Nclex practices cardiovascular
The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipate? Select all that apply. 1. The client should be placed on a cardiac monitor. 2. The PHCP massages the carotid artery for a full minute. 3. The head should be turned toward the side to be massaged. 4. Rhythm strips should be obtained before, during, and after the procedure. 5. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.
1. The client should be placed on a cardiac monitor. 4. Rhythm strips should be obtained before, during, and after the procedure. 5. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.
to use and external cardiac defibrillator on a client, which action should be preformed to check the cardiac rhythm? 1. holding the defibrillator paddles firmly against the chest 2.applying the adhesice patch electrodes to the skin and moving away from the client 3.applying standard electrocardiographinc monitoring leads to the client and observing the rhythm 4. connecting standard eletrovardiographic electrodes to a transtelephonic monitoring device
2 applying adhesive patch electrodes to the skin and moving away from the client.
A client is wearing a continuous cardiac monitor which begins to alarm at the nurse's station the nurse sees no electrocardiographic complexes on the screen. The nurse should do which action First? 1. Call a code blue 2. Check the clients status and lead placement 3. Call the primary health care provider 4 press the recorder button on the ECG console
2 check the clients status and lead placement
the nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia, followed by ventricular fibrillation. the client suddenly loses consciousness. which intervention should the nurse do first? 1. Go to the nurse's station quickly and call a code 2. Run the get a defibrillator from an adjacent nursing unit 3. call for help and initate cardiopulmonary resuscitation 4. start oxygen by cannula at 10l/ minute and lower the head of the bed
3 call for help and initiae cardiopulmonary resuscitation
The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? 1. Dyspnea 2. Hacking cough 3. Dependent edema 4. Crackles on lung auscultation
3. Dependent edema
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring? 1. Pneumonia 2. Pulmonary edema 3. Pulmonary embolism 4. Myocardial infarction
3. Pulmonary embolism
the nurse is preparing to ambulate a postoperative client after cardiac surgery. the nurse plans to do which to enable the client to best tolerate the ambulation? 1. provide the client with a walker 2. remove the telemetry equipment. 3. encourage the client to cough and deep breathe 4 premedicate the client with an analgesic before ambulating
4 premedicate the client with an analgesic before ambulating
the nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. the nurse immediately notifies the resisted nurse (RN) and expects which interventions to be prescribed? (select all that apply) 1. administering oxygen 2. inserting a Foley catheter 3. administering furosemide 4. administering morphine sulfate intravenously 5. transporting the client to the coronary care unit 6. placing the client in a low fowlers side lying position
1,2,3,4
A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item? 1. Smoking history 2. Recent exposure to allergens 3. History of recent insect bites 4. Familial tendency toward peripheral vascular disease
1. Smoking history
The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse should make which determination about the client's neurovascular status? 1. Moderately impaired, and the surgeon should be called 2. Normal, caused by increased blood flow through the leg 3. Slightly deteriorating, and should be monitored for another hour 4. Adequate from an arterial approach, but venous complications are arising
2. Normal, caused by increased blood flow through the leg
a postcardiac surgery client with a blood urea nitrogen (BUN) level of 45mg/dl (16.2mmol/L) and a serum creatinine level of 2.2mg/dL (193.6 mcmol/l) has a total 2 hour urine output of 25 ml. The nurse understands that the client is at risk for which condition 1. hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. urinary tract infection
2. acute kidney injury
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally? 1. Rhonchi 2. Crackles 3. Wheezes 4. Diminished breath sounds
2. Crackles
the nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. the nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. limiting movement of the abduction of the left arm 2.limiting movement and abduction of the right arm 3. assisting the client to get out of bed and ambulate with a walker 4. having the pt do active range of motion to the right arm
2 limmiting movement and abduction of the right arm
the nurse is monitoring a client following cardioversion. Which obsercations should be of highest priority to the nurse? 1. blood pressure 2 status of airway 3.oxygen flow rate 4. level of consciousness
2 status of airway
The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement? 1. "Smoking cessation is very important." 2. "Moving to a warmer climate should help." 3. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine as prescribed will decrease vessel spasm."
2. "Moving to a warmer climate should help."
The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. Limiting movement and abduction of the left arm 2. Limiting movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm
2. Limiting movement and abduction of the right arm