Perfusion 37/40

The nurse is caring for as 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop? Neurogenic shock Cardiogenic shock Septic shock Anaphylactic shock

Cardiogenic shock

A nurse is caring for a client who has had an automatic cardiac defibrillator implanted. What instructions should the nurse provide to the client? Avoid using microwave ovens. Avoid devices with a magnetic field. Avoid driving for at least 3 months. Use digital cellular telephones.

Avoid devices with a magnetic field.

The nurse is taking a health history of a toddler with a suspected congenital heart defect. Which response by the mother could indicate that the child is experiencing hypercyanotic spells? "He does not seem to have difficulty breathing." "He likes to stop and squat wherever he walks." "He walks very quickly and never stops moving." "He takes one nap a day and is fairly active."

"He likes to stop and squat wherever he walks."

A client scheduled for a catheter ablation procedure confides to the nurse that he is worried about having some of his heart cells destroyed. The best response by the nurse is which of the following? "The doctor knows best; just let her worry about which heart cells to destroy." "Only the specific cells causing your dysrhythmia are destroyed; your heart will function better without these cells." "Don't worry. All resuscitation equipment is kept nearby when these procedures are being done." "Everything will turn out fine; do not worry about your heart cells."

"Only the specific cells causing your dysrhythmia are destroyed; your heart will function better without these cells."

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage. A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. Splinting of the affected ribs will be initiated and limitation of upper body activity recommended.

A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.

On auscultation, which finding suggests a right pneumothorax? Inspiratory wheezes in the right thorax Bilateral inspiratory and expiratory crackles Bilateral pleural friction rub Absence of breath sounds in the right thorax

Absence of breath sounds in the right thorax

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? Tension pneumothorax Increased drainage Tidaling Air leak

Air leak

The ECG of a new patient shows a P wave slightly different than normal. The nurse is considering the possibility of premature atrial contractions (PAC). The nurse will ask about which factors when taking this client's history? nicotine caffeine hyperthyroidism or other metabolic disorders All options are correct.

All options are correct.

The nurse is in the mall and observes a client slump to the floor. The nurse assesses the client and notes no pulse. The nurse calls for assistance to others in the mall and requests which piece of equipment? A cell phone to call 911 A blood pressure cuff A stethoscope An automatic external defibrillator

An automatic external defibrillator

Which client requires frequent monitoring for symptomology associated with acute respiratory distress syndrome (ARDS)? An adult with 3rd degree burns over 20% of the body An older adult diagnosed with chronic obstructive pulmonary disease (COPD) A premature neonate A teenager diagnosed with cystic fibrosis

An older adult diagnosed with chronic obstructive pulmonary disease (COPD) ??

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is A middle-aged woman with metastatic breast cancer and a BMI of 26 An older adult man with end-stage renal disease and an infected dialysis access site An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection A young female adolescent who developed shock from tampon use during menses

An older adult man with end-stage renal disease and an infected dialysis access site

Which would the nurse most likely expect as treatment for a pneumothorax? Allergy exposure control Chest tube insertion Anti-infective therapy Surfactant replacement

Chest tube insertion

For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority? Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage.

Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.

A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock? Anaphylactic Neurogenic Obstructive Septic

Neurogenic

A mother asks why her infant with a cyanotic heart defect turns blue. What is the best response by the nurse? This is a sign of heart failure. This is due to the lack of oxygen to the brain. This is considered a medical emergency and needs immediate surgery. This is due to a decreased amount of oxygen to the peripheral tissue.

This is due to a decreased amount of oxygen to the peripheral tissue.

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock? Pooling of secretions in the lungs Weak and rapid pulse rate Warm, dry skin Obstructed airway

Weak and rapid pulse rate

The nurse is caring for a 3-month-old infant with history of congenital heart disease. The infant is brought to the emergency department with nausea and vomiting for 3 days. Admission laboratory results confirm dehydration. The nurse realizes that the dehydrated infant is at risk for: seizure activity. jaundice. a cerebrovascular accident. tachycardia.

a cerebrovascular accident.

The nurse is caring for a group of clients. Which client should the nurse see first? a client with stable angina who took one sublingual nitroglycerine 30 minutes ago a client with a placement of a coronary artery stent 30 minutes ago a client with a history of sinus tachycardia who is to receive a beta-blocker a client with new onset of atrial fibrillation who has a heart rate of 95

a client with a placement of a coronary artery stent 30 minutes ago

A client with a chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is: a decrease in pressure in the tube. a tension pneumothorax. an increase of blood in the pleural space. a bilateral pneumothorax.

a decrease in pressure in the tube.

The nurse is assessing a client with symptomatic bradycardia. What medication does the nurse anticipate will be ordered by the healthcare provider to treat the bradycardia? diltezam atropine lidocaine adenosine

atropine

Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for: defibrillation. intubation. suctioning. needle thoracotomy.

needle thoracotomy.

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax? decreased sensation on the affected side increased fremitus Cheyne-Stokes respirations diminished or absent breath sounds on the affected side

diminished or absent breath sounds on the affected side

The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse? administration of digoxin insertion of an I.V. line immediate defibrillation scheduling a pacemaker insertion

immediate defibrillation

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which organ? Lungs Liver Brain Kidneys

lungs

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best? "Warfarin prevents atrial fibrillation from progressing to a lethal arrhythmia." "It's just a coincidence; most clients with atrial fibrillation don't receive warfarin." "Warfarin prevents clot formation in the atria of clients with atrial fibrillation." "Warfarin controls heart rate in the client with atrial fibrillation." SUBMIT ANSWER

"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents ask the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the the nurse? "I can only place oxygen on your child if the doctor orders oxygen." "This is something we should talk with the physician about. Maybe it would help your baby." "Oxygen isn't always the best treatment for your child's condition. Surgery is necessary." "While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help."

"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help."

A client has a sucking stab wound to the chest. Which action should the nurse take first? Prepare to start an I.V. line. Draw blood for a hematocrit and hemoglobin level. Apply a dressing over the wound and tape it on three sides. Prepare a chest tube insertion tray.

Apply a dressing over the wound and tape it on three sides.

The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Serum thyroid level findings Arterial blood gas (ABG) findings White blood cell count findings Red blood cells (RBCs) and hemoglobin count findings

Arterial blood gas (ABG) findings

The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child's mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. What should the nurse mention in explaining how this diagnostic test works? A radioactive substance is injected intravenously into the bloodstream and is traced and recorded on video High-frequency sound waves are directed toward the heart A microphone is placed on the child's chest to record heart sounds and translate them into electrical energy X-rays are directed toward the heart

High-frequency sound waves are directed toward the heart

The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse's best explanation? In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output. Sinus bradycardia means your heart is not beating fast enough to keep you alive. Sinus bradycardia is nothing to worry about. In many clients a heart rate slower than 70 beats per minute is considered to slow to maintain an adequate cardiac output.

In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output.

A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which intervention to improve oxygenation and provide comfort for the client? Force fluids for the next 24 hours Administer small doses of pancuronium Assist the client into a chair Position the client in the prone position

Position the client in the prone position

Which would a nurse identify as being involved with acute respiratory distress syndrome? Progressive loss of lung compliance Collapse of the alveoli Permanent inflammation of the airways Hyperresponsiveness of the airways

Progressive loss of lung compliance

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention? Client stating pain level of 7 out of 10 that decreases with pain medication Oxygen saturation level of 96% on 3 L of oxygen Client dozing when left alone but awakening easily Respiratory rate of 44 breaths/minute

Respiratory rate of 44 breaths/minute

The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter? Triangular Square Sawtooth Sinusoidal

Sawtooth

Which type of shock is caused by an infection? Cardiogenic Anaphylactic Septic Hypovolemic

Septic

You are assessing a 6-year-old girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child? She is having an allergic reaction and going into cardiogenic shock. She is having an allergic reaction and going into anaphylactic shock. She is having an allergic reaction and going into neurogenic shock. She is having an allergic reaction and going into obstructive shock.

She is having an allergic reaction and going into anaphylactic shock.

The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding? Intact rooting reflex Softening of the nail beds Steady weight gain since birth Appropriate mastery of developmental milestones

Softening of the nail beds

A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis? Coarctation of aorta Pulmonary stenosis Aortic stenosis Tetralogy of Fallot

Tetralogy of Fallot

The nurse is evaluating the therapeutic goal of a client with history of cardiac dysrhythmias and newly completed radiofrequency catheter ablation. Which client-centered goal is mostappropriate? The client will have a lowered blood pressure from the dilation of arterial vessels. The client will experience reperfusion of ischemic heart tissue. The client will have no fainting from overstimulation of the heart. The client will have a regular heart rhythm from destruction of errant tissue of the heart.

The client will have a lowered blood pressure from the dilation of arterial vessels.

The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? pH 7.87, PaCO2 38, HCO3 28 pH 7.49, PaCO2 34, HCO3 25 pH 7.47, PaCO2 28, HCO3 30 pH 7.25, PaCO2 48, HCO3 24

pH 7.25, PaCO2 48, HCO3 24