RANKING AND SATA TEST 1 SPRING

2,3,5

The client is admitted to the ED and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? SATA 1. obtain a midstream urine specimen 2. Attach the telemetry leads/monitor to the client 3. start a SL in the R arm 4 draw a basal metabolic panel (BMP) 5. REquest a stat order for a 12 lead ECG

3 2 4 5 1 (3: Because this is less than 1 mL, the nurse should draw this med up in a 1 mL TB syringe to ensure accuracy of dosage 2: The nurse should dilute the med with NS to a 5-10 mL bolus to help decrease pain during admin and maintain the IV site longer. Administering 0.25 mg of digoxin in 0.5 mL is very difficult if not impossible to push over 5 full minutes which is the manufacturers recommended PUSH RATE. If the med is diluted to a 5-10 mL bolus it is easier for the nurse to admin the med over 5 mins 4: The nurse must check two identifiers per JAHCO 5: The nurse should clamp the tubing between the port and primary IV line so the med will enter the vein and not ascend up the IV tubing 1: Cardiovascular and narcotic meds are administered over 5 mins)

11. The nurse is preparing to admin digoxin 0.25 mg IVP to a client in severe CHF who is receiving D5W/0.9 NaCL @ 25 mL/hr. Rank in order of importance: 1. Admin the med over 5 minutes 2 Dilute the med with NS 3.. Draw up the med in a TB syringe 4. Check the Pt ID band 5 Clamp the primary tubing distal to the port

3,4 (COLLAB interventions: 3&4 WRONG #5 the diet would be collaborative but a diet will not be ordered because the client will be NPO)

The nurse is caring for a client dx with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? 1. Perform a complete pain assessment 2. Assess the VS freq 3 Admin a PPI IV 4. OBtain permission and admin blood products 5. Monitor intake of soft bland diet

5 4 1 2 4 2 4 2 4 3 ( The client should be placed on telemetry upon admission to the unit. When the client experiences chest pain, vital signs should be checked immediately, followed by the ECG. Nitroglycerin is usually tried before morphine to relieve the chest pain. Hypotension is a side effect of nitroglycerin. Blood pressure and heart rate are monitored whenever nitroglycerin is administered. When nitroglycerin fails to relieve chest pain, IV morphine is the next action, and the health care provider should be notified. Focus: Prioritization)

4. The health care provider's orders for Ms. J, who is currently experiencing chest pain, are as follows. List the orders in the sequence in which they should be completed. (Answers may be used more than once.) 1. Obtain a 12-lead electrocardiogram (ECG) when the client experiences chest pain. 2. Administer nitroglycerin (Nitrostat) 0.6 mg sublingually every 5 minutes as needed for chest pain. 3. Administer morphine 2 mg IV push as needed for chest pain. 4. Monitor blood pressure and heart rate. 5. Place on a telemetry monitor. _______, _______, _______, _______, _______, _______, _______, _______, _______, _______

1,2,4,5 (1, a 2lb weight gain indicates retain fluid and should contact HCP, 2 Keeping HOB elevated will help breathing, 4, Na retains water 5, isotonic exercise such as walking, swimming helps tone the muscles. WRONG: #3 loop should be taken in morning)

40 The cardiac nurse is teaching the client diagnosed with CHF. Which teaching interventions should the nurse discuss with the client. SATA 1. Notify the HCP if the client gains more than 2 lbs in one day 2. keep the HOB elevated when sleeping 3. Take the loop diuretic once a day before sleep 4 Teach the client which foods high in Na should be avoided 5 Perform isotonic exercises at least once a day

1,3,4 (1 The HCP must order insertion of a Sengstaken-Blakemore tube, so this is collaborative 3. This is a collab intervention the nurse should implement needs HCP orders 4. Obtaining lab data requires HCP orders)

53 The nurse is caring for a client who is hemorrhaging from a duodenal ulcer. Which collaborative interventions should the nurse implement? SATA 1. Prepare to admin a SEngstaken-Blakemore tube 2. Assess the VS 3. Admin PPI IV 4.. Obtain a type and crossmatch for 4 units of blood 5. Monitor the I&O's

1, 2, 6 ( Measuring vital signs, recording intake and output, and assisting clients with activities of daily living are all within the scope of practice of the UAP. Administration of IV drugs, venipuncture for laboratory tests, and assessment are beyond the scope of practice of UAPs. Focus: Delegation, supervision, assignment)

6. Because Ms. S continues to experience chest pain and has elevated levels of cardiac markers, the following interventions have been ordered. Which interventions may you assign to an experienced UAP? (Select all that apply.) 1. Measuring vital signs every 2 hours 2. Accurately recording intake and output 3. Administering tenecteplase (TNKase) IV push 4. Drawing blood for coagulation studies 5. Assessing the cardiac monitor every 4 hours 6. Assisting the client to the bedside commode

3 1 4 2 5 (3: This client may be chilling indicating a rise in Temp, assess first to see if interventions needed based on progression septicemia. 1: This client should be assessed to ensure stable because chest pain during last shift 4: The nurse should assess the client next because although confusion expected the nurse must determine if new situation occuring 2: Client has psychosocial needs but it must be addressed and steps to resolve 5 A dressing change can take time . Its not life threat.)

68 The nurse on a medical unit is making rounds and recieving shift report which client should the nurse see first? Rank in order of priority 1 The 45 y/o who complained of chest pain midnight last night and received NTG SL 2 The 62 yo client who is complaining no one answered the call light for 2 hr yesterday 3 The 29 yo client dx with septicemia who called to request more blankets because of being cold 4. The 78 yo dx with dementia whose daughter is concerned because the client seems more confused today 5 The 37 yo with a stage 4 pressure ulcer and the dressing needs to be changed today

1,3,4 (1, nitro tabs vasodilate to provide O2 to heart, 3, the nurse should assess the VS as part of assessment of current situation 4 supplemental O2 assists in getting higher concentration to heart muscle. WRONG: #2 client should sit immed. all px activity stop #5 ward secretary cant take orders only RN should discuss with HCP)

69 While ambulating in the hall with the nurse the client dx with MI complains of chest pain. Which interventions should the nurse implement? SATA 1. Admin nitro 0.4 mg SL STAT 2 Have the client walk back to the room 3 Take the client VS 4. Place the client on supplemental O2 5 Ask the ward secretary to call the HCP for orders

1,2,5 (1,2,5 The nurse should not admin any PO meds since the client is NPO)

9. At 0830 The day shift nurse is preparing to admin medications to the client NPO for an endoscopy. Which medication should the nurse question administering? SATA 1. Lanoxin (digoxin) 0.125 mg PO qd 2. furosemide 40 mg PO bid 3. Zantac (ranitidine) 150 mg in 250 mL NS IV continuous infusion q 24 hr 4 Vancomycin 850 mg IVPB q24h 5 Mylanta 30 mL PO PRN heartburn

5 4 3 2 1 (5: The nurse first must obtain informed consent prior to blood admin 4: The nurse needs to complete the pre transfusion assessment including assess for any signs of allergic reaction PRIOR to administering unit of blood 3: The blood must be hung with Y-tubing and NS, and an 18 gauge angiocath is preferred 2: The nurse must check the unit of blood from the lab with another nurse and with the clients blood band 1: During the first 15 mins the blood transfusion must be administered slowly to determine if the client is going to have an allergic reaction)

9. The cardiac RN is preparing to admin 1 unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority. 1. Infuse the unit of blood at 20 gtt/min the first 15 min 2 Check the unit of blood and the clients blood band with another nurse 3. Initiate the Y-tubing with NS via an 18 guage angiocatheter 4 Assess the clients VS and lung sounds and assess for a rash 5. Obtain informed consent for the unit of blood from the client

1 (although obtaining the ECG, chest radiograph and CBC are all important, the nurses priority action should be to relieve the crushing chest pain. Therefore administering the morphine sulfate is the priority action)

A 60 year old comes into the ER with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include O2 by nasal cannula at 4L/min. CBC, chest radiograph, a 12 lead ECG and 2 mg of morphine sulfate given IV. The nurse should first: 1.. administer the morphine 2. obtain a 12 lead ECG 3. obtain blood work 4. prescribe the chest radiograph

1 3 4 2 (Because atrial fibrillation causes a decrease in cardiac output, the HR increases in response to this drop. As a result of an increased HR the O2 demands of the heart increase. It is important O2 is administered first to compensate for the increased workload and o2 demand. Placing the client on a cardiac monitor will help confirm a diagnosis of atrial fibrillation. Performing VS will determine the client response to the abnormal rhythm and responses to treatment. If the rhythm is determined to be atrial fibrillation it will be necessary for an IV to be inserted so medication can be administered)

A client has atrial fibrillation and a HR of 165 bpm. In which order from first to last should the nurse implement these prescriptions? Use all options, no commas 1. admin o2 via nasal cannula 2.. gather supplies for IV insertion 3. place the client on ECG monitor 4. obtain VS including BP, HR, RR, T and O2 sat

2,5 (It is important for clients to wear hearing aids to this procedure so that they can hear the questions posed to them by the healthcare team. Chest pain often occurs when the balloon within the stent is inflated and deployed into the coronary artery. It is expected and brief but should still be reported by the client. During the procedure and for a prescribed amount of time after the procedure the client will need to remain flat in bed with the right leg straight., NOT flexed, to prevent bleeding from the access site. The site is not routinely stitched. It is a puncture rather than an incision requiring sutures. The client may be given IV medication to help with comfort, but the client is kept awake to answer questions and to hear instructions and explanations. General anesthesia is not given)

A client is scheduled for insertion of a coronary stent with right groin access. Which teaching points should the nurse include in this clients pre- operative teaching plan? select all that apply 1. If you have a hearing aid you will need to remove it for the procedure 2. If you have chest pain during the procedure please tell the staff when or if this occurs 3. The stitches at your right groin will be able to be removed in 7-10 days following the procedure 4. you will be given general anesthesia and will be asleep throughout the procedure 5. You will need to remain flat throughout the procedure 6 You will need to keep your right leg in a flexed position for 1-2 hrs following the procedure

1,2,4,5 (VS give an important initial assessment of this clients status. The client may experience burns from the patches and current used for the cardioversion. Therefore it is important to assess the skin on the chest wall for redness or burns. Because conscious sedation is used for this procedure, assess the LOC also is an important initial step. Attaching the client to cardiac monitoring is also important to assess rhythm abnormalities. There is no arterial puncture associated with this procedure.)

A client returns to the nursing unit following a successful synchronized cardioversion using transthoracic chest wall patches. The nurse should assess which when the client returns to the room? SATA 1 VS 2. skin of chest wall 3. arterial puncture site 4. LOC 5 cardiac rhythm

1,4,5 (Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, BP and HR. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the HR. It can depress RR; however such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme inhibitor drugs, not morphine may help to prevent ventricular remodeling)

A client with acute chest pain is receiving IV morphine sulfate. Which is the expected effect of morphine? Select all that apply 1. reduces myocardial oxygen consumption 2 promotes reduction in RR 3 prevents ventricular remodeling 4. reduces BP and HR 5 reduces anxiety and fear

a,c (RIGHT;A; A client with ttl chol level greater than 200 is at increased risk heart disease. C; A client who has LDL greater than 130 is at increased risk for heart disease. WRONG ANSWERS: B; HDL greater than 55 for female or greater than 45 for male decreases clients risk for HD. D; A triglyceride between 35-135 female or 40-160 male is in range. E; Troponin I level is monitored to detect cardiac injury a Troponin I less than 0.03 is wnl)

A nurse at HCP office reviewing lab test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? SATA a. Cholesterol (total) 245 mg/dL b. HDL 90 mg/dL c LDL 140 mg/dL d. Triglycerides 125 mg/dL e. Troponin I 0.02 ng/mL

a,b,e (Correct: A,B,E: Dyspnea, fatigue and peripheral edema are manifestations of R sided valvular heart disease. WRONG: C; a normal or rapid pulse and irreg rhythm are manifestations of L sided valv heart disease. D: a pleural friction rub is a manifestation of pleurisy or pneumonia)

A nurse educator is reviewing expected findings in a client who has right sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? SATA a. dyspnea b. client report of fatigue c. bradycardia d. pleural friction rub e. peripheral edema

a,c (Correct: A; the nurse should wear gloves when handling pacemaker leads. C; The client should wear a sling to minimize shoulder movement and promote secure anchoring of the lead wires. WRONG: B; 3 pronged grounding plugs reduce the risk of accidental electrical discharge by equipment being used. D: The nurse should hold lead wires with some slack in them to prevent dislodging the wires when being turned. E; The nurse should keep extra batteries at the bedside for quick access when needed.)

A nurse is admitting a client to the coronary care unit following placement of a temp pacemaker. Which of the following nursing actions should the nurse use to promote client safety? SATA A. Wear gloves when handling pacemaker leads B Ensure electronic equipment has 3 pronged grounding plugs C. Minimize the clients shoulder movements D. Hold the lead wires taut when turning the client E. Keep extra pacemaker batteries at least 300 ft away from the client

B,C,E (b; The nurse should expect the pt to have bilateral crackles for an increased CVP and PAWP C; The nurse would expect the client to have JVD with elevated CVP &PAWP. E: The nurse should expect the client to have hepatomegaly with elevated CVP and PAWP. WRONG ANSWERS: a; clients CVP and PAWP are above the expected reference range poor skin turgor for decreased CVP, d; dry mucous membranes are sign of decreased CVP PAWP NORM CVP 0-5; NORM PAWP 6-12 A HIGH CVP INDICATES FVE, A HIGH PAWP 6-12 INDICATES FVE)

A nurse is assessing a client who is undergoing hemodynamic monitoring The client has a CVP of 7 mmHg, and a PAWP of 17 mmHg Which of the following findings should the nurse expect? (SATA) a. poor skin turgor b. bilateral lung crackles c. JVD d dry mucous membranes e. hepatomegaly

b,c (CORRECT: B; cap refill > than 2-4 seconds is not wnl and should be reported. C; mottled appearance of affected extrem should be reported. WRONG: A; a trace of blood on dressing expected. D; pain that decreases with IV BOLUS not immed. concern. E: 2+ pulse wnl)

A nurse is caring for a client following a peripheral bypass graft surgery of the left lower extremity. which of the following findings pose an immed. concern? SATA a. trace of bloody drainage on dressing b. cap refill of affected limb of 6 sec c. mottled appearance of limb d throbbing pain of affected limb that is decreased following IV bolus analgesic e pulse of 2+ in affected limb

a,c (CORRECT A; A cool clammy foot can indicate femoral hematoma secondary to insert of lead wires and should be reported. C: persistent hiccups can indicate lead wire perforation and stimulation of the diaphragm should be reported WRONG: B; a pacing spike followed by QRS is wnl, D; HR wnl, E BP wnl)

A nurse is caring for a client following the insert of a temp venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? (SATA) a cool clammy foot with cap refill of 5 sec b. observed pacing spike followed by QRS complex c. Persistent hiccups d. HR 84 bpm e. BP 104/62

a,b,e (Correct ABE Wrong C; DECREASED urinary output expected S/s D: Pink frothy sputum is expected S/s for pt with pulmonary edema.)

A nurse is completing the admission assessment of a client who has suspected pulm edema. Which of the following manifestations are expected findings? SATA a. tachypnea b. persistant cough c. increased urinary output d thick yellow sputum e. orthopnea

a,c,e (CORRECT: A; Hx of congenital malformations is a risk factor. C; HTN risk factor. E; a murmur indicates turbulent blood flow, which is often from valvular heart disease. WRONG: B; Strep or Rheumatic fever is a risk factor. D. A SUDDEN wt gain could indicate fluid collected related to L sided valvular heart disease)

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? SATA a. surgical repair of an atrial septal defect at age 2 b. measles in childhood c. HTN for 5 years d. weight gain of 10 lb in past year e. diastolic murmur present

1,2,5

A nurse is working with a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? SATA 1. follow up ECG 2. Energy setting s used 3. IV fluid intake 4. Urinary output 5. Skin condition under electrodes

a,c,d (CORRECT: A; The nurse should use a 10 mL flush NS to avoid excess pressure that can cause cath fracture/rupture. C: The nurse should cleanse the port with alcohol or chlorohex for 15 sec and allow to air dry prior to use. D; The nurse should maintain a transparent dressing over the site to decrease risk of infect. and allow visualization. The nurse should plan to change the dressing q7d and when wet, loose or soiled. WRONG: B; Avoid use of force if resistance met. E: Flush PICC with 10 mL NS before, between and after medications. A flush of 5 mL heparin is recommended when PICC line not actively in use.)

A nurse planning care for a client with a PICC line in the R arm. Which of the following interventions should the nurse include in the plan of care? (SATA) a. Use 10 mL syringe to flush the PICC line b. Apply gentle force if resistance is met during injection c. Cleanse ports with alcohol for 15 seconds prior to use d maintain a transparent dressing over the site e Flush with 10 mL heparin before and after medication admin

2 4 3 1 (Even though the chest pain experienced by Client 2 is resolved, it was recent and requires reassessment. Client 4 is scheduled to leave for major surgery very soon. The nurse should check this client and the clients chart and make certain that everything is ready so as not to delay the surgery. Client 3 has scheduled medications for BP control. While not experiencing any acute problems, this medication should be administered as scheduled. Client 1 is stable at this time and can be seen last.)

A nurse working the day shift on a cardiac unit receives the following shift report: At the conclusion of the report it is 0730. Put the clients in order from first to last in which the nurse should plan to assess them. All options must be used 1 client 1. Admitted yesterday morning with hypokalemia Awaiting repeat electrolyte lab results drawn at 0600 2. Client 2: Experiencing chest pain at 0630. Pain resolved after 2 sublingual nitro tablets 3. Client 3: Scheduled for oral antihypertensive medication at 0900. Incontinent of urine during the night 4. Client 4: Scheduled for coronary artery bypass surgery at 0800. The clients family is in the clients room

2 4 3 1 (Even though the chest pain experienced by Client 2 is resolved, it was recent and requires reassessment. Client 4 is scheduled to leave for major surgery very soon. The nurse should check this client and the clients chart and make certain that everything is ready so as not to delay the surgery. Client 3 has scheduled medications for BP control. While not experiencing any acute problems, this medication should be administered as scheduled. Client 1 is stable at this time and can be seen last.)

A nurse working the day shift on a cardiac unit receives the following shift report: At the conclusion of the report it is 0730. Put the clients in order from first to last in which the nurse should plan to assess them. All options must be used 1 client 1. Admitted yesterday morning with hypokalemia Awaiting repeat electrolyte lab results drawn at 0600 2. Client 2: Experiencing chest pain at 0630. Pain resolved after 2 sublingual nitro tablets 3. Client 3: Scheduled for oral antihypertensive medication at 0900. Incontinent of urine during the night 4. Client 4: Scheduled for coronary artery bypass surgery at 0800. The clients family is in the clients room

5 2 4 1 3 (5: victim placed on back 2: just look quickly 4: get an AED or 911. The faster defib the better outcomes 1: Initiate compressions immed. Breathing not initiated without barrier device 3: Compression rate is 30:1) According to the 2010 AHA guidelines which steps of CPR for an adult suffering from cardiac arrest should the nurse teach individuals in the community? RANK IN ORDER OF PERFORMANCE 1. Place the hands over the lower half of the sternum 2. Look for obvious signs of breathing 3. Begin compressions at a ratio of 30:2 4. Call for an AED immed 5. Position the victim on the back)

According to the 2010 AHA guidelines which steps of CPR for an adult suffering from cardiac arrest should the nurse teach individuals in the community? RANK IN ORDER OF PERFORMANCE 1. Place the hands over the lower half of the sternum 2. Look for obvious signs of breathing 3. Begin compressions at a ratio of 30:2 4. Call for an AED immed 5. Position the victim on the back

1,3,4 (The client has atrial fibrillation and will have an irregularly irregular pulse and will commonly be tachycardic, with rapid ventricular responses (HR) typically in the 110 to 140 range, but rarely over 150-170. The goal of treatment is the restoration of sinus rhythm. With a heart rate >150 and symptoms of sob, dizziness and syncope, and chest pain, synchronized cardioversion will most likely be the treatment of choice. With more controlled HR and more minor S/S, chemical conversion with drugs such as diltiazem and digoxin prior to other interventions such as synchronized cardioversion with appropriate anticoagulation may be attempted. Because of the decreased cardiac output, monitoring is essential. Obtaining consent for cardioversion requires a prescription from the HCP, but with the current HR having cardioversion is a very strong possibility for this client. Defib is used for ventricular fibrillation, not atrial fibrillation. Teaching the client about warfarin will be a possibility, but not an immediate intervention. Clients in continued atrial fib usually require some form of anticoagulation. Drawing labs for CBC's to detect anemia or infection, and thyroid function studies (to determine thyrotoxicosis a rare but not to be missed cause, especially in older adults) serum electrolytes and BUN/creatinine (looking for electrolyte disturbances or renal failure) are commonly drawn for determining the cause of the atrial fibrillation, they are not an immediate action)

An 85 year old client is admitted to the ER at 2000 hrs with syncope, shortness of breath, and reported palpitations. (see notes below) At 2015 the nurse places the client on the ECG monitor and identifies the following rhythm (Afib) What should the nurse do? SATA Admitted: 2000 hours HR 150 BP 90/62 O2 sat 92% room air RR 22 client is sob states "heart is jumping out of my chest and hurts some, I am having trouble catching my breath, I dont want to faint again" 1. apply oxygen 2.. prepare to defibrillate 3. monitor VS 4. have the client sign the consent for cardioversion as prescribed 5. teach the client about warfarin treatment and the need for frequent blood testing 6. draw a CBC count and thyroid function study

2 1 3 4 (To decrease myocardial workload and promote timely intervention, the client should be assisted to the bed. Assessing the VS provides the data needed to determine client tolerance. Early initiation of an IV access will enable timely medication administration if it is emergently needed. While a 12 lead ECG is needed it can be obtained after the IV is initiated)

Cardiac telemetry shows that a client who is up to the bathroom has converted from normal sinus rhythm with a rate of 72 to atrial fibrillation with a ventricular response rate of 100 bpm. In what order from first to last should the nurse perform these interventions? Use all and no commas 1. assess the VS 2 assist the client to bed 3. initiate IV access 4. obtain a 12 lead electrocardiogram stat

1,2 (An admission assess is independent, 2 eval BP is independent.)

GCS 3The client admitted to the hospital with hemorrhaging from a duodenal ulcer. Which interventions should Ms. Kathy instruct the primary nurse to implement? SATA 1. complete the admission assessment 2. evaluate BP lying, sitting, and standing 3. Admin IV antibiotics 4. admin blood products 5. obtain hemoglobin and hematocrit

1 4 5 2 3 (1 Assess to determine if client is hypovolemic or in shock the stem does not provide info to state client is hypovolemic. 4 Start IV to replace fluid volume 5 While the nurse starts IV a sample can be sent for match 2 A NG tube should be inserted to direct iced saline to cause constriction which will decrease the bleed 3 The iced lavage will decrease bleeding)

The client is admitted to the ED complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement? LIST IN ORDER OF PRIORITY 1. Assess the clients VS 2. Insert a NG tube 3. Begin iced saline Lavage 4. Start and IV with an 18 gauge needle 5. Type and crossmatch for blood transfusion

2,4 (CLIENT WILL BE NPO TO PREPARE FOR INTUBATION)

The 26 y/o male client in the PACU has a HR of 110 and rising temp and complaining of muscle stiffness. Which interventions should the nurse implement? SATA 1. Give a back rub to the client to prevent stiffness 2. Apply ice packs to the axillary and groin 3.. Prepare ice slush for the client to drink 4. Prepare to admin dantrolene 5. reposition the client on warming blanket

4 (The client is exhibing signs of DIC, which requires IV therapy. This is a life threatening complication that requires immediate medical intervention. so the nurse must notify the HCP first)

The ICU nurse is caring for a client and notes blood oozing out from under the Tegaderm dressing over the peripheral IV site, bleeding gums, and blood in the urinary cath bag. Which intervention should the nurse implement first? 1. Check the H&H 2 Monitor the clients pulse oximeter reading 3. apply pressure to the IV site 4. Notify the HCP

b,d,e

The nurse is assessing the client with metabolic alkalosis. Which findings would likely be observed in this client? Select all that apply. a Kussmaul's respirations b Numbness of the extremities c Vomiting and nausea d Warm flushed skin e Circumoral paresthesia f Hypertonic muscle contractions

1,2,4,5,6 (The nurse must have assessment data and verify VS if necessary in order to determine the action required. If there is a significant change in the clients condition, the charge nurse should be notified in order to help the nurse with both this client and the nurses other assigned clients if necessary. Most acute care facilities have a rapid response team that can also help assess and intervene with basic standing orders if necessary. Positioning the client semi fowlers is a nursing action that may assist the client with breathing and relieve SOB. It is important that the nurse reassure the client and stay calm remaining with the client. The nurse must notify the HCP of the change in condition.)

The UAP reports to the nurse that the client is "feeling short of breath" The clients BP was 124/78, 2 hours ago with a HR of 82bpm. the UAP reports that BP is now 84/44 with a HR of 54 bpm. and the client stated "I just do not feel good". What actions should the nurse take? SATA 1. confirm the clients VS and complete a quick assessment 2. inform the charge nurse of the change in condition, and initiate the hospitals rapid emergency response team 3. make a quick check on other assigned clients before spending the amount of time required to take care of this client 4. position the client semi fowlers 5. stay with the client and reassure the client 6. call the HCP and report using SBAR

1,2,4,5,6 (The nurse must have assessment data and verify VS if necessary in order to determine the action required. If there is a significant change in the clients condition, the charge nurse should be notified in order to help the nurse with both this client and the nurses other assigned clients if necessary. Most acute care facilities have a rapid response team that can also help assess and intervene with basic standing orders if necessary. Positioning the client semi fowlers is a nursing action that may assist the client with breathing and relieve SOB. It is important that the nurse reassure the client and stay calm remaining with the client. The nurse must notify the HCP of the change in condition.)

The UAP reports to the nurse that the client is "feeling short of breath" The clients BP was 124/78, 2 hours ago with a HR of 82bpm. the UAP reports that BP is now 84/44 with a HR of 54 bpm. and the client stated "I just do not feel good". What actions should the nurse take? SATA 1. confirm the clients VS and complete a quick assessment 2. inform the charge nurse of the change in condition, and initiate the hospitals rapid emergency response team 3. make a quick check on other assigned clients before spending the amount of time required to take care of this client 4. position the client semi fowlers 5. stay with the client and reassure the client 6. call the HCP and report using SBAR

2 4 3 1 5 (2: the nurse should check the clients H&H . Most facilities have a procedure to only admin PRBCs only when the H/H are less than 8 and 24. 4: The client must consent to receiving the blood 3: The nurse must assess the clients px status prior to picking up the blood in case there is a situation that requires consult with the HCP 1: if ordered a diuretic is usually administered between units to prevent FVE 5: Return the bags after infusion)

The client dx with CHF and iron def anemia is prescribed a unit of PRBCs. Rank the interventions in order of performance: 1. Admin furosemide (Lasix) a loop diuretic between units 2. Check the clients hgb and hct 3. Assess the lung sounds and periphery 4. Have the client sign a permit to receive blood 5. Return the empty bags to the lab

5 1 2 4 3

The client dx with pneumonia and complains of tenderness and pain in the L calf and the nurse assesses a positive homans sign. Which interventions should the nurse implement? RANK in order of priority 1. Notify the HCP 2. Initiate an IV 3. Monitor the PTT 4. Admin cont Heparin infusion 5. Instruct the client to not get out of bed

1,3,4 (Need signed consent, Assess for CHF and signs of left sided heart failure including crackles and signs FVE. Additional findings of JVD and peripheral edema, and liver engorgement indicate R sided heart failure. Check for allergies is important. WRONG: #2 Need 18-20 guage catheter for blood products. #5 A keep open of NS would be hung D5W causes RBCs to hemolyze in the tubing)

The client has a hct of 22.3% and a hgb of 7.7 The HCP has ordered 2 units of PRBCs to be tranfused. Which intervention should the nurse implement? SATA 1. Obtain signed consent 2 Initiate 22 guage IV 3 Assess the clients lungs 4. Check for allergies 5. Hang a keep open IV of D5W

2 1 4 5 3

The client has received IV solutions for 3 day s thru a 20 guage IV cath placed in the L cephalic vein. On the morning rounds the nurse notes the IV site is tender to palpation, it is edematous, and a red streak has formed. Which interventions should the nurse implement? RANK IN PRIORITY ORDER 1 start a new IV in the R hand 2. DC the IV line 3. Complete an incident report 4. Place a warm washcloth over the site 5. Document the situation in the clients chart

3,4,5 (weigh daily in same clothing at same time to monitor FVE, Tubing is changed with every bag because the high glucose level can cause bacterial growth. I&O are monitored to observe fluid balance WRONG: 1: TPN is hypertonic, it is administered by way of a pump to prevent rapid infusion, should not be administered without a pump!! #2 The glucose is checked q6h not every 24)

The client is NPO and receiving TPN via subclavian line. Which precautions should the nurse implement? SATA 1. place the TPN on a gravity IV line 2. Monitor the clients glucose q24h 3. Weigh the client first thing in the morning 4. Change the clients IV tubing with every TPN bag administered 5. monitor the clients intake and output every shift

1,2,4 (Explanation: If the client is experiencing hypovolemic shock related to blood loss in surgery, the hemoglobin (oxygen carrying capacity) will be lowered. The central venous pressure will drop with hypovolemic shock. Pulmonary artery wedge pressure indicates left ventricular function. NORMS: Pulmonary Artery Pressure (PA) Systolic 20-30 mmHg (PAS) Diastolic 8-12 mmHg (PAD) Mean 25 mmHg (PAM). The hematocrit is the number of red blood cells per cubic millimeter. The troponin is elevated, but indicates cardiac muscle damage, not hypovolemia.)

The client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock? Select all that apply. 1 Hemoglobin of 5g 2 Central venous pressure of 2mm of mercury 3 Pulmonary artery wedge pressure of 16mm of mercury 4 Hematocrit of 22% 5 Troponin (T 1) level of 4mcg/L

3 4 2 1 (The nurse should first connect the client to the monitor by attaching the electrodes. ECG can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances and the effects of drugs on the clients heart The nurse should next obtain VS to establish a baseline. Next the nurse should administer the morphine, morphine is the drug of choice in relieving myocardial infarction pain it may cause a transient decrease in BP. When the client is stable, the nurse can obtain a history of the clients drug use)

The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? Use all options. do not separate with comma. 1. obtain a history of which drugs the client has used recently 2. administer the prescribed dose of morphine 3. position the electrodes on the chest 4.. take VS

a,c,d

The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test? Select all that apply. a Creatine kinase b Ammonia c Myoglobin d Troponin T e Gamma-glutamyl transferase f Bilirubin

3 (Adenosine SVT WRONG: #1 atropine with asystole or symp sinus brady #2 amiodarone with Ventricular dyxfx #4 dobutamine with HF)

The client is experiencing SVT Which antidysrhythmic med should the nurse prepare to admin? 1. atropine 2. amiodarone 3. adenosine 4. dobutamine

1 3 2 5 4 (1: PAtent airway 3: Start IV to admin meds 2: Epi every 10-15 mins until reaction subsides 5: Benadryl 4: Teach to prevent in future)

The client is experiencing an anaphylactic reaction to bee venom. Which interventions in order of priority should the nurse implement? List in order of priority 1. Establish patent airway 2. Admin epi IV 3. start an IV with NS 4. Teach the client to carry an Epi pan when outside 5. Admin Benadryl IVP

1,3,4,5 (Vfib indicates no heartbeat. Start CPR. You will need the crash cart and defib ready. Amiodarone is used in ventricular dysrhythmias, WRONG #2 Adenosine is for SVT)

The client is in V-fib. Which interventions should the nurse implement? SATA 1. Start CPR 2. Prepare to admin adenosine (the antidysrhythmic) IVP 3. Prepare to defibrillate the client 4. Bring the crash cart to bedside 5. Prepare to admin amiodarone (the antidysrhythmic) IVP

a,b,c (Explanation: Prior to the Cardiac Computer Tomography Angiography, the nurse should check renal function by reviewing the creatinine levels, question the client regarding allergies to shellfish and iodine, and obtain a permit for the procedure. Answer D is incorrect since a cardiac CTA does not affect hearing. Answer E is incorrect since drinking increased amounts of fluid should be done after the exam. There is no need to force fluids prior to the exam.)

The client is scheduled for a cardiac CTA. Prior to the cardiac CTA, the nurse should do which of the following? Select all that apply. a Check the client's creatinine. b Question the client regarding allergies to shellfish. c Obtain a consent from the client or responsible person. d Question the client regarding difficulty hearing. e Instruct the client to drink 8 glasses of water the day prior to the exam.

1,2,3,4 (You dont defib a client with a heart beat And this drug can cause hepatomegaly so watch liver too)

The client is showing ventricular ectopy and the HCP orders amiodarone (Cordarone) IV. Which interventions should the nurse implement? SATA 1. Monitor telemetry continuously 2. Assess the clients respiratory status 3. evaluate liver fx studies 4. Confirm orig order with another nurse 5. Prepare to defib the client at 200 Joules

2,3,4 (WRONG: #1 duh. once incision heals the client can shower or tub bathe. #5!!! The client should notify the HCP if the pulse is 5 beats or slower than the preset rate!!)

The client who just received a permanent pacemaker is admitted to the telemetry floor. The nurse writes the problem "knowledge deficit" on the care plan Which interventions should be included in the plan of care? SATA 1. Take tub baths instead of showers the rest of his/her life 2. Do not hold electrical devices near the pacemaker 3. Cary the pacemaker ID card at all times 4. Count the radial pulse one full minute every morning 5. Notify the HCP if the pulse is 12 beats slower than the preset rate

1, 4, 6 ( Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced ED LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation)

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? (Select all that apply.) 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

4 3 2 1 5 (4: multifocal PVC is LIFE THREAT 3: Myasthenia gravis must have med as close to specific time as possible. It allows skeletal muscle to function, if delayed the client may experience resp distress 2: Pain is a priority, and should be attended after the life threatening issues attended 1: This client is symptomatic, and diuretic should help with dyspnea 5: IV antibiotics are priority but the client has received several doses of the med or there would not be a trough level vanc; 10-20 norm; so this can wait unit the others are covered)

The nurse has received report and has the following medications due or being requested In which order should the nurse administer the medications? LIST IN ORDER OF PRIORITY 1. Furosemide, IVP daily to client dx with HF who is dyspneic on exertion 2. Morphine, IVP prn to a client dx with lower back pain who is complaining of pain "10" on 0-10 scale 3. Admin neostigmine (prostigmine) PO to a client dx with myasthenia gravis 4. Admin lidocaine and antidysrhythmic IVP prn to a client in normal sinus rhythm with multifocal PVCs 5. Admin vancomycin, to a client dx with a staph infection who has a trough level of 14

1,2,5,6 (monitor for signs HF or cardiovascular changes. Clients at risk for emboli with Afib, so should be on anticoags and antiplatelet, Assessing neuro helps watch for emboli. WRONG: #3 no evidence client needs to sleep in the orthopneic position. #4 BA exercises are useful for clients who have PAD but no effect on Afib)

The nurse identifies the concept of altered tissue perfusion related to a client admitted with A-fib. Which interventions should the nurse implement ? SATA 1. Monitor the BP and apical pulse q4h 2. Place the client on I&O qshift 3. Require the client to sleep with the HOB elevated 4. Teach the client to perform Buerger Allen exercised daily 5. Determine if the client is on antiplatelet or anticoagulant meds 6. Assess the clients neuro status q shift and prn

2 3 5 4 1 (#2 Consent FIRST #3 Want site ready for admin before getting product #5 get the blood from the lab #4 must be checked by 2 RNs at bedside with clients crossmatch bracelet and unit of blood #1AFter all prev ste[ps completed then start the infusion slowly for the first 15 mins to determine if the client will have a reaction)

The nurse is administering a transfusion of PRBCs to a client. which intervention should the nurse implement? List in order of performance: 1. start the transfusion slowly 2. have the client sign the permit 3. Assess the IV site for size and patency 4. Check the blood with another nurse at bedside 5. Obtain the blood from the lab

1,3,4 (CLIENTS SAFETY)

The nurse is administering an opiod narcotic to the client Which interventions should the nurse implement for the clients safety? SATA 1. Compare the hospital number on the Mar to the clients wrist band 2 Have a witness verify the wasted portion of a narc 3. Assess the clients VS prior to admin 4. Determine if the client has any allergies to meds 5 Clarify all pain meds orders with the HCP

1 2 4 3 (When a client returns from having a transluminal balloon angioplasty with femoral access, the nurse should first obtain baseline VS and O2 sat to determine evidence of bleeding or decreased tissue perfusion. The nurse should next assess the pedal pulses to determine if the client has adequate peripheral tissue perfusion Next the nurse should inspect the cath site and then determine color and sensation in the affected leg)

The nurse is caring for a client who has just returned from having a percutaneous transluminal balloon angioplasty with femoral artery access. In which order, from first to last, should then nurse obtain information about the client? use all options, do not separate with commas 1. VS and O2 sat 2. pedal pulses 3. color and sensation of extremity 4. cath site

2,3,5 (Type 2 HIT is an immune mediated disorder that typically occurs after exposure to heparin for 4-10 days and has life threatening and limb threatening thrombotic complication. The client clots rather than bleeds. Spontaneous bleeding is not associated with HIT. Clots would indicated HIT either DVT or PE, sometimes arterially which can cause an MI. Hit IS a decrease in baseline plateelet count by 50%. It may manifest as lesions at the site of heparin injection or chills fever, dyspnea or chest pain)

The nurse is caring for a client who is receiving heparin therapy IV. Which assessment data would indicate to the nurse the client is developing Heparin induced thrombocytopenia (HIT) SATA 1. The client has spontaneous bleeding from around the IV site 2. The client complains of chest pain on inspiration and becomes restless 3 The clients platelet count on admission was 420 and now is 200 4. The client complains that the gums bleed when brushing the teeth 5. The client has developed skin lesions at the IV site

1,3,4 (Clopidogrel is generally well absorbed and may be take with or without food it should be taken at the same time every day and while food may help prevent potential GI upset, food has no effect on the absorption of the drug. Bleeding is the most common adverse effect of clopidogrel, the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of clopidogrel, the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for MI, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking clopidogrel)

The nurse is caring for a client who recently experienced a MI and has been started on clopidogrel. The nurse should develop a teaching plan that includes which points? Select all that apply 1. the client should report unexpected bleeding or bleeding that lasts a long time 2. the client should take clopidogrel with food 3. The client may bruise more easily and may experience bleeding gums 4. Clopidogrel works by preventing platelets from sticking together and forming a clot 5 The client should drink a glass of water after taking clopidogrel

4,5

The nurse is caring for a group of clients on a medical surgical nursing unit. Which task(s) can be delegated to UAP? SATA 1. Assess pedal pulses on a client just returned from a cardiac angiogram 2. admin O2 via nasal cannula to a client with O2 sat of 89% 3. Admin Tylenol to a client with a pain level of "5" out of "10" 4.. Perform VS and O2 sat on client returning from a cath lab 5. obtain I&O on a client experiencing heart failure

1,2,3,4,5 (yes all of them)

The nurse is demonstrating the use of a blood pressure monitor to a client newly diagnosed with HTN. WHich should the nurse teach the client? SATA 1. Tell the client to make sure the cuff is over the artery 2. Teach the client to notify the HCP if the BP is >160/100 3. Instruct the client about orthostatic hypotension 4. Encourage the client to keep a record of the BP readings 5. Explain that even when the BP is wnl the meds should still be taken

2,5,6 (Simvastatin is used in combination with diet and exercise to decrease elevated cholesterol. The client should take simvastatin in the evening and the nurse should instruct the client that if a dose is missed to take it as soon as remembered but not to take at the same time as the next scheduled dose. It is not necessary to take the pill with food The client does not need to limit greens (that would be with warfarin) but the nurse should instruct the client to avoid grape fruit juices which can increase the amount of the drug in the bloodstream. A serious side effect is myopathy and the client should report muscle pain or tenderness to the HCP)

The nurse is developing a teaching plan for a client who will be starting a prescription for simvastatin 40 mg/day/ What instructions should the nurse give the client? SATA 1. take once a day in the morning 2. if you miss a dose take it when you remember 3. limit greens such as lettuce to prevent bleeding 4. Be sure to take the pill with food 5. report muscle pain or tenderness to your HCP 6. continue to follow a diet that is low in saturated fats

1,2,5

The nurse is initiating a blood transfusion. Which interventions should the nurse implement? SATA 1. Assess the lung fields 2. Have the client sign consent 3. Start an IV with a 22 gauge cath 4. Hang 250 mL D5w at keep open rate 5. Check the chart for the HCP order

1,3,5

The nurse is interviewing a surgical client in the holding area. Which info should the nurse report to the anesthesiologist? SATA 1. The client has loose, decayed teeth 2. The client is experiencing anxiety 3. The client smokes 2 packs a day 4. The client has a chest xray that does not show infiltrates 5. The client reports using herbs

1,2,4,5 (ORthostatic hypotension is a drop in BP that occurs with position changes, usually to a more upright position. Often occurs in elderly clients, and it is a common cause of falls. Nurses must assess clients for and assist all clients with standing to aid in prevention of decreased orthostatic systolic BP and reduce symptoms in elderly clients with progressive OT. Nurses must teach clients to gradually change position, and conduct a fall risk assessment. SCD's may be helpful in clients at high risk and should be considered when developing a care plan. Antihypertensives may precipitate dangerous drops in BP. Clients should be encouraged to be ambulatory)

The nurse is planning care for a group of elderly clients who are affected by orthostatic hypotension. What should the nurse do? SATA 1. Assist the clients to stand to help prevent falls 2. Teach clients how to gradually change their position 3 request a prescription for an antihypertensive med for clients at high risk 4. conduct fall risk assessments 5. consider use of SCDs for high risk clients 6. Place the clients on bed rest

1,2,4 (1: green leafies contain Vit K, which is the antidote for warfarin. when achieving ther range for the INR, a change in consumption of the green leafy veges will change the anticoagulant effect on the body. 2: The INR is the level the HCP will use to guage the effects of the warfarin. 4 dark tarry stool indicates bleed GI. )

The nurse is teaching the client dx with DVT and prescribed warfarin. which should the nurse teach the client? SATA 1. Keep a constant amt of green leavy veges in the diet 2. Instruct the client to have reg INR lab work done 3. Tell the client to go to the hospital for any bleeding 4. Inform the client to notify the HCP for dark tarry stools 5. Encourage the client to avoid all green leafy veges 6. Have the client take iron orally to prevent bleeding

1,2,4 (Complications assoc with admin of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air occlusive dressing and all connections of the system must be secure. Ambulation and ADLs are encouraged and not limited during the admin of TPN)

To prevent complications associated with TPN admin through a central line, the nurse should: SATA 1 use strict aseptic technique for all dressing changes 2. secure all connections of the system 3. encourage bed rest 4. cover the insertion site with a moisture proof dressing

a,b (The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.)

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. A The RR intervals are relatively consistent B One P wave precedes each QRS complex C Four to eight complexes occur in a 6 second strip D The ST segment is higher than the PR interval E The QRS complex ranges from 0.12 to 0.20 second

1,2,3,4 (When preparing a client for a cardiac angiogram, the nurse should determine if the client has an allergy to the liquid contrast medium used in the procedure. Contrast dyes contain iodine and the administration of a dye could lead to an anaphylactic response in clients who are allergic to the dye. An IV infusion will be started before the procedure to administer the dye The clients should not eat or drink for 8 hrs prior to the procedure. The client may experience flushing sensation, but this is a normal response and does not indicate a life-threatening reaction. The client may receive light sedation, but not an anesthetic as the client must be awake to follow instructions. The client should be instructed to lie still during the procedure.)

When preparing a client for a cardiac angiogram, which actions should the nurse take? SELECT ALL THAT APPLY: 1. Determine if the client has an allergy to the liquid contrast media 2. inform the client that an IV infusion will be started before the procedure 3. remind the client to have nothing to drink before the procedure 4 instruct the client to remain still during the procedure 5. explain that the client will receive a fast acting anesthetic

2,4,5 (Trendelenburg, not REVERSE trendelenburg.)

Which interventions should the ED nurse implement for a client who has an AP of 122 and BP of 80/50? SATA 1. Put client in reverse trendelenberg 2. Start IV line with 18 gauge cath 3. Have the client complete the admission process 4. cover the client with blankets and keep warm 5. REquest the lab draw a type and crossmatch

a,b,d,e (Explanation: A, B, D, and E can all be performed by the licensed practical nurse. Removing a peripherally inserted central line should be performed by the RN or the doctor.)

Which task should be delegated to the licensed practical nurse? Select all that apply. a Administering heparin subcutaneously b Feeding the client with a percutaneous endoscopy gastrostomy tube c Removing a peripherally inserted central line d Monitoring chest tube drainage e Performing tracheostomy care

1, 2 ( The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization)

While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/60 to 138/85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

2 4 3 1 ( The primary goal is to decrease the cardiac ischemia that may be causing the client's tachycardia. This would be most rapidly accomplished by decreasing the workload of the heart and administering supplemental oxygen. Changes in blood pressure indicate the impact of the tachycardia on cardiac output and tissue perfusion. Finally, the physician should be notified about the client's response to activity, because changes in therapy may be indicated. Focus: Prioritization)

You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 beats/min. In which order will you take the following actions? 1. Call the client's physician. 2. Have the client sit down. 3. Check the client's blood pressure. 4. Administer PRN oxygen by nasal cannula. _____, _____, _____, _____

a,b,d (Explanation: If the client is experiencing hypovolemic shock related to blood loss in surgery, the hemoglobin (oxygen carrying capacity) will be lowered. The central venous pressure norm 0-5; will drop with hypovolemic shock. Pulmonary artery wedge pressure; norm 6-12; indicates left ventricular function. The hematocrit norm 36-54; m-f;is the number of red blood cells per cubic millimeter. The troponin norm 0.00 -0.004; is elevated, but indicates cardiac muscle damage, not hypovolemia.)

he client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock? Select all that apply. a Hemoglobin of 5g b Central venous pressure of 2mm of mercury c Pulmonary artery wedge pressure of 16mm of mercury d Hematocrit of 22% e Troponin (T 1) level of 4mcg/L

a,b,c (CORRECT: A; The use of cardiopulm bypass reduces the demand for O2, which reduces risk of inadeq oxygenation of vital organs. B; motion of the heart ceases during the procedure to allow placement of graft near affected coronary artery. C; the core body temp is lowered for the procedure, rewarming occurs through heat exchanges in the cardiopulmonary bypass machine. WRONG: D; the use of cardiopulmonary bypass decreases the rate of metabolism. E; The flow to the heart is maintained by the action of the bypass machine)

nurse educator is reviewing the use cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? SATA a The clients demand for O2 is lowered b Motion of the heart ceases c. rewarming of the client takes place d. the clients metabolic rate is increased e. blood flow to the heart is stopped

a,d,e (CORRECT: A; A client with acid base imbalance such as met alkalosis is at risk for a dysrhythmia. D: a client who has lung disease such as COPD is at risk for dysrhythmia E: a client who has cardiac disease and underwent stent placement is at risk. WRONG: b/c are wnl.)

nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being aat risk for developing a dysrhythmia? SATA a. A client who has metabolic alkalosis b. A client who has a serum K level of 4.3 c. A client with SaO2 of 96% d. A client with COPD e. A client who underwent stent placement in a coronary unit