricular depolarization d. Ventricular repolarization

c. Ventricular depolarization

23. A deathly ill patient from a culture different than the nurse's is admitted. Which question is appropriate to help the nurse provide culturally competent care? a. "If you die, will you want an autopsy?" b. "Do you have any preferences for what happens if you are dying?" c. "Are you interested in learning about palliative or hospice care?" d. "Tell me about your expectations of care during hospitalization."

d. "Tell me about your expectations of care during hospitalization."

42. A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? a. Give morphine iv b. Initiate cardiac monitoring c. Start an iv infusion of lactated ringers d. Administer oxygen therapy

d. Administer oxygen therapy

21. The nurse is caring for a patient with a chest tube for a pneumothorax. A family member trips on the tubing and pulls the chest tube out. The patient's HR increases to 140 bpm, and the SpO2 drops to 88%. There is an audible air leak at the insertion site. What should the nurse do? a. Assess lung sounds b. Notify the healthcare provider c. Apply an occlusive sterile dressing and secure it on 4 sides d. Apply an occlusive sterile dressing and secure it on 3 sides

d. Apply an occlusive sterile dressing and secure it on 3 sides

42. A patient has just returned to the nursing unit following a cardiac catheterization. What nursing intervention does the nurse perform first? a. (?) and shortness of breath b. Administer IV normal saline c. Administer pain medication d. Assess insertion sites for hematoma formation

d. Assess insertion sites for hematoma formation

15. A patient overdosed on Xanax, develops respiratory failure, and is successfully intubated. The nurse anticipated what initial mode of ventilation on the ventilator? a. Synchronized intermittent mandatory ventilation b. Pressure support ventilation c. PEEP 15 - (ARDS) d. Assist-controlled ventilation

d. Assist-controlled ventilation

19. During the patient's acute postoperative period following repair of an AAA, the nurse should ensure that which goal is achieved? a. Iv fluids are given to maintain urine output of 100 ml/hr b. The patient's bp is kept lower than the baseline to prevent leaking at the incision site c. Hypothermia is maintained to decrease oxygen needs d. BP and all peripheral pulses are assessed at least every hour

d. BP and all peripheral pulses are assessed at least every hour

A patient with an acute mi is having multifocal pvsd (rhythm attached). He is alert and has a hp of 116/78 mm hg with a regular pulse of 86 bpm. What is priority nursing? a. Be prepared to administer cardiopulmonary resuscitation b. Ask the patient to perform valsalva maneuver c. Prepare to administer antidysrhythmic drugs per protocol d. Continue to assess the patient

d. Continue to assess the patient

8. A patient in acute respiratory failure is receiving acv with a peep of 10 cm h20. What signs alert the nurse to undesirable effects of increased airway and thoracic pressure? a. Decreased pao2 b. Increased crackles c. Decreased spontaneous respirations d. Decreased bp

d. Decreased bp

1. A patient admitted to the coronary care unit with a ST segment elevation myocardial infarction is restless and anxious. The blood pressure is 86/48 mm hg and the heart rate is 132 beats/min. Based on this information which patient problem is the priority? a. Stress management b. Acute pain c. Anxiety d. Decreased cardiac output

d. Decreased cardiac output

2. A nurse assesses a patient who is receiving from a thoracentesis. Which assessment finding is most concerning to the nurse? a. Respiratory rate of 25 breaths/min b. Expiratory wheezes in the upper and lower lobes c. Heart rate 115 beats/min d. Diminished breath sound on the affected side

d. Diminished breath sound on the affected side

39. A patient with a possible pulmonary embolism reports chest pain with difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Notify the patient's health care provider b. Prepare patient for a spiral computed tomography c. Administer anticoagulant drug therapy d. Elevate the head of bed to a semi fowler's position

d. Elevate the head of bed to a semi fowler's position

20. A client has just been intubated and placed on a mechanical ventilator. What is the first assessment of the tube placement? a. Auscultation of breath sounds b. Chest X-ray c. Pulse oximetry reading of 95% d. End tidal CO2 monitoring

d. End tidal CO2 monitoring

17. A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Atropine b. Dexamethasone c. Furosemide d. Heparin

d. Heparin

22. A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? a. Intracardiac shunt b. Fluid overload c. Left ventricular failure d. Hypovolemia

d. Hypovolemia

36. A nurse is viewing the cardiac monitor in the patient's room and notes that the patient has just gone into the rhythm attached. The patient is unresponsive and pulseless. The nurse would prepare to do which of the following? a. Prepare the synchronized cardioversion b. Administer magnesium intravenously c. Administer amiodarone (Cordarone) intravenously d. Immediately defibrillate

d. Immediately defibrillate

42. A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 6 breaths/min. His spontaneous respirations are 17 breaths/min. He receives a dose of morphine sulfate and his respirations decrease to 6 breaths/min. What adjustments need to be made to the patient's ventilator settings? a. Change to assist/control ventilation at a rate of 4 breaths/min b. Add positive end expiratory pressure (PEEP) c. Add pressure support d. Increase the respiratory rate

d. Increase the respiratory rate

25. A nurse is teaching a nursing student about the modes of volume ventilation. Which statement regarding the assist control mode indicates the student understood the information? a. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume b. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts c. It applies positive pressure during both ventilator breaths and spontaneous breaths d. It delivers gas at preset rate and pressure regardless of the patient's inspiratory efforts

d. It delivers gas at preset rate and pressure regardless of the patient's inspiratory efforts

48. A nurse is teaching a nursing student about the modes of volume ventilation. Which statement regarding the assist control mode indicates the student understood the information? a. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume b. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts c. It applies positive pressure during both ventilator breaths and spontaneous breaths d. It delivers gas at preset rate and pressure regardless of the patient's inspiratory efforts

d. It delivers gas at preset rate and pressure regardless of the patient's inspiratory efforts

40. The nurse is questioning the accuracy of the arterial catheter readings. The two actions the nurse should perform to ensure the accuracy of the transducer? a. Obtain blood return on the arterial line and closing all the stopcocks b. Have the patient lay flat and close the transducer to air. c. Obtain a cuff blood pressure and adjust the monitor to match d. Level the transducer to the phlebostatic axis and zero the transducer.

d. Level the transducer to the phlebostatic axis and zero the transducer.

14. Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? a. Stable angina b. Abdominal Indigestion c. Absent pedal pulse d. Lower back pain (quizlet)

d. Lower back pain (quizlet)

37. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolism and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility

d. Mobility

23. A patient experienced a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse should be concerned if which finding is observed during the initial assessment? a. Large bruise on the chest b. Complaint of the chest wall pain c. Heart rate of 110 beats/min d. Paradoxical chest movement

d. Paradoxical chest movement

10. A nurse working in the ICU sees the following rhythm on the monitor. The nurse goes into the room and finds the patient cool, clammy, and in and out of consciousness. What priority action by the nurse? (first degree heart block) a. Document the finding and continue to monitor b. Prepare for defibrillation c. Begin chest compressions d. Prepare to administer atropine

d. Prepare to administer atropine

36. A nurse working in the ICU sees the following rhythm on the monitor. The nurse goes into the room and finds the patient cool, clammy, and in and out of consciousness. What priority action by the nurse? (first degree heart block) a. Document the finding and continue to monitor b. Prepare for defibrillation c. Begin chest compressions d. Prepare to administer atropine

d. Prepare to administer atropine

41. A mode of pressure targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is a. Positive end expiratory pressure b. Continuous positive airway pressure c. T piece adapter d. Pressure support ventilation

d. Pressure support ventilation`

2. One of the early symptoms of hypoxemia on the nervous system is a. Cyanosis b. Tachycardia c. Tachypnea d. Restlessness

d. Restlessness

45. One of the early signs of hypoxemia in the nervous system is a. Cyanosis b. Tachycardia c. Tachypnea d. Restlessness

d. Restlessness`

`30. A nurse provides oral care for the patient who is mechanically ventilated. What is the best rationale for providing this care? a. Routine oral care may reduce the risk of tooth decay b. The patient's oral cavity requires regular moisture c. The patient is fully dependent on the nurse's action d. Resume oral care may reduce the risk of pneumonia

d. Resume oral care may reduce the risk of pneumonia

23. A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk for ventilator associated pneumonia? a. Perform hand hygiene prior to suctioning the client's et tube b. Turn the client every 4 hr c. Position the head of the client's bed in the flat position d. Rinse the client's mouth with an antimicrobial solution every 4 hr

d. Rinse the client's mouth with an antimicrobial solution every 4 hr

11. A patient with chest pain that is unrelieved by nitroglycerin is admitted to the coronary care unit for observation and diagnosis. While the patient has continuous ECG monitoring, what finding would most concern the nurse? a. Occasional PVCs (Too much coffee or caffeine or stress) b. A PR interval of 0.18 seconds (Range: 0.12-0.20) c. QRS complex change d. ST-segment elevation (ST STEMI 100% block, NSTEMI 30% block)

d. ST-segment elevation (ST STEMI 100% block, NSTEMI 30% block)

34. To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what reason does the nurse assess the patient? a. Decreased movement and diminished breath sounds on the affected side b. Muffled and distant heart sounds with decreasing blood pressure c. Dull percussion sounds on the injured side d. Severe respiratory distress and tracheal deviation

d. Severe respiratory distress and tracheal deviation

35. Inability to communicate is distressing to patients in the critical care environment who cannot speak. The nurse should utilize all of the following methods to promote communication except: a. Computer keyboards b. Notepads c. Picture boards d. Speaking in a loud voice

d. Speaking in a loud voice

16. An unlicensed assistive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. Reminding the patient to cough and deep breath every 2 hours b. looping the drainage tubing on the bed c. Securing the drainage container in an upright position d. Stripping or milking the chest tube to promote drainage

d. Stripping or milking the chest tube to promote drainage

3. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Mean arterial pressure b. Pulmonary artery wedge pressure c. Pulmonary vascular resistance d. Systemic vascular resistance

d. Systemic vascular resistance

44. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Pulmonary vascular resistance (PVR) b. Mean arterial pressure (MAP) c. Pulmonary artery wedge pressure (PAWP) d. Systemic vascular resistance (SVR)

d. Systemic vascular resistance (SVR)

46. A nurse is caring for a patient on a ventilator with ventilator settings with a preset tidal volume. Which best describes the tidal volume (VT) in this setting? a. The amount of oxygen in the surrounding air b. The number of breaths each minute c. The pressure needed for each breath of the patient d. The amount of air inhaled with each breath

d. The amount of air inhaled with each breath

45. Prone positioning is being used for a patient with acute respiratory distress syndrome (ARDS). Which information obtained by the nurse indicates that the positioning is effective? a. Endotracheal suctioning results in clear mucous return b. Sputum and blood cultures show no growth after 48 hours. c. The skin on the patient back is intact and without redness d. The patient's PaO2 is 89 mm Hg and the SaO2 is 91%

d. The patient's PaO2 is 89 mm Hg and the SaO2 is 91%

21. Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action? a. The system is delivering 3 mL of flush solution per hour. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The flush bag and tubing were changed 2 days previously d. The right-hand feels cooler than the left hand (One side is occlusion)

d. The right-hand feels cooler than the left hand (One side is occlusion)

2. Positive end expiratory pressure is a mode of ventilatory assistance that produces the following conditions: a. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure b. Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume c. The patient must have a respiratory drive, or no breaths will be delivered d. There is pressure remaining in the lungs at the end of expiration that is measured in cm h20

d. There is pressure remaining in the lungs at the end of expiration that is measured in cm h20

15. Positive end-respiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following conditions: a. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure. b. Each time the patient initiates a breath, the ventilator delivers a full present tidal volume c. The patient must have a respiratory drive, or no breaths will be delivered. d. There is pressure remaining in the lungs at the end of the expiration that is measured in cm H2O.

d. There is pressure remaining in the lungs at the end of the expiration that is measured in cm H2O.

48. The patient's arterial blood gas (ABG) values on room air are PaO2 70 mm hg, ph 7.31, PaCO2 52 mm hg, HCO3 24 meq/L. What is the interpretation of the patients ABG? → needs to be double check!! a. Compensated respiratory alkalosis b. Compensated respiratory acidosis c. Uncompensated metabolic alkalosis PaO2: 80-100, PaCO2: 35-45, HCO3: 22-28, pH: 7.35-4.5 d. Uncompensated respiratory acidosis (Because HCO3 is normal)

d. Uncompensated respiratory acidosis (Because HCO3 is normal)

44. Which risk factor should the nurse focus on when teaching a patient who has 5-cm abdominal aortic aneurysm? a. Abdominal trauma history b. Male gender c. Turner syndrome d. Uncontrolled hypertension

d. Uncontrolled hypertension

32. To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. Auscultate for bilateral breath sounds b. Observe for symmetrical chest movement c. Obtain a portable chest x ray d. Use an end tidal CO2 monitor

d. Use an end tidal CO2 monitor

37. A nurse is caring for a 72 year old female patient in the ICU after a pacemaker insertion. Interpret the following rhythm? a. Dual-chamber bag b. Transcutaneous pacing c. Atrial pacing d. Ventricular pacing

d. Ventricular pacing

20. The nurse is caring for mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (SATA) f. Kink in the ventilator tubing (quizlet) g. Spontaneous breathing h. Need for suctioning i. Disconnection from the ventilator j. Cough or attempting to talk

f. Kink in the ventilator tubing (quizlet) h. Need for suctioning j. Cough or attempting to talk