quiz 5
The nurse would expect which of the following atrial rates to correlate with an idioventricular rhythm? A)20 to 40 B)Not measurable C)100 to 250 D)220 to 350
A) 20-40
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? A)Metoclopramide (Reglan) B)Famotidine (Pepcid) C)Nizatidine (Axid) D)Esomeprazole (Nexium)
A) Metoclopramide Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid), nizatidine (Axid), or ranitidine (Zantac). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.
Which is a symptom of severe thrombocytopenia? A)Petechiae B)Inflammation of the mouth C) Inflammation of the tongue D) Dyspnea
A) Petechiae
Which of the following is a term used to describe the process of ingestion and digestion of bacteria by cells? A)Phagocytosis B) Thrombocytosis C)Poikilocytosis D)Apoptosis
A) Phagoyctosis
The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V1? A) Right side of sternum, fourth intercostal space B)Left side of sternum, fourth intercostal space C)Midway between V2 and V4 D)Mid-clavicular line, fifth intercostal space
A) Right side of sternum, fourth intercostal space view V1, the electrodes would be placed on the right side of the sternum, fourth intercostal space. V2 is the left side of the sternum, fourth intercostal space. V3 is midway between V2 and V4. V4 is at the mid-clavicular line, fifth intercostal space.
What is the drug of choice for a stable client with ventricular tachycardia? A)Atropine B)Amiodarone C) Procainamide D) Lidocaine
B) Amiodarone
The nurse cares for a client with acute myeloid leukemia with severe bone pain. What pathophysiological concept does the nurse understand is the reason for the client's pain? A)Abnormal blood cells deposit in small vessels. B)Bone marrow expands. C) Lymph nodes expand. D)Abnormal blood cells crystalize.
B) Bone marrow expands
A nurse cares for a client with early Hodgkin lymphoma. While assessing the client, the nurse will most likely find painless enlargement of which lymph node? A)Axillary B)Cervical C)Inguinal D)Popliteal
C) Cervical
A nurse who provides care in a busy postsurgical unit recognizes that patients are at particular risk of thromboembolism during their immediate postoperative recovery. Which of the following interventions best facilitates venous blood flow and the prevention of thrombosis? A)Correct application of compression stockings B)Use of intermittent pneumatic compression devices C)Early ambulation D)Prophylactic warfarin (Coumadin)
C) Early ambulation Early ambulation is most effective in preventing venous stasis. Stockings and compression devices are clinically useful interventions for patients who are unable to ambulate, but early mobilization is preferred. Warfarin is not used for the general prevention of DVT in postsurgical patients.
The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis? A)PP interval B) QT interval C) RR interval D)TP interval
C) RR interval The rhythm is often identified at the same time the rate is determined. The RR interval is used to determine ventricular rhythm and the PP interval to determine atrial rhythm. If the intervals are the same or if the difference between the intervals is less than 0.8 seconds throughout the strip, the rhythm is called regular. If the intervals are different, the rhythm is called irregular.
A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the: A)Internal iliac. B)Common femoral. C)Popliteal. D) Posterior tibial.
D) posterior tibial Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: A)pallor and coolness of the left foot. B)a decrease in the left pedal pulse. C)loss of hair on the lower portion of the left leg. D)left calf circumference 1" (2.5 cm) larger than the right.
D)left calf circumference 1" (2.5 cm) larger than the right. Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.
A patient's most recent blood work reveals an elevated level of reticulocytes. The nurse recognizes that this assessment finding may be suggestive of: A)An infectious process B)A lack of oxygen-carrying capacity C)Fluid volume deficit D)Oxygen toxicity
A) A lack of o2 carrying capacity
A client is scheduled for an elective electrical cardioversion for a sustained dysrhythmia lasting for 24 hours. Which intervention is necessary for the nurse to implement prior to the procedure? A) Administer moderate sedation IV and analgesic medication as prescribed B)Administer the prescribed digitalis to the client before the scheduled procedure C)Administer anticoagulant therapy as prescribed prior to the procedure D)Maintain the client on NPO status for 8 hours prior to the procedure
A) Administer moderate sedation IV and analgesic medication as prescribed
The nurse is scheduling gastrointestinal (GI) diagnostic testing for a client. Which GI test should be scheduled first? A)Radiography of the gallbladder B) Barium enema C) Small bowel series D)Barium swallow
A) Radiography of the gallbladder Radiography of the gallbladder should be performed before other GI exams in which barium is used because residual barium tends to obscure the images of the gallbladder and its duct.
Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low? A) U wave B) T wave C)P wave D)QT interval
A) U wave The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a client's serum potassium level is low. The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or "peaked" if a client's serum potassium level is high. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization.
The nurse at a long-term care facility is conducting an admission assessment of a new male resident who is Caucasian. On inspection of the resident's lower extremities, the nurse notes that his shins and ankles have a gray-brown color tone and are visibly shiny. The nurse should conduct further assessments in light of the possibility that the resident may have: A)Venous insufficiency B)An arterial occlusion C)Raynaud's disease D) A deep vein thrombosis
A) Venous insufficiency
Bone marrow is soft tissue within specific bones which manufactures blood cells; that is, maintains a role in hematopoiesis. There are several structures in the hematopoietic and lymphatic systems that contribute to the manufacture of blood cells. Which structure does not participate in blood cell production? A)yellow bone marrow B) red bone marrow C) lymphoid tissue D)pluripotential stem cells
A) Yellow bone marrow
A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia? A)hemoglobin S B)hemoglobin F C)hemoglobin A D)hemoglobin M
A) hemoglobin S
A nurse is completing an assessment on a client and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which term? A) Lymphadenitis B)Lymphangitis C)Lymphedema D)Elephantiasis
A) lymphadentitis Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.
The nurse knows which heart rhythm occurs when the atrial and ventricular rhythms are both regular, but independent of each other? A)Third-degree atrioventricular (AV) heart block B)Second-degree heart block C) First-degree AV block D)Asystole
A) third degree atrioventricular heart block In third-degree AV heart block there is no relationship or synchrony between the atrial and ventricular contraction. Each is beating at its own inherent rate and is independent of each other, thus the cardiac output is affected. Second-degree AV block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. First-degree AV block occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval. During asystole, there is no electrical activity.
While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit? A) Between 40 and 80 mL B)Approximately 80 to 120 mL C)Between 120 and 160 mL D)Greater than 160 mL
B) 80-120
A client complains of extreme fatigue. Which system should the nurse suspect is most likely affected? A)Neurological B) Hematological C)Integumentary D)Respiratory
B) Hematological
A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? A)The aneurysm has become obstructed. B) The aneurysm may be preparing to rupture. C)The client is experiencing inflammation of the aneurysm. D)The client is experiencing normal sensations associated with this condition.
B) The aneurysm may be preparing to rupture
The nurse explains to a patient that the primary cause of a varicose vein is: A)Phlebothrombosis. B)An incompetent venous valve. C)Venospasm. D)Venous occlusion.
B) an incompetent venous valve Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves
The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds? A)Normal B)Hypoactive C)Hyperactive D)Borborygmi
C) Hyperactive Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma, 2012).
Which statement indicates the client understands teaching about induction therapy for leukemia? A) "I will start slowly with medication treatment." B)"I will need to come every week for treatment." C) "I will be in the hospital for several weeks." D) "I know I can never be cured."
C) I will be in the hospital for several weeks Induction therapy involves high doses of several medications and the client is usually admitted to the hospital for several weeks. The treatment is started quickly and the goal is to cure or put the disease into remission.
The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal? A)Recover from the general anesthesia B)Decrease nausea and vomiting C)Increase the amount of fluids D)Ambulate independently
C) Increase amount of fluids
When no atrial impulse is conducted through the AV node into the ventricles, the client is said to be experiencing which type of AV block? A)First degree B)Second degree, type I C)Second degree, type II D) Third degree
D) third degree In third degree heart block, two impulses stimulate the heart, one impulse stimulates the ventricles and other stimulates the atria. In first degree heart block, all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. In second degree AV block, type I, all but one of the atrial impulses are conducted through the AV node into the ventricles. In second degree AV block, type II, only some of the atrial impulses are conducted through the AV node into the ventricles.
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first? A)Sustained asystole B)Supraventricular tachycardia C) Atrial fibrillation D)Ventricular fibrillation
D) ventricular fibrillation
The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate? A) 0.10 B)0.25 C)0.35 D)0.50
D)0.50
Nursing management of a patient receiving heparin includes monitoring for heparin-induced thrombocytopenia. Choose the result that indicates the potential for spontaneous intracranial hemorrhage, which is life-threatening. A platelet count of: A)90,000 to 150,000 mm3 B)50,000 to 80,000 mm3 C)20,000 to 40,000 mm3 D)10,000 to 14,500 mm3
D)10,000 to 14,500 mm3
A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? A)Doppler ultrasound B )Magnetic resonance angiography (MRA) C)Angiography D)Comtomography angiography (CTA)puted
D)Computed tomography angiography (CTA) A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.
A group of new nurses are going to work on the telemetry unit. They are taking a class on electrocardiograms (ECGs) and arrhythmias. What would the staff educator tell this class about ST segments? A)The part of an ECG that reflects repolarization of the ventricles B)The part of an ECG used to calculate ventricular rate and rhythm C)The part of an ECG that reflects the time from ventricular depolarization through repolarization D) The part of an ECG that reflects the end of the QRS complex to the beginning of the T wave
D)The part of an ECG that reflects the end of the QRS complex to the beginning of the T wave The ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave; the part of an ECG used to calculate ventricular rate and rhythm is the RR interval; the part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval.
A client with an atrial dysrhythmia has come to the clinic for a follow-up appointment and to talk with the health care provider about options to stop this dysrhythmia. What procedure could be used to treat this client? A)Elective electrical cardioversion B)Chemical cardioversion C) Mace procedure D)Elective electrical defibrillation
A) Elective electrical cardioversion Elective electrical cardioversion is a nonemergency procedure done by a physician to stop rapid, but not necessarily life-threatening, atrial dysrhythmias. Chemical cardioversion is not a procedure; it is drug therapy. A Mace procedure is a distractor for this question. Defibrillation is not an elective procedure.
A client informs the nurse that he is having a difficult time coping with seasonal allergies and has taken some over-the-counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies? A)Elevated eosinophils B)Elevated basophils C) Elevated monocytes D)Elevated neutrophils
A) Elevated eosinophils Eosinophils phagocytize foreign material. Their numbers increase in allergies, some dermatologic disorders, and parasitic infections. Basophils are also capable of phagocytosis; they are active in allergic contact dermatitis and some delayed hypersensitivity reactions. Monocytes engulf microbial invaders and display the antigenic surface to T lymphocytes. Neutrophils are a major component of the inflammatory response and defense against bacterial infection.
Which cells have the lifespan of 1 to 2 days and perform phagocytosis? A) Leukocytes B) Platelets C) Erythrocytes D)Lymphocytes
A) Leukocytes
The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? A)Surgical debridement B) Nonselective debridement C)Enzymatic debridement D)Selective debridement
B) Nonselective debridement Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.
A 20-year-old man has been admitted to the emergency department with a femoral fracture as a result of a motorcycle accident. When the nurse is taking the patient's history, he states, "I had leukemia when I was little kid but they managed to cure it." The nurse should suspect that this patient likely had what type of leukemia? A)Acute lymphoid leukemia (ALL) B)Chronic lymphoid leukemia (CLL) C)Acute myeloid leukemia (AML) D)Chronic myeloid leukemia (CML)
A) Acute lymphoid leukemia ALL is most common in young children, with boys affected more often than girls; the peak incidence is 4 years of age. After 15 years of age, ALL is relatively uncommon. CLL, AML, and CML are all more common in adults and older adults than in children.
Which of the following medications is considered a thrombolytic? A)Alteplase B)Heparin C)Coumadin D)Lovenox
A) Alteplase
An client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults? A)dementia B)stomatitis C)glossitis D) ataxia
A) Dementia Pernicious anemia may be accompanied by a dementia with symptoms similar to Alzheime's disease. Therefore, clients experiencing cognitive changes should be screened because early detection of pernicious anemia is critical to prevent neurologic damage.
Which protein in plasma functions primarily as immunologic agents? A) Gamma globulins B)Albumin C) Fibrinogen D)Beta globulins
A) Gamma globulins Globulins are divided into three groups: alpha, beta, and gamma. The gamma globulins are also called immunoglobulins. Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. Therefore options B, C, and D are incorrect.
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: A)Hemorrhage. B)Thrombosis of the graft. C) Decreased motor function. D)Stent dislodgement.
A) Hemorrhage
A patient has a persistent third-degree heart block and has had several periods of syncope. What priority treatment should the nurse anticipate for this patient? A)Insertion of a pacemaker B)Administration of atropine C) Administration of epinephrine D) Insertion of an implantable cardioverter defibrillator (ICD)
A) Insertion of a pacemaker
The nurse knows that synchronization of cardioversion prevents the discharge from occurring during the vulnerable period of which of the following? A)Ventricular repolarization B)Atrial depolarization C) Ventricular depolarization D)Purkinje fiber repolarization
A) Ventricular repolarization The synchronization of cardioversion prevents the discharge from occurring during the vulnerable period of repolarization (T wave), which could result in ventricular tachycardia (VT) or ventricular fibrillation. The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. The U wave represents repolarization of the Purkinje fibers.
An elderly client is hospitalized for induction of chemotherapy to treat leukemia. The client reports fatigue to the nurse. What nursing intervention would best address the client's fatigue? A)Have the client maintain complete bedrest. B)Assist the client to sit in a chair for meals. C)Talk to the family about not visiting so the client can obtain rest. D) Provide sedentary activities only, such as watching television.
B) Assist client to sit in a chair for meals Fatigue is a common symptom with clients who have leukemia. Despite the fatigue, clients still need to maintain some physical activity. An example of physical activity is having the client sit in a chair for meals. The nurse does not want to encourage complete bedrest or sedentary activities, such as watching television, due to possible deconditioning. The nurse has not discussed with the client about limiting family visits. The client may want some family to visit.
Which is the major function of neutrophils? A)Rejection of foreign tissue B)Phagocytosis C)Destruction of tumor cells D) Production of immunoglobulins
B) Phagocytosis Once a neutrophil is released from the marrow into the circulation, it stays there for only about 6 hours before it migrates into the body tissues to perform its function of phagocytosis (ingestion and digestion of bacteria and particles). Neutrophils die there within 1 to 2 days. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies called immunoglobulins.
Undersensing occurs as a pacemaker malfunctions. The nurse understands undersensing occurs as a result of which event? A)The complex does not follow the pacing spike B)Pacing spike occurs at the preset level C)Total absence of the pacing spike D)Loss of pacing artifact
B) pacing spike occurs at the present level Undersensing means that the pacing spike occurs at preset interval despite the patient's intrinsic rhythm. Loss of capture occurs when a complex does not follow a pacing spike. Loss of pacing is total absence of the pacing spike. Oversensing occurs when there is a loss of pacing artifact.
Which nursing intervention should be incorporated into the plan of care for a client with impaired liver function and a low albumin concentration? A)Implement neutropenic precautions B)Apply prolonged pressure to needle sites or other sources of external bleeding C) Monitor for edema at least once per shift D)Monitor temperature at least once per shift
C) Monitor for edema at least once per shift Albumin is particularly important for the maintenance of fluid balance within the vascular system. Capillary walls are impermeable to albumin, so its presence in the plasma creates an osmotic force that keeps fluid within the vascular space. Clients with impaired hepatic function may have low concentrations of albumin, with a resultant decrease in osmotic pressure and the development of edema.
An operating room nurse is caring for a client who is having a pacemaker implanted. Thehealth care provider has requested a demand mode pacemaker for this client. What is this type of pacemaker? A) A fixed-rate pacemaker B)A temporary pacemaker C)Self-activated D)Asynchronous
C) Self activated
When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating A)normal sinus rhythm. B)sinus bradycardia. C)sinus dysrhythmia. D)sinus tachycardia.
C) Sinus dysrhythmia
When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase? A)Starch B)Protein C) Triglycerides D) Glucose
C) Triglycerides Pancreatic lipase acts on lipids, especially triglycerides. Salivary amylase and pancreatic amylase act on starch. Pepsin and hydrochloric acid in the stomach and trypsin from the pancreas act on proteins. Insulin acts on glucose.
A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: A) place a heating pad around the affected calf. B)elevate the affected leg as high as possible. C) keep the affected leg level or slightly dependent. D)shave the affected leg in anticipation of surgery.
C) keep the affected leg level or slightly dependent While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.
A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? A)Pancytopenia B) Thrombocytopenia C)Anemia D) Neutropenia
D) Neutropenia
Why would it be important for the nurse to obtain information regarding dietary history of a client with a possible abnormality of the hematopoietic or lymphatic system? A) It could determine if the illness is self-induced by nutritional starvation. B)If the client has impaired protein intake, it will cause diseases of the hematopoietic system. C)Altered nutrition is the cause of abnormalities of the hematopoietic and lymphatic system. D)Compromised nutrition interferes with production of blood cells and hemoglobin.
D)Compromised nutrition interferes with production of blood cells and hemoglobin