L4E3

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin 2. Obtain a stat 12 Lead ECG 3. Have the client sit down immediately 4. Assess the client's vital signs

3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.

The client has just returned from a cardiac catherization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90 2. The client's groin dressing is dry and intact 3. The client refuses to keep the leg straight 4. The client denies any numbness and tingling

3. The client bends the legs, it could cause insertion site bleeding. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.

Which population is at a higher risk for dying from a myocardial infarction? 1. Caucasian Males 2. Hispanic Females 3. Asian Males 4. African American Females

1. African American Females are 35% more likely to die from CAD than any other population. This population has significantly higher rates of HTN, and it occurs at a younger age. The higher risk of death from an MI is also attributed to a delay in seeking emergency care - an average of 11 hours

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately 2. Elevate the head of the client's bed 3. Document this as a normal and expected finding 4. Administer morphine intravenously

1. An S3 indicates left ventricular failure and should be reported to the healthcare provider. It is a potentially life threatening complication of a myocardial infarction

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? 1) Lactated Ringer's 2) 0.9% sodium chloride 3) 5% dextrose in 0.9% sodium chloride 4) 5% dextrose in 0.45% sodium chloride

2) 0.9% sodium chloride Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure.

Which lab result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time (PT) 2. A low fibrinogen level 3. An increased platelet count 4. An increased white blood cell count

2. Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.

The client is one day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine 2. Assess the client's chest dressing and vital signs 3. Encourage the client to turn from side to side 4. Check the client's telemetry monitor

2. The nurse must always assess the client to determine if the chest pain that is occurring is expected post-operatively or if it is a complication of surgery.

Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? 1. Keep the client in the supine position with legs elevated 2. Discuss a heart transplant, which is a definitive treatment 3. Prepare the client for coronary artery bypass graft 4. Teach the client to take a calcium channel blocker in the morning

2. Without a heart transplant, this client will end up in end-stage heart failure. A transplant is the only treatment for a client with cardiomyopathy.

Which preprocedure information should be taught to the female client having an exercise stress test in the morning? 1. Wear open-toed shoes to the stress test 2. Inform the client not to wear a bra 3. Do not eat anything for 4 hours 4. Take the beta blocker one hour before the test

3. NPO decreases the chance of aspiration in case of emergency. In addition, if the client has just had a meal, the blood supply will be shunted to the stomach for digestion and away from the heart, perhaps leading to an inaccurate test result.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction

?3. Troponin is the enzyme that elevates within 1 to 2 hours

A client with thrombocytopenia presents to the primary care center. During assessment, the nurse notices petechiae. The nurse anticipates that which of the following laboratory results would support the presence of a hemostatic disorder? a. Decreased erythrocyte count b. A platelet count that is less than 150,000 uL c. An elevated lymphocyte count d. A hemoglobin value of 14 or more

B

Which of the following are signs of a rupturing AAA? Select all that apply: A) Increased BP B) Decreased Hct C) Low Back Pain D) Decreased BP E) Intermittent abdominal pain

B,C, and D. The patient is losing blood pressure and dropping hematocrit due to bleeding. Pain is a key sign of a rupturing (or close to rupturing) Aortic Abdominal Aneurysm. Usually, when rupturing, the pain becomes constant rather than intermittent.

Which of the following aneurysms is the most likely to dissect? A) Abdominal Aortic B) Thoracic C) Peripheral D) They are all equally likely

B. The thoracic region of the aorta often has the highest pressure and force due to being closest to the heart.

What would be the nurse's priority action for the patient in the previous question? A) Administer morphine 1 mg IV B) Call the doctor and ask him to order a chest X-Ray C) Hook the patient up to 2L oxygen via nasal cannula D) Massage place where the pain is

C. Although pain management is important, it is not a priority in this instance. It is important to get a chest X-Ray or CT scan of the chest in order to diagnose the thoracic aneurysm, however, it is not the first thing to be done. C is correct because it focuses on the immediate oxygen need. You should never massage an aneurysm.

Which surgical technique allows for shorter recover times: An open surgical repair or an endovascular graft? Why?

Endovascular graft. Because it does not require a large incision to gain vascular access

True or false a. thrombotic thrombocytopenic purpura is characterized by decreased platelets, decreased rbc, and decreased agglutination function of platelets

a. false, there is increased agglutination function of platelets

T he nurse making a care plan for a client withsevere thrombocytopenia should include whichof the following? 1. C areful examination of spinal fluid obtainedby lumbar puncture 2. A private room with reverse isolationprecautions 3. A void intramuscular administration ofmedications 4. C areful monitoring of urinary output whiletitrating the dosage of furosemide (Lasix)

answer: 3. S evere thrombocytopenia is a platelet count of, 10,000 to 20,000/mm3. The client with thislow number of platelets is at great risk ofbleeding from any invasive procedure.Intramuscular injections can cause a hematomain the muscle and should be avoided ifpossible. A lumbar puncture would put theclient at an unnecessary risk of bleeding. A private room is not indicated unless there areother reasons for isolation (infection,neutropenia). Furosemide is a diuretic and notused as therapy for thrombocytopenia.

When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to: a.Discourage the use of stool softeners. b.Assess temperature readings every six hours. c.Avoid invasive procedures. d. Encourage the use of a hard, brittle toothbrush.

answer: c Thrombocytopenia is characterized by an increased number of circulating platelets in the blood. Older persons with thrombocytopenia are at significantly increased risk of thrombosis, and careful monitoring of platelet levels and symptoms is indicated.

An elderly client is admitted to the hospital Emergency Department (ED) with complaints of headache, visual disturbances, and burning pain, and erythema of the hands and feet. To accurately diagnose thrombocytopenia, the physician most likely will order: a.Peripheral blood smear. b.Allogenic bone marrow transplant. c.Bone marrow aspiration. d. Splenectomy.

c.Bone marrow aspiration. Thrombocytopenia is characterized by an increased number of circulating platelets in the blood. Accurate diagnosis requires bone marrow aspiration. Allogenic bone marrow transplantation is prescribed for younger persons with myelofibrosis. A splenectomy may be prescribed for persons with myelofibrosis

True or false: c. The nurse suspects heparin induced thrombocytopenia when a patient receiving heparin requires dereased heparin to maintain therapeutic activated thromboplastin times

false, increased heparin

True or false b, a classic manifestation of thrombocytopenia that the nurse would expect to find is ecchymosis

false, the nurse would find petachia

The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

1,3,4,5

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

1. chronic A-fib treated with anticoagulant, places patient at risk for bleeding

The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes

1. this describes normal sinus rhythm

Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.

2

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which INITIAL question? 1) "Have you ever had a transfusion before?" 2) "Why do you think that you need the transfusion?" 3) "Have you ever gone into shock for any reason in the past?" 4) "Do you know the complications and risks of a transfusion?"

1) "Have you ever had a transfusion before?" Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? SELECT ALL THAT APPLY. 1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery. 3) Take iron supplements before surgery to boost hemoglobin levels. 4) Request that any donated blood be screened twice by the blood bank. 5) Take adequate amounts of vitamin C several days prior to the surgery date.

1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery. Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? 1) Expiration date 2) Presence of clots 3) Blood group and type 4) Blood identification number

1) Expiration date Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage is usually limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1) Septicemia 2) Hyperkalemia 3) Circulatory overload 4) Delayed transfusion reaction

1) Septicemia Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include CHILLS, FEVER, VOMITING, DIARRHEA, HYPOTENSION, and the development of SHOCK. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which PRIORITY item? 1) Vital signs 2) Skin color 3) Urine output 4) Latest hematocrit level

1) Vital signs Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs BEFORE the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion.

Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart Failure 2. Activity intolerance 3. Powerlessness 4. Anticipatory grieving

1. Medical client problems indicate the nurse and the physician must collaborate to care for the client; the client must have medications for heart failure.

The client is admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site 2. Sudden onset of chest pain and frothy sputum 3. Foul smelling, concentrated urine 4. A reddened, inflamed central line catheter site

1. Signs and symptoms of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from every body orifice and into the tissues

The client comes into the emergency department saying, "I am having a heart attack" Which question is most pertinent when assessing the client? 1. "Can you describe the chest pain" 2. "What were you doing when the pain started" 3. "Did you have a high-fat meal today" 4. "Does the pain get worse when you lie down"

1. The chest pain for MI is usually described as an elephant sitting on the chest or a belt squeezing the substernal midchest, often radiating to the jaw or left arm.

The client diagnosed with a myocardial infarction asks the nurse, "why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about 4 to 6 weeks to heal" 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias" 3. "Your doctor has ordered bedrest. Therefore, you must stay in bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger"

1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about 6-8 weeks for scar tissue to form

The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? 1. Discuss the order with the health-care provider 2. Take the client's apical pulse rate before administering 3. Check the client's potassium level before giving the medication 4. Determine if a digoxin level has been drawn

1. This dose is 10 times the normal dose for a client with CHF. This dose is potentially lethal.

The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the 3 month orientation? 1. The client with an abnormal peritoneal resection who has a colostomy 2. The client diagnosed with pneumonia who has acute respiratory distress syndrome 3. The client with a head injury developing disseminated intravascular coagulation 4. The client admitted with a gunshot wound who has an H&H of 7 and 22

1. This is major surgery but has a predictable course with no complications identified in the stem and a colostomy is expected with this type of surgery. The graduate nurse could be assigned this patient.

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? 1) 5 minutes 2) 15 mintues 3) 30 minutes 4) 45 mintues

2) 15 mintues Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST? 1) Maintain bed rest with legs elevated 2) Place the client in high-Fowler's position 3) Increase the rate of infusion of intravenous fluids 4) Consult with the HCP regarding initiation of oxygen therapy.

2) Place the client in high-Fowler's position Rationale: New onset of tachycardia, bounding pulses, crackles and wheezes post-transfusion are evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of intravenous fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client? 1) To treat the loss of platelets 2) To promote rapid volume expansion 3) Because a transfusion must be done slowly 4) Because it will increase the hemoglobin and hematocrit levels

2) To promote rapid volume expansion Rationale: Fresh-frozen plasma is often used for volume expansion as a results of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select All that Apply 1. Obtain a midstream urine specimen 2. Attach telemetry monitor to the client 3. Start a saline lock in the right arm 4. Draw a baseline metabolic panel (BMP) 5. Request an order for a STAT 12-lead ECG

2. Anytime a nurse suspects cardiac problems, the electrical conductivity of the heart should be assessed. 3. Emergency medications for heart problems are primarily administered intravenously, so starting a saline lock in the right arm is appropriate. 5. A 12-lead ECG evaluates the electrical conductivity of the heart from all planes.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement first? Select All that Apply 1. Administer morphine sulfate Intramuscularly 2. Administer an aspirin orally 3. Apply oxygen via nasal cannula 4. Place the client in a supine position 5. Administer nitroglycerin subcutaneously

2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischeima, thereby decreasing pain

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis 2. Diaphoresis and cool clammy skin 3. Intermittent claudication and paloor 4. Jugular vein distention and dependent edema

2. Diaphoresis is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this in turn, leads to cold, clammy skin

The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the healthcare provider.

2. will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention

The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

3. Patient is symptomatic, prepare for pacemaker

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? 1) An air vent 2) Tinted tubing 3) An in-line filter 4) A microdrip chamber

3) An in-line filter Rationale: The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? 1) Begin the transfusion as prescribed. 2) Administer an antihistamine and begin the transfusion. 3) Delay hanging the blood and notify the health care provider. 4) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.

3) Delay hanging the blood and notify the health care provider. Rationale: If the client has a temperature higher than 100 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken NEXT? 1) Remove the intravenous (IV) line. 2) Run a solution of 5% dextrose in water. 3) Run normal saline at a keep-vein-open rate. 4) Obtain a culture of the tip of the catheter device removed from the client.

3) Run normal saline at a keep-vein-open rate. Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would NOT remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should NOT be removed. Second, cultures are performed when infection, NOT transfusion reactions, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

The client diagnosed with a myocardial infarction is six hours post-right femoral percutanous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight 2. The pressure dressing to the right femoral area is intact 3. The client is complaining of numbness in the right foot 4. The client's right pedal pulse is +3 and bounding

3. Any neurovascular assessment data that is abnormal requires intervention by the nurse; numbness may indicate decreased blood flow to the right foot

The client who has had a myocardial infarction is admitted to the telementry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker 2. Physical therapy 3. Cardiac rehabilitation 4. Occupation therapy

3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercises, diet teaching, and classes on modifying risk factors.

Which client would most likely be misdiagnosed for having a myocardial infarction? 1. A 55 year old Caucasian male with crushing chest pain and diaphoresis 2. A 60 year old Native American male with an elevated troponin level 3. A 40 year old Hispanic female with a normal ECG 4. An 80 year old Peruvian female with normal CK-MB at 12 hours

3. Clients who are misdiagnosed concerning MIs usually present with atypical symptoms. They tend to be female, younger than 55, members of a minority group, and have normal ECGs

Which collaborative treatment would the nurse anticipate in the client diagnosed with DIC? 1. Administer oral anticoagulants 2. Prepare for plasmapheresis 3. Administer fresh frozen plasma 4. Calculate the intake and output

3. Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging leg movements 2. Report this behavior to the charge nurse as soon as possible 3. Praise the UAP for encouraging the client to move legs 4. Take no action concerning the UAP's behavior

3. The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for developing deep vein thrombosis, and moving the legs will prevent this from occurring.

The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation.

3. activate team arrival and code care being brought

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.

3. determine if the client is in cardiac arrest and then treat as v fib. If heart is beating, nurse would then administer lidocaine

The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.

3. easiest intervention should be first, if client doesn't respond then should could have another nurse go check

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1) Infusion pump 2) Pulse oximeter 3) Cardiac monitor 4) Blood-warming device

4) Blood-warming device Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

The client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1) Increased hematocrit level 2) Increased hemoglobin level 3) Decline of elevated temperature to normal 4) Decreased oozing of blood from puncture sites and gums

4) Decreased oozing of blood from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1) Hematocrit level 2) Erythrocyte count 3) Hemoglobin level 4) White blood cell count

4) White blood cell count Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.

The client is 3 hours post myocardial infarction. Which data would warrant immediate intervention by the nurse? 1. Bilateral peripheral pulses 2+ 2. The pulse oximeter reading is 96% 3. The urine output is 240 mL in the last 4 hours 4. Cool, clammy, diaphoretic skin

4. Cold, clammy skin is an indicator of cardiogenic shock, which is a complication of MI and warrants immediate intervention.

Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? 1. A 35 year old pregnant client with placenta previa 2. A 42 year old client with a pulmonary embolus 3. A 60 year old client receiving hemodialyasis 3 days a week 4. A 78 year old client with septicemia

4. DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64 2. The client's calcium level is elevated 3. The client's telemetry shows occasional PVCs 4. The client's blood pressure is 90/62

4. The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with DIC. Which would be an appropriate goal? 1. The client's clot formations will resolve in two days 2. The saturation of the client's dressings will be documented 3. The client will use lemon-glycerin swabs for oral care 4. The client's urine output will be > 30 mL per hour

4. The problem is addressing the potential for hemorrhage, and a urine output of greater than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not in shock.

Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client.

4. prevent team members from possible shock

The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.

4. there is no set treatment for tachycardia, determine cause-most likely pain in this case

A child is admitted to the hospital with a suspecteddiagnosis of idiopathic thrombocytopenicpurpura (ITP), and diagnostic studiesare performed. Which of the following diagnosticresults are indicative of this disorder? 1 An elevated platelet count 2 Elevated hemoglobin and hematocrit levels 3 A bone marrow examination showing anincreased number of megakaryocytes 4 A bone marrow examination indicating an increased number of immature white blood cells

Answer: 3 Rationale: The laboratory manifestations of ITP include the presence of alow platelet count of usually less than 20,000 cells/mm3. Thrombocytopeniais the only laboratory abnormality expected with ITP. If there hasbeen significant blood loss, there is evidence of anemia in the blood cellcount. If a bone marrow examination is performed, the results with ITPshow a normal or increased number of megakaryocytes, which are the precursorsof platelets. Option 4 indicates the bone marrow result that wouldbe found in a child with leukemia.

When teaching a patient about risk factors for AAA, which of the following, if stated by the patient indicates correct understanding? A) Taking ACE inhibitors or ARBS B) Being female C) Genetic disorder D) Straining while pooping

C. Aortic Aneurysm can be caused by being male, smoking, family history or congenital weakness, and hypertension

What would be the treatment option of choice for an AAA that is 6 cm? A) Blood pressure medication B) Thrombolytic Agent C) Crestor D) Surgery

D. For Aneurysms larger than 5.5 cm, surgery is the treatment of choice. If smaller, antihypertensive may be prescribed to lower pressure on aortic wall. B and C are not appropriate in this situation

Your patient presents to the E.D. with severe pain in the upper chest while lying down, shortness of breath, and hoarseness while talking. The neck veins appear distended. He states that he has never had pain like this before. What problem do you expect your patient to have? A) MI B) Atelectasis C) Blindness D) Thoracic Aneurysm

D. These are all classic symptoms of a thoracic aneurysm

A patient with thrombocytopenia with active bleeding has 2 units of platelets prescribed. To administer the platelets the nurse: a. checks for abo compatibility b. agitates the bag periodically during the transfusion c. takes vital signs every 15 minutes during the procedure d. refrigerates the second unit until the first unit has transfused

answer: b agitates the bag periodically during the transfusion. platelets adhere to plastic bags and should be gently agitated throughout the transfusion. platelets do not have a b or rh antibodies so abo compatibility is not a consideration. baseline vital signs should be taken before the transfusion is started and the nurse should stay with patient during first 15 minutes platelets are stored at room temp and should not be refrigerated

During assessment of a patient with thrombocytopenia, the nurse would expet to find? a. sternal tenderness b. petechial and purpura c. jaundiced sclera and skin d. tender enlarged lymph nodes.

answer: b. petachiae and purpura rationale: petechiae are small, flat, red, or red brown pinpoint microhemorrhages that occur ont eh skin when platelet levels are low and when they are numerous, they group causing reddish bruises known as purpura. jaundice occurs when anemias are of a hemolytic origin, resulting in accumulation of bile pigments from rbc, enlarged lymph nodes are associated with infection, sternal tendernesss w leukemias

During care for patient with thrombocytopenia, the nurse: a. takes frequent temperatures to assess for fever b. maintains the patient on strict bed rest to prevent injury c. monitors patient for headaches, vertigo, or confusion d. removes oral crusting and scabs with firm friction every two hours

answer: c Rationale: the major complication of thrombocytopenia is hemorrhage, and it may occur in any area of the body. cerebral hemorrhage may be fatal and evaluation of mental status for cns alteration to id cns bleeding is very important. fever is not a common finding in thrombocytopenia. protection from injury to prevent bleeding is an important nursing intervention, but strict bed rest is not indicated. oral care is performed very gently with minimum friction and soft swabs