practice questions - exam 3 2110

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct? "The client is in shock because the blood volume has decreased in the system." "The client is in shock because the heart is unable to circulate the body fluids." "The client is in shock because all peripheral blood vessels have massively dilated." "The client is in shock because your loved one is not responding and brain dead

The client is in shock because the blood volume has decreased in the system."

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving oxygenated blood from the lungs? left ventricle right atrium right ventricle left atrium

The left atrium receives oxygenated blood from the lungs. The left ventricle pumps that blood to all the cells and tissues of the body. The right atrium receives deoxygenated blood from the venous system. The right ventricle pumps that blood to the lungs to be oxygenated.

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include? "Client will verbalize the intention to stop smoking." "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours." "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol." "Client will verbalize the intention to avoid exercise."

"Client will verbalize the intention to stop smoking."

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: "I'm clear when my chest X-ray is negative." "I'm contagious as long as I have night sweats." "I'll stop being contagious when I have a negative acid-fast bacilli test." "My tuberculosis isn't contagious after I take the medication for 24 hours."

"I'll stop being contagious when I have a negative acid-fast bacilli test."

The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply. breathing without assistance of the ventilator inability to speak adequate cough and gag reflexes acceptable arterial blood gas values labile vital signs

breathing without assistance of the ventilator adequate cough and gag reflexes acceptable arterial blood gas values

A client reports light-headedness, chest pain, and shortness of breath. They physician orders tests to ascertain what is causing the client's problems. Which test is used to identify cardiac rhythms? echocardiogram electroencephalogram electrocardiogram electrocautery

electrocardiogram

Which area of the heart is located at the third intercostal (IC) space to the left of the sternum? epigastric area aortic area erb point pulmonic area

erb point

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? Pulmonary contusion Flail chest Simple pneumothorax Cardiac tamponade

flail chest

What is the major clinical use of dobutamine? treat hypotension. treat hypertension. increase cardiac output. prevent sinus bradycardia.

increase cardiac output

A client presents to the ED with a myocardial infarction. Prior to administering a prescribed thrombolytic agent, the nurse must determine whether the client has which absolute contraindication to thrombolytic therapy? prior intracranial hemorrhage recent consumption of a meal use of heparin shellfish allergy

prior intracranial hemorrhage

The nurse is administering propranolol to a client on a telemetry unit. What will the nurse monitor the client for?

pt on beta blockers should be monitored for heart block

The nurse is reviewing the laboratory results for a client with heart failure. Which laboratory value will the nurse report to the health care provider? calcium 9.8 mg/dL potassium 3.9 mEq/L sodium 148 mEq/L magnesium 2.5 mg/dL

sodium 148 meq/ml Normal sodium levels are between 135 and 145 mEq/L, so the sodium value is abnormal. The remaining values are normal. Normal potassium levels range from 3.5 to 5.0 mEq/L. The normal range for calcium level is 8.5 to 10.5 mg/dL. Normal magnesium levels range from 1.8 to 3.0 mg/dL.

After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm? 0.12 and 0.2 seconds. 0.05 and 0.1 seconds. 0.25 and 0.4 seconds. 0.15 and 0.3 seconds.

0.12 and 0.2 seconds.

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). 60; 50 75; 40 60; 40 75; 50

60, 50 Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to less than 60 mm Hg on room air) and hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to greater than 50 mm Hg with an arterial pH of less than 7.35).

In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupations? Select all that apply. Mechanic Rock quarry worker Stone cutter Nurse Banker Miner

A quarry worker and stone cutter are exposed to rock dust and silica. A miner can inhale dust, causing silicosis or pneumoconiosis

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? A rapid, bounding pulse A slow and imperceptible pulse A slow but steady pulse A weak and thready pulse

A rapid, bounding pulse

A nurse reviews an ECG strip for a client who is admitted with symptoms of an acute MI. The nurse should recognize what classic ECG changes that occur with an MI? Select all that apply. ST-segment elevations Absent P-waves T-wave hyperactivity and inversions U-wave elevations Abnormal Q-waves

Abnormal Q-waves T-wave hyperactivity and inversions ST-segment elevations

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is Acute pain related to upper airway irritation Ineffective airway clearance related to excess mucus production Deficient fluid volume related to increased fluid needs Deficient knowledge related to prevention of upper respiratory infections

All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.

The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" What is the appropriate response by the nurse? Bok choy, cooked leeks, alfalfa sprouts Cranberries, apples, popcorn Apricots, dried peas and beans, dates Asparagus, blueberries, green beans

Apricots, dried peas and beans, dates

The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure? Vagus nerve Sympathetic nerve fibers Baroreceptors Chemoreceptors

Baroreceptors Baroreceptor sense pressure in nerve endings in the walls of the atria and major blood vessels. The baroreceptors respond accordingly to raise or lower the pressure

The nurse is assisting with a bronchoscopy at the bedside in a critical care unit. The client experiences a vasovagal response. What should the nurse do next?

Check blood pressure

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids Rubbing the hands together with antiseptic solution until dry when exiting the client's room Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? Hoarseness for 2 weeks Epitaxis, twice this week fever cant sleep

Hoarseness is a early sign of laryngeal cancer

The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)? Bradycardia Hypovolemia Alkalosis Hypokalemia

Hypokalemia

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer? Morphine sulfate (Morphine) Meperidine hydrochloride (Demerol) Nitroglycerin transdermal patch Isosorbide mononitrate (Isordil)

Morphine sulfate (Morphine)

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? Puts on clean gloves; removes and discards the soiled dressing in a biohazard container Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide

Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? Placing the client in respiratory isolation Monitoring the client's fluid intake and output Wearing gloves during all client contact Assessing the client's temperature every 8 hours

Placing the client in respiratory isolation The client is showing signs of tb

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply. Refer the client to a physician for antibiotic therapy. Provide warm salt-water gargles. Administer oral ibuprofen. Recommend guaifenesin. Teach the client about handwashing.

Provide warm salt-water gargles. Administer oral ibuprofen. Recommend guaifenesin. Teach the client about handwashing.

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave PR interval QT interval QRS complex

QRS The QRS complex represents ventricular depolarization. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria. The PR interval is a component of an ECG tracing reflecting conduction of an electrical impulse through the AV node. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization.

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to Properly dispose of used tissues Stay in bed when experiencing a fever Seek medical help if he experiences inability to swallow Place an ice collar on the throat to relieve soreness

Seek medical help if he experiences inability to swallow

A client is diagnosed with an arrhythmia at a rate slower than 60 beats/minute with a regular interval between 0.12 and 0.20 seconds. What type of arrhythmia does the client have? sinus bradycardia atrial bradycardia none heart block

Sinus bradycardia is an arrhythmia that proceeds normally through the conduction pathway but at a slower than usual (less than 60 beats/minute) rate.

A client seeks medical attention for a hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx? Nausea Sore throat Deviated trachea Facial pain

Sore throat

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Sudden onset of lung impairment in a client who had compromised lung function Insidious onset of lung impairment in a client who had normal lung function Sudden onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had compromised lung function

Sudden onset of lung impairment in a client who had normal lung function

The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response? Preload controls the heart rate. Stroke volume controls the heart rate. Force of contractility controls the heart rate. The autonomic nervous system controls the heart rate.

The autonomic nervous system controls the heart rate.

At what point in shock does metabolic acidosis occur? Decompensation (Progressive) Irreversible Early Late

Decompensation (Progressive)

The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a co-morbidity of multiple sclerosis, so the nurse knows the stress test will be drug-induced. What drug will be used to dilate the coronary arteries? Thallium Ativan Diazepam Dobutamine

Dobutamine Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) dilate coronany artery

What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Draining secretions, air, and blood from the thoracic cavity is necessary.

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? Elevate the legs higher than the heart. Place a cool compress on head. Cover the client with a blanket. Shake the client to arouse.

Elevate the legs higher than the heart. To promote perfusion

A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention? Perform postural drainage Perform chest physiotherapy Perform nasotracheal suctioning Encourage the client to cough

Encourage the client to cough

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? "I am going to have a tuna fish sandwich for lunch." "It is all right if I drink a glass of red wine with my dinner." "It is fine if I eat sushi with a little bit of soy sauce." "It is all right if I have a grilled cheese sandwich with American cheese."

"It is all right if I have a grilled cheese sandwich with American cheese."

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? Re-zero the equipment and take another reading. Call the health care provider and obtain an order for a fluid bolus. Call the physician and obtain an order for a diuretic. Continue to monitor the client as ordered.

Continue to monitor the client as ordered.

A client is admitted for treatment of Prinzmetal angina. When developing this client's care plan, the nurse should keep in mind that this type of angina is a result of what trigger? An unpredictable amount of activity. Activities that increase myocardial oxygen demand. Coronary artery spasm. The same type of activity that caused previous angina episodes.

Coronary artery spasm. Prinzmetal angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; anginal pain becomes increasingly severe.

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs? Initiate enteral feedings. Encourage sweet foods. Offer plenty of thin liquids. Liberally season foods.

Initiate enteral feedings. Postoperatively, the client may not be permitted to eat or drink for at least 7 days

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? It will prevent the alveoli from overexpanding. It will assist with widening the airway. It increases the respiratory rate to improve oxygenation. It prolongs exhalation.

It prolongs exhalation we want the patient to get rid of excess air trapped inside them

Which term describes the ability of the heart to initiate an electrical impulse?

automaticity