A&C II Exam 2
Peripheral resistance against which the heart must pump.
Afterload
What are some common ineffective methods that parents use to assist their child in coping? Select all that apply. A) Being present and supportive. B) Encouraging digressive behavior. C) Promising gifts. D) Providing choices whenever possible.
B & C
What is the primary goal in treatment of all types of shock? A) Increase blood pressure. B) Decrease acidosis. C) Decrease heart rate. D) Increase perfusion of tissues.
D) increase perfusion of tissues
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? A. Dobutamine B. Methylprednisolone C. Furosemide D. Epinephrine
D. Epinephrine The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock
which medication administration decreases effects of hypoxia?
oxygen
Which clinical manifestations are associated with acute glomerulonephritis? 1) Normal blood pressure, generalized edema, oliguria. 2) Periorbital edema, hypertension, dark colored urine. 3) Fatigue, elevated serum lipid levels, elevated serum protein levels. 4) Temperature elevation, circulatory congestion, normal BUN and serum creatinine levels.
2) Periorbital edema, hypertension, dark colored urine
TOF includes which 4 defects
1. Ventricular septal defect 2. Pulmonary Stenosis 3. Overriding aorta 4. RV hypertrophy
What structures in fetal circulation play a role in shunting blood away from the lungs? Select all that apply A) ductus arteriosus B) ductus venosus C) umbilical artery D) foramen ovale E) umbilical vein
A & D ductus arteriosus and foramen ovale
Assuming vascular volume is adequate, which medication would have the strongest effect on raising the blood pressure in a hypotensive patient? A) Norepinephrine (Levophed) B) Dobutamine (Dobutrex) C) Epinephrine (Adrenalin) D) Nitroglycerin (Tridil)
A) Norepinephrine (Levophed)
What structures in fetal circulation play a role in shunting blood away from the lungs and liver? Select all that apply A) ductus arteriosus B) ductus venosus C) umbilical artery D) foramen ovale E) umbilical vein
A, B, & D ductus arteriosus, Ductus venosus & foramen ovale
What is a common method of coping used by school-aged children during hospitalization? A) Decreased bonding B) Manipulation. C) Agitation. D) Rationalization.
C) Agitation
Amount of blood pumped by each ventricle in one minute
Cardiac Output
Aspect of cardiac function most likely affected by myocardial ischemia.
Contractility
A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child? A. "I promise I won't tell anyone about this" B. "Let's discuss what happened with your family" C. "Your family is bad for doing this to you D. "It is not your fault that this happened
D. "It is not your fault that this happened The nurse should reinforce to the child that the abuse is not his fault.
which medication administration reduces preload?
Furosemide
An anterior wall infarction of the left ventricle is most likely associated with a coronary artery disease lesion in which vessel in this picture?
Left anterior descending artery
Volume of blood in the ventricles at the end of diastole.
Preload
A 6 month old who has episodes of cyanosis after crying could have the congenital heart defect of decreased pulmonary blood flow called ____________________
Tetralogy of Fallot
Coronary perfusion occurs during this phase of the cardiac cycle.
Ventricular diastole
Ejection of blood caused by contraction of the myocardium.
Ventricular systole
The resistance caused by the walls of blood vessels against which the left ventricle has to pump to eject blood is _______________
afterload
A hole in the septum between the right and left atria.
atrial septal defect
A constricture of the lumen of the aorta, usually at or near the ductus arteriosis.
coarctation of the aorta
The failure to close of the normal fetal circulation conduit between the pulmonary artery and the aorta.
patent ductus arteriosus
A hole in the septum between the right and left ventricles.
ventricular septal defect
The nurse has just received an assignment for the shift. Which of the following patients should the nurse check first? 1) A 61-year-old man who is admitted for a possible myocardial infarction and is complaining of chest pain 2) A 45-year-old woman who has just returned from surgery and says she feels nauseated 3) A 71-year-old man who was admitted for a fractured hip and is complaining of pain in his leg 4) A 59-year-old woman with a recent blood pressure of 160/90 and a pulse of 70 beats/minute
1) A 61-year-old man who is admitted for a possible myocardial infarction and is complaining of chest pain The man who is complaining of chest pain needs immediate attention because he may be having an MI. If the nurse intervenes immediately it may be possible to prevent myocardial damage and death. The woman returning from surgery needs anti-nausea medication and the man with hip pain needs pain medication, but these are not life-threatening situations and should be dealt with in as soon as possible. Perhaps intervening with these patients could be delegated. The woman's blood pressure is high, but again, this is not a life-threatening situation.
What is the difference between angina and acute myocardial infarction (MI)? 1) Angina is a warning sign with no permanent damage, while an MI is actual damage to the heart muscle. 2) Angina and an MI are the same only different terms used by health care providers. 3) Angina is permanent damage while an MI is not. 4) Angina occurs several days after an MI if it is not treated properly.
1) Angina is a warning sign with no permanent damage, while an MI is actual damage to the heart muscle. Angina is caused by decreased blood supply to the heart and is a warning sign that the heart muscle is not receiving adequate perfusion. The heart muscle is ischemic, but if blood supply is re-established or if oxygen demand is decreased, there is not permanent damage to the heart muscle. An MI is actual death of cardiac cells due to anoxia. They are not used interchangeably. Angina usually occurs before an MI, not after.
On an EKG strip what does the P wave represent? 1) Atrial depolarization 2) Atrial repolarization 3) Ventricular depolarization 4) Ventricular repolarization
1) Atrial depolarization The P wave reflects electrical activity in the heart while the atria are depolarizing and contracting. Atrial repolarization or return to pre-contraction state is usually hidden in the QRS complex. Ventricular depolarization is represented by the QRS complex and ventricular repolarization is represented by the T wave.
Deoxygenated blood flows from the right ventricle to the left ventricle. What defect does this most likely describe? 1) Tetralogy of Fallot 2) Coarctation of the aorta 3) Atrial septal defect 4) Ventricular septal defect
1) Tetralogy of Fallot
Which is true related to kidney function? 1) The kidney receives approximately ¾ of the cardiac output. 2) An end product of protein metabolism is urea. 3) Newborn infants are able to excrete water at rates similar to those of older persons. 4) Protein is a normal finding in the urine because protein molecules are too big to be reabsorbed.
2) An end product of protein metabolism is urea
A nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. The child's mother asks about why this has occurred. The nurse knows that this is most likely the result of which of the following? 1) Poor appetite 2) Reduction of edema 3) Restriction to bed rest 4) Increased potassium intak
2) Reduction of edema
Which of the following statements characterizes cardiogenic shock? 1) Increasing stroke volume in the face of decreasing cardiac output. 2) The heart failing to function as a pump 3) Increasing stroke volume in the face of increasing cardiac output 4) Massive loss of blood
2) The heart failing to function as a pump In cardiogenic shock the heart is damaged by lack of blood supply to the muscle and therefore, it cannot do its job of pumping blood through the blood vessels. Number 1 is a compensatory mechanism for decreased cardiac output. Number 3 is a description of Starling's law. Massive blood loss results in hypovolemic shock.
Which of the following phrases best describes acute glomerulonephritis? 1) A syndrome involving a gain in nonvolatile acids or a loss of base 2) A disorder occurring after an antecedent streptococcal infection 3) A disorder resulting in massive urinary protein loss 4) A disorder involving a defect in the kidneys' ability to concentrate urine
2) a disorder occurring after an antecedent streptococcal infection
What type of infection usually precedes the onset of glomerulonephritis? 1) Herpes simplex 2) Pseudomonas 3) Beta-hemolytic streptococcus 4) Escherichia coli
3) Beta-hemolytic streptococcus Glomerulonephritis is a disease process that is often preceded by a beta-hemolytic strep infection, often strep throat. Antibodies react against antigens that are associated with the bacteria. Complexes are formed that circulate, get caught in the basement membrane of the kidney and cause kidney damage. This is not an infection in the kidney, but rather damage caused by the body's immune response. Viruses (hepatits, rubella) and drugs can also cause this type of damage. But the other microorganisms mentioned here are not implicated.
Myocardial reperfusion is indicated by which of the following symptoms? 1) Hypertension 2) Decrease in CPK level 3) Chest pain relief 4) Tachycardia
3) Chest pain relief When the heart is reperfused after an ischemic episode, pain is relieved because oxygen is available to the tissues. Several clinical markers occur when the myocardium is reperfused. They are: 1) return of ST segment to baseline on the EKG, 2) resolution of chest pain, 3) the presence of reperfusion arrhythmia of which are ventricular arrythmias, and 4) a marked, rapid rise of the CK-MB enzyme within 3 hours of therapy, peaking within 12 hours.
What is the most common manifestation of a myocardial infarction? 1) Pain across the shoulders 2) Decreased blood pressure 3) Crushing chest pain 4) Abdominal pain
3) Crushing chest pain Crushing chest pain is the most common manifestation of an MI. It is caused by heart muscle tissue damage. The others are not common signs of an MI.
A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider? A) yellow nasal discharge B) facial edema C) poor appetite D) irritability
A) yellow nasal discharge Yellow or green discharge is an indication of an upper respiratory infection. Children who have nephrotic syndrome are at constant risk for infection, the nurse should report this finding to the provider.
A nurse is assessing an infant that has a coarctation of the aorta. Which of the following is a clinical manifestation? A. Increased blood pressure in the arms with decreased BP in the legs B. Decreased BP in the arms with increased BP in the legs C. Severe generalized cyanosis D. Pulmonary Edema
A. Increased blood pressure in the arms with decreased BP in the legs There is a narrowing next to the ductus arteriosus which results in an increased pressure proximal to the defect with a decreased pressure distal to the obstruction. There fore, an increased BP in the arms with a decreased BP in the legs would be a clinical manifestation of COA
A nurse is admitting a client who has a serum calcium level of 12.3 mg/dl and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? A. Lethargy B. Hyperactive deep tendon reflexes C. Prolonged ST segment D. Hyperactive bowel sounds
A. Lethargy A serum calcium level of 12.3 mb/dl is above the expected reference range. The nurse should monitor the client for lethargy, generalized weakness, and confusion
A nurse is caring for a adolescent who has a diagnosis of acute glomerulonephritis. Which of the following should be reported immediately to the provider? A) hematuria B) edematous ankles C) BP of 160/90 mmHg D) urinary output of 310 mL during the past 8 hours
C) BP of 160/90 mmHg AGN is classified as intrarenal acute kidney injury. Fluid retention and the buildup of nitrogenous wastes lead to hypertension. HTN is associated with thickening and loss of elasticity in the arterial walls.
Procedures performed on young children are usually done in the treatment room because: A) it is the most aseptic environment for the treatment. B) children are less afraid in a different environment. C) the child's room should be considered a safe haven. D) the treatment room is soundproof.
C) The child's room should be considered a safe haven
A client who has a history of MI is prescribed aspirin 325 mg.. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A) analgesic B) anti-inflammatory C) antiplatelet aggregate D) antipyretic
C) antiplatelet aggregate Aspirin is used to decrease the likelihood of blood clotting. It is also used to reduce the risk of a second stroke or heart attack by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart.
Which of the following are two benefits of an intraaortic balloon pump? A) Decreased preload and increased afterload. B) Increased contractility and afterload. C) Decreased afterload and increased coronary artery filling. D) Increased coronary artery filling and increased preload.
C) decreased afterload and increased coronary artery filling
A patient with angina who has episodes of ventricular tachycardia and ventricular fibrillation would be a good candidate for what? A) Percutaneous transluminal coronary angioplasty. B) Coronary artery bypass surgery. C) Implantable cardioverter-defibrillator. D) Intra-aoric balloon pump counterpulsation.
C) implantable cardioverter-defibrillator
A nurse is caring for a client who is at a risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A) hypotension B) anuria C) increased RR D) decreased level of consciousness
C) increased RR When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.
An advantage of using the internal mammary artery instead of the saphenous vein for myocardial revascularization is which of the following? A) Dissection of the vessel is easier. B) Cardiopulmonary bypass time is decreased. C) Long term patency is greater. D) Risk of post operative bleeding is reduced.
C) long term patency is greater
a nurse is caring for a child who has nephrotic syndrome and is receiving a high-dose corticosteroid therapy. To detect an electrolyte imbalance caused by corticosteroid use, the nurse should monitor the child for which of the following? A) Hunger B) poor skin turgor C) muscle weakness D) Itching
C) muscle weakness Corticosteroid use can lead to hypokalemia, which features manifestations of muscle weakness and cardiac arrythmia.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A) check the client's BP B) auscultate heart tones C) perform a 12-lead ECG D) determine if pain radiates to the left arm
C) perform a 12-lead ECG The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a MI
A nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a MI. While waiting for the troponin levels reports, the client asks what this blood test will show. Which of the following explanations should the nurse provide to the client? A) troponin is an enzyme that indicates damage to the brain, heart, and skeletal muscle tissues B) troponin is a lipid whose levels reflect the risk for CAD C) troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart D) troponin is a protein that helps transport oxygen throughout the body
C) troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart Troponin is a myocardial muscle that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point of care testing for clients who are having an MI.
A clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found with this disorder? A. Pallor B. Hyperactivity C. Exercise intolerance D. GI disturbances
C. Exercise intolerance Aortic stenosis (AS) is narrowing or stricture of the aortic valve causing resistance of blood flow in the left ventricle, decreased CO, left ventricular hypertrophy and pulmonary congestion. A child with AS shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods.
After the birth of a newborn with severe coarctation of the aorta, the physician orders a prostaglandin infusion. As the nurse you know that this medication will have what typeof therapeutic effects? Select all that apply A. Prevent the foramen ovale from closing B. Maintain patency of the ductus arteriosus C. Decrease the workload on the left ventricle D. Increase blood flow to the lower extremities
B. Maintain patency of the ductus arteriosus C. Decrease the workload on the left ventricle D. Increase blood flow to the lower extremities
Assessment finding of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of HF. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? A. Aortic stenosis B. PDA C. ASD D. VSD
B. PDA A PDA is failure of the fetal ductus arteriosus to close. Machinery-like murmur is present and the infant shows signs of HF
A nurse is teaching a patient who has nephrotic syndrome. Which of the following patient statements indicates a need for further teaching? A) "i can expect to have swelling in my face" B) "i will lose protein in my urine" C) "I should expect my doctor to prescribe a kidney biopsy" D) "i should increase my sodium intake"
D) I should intake my sodium intake This needs further teaching because a low-sodium diet is appropriate for a client who has nephrotic syndrome due to the edema associated with this disorder.
A nurse is making her plan of care for a child with an atrial septal defect. Upon assessment, the nurse expects to find: A. Absent femoral pulses, bounding pulses in the arms, fatigue B. Loud machinery-like murmur, poor feeding C. Fatigue, dyspnea, S2 heart sound is fixed and split D. Fatigue, cyanosis, harsh pan systolic murmur
C. Fatigue, dyspnea, S2 heart sound is fixed and split These are signs of ASD. Dyspnea and fatigue occur due to blood being shunted away from the systemic circulation and into the pulmonic circulation. Murmur is heard over the pulmonic area because of the extra amount of blood cross the pulmonic valve makes it close consistently later than the aortic valve. The second heart sound will be split and fixed
How should the nurse manage family presence when dealing with children? A) Maintain strict visitation policies. B) Include the entire family when discussing private information. C) Allow visitation for parents and siblings only. D) Provide parents and patient with necessary information regarding treatment plan.
D
When establishing a rapport, what is the best way to communicate a treatment plan to a school-aged child? A) Provide reassurance that they will not feel any discomfort. B) Provide minimal information in order to prevent anxiety. C) Instruct parents to explain treatment plan to their child. D) Explain treatment plan and encourage questions.
D) Explain treatment plan and encourage questions School-age children have a good foundation for understanding verbal communication and want to participate.
which medication administration reduces afterload?
captopril
Ability of the heart to respond to metabolic demands by increasing cardiac output.
cardiac reserve
For a child with recurring nephrotic syndrome, which of the following areas of potential disturbance should be a prime consideration when planning ongoing nursing care for this child? 1) Muscle Coordination 2) Visual disturbances 3) Intellectual Development 4) Body Image
4) Body image Because of the massive edema, changes in body image occur and would be of concern for this child. The other choices are not manifestations of nephrosis so would not be considerations with this disease process.
If a person is in left-sided heart failure, what would be the earliest signs to indicate this? 1) Pedal edema 2) Hepatomegaly 3) Jugular vein distention 4) Crackles or rales
4) Crackles or rales When a person is in left heart failure, the pumping function of the left ventricle is impaired and blood is not pumped out as effectively as it should be. That causes blood coming from the lungs via the pulmonary veins to back up and pressure to rise in the left atrium and pulmonary veins. This in turn causes a rise in hydrostatic pressure in pulmonary capillaries which makes fluid move from the capillaries to the interstitial spaces of the lungs. This results in pulmonary congestion that is manifested by crackles or rales. Think of L = lungs. The other answers are signs of right-sided failure that results when the right ventricle fails to pump blood effectively resulting in back-up pressure in systemic circulation.
The nurse is planning care for a 3-year-old boy who has nephrotic syndrome and severe edema. Which nursing intervention is appropriate for the nursing diagnosis of impaired skin integrity? 1) Administer corticosteroids on time with careful monitoring for infections. 2) Include daily weight, strict intake and output, daily checks for proteinuria. 3) Enforce bedrest when his edema is the worst. 4) Provide support for edematous areas such as legs, abdomen and even scrotum.
4) Provide support for edematous areas such as legs, abdomen and even scrotum.
Thrombolytic therapy for myocardial infarction (MI) is commonly associated with complications. Which of the following is the most common complication of thrombolytic therapy? 1) Tachycardia 2) Ventricular ectopic beats 3) Hypertension 4) Bleeding
4) bleeding
Cholesterol, frequently discussed in relation to atherosclerosis, is a substance that 1) may be controlled entirely by eliminating food sources 2) is found in many foods, both plant and animal sources 3) persons would be better off without it because it causes cardiovascular disease process 4) circulates in the blood, the level of which responds usually to dietary substitutions of unsaturated fats for saturated fats
4) circulates in the blood, the level of which responds usually to dietary substitutions of unsaturated fats for saturated fats Cholesterol is a substance that is necessary for normal functioning of the body. It is needed to produce steroid hormones and to facilitate transport of fatty acids. High levels are associated with an increased risk of cardiovascular disease. It normally circulates in the blood and usually responds to changes in diet. However, for some people, diet alone will not control high levels of cholesterol. Their livers synthesize cholesterol from fats that are ingested. They need medication, such as statins, to keep their levels within normal range. Cholesterol is found in animal food. The animal must have a liver to synthesize cholesterol. Plants foods do not contain it.
The nurse is assessing an infant who is admitted for congestive heart failure. Which sign would the nurse most likely find? 1) Pedal edema 2) Sudden weight loss 3) Unexplained bruising 4) Dyspnea
4) dyspnea Pedal edema is a common sign of heart failure in an adult because of the dependent position of their feet.
Which of the following conditions produces a hypovolemic shock state? 1) carbon monoxide poisoning 2) tension pneumothorax 3) pulmonary emboli 4) third spacing (movement of fluid from the vascular to the interstitial space)
4) third spacing (movement of fluid from the vascular to the interstitial space) The only one of these conditions that results in hypovolemia is movement of fluid from the vascular space to the interstitial space, leaving the blood volume too low. The rest of these conditions have more to do with respiratory problems - not hypovolemia. Shock may occur but it does via another mechanism.
Which dysrhythmia is immediately life-threatening? 1) Premature ventricular contraction 2) Atrial fibrillation 3) Sinus rhythm 4) Ventricular fibrillation
4) ventricular fibrillation Ventricular fibrillation is a life-threatening emergency because with this dysrhythmia the heart muscle is simply quivering without organized contraction and relaxation. Cardiac output falls and blood cannot be pumped effectively to perfuse body tissues. Premature ventricular contractions are a result of an irritable myocardium and can result in a problem if too many occur during a specific time period. But generally they are not considered to be life-threatening. Many people, especially elderly people, have atrial fibrillation and do not have symptoms. Atrial fibrillation needs to be treated but is not an emergency. Sinus rhythm is considered normal
How does narrowing of coronary arteries due to athersclerosis affect the heart? 1) Blood flow to the myocardium is decreased. 2) Electrolyte abnormalities occur due to atherosclerosis. 3) Hardening of the chambers of the heart occurs. 4) Increased amounts of blood are shunted to the lungs.
1) Blood flow to the myocardium is decreased Coronary arteries supply blood to the heart muscle. When there is narrowing of arteries that supply cardiac muscle there is decreased blood flow to the heart. This can result in a myocardial infarction or heart attack. Electrolyte abnormalities can occur but are a result of cell damage and not of atherosclerosis itself. Hardening of the chambers of the heart does not occur. Blood is not shunted to the lungs because of atherosclerosis.
A transmural wall MI involves 1) Damage that extends through the entire ventricular wall. 2) Scarring of the superficial inner lining of the ventricle. 3) Disruption of delicate tissue lining the inner wall of the ventricle. 4) Disturbance of the area around the Bundle of HIS
1) Damage that extends through the entire ventricular wall Transmural means through the entire wall.
Drugs that block beta receptors (i.e. propanolol, esmolol, nadolol, etc.) will: 1) Decrease automaticity 2) Increase contractility 3) Increase conduction 4) Stimulate the atrioventricular (AV) node
1) Decrease automaticity Beta-adrenergic blockers have the ability to inhibit sympathetic nervous stimulation to the heart which decreases automaticity (the ability to initiate an impulse spontaneously and continuously). This results in a decrease in heart rate and contractility, which decreases the workload of the heart.
Which is a modifiable risk factor for coronary artery disease (CAD)? 1) Diet 2) Sex 3) Age 4) Race
1) Diet Diet is the only factor of the three that can be changed. Research shows that a diet high in saturated fats and cholesterol increases the risk of CAD. And if diet can be improved the chance of developing CAD decreases. While sex, age and race are also factors that increase the risk of CAD, they are non-modifiable or non-changeable.
A physiological response to impaired circulation and decreased peripheral perfusion can lead to which of the following acid-base disorders? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis
1) Metabolic Acidosis Decreased perfusion of tissues with oxygen can result in anaerobic metabolism. The byproducts of this type of metabolism are strong acids such as lactic acid and if they are not quickly eliminated from the body result in metabolic acidosis.
Why is diastole so important to the functioning of heart muscle? 1) Perfusion of the coronary arteries occurs during diastole. 2) Ventricular contraction occurs during diastole. 3) Blood is ejected from the heart during diastole. 4) Ventricular muscle depolarization occurs during diastole.
1) Perfusion of the coronary arteries occurs during diastole Diastole is the time that the coronary muscle is provided with oxygenated blood so that it can do the important job of pumping blood throughout the body. Blood flow into the coronary arteries occurs during diastole, when the ventricles are relaxed and are filling with blood.
Where is the primary pacemaker of the heart located? 1) Right atrium 2) Left atrium 3) Right ventricle 4) Right pulmonary artery
1) Right atrium The sino-atrial node is the primary pacemaker of the heart and it is located in the right atrium. Refer to your texts for the exact location. The other answers are not locations of the primary pacemaker.
A patient is given Lopressor, (metoprolol), a beta-blocking agent. What should the nurse include in the teaching plan for this patient related to this drug? 1) Take the pulse before each dose of Lopressor. 2) Get up slowly because dizziness may occur. 3) Be sure and take a potassium supplement daily. 4) Report an increase in urine output.
1) Take the pulse before each dose of Lopressor Lopressor is a beta-blocker and is given to decrease the workload on the heart by causing vasodilation. This results in a decreased blood pressure which might cause orthostatic hypotension until the patient gets used to the drug. Patients should be taught also to check their pulse rate because this drug can slow the heart rate. It is not necessary to take potassium supplements while taking this drug because it does not cause loss of potassium. Lopressor does not affect urine output.
The nurse is caring for a child with nephrotic syndrome. Which of the following is the best way to evaluate total fluid losses and gains while the child is hospitalized? 1) Weigh the child daily. 2) Check the serum potassium level. 3) Measure the abdominal girth. 4) Ask the mother what the child weighed before she became ill.
1) Weigh the child daily Weighing the child daily at the same time with the same amount of clothing is critical in determining fluid balance. It is essential that the weight is documented as soon as possible since treatment changes are often based on weight gain or loss. While serum potassium level is important to detemine, and in fact the most critical electrolyte in the overall electrolyte status, it does not tell us much about fluid gains and losses. Measuring the abdominal girth gives us information about ascites but not about fluid retention in other areas of the body. So it is not the best way to evaluate overall fluid balance. Asking the mother about child's weight is not accurate in determining fluid balance.
What is the most common early complication of cardiac catheterization? 1) Cardiac dysrhythmias 2) Infection 3) Fluid overload 4) Electrolyte imbalance
1) cardiac dysrhythmias
What is the most common physiological sign of heart failure? 1) Decreased cardiac output 2) Decreased pulse rate 3) Increased perfusion of the brain 4) Vasodilation
1) decreased cardiac output When heart muscle fails it does not contract as it should normally. Remember that cardiac output (CO) is stroke volume X heart rate. If the muscle does not contract normally, stroke volume decreases, thus decreasing CO. The heart rate in heart failure will increase, not decrease, to help compensate. There may be decreased perfusion of the brain rather than increased perfusion because of decreased CO. Vasoconstriction usually occurs to help increase tissue perfusion rather than vasodilation.
When taking an admission history of a client with right ventricular heart failure, the nurse would expect the client most likely to complain of 1) nausea, edema in legs, fatigue 2) fatigue, vertigo, headache 3) weakness, palpitations, nausea 4) dyspnea, coughing, fatigue
1) nausea, edema in legs, fatigue Answer 2, 3 and 4 would more likely be seen with left sided heart failure. Remember "left=lung". Right-sided heart failure causes backward blood flow to the right atrium and venous circulation. Pressure rises in the right side of the heart and leads to venous congestion. Venous congestion in the systemic circulation results in peripheral edema, JVD, hepatomegaly, splenomegaly, and vascular congestion of the GI tract. Nausea can result from vascular congestion of the GI tract. Fatigue is common to both right and left-sided heart failure and is one of the earliest symptoms. It is caused by a decrease in CO, impaired circulation, and decreased oxygenation of the tissues and anemia.
Why is maintenance of fluid and electrolyte balance more critical in infants than in adults? 1) Renal function is immature in infants. 2) Cellular metabolism is less stable than in adults. 3) The proportion of water in infants' bodies is less than that in adults. 4) The daily fluid requirement per unit of body weight is less than that in adults
1) renal function is immature in infants
Which of the following represents an effective nursing intervention to reduce cardiac demands and decrease cardiac workload? Choose all that apply. 1) Clustering nursing care to provide for periods of uninterrupted rest. 2) Developing and implementing a developmentally appropriate plan of care as tolerated. 3) Feeding the infant over a longer period of time. 4) Allowing the infant to have his or her own way to avoid conflicts.
1, 2
A patient is in hypovolemic shock. Early signs of hypovolemic shock compensatory stage include what? Choose all that apply. 1) Restlessness 2) Thirst 3) Increased heart rate 4) Decreased blood pressure 5) Apathy 6) Decreased respiratory rate 7) Unconsciousness
1, 2, 3
Common post-operative complications after a coronary artery bypass graft include what? Choose all that apply. 1) Atelectasis. 2) Hypotension 3) Dysrhythmias 4) Hemorrhage 5) Neurogenic shock 6) Diabetes 7) Wound infection
1, 2, 3, 4, & 7
Pharmacological actions of digoxin (Lanoxin) include which of the following? Choose all that apply. 1) Slows the heart rate. 2) Increases strength of cardiac contraction. 3) Increases potassium retention. 4) Improves appetite. 5) Increases blood flow to the kidney. 6) Increases peristalsis. 6) Promotes vasodilation.
1, 2, 5
A child has been admitted to the unit with nephrotic syndrome. The child's mother reports that a cousin had acute glomerulonephritis (AGN) last year and she asks a nurse how these two diseases compare, since they both affect the kidneys. The nurse's best response would include the information that both diseases: 1) produce smoky colored urine. 2) cause a greatly reduced urine output. 3) demonstrate a genetic inheritance pattern. 4) involve antibiotic therapy for treatment.
2) cause a greatly reduced urine output Typical symptoms of nephrotic syndrome are clear, frothy urine that is diminished in volume. AGN presents with smoky urine that is also diminished in volume. AGN is a postinfectious disease with no genetic basis. Antibiotics are not used in nephrotic syndrome. Oilguria is usually defined as 0.5 to 1.0 mL/kg/hr
A patient in heart failure is given a diuretic. What is the purpose of giving this type of drug to a patient in heart failure? 1) Increase myocardial contraction 2) Decrease workload of the heart 3) Prevent electrolyte imbalance 4) Increase cardiac output
2) decrease workload of the heart A diuretic is a drug that removes fluid from the blood stream. Less fluid in the blood stream means that there is less preload or less fluid returning to the right side of the heart to be pumped through the heart. This decreases the workload of the heart and is done when a failing heart should rest. Cardiac glycosides such as digoxin increase myocardial contraction. Some diuretics cause electrolyte imbalances, not prevent them. Electrolyte status must be carefully monitored. Decreasing the volume of blood in the system as diuretics do, will not increase cardiac output.
Nuclear imaging with radioactive isotopes is scheduled for a patient with chest pain. The nurse explains to the patient that this test will: 1) outline the blood flow through the chambers of the heart 2) identify the areas of ischemia or infarction of the heart muscle 3) identify abnormalities in heart wall motion and contraction 4) evaluate the irritability of the heart and risk for arrhythmias
2) identify the areas of ischemia or infarction of the heart muscle Myocardial nuclear scans, done by injecting IV radioactive isotopes, can help establish the diagnosis of acute MI when other data are inconclusive. The amount of radioisotope present in each myocardial region is determined by two factors: 1) the amount of coronary blood flow to that region and 2) the degree of viable myocardium. Ischemia or infracted myocardial regions receiving little or no coronary blood flow accumulate little or no radioisotope. Such regions appear as "cold spots" on the scan and thus indicate an area of ischemia or infarct.
The nurse realizes that the pain associated with a coronary artery occlusion is caused primarily by: 1) arterial spasm 2) ischemia of the heart muscle 3) blocking of the coronary veins 4) irritation of nerve endings in the cardiac plexus
2) ischemia of the heart muscle The exact cause of the pain is unknown, but it is theorized that the pain is neurogenic and comes from the site of ischemia. Probably the pain associated with an MI is a result of coronary artery occlusion. When the heart muscle doesn't get enough O2, ischemia results. This causes acids to build up in the tissues from anerobic metabolism. The acids irritate the tissue and cause pain. Arterial blockage is what causes the decreased O2 delivery - not spasm. Blocking of veins does not cause pain. The lactic acid buildup from lack of O2 does irritate nerve but this occurs where ever the damage is, not just in the cardiac plexus.
Which one of the following conditions is reversible? 1) Cardiomyopathy 2) Myocardial ischemia 3) Myocardial infarction 4) Heart muscle necrosis
2) myocardial ischemia Myocardial ischemia is decreased blood flow to the heart muscle. If blood flow can be reestablished before heart muscle damage is done, mycardial ischemia can be reversed. The other conditions are permanent and cannot be reversed.
Defects associated with tetralogy of Fallot include 1) severe coarctation of the aorta, severe aortic valve stenosis, and severe mitral valve stenosis. 2) ventricular septal defect, overriding aorta, pulmonic stenosis, and right ventricular hypertrophy. 3) tricuspid valve atresia, atrial septal defect, and hyposplastic right ventricle. 4) origin of the aorta from the right ventricle and of the pulmonary artery form the left ventricle.
2) ventricular septal defect, overriding aorta, pulmonic stenosis, and right ventricular hypertrophy
Which manifestations are indicative of right-sided heart failure? Choose all that apply. 1) Pulmonary congestion 2) Pitting ankle edema 3) Anorexia 4) Elevated central venous pressure 5) Frothy sputum 6) Tender, enlarged liver 7) Changes in mental status
2, 3, 4, 6 Yes! Peripheral edema is a hallmark of right heart failure because hydrostatic pressure in systemic circulation rises forcing fluid into interstitial spaces in the periphery and in the GI tract. Yes! Anorexia is experienced in right heart failure because hydrostatic pressure in systemic circulation and the GI system rises forcing fluid into interstitial spaces in the periphery and in the GI tract. Edema of the GI tract leads to poor functioning and anorexia and nausea result. Yes! Elevated CVP results from increased pressure in the system because the right ventricle is not an effective pump of blood through the right side of the heart. Pressure backs up and CVP rises. Yes, hepatomagaly is experienced as right heart failure progresses because hydrostatic pressure in systemic circulation and the GI system rises forcing fluid into interstitial spaces in the GI tract. Edema of the GI tract is often seen as a tender, enlarged liver.
Therapeutic management in nephrotic syndrome includes the administration of prednisone. The nurse teaches which of the following as correct administration guidelines? 1) Corticosteriod therapy is begun after BUN and serum creatinine elevation. 2) Prednisone is administered orally in a dosage of 4 mg/kg of body weight. 3) After a child is free of proteinuria and edema, the daily dose of prednisone is gradually tapered over several weeks to months. 4) The drug is discontinued as soon as the urine is free from protein
3) After a child is free of proteinuria and edema, the daily dose of prednisone is gradually tapered over several weeks to months.
A 59-year-old male is admitted to your unit with the diagnosis "rule out myocardial infarction." He stated one hour ago that he was at work when he felt severe chest pain, became cool and clammy, and felt nauseated. He came immediately to the hospital. The ECG indicates ST segment elevation and a pathological Q wave. His troponin levels are elevated. He has not responded to nitrates in the emergency department. His vital signs are as follows: blood pressure 98/68 pulse 107 respiratory rate 32 Based on the preceding description, which initial treatment is indicated? 1) Fibrinolytic therapy 2) CABG (coronary artery bypass graft) surgery 3) Emergent percutaneous coronary intervention (PCI) 4) Calcium channel blockers
3) Emergent percutaneous coronary intervention (PCI) CABG is more invasive than PCI and is considered if the patient is not a candidate for PCI. Nothing in this patient's description indicates that he would not be a candidate for PCI initially.
Which of the following signs and symptoms are characteristic of minimal change nephrotic syndrome? 1) Gross hematuria, proteinuria, fever 2) Hypertension, edema, hematuria 3) Poor appetite, proteinuria, edema 4) Hypertension, edema, proteinuria
3) Poor appetite, proteinuria, edema
What is the function of the right atrium? 1) Receives blood from the lungs 2) Transports blood from the right ventricle to the lungs 3) Pumps blood from the vena cava to the right ventricle
3) Pumps blood from the vena cava to the right ventricle The right atrium is the upper right chamber of the heart and it receives unoxygenated blood from the body via the vena cava and sends it to the right ventricle. #1 is a description of the left atrium. #2 is a description of the pulmonary artery. #4 is a description of the left ventricle or left lower chamber of the heart.
The nurse assesses a patient in heart failure and finds congestion in the lungs and pedal edema. These signs are consistent with which type of congestive heart failure? 1) Right-sided heart failure 2) Left-sided heart failure 3) Right- and left-sided heart failure 4) Atherosclerotic heart failure
3) Right-and-left sided heart failure These 2 signs are consistent with those seen in both right and left heart failure. Congestion in the lungs is typical of left-sided heart failure - remember L = lungs. This is because there is backup pressure from a failing left ventricle into lungs which causes fluid to ooze into the interstitial spaces around the alveoli. Pedal edema is a sign of right-sided heart failure because the failing right ventricle causes backup of pressure in the system. Fluid oozes from capillaries in extremities into interstitial spaces there as well. Because feet are usually in a dependent position, gravity causes fluid accumulation in the feet. "Atherosclerotic" is not a type of heart failure.
A nurse involved in preoperative teaching for a preschool child scheduled for cardiac surgery would be sure that preparation for surgery was: 1) detailed in nature so that the child knew everything there was to know about the surgery. 2) geared toward the child's parents since the child is too young to understand anything about the surgery. 3) developmentally appropriate to the child's stage of growth and development. 4) done several days before the actual operation so that the child had the opportunity to think of any questions or concerns.
3) developmentally appropriate to the child's stage of growth and development.
Which drugs are most often given to children with congenital heart disease (CHD) to specifically decrease the workload of the heart? 1) Opioids 2) Nitroglycerin 3) Diuretics 4) Potassium supplements
3) diuretics
Following a coronary artery bypass graft (CABG) procedure, a client develops a temperature of 102°F (38.8°C). The nurse notifies the physician because elevated temperatures: 1) may be a forerunner of hemorrhage 2) cause diaphoresis and possible chilling 3) increase the cardiac output 4) may indicate cerebral edema
3) increase the cardiac output A main goal of CABG post-surgical care is to decrease the workload of the heart. So anything that increases cardiac output by making the heart work harder should be avoided. Temperature increases metabolism and the extra O2 requirements of tissues demand that the heart pump harder to meet the need. Increased temperature might also indicate a developing infection. It is not a forerunner of hemorrhage - watch for increased chest tube drainage for that. The increased temperature might cause diaphoresis and chilling - but the nurse does not call the physician because of this. Increased temperature could possibly indicate cerebral edema - but this is unlikely because there would be other more characteristic signs.
After the physician directs the nurse to add potassium to a child's IV fluid, the nurse should first: 1) monitor apical pulse rate. 2) monitor blood pressure hourly. 3) monitor intake and output to assess kidney function. 4) monitor respiratory rate and depth.
3) monitor intake and output to assess kidney function
A newborn infant is diagnosed as having a patent ductus arteriosus. The knowledgeable pediatric nurse understands that this congenital heart defect involves: 1) narrowing of the aorta. 2) origination of the pulmonary artery from the left ventricle and origination of the aorta from the right ventricle. 3) persistence of the fetal opening between the pulmonary artery and the aorta. 4) obstruction of left ventricular outflow at the level of the aortic valve.
3) persistence of the fetal opening between the pulmonary artery and the aorta
What is the main function that fetal heart structures such as the ductus arteriosus perform? 1) To prevent fluid overload in the fetus. 2) To shunt blood toward fetal lungs. 3) To provide oxygenated blood to the fetal brain. 4) To allow a way for wastes to be removed.
3) to provide oxygenated blood to the fetal brain
A nurse is reviewing the laboratory results of an adolescent who has chronic glomerulonephritis. Which of the following findings should the nurse expect? A) BUN 50 mg/dL B) serum potassium 3.8 mg/dL C) absence of proteinuria D) serum phosphorus 4.0 mg/dL
A) BUN 50 mg/dL\ The nurse should expect the adolescent to have a BUN above the normal rage due to kidney injury and the inability to filter and excrete urea and nitrogen from the blood.
Which of the following is the best method to treat cardiomyopathy? A) Heart transplantation. B) CABG (coronary artery bypass graft). C) IABP (intraaortic balloon pump assist). D) Coronary angioplasty.
A) Heart transplantation Because the heart muscle is diseased in cardiomyopathy, the best treatment is a heart transplant. CABG and coronary angioplasty are treatments for coronary artery disease in which there is still viable heart muscle. An IABP is a temporary measure to help maintain cardiac output when the heart fails. It is not a permanent treatment for cardiomyopathy.
A nurse on a medical unit is caring for a client who has angina pectoris and reports chest pain with a severity of 6 on a 10 scale. The nurse administers sublingual nitroglycerin. After 5 minutes, the client states that his chest pain is now at a 3. Which of the following actions should the nurse take? A) administer another nitroglycerin tablet B) assess the client's blood pressure C) obtain an ECG D) check the client's apical heart rate
A) administer another nitroglycerin tablet administration guidelines for sublingual nitroglycerin indicate that it is appropriate to administer another tablet 5 minutes after the first if the patient is still reporting pain
A patient with mitral regurgitation and severe left main coronary artery disease would be a candidate for: A) cardiac surgery. B) Percutaneous coronary intervention (PCI). C) Percutaneous balloon valvuloplasty (PBV) D) Intra-aortic balloon pump counterpulsation
A) cardiac surgery
A nurse in the ER is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A) increased heart rate B) widening pulse pressure C) increased deep tendon reflexes D) pulse oximetry of 96%
A) increased HR The nurse should anticipate an increased HR as an early indication of shock because the body attempts to compensate for decreased circulatory volumes.
During a well-baby checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse's first action should be to: A) Lay the child flat to promote hemostasis B) Lay the child flat with the legs elevated to increase blood flow to the heart C) Sit on the parent's lap, with legs dangling to promote decreased venous return D) Hold the child in knee-chest position to decrease venous blood return
A) lay the child flat to promote hemostasis
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine/hour. The nurse should place the client on which of the following diets? A) low sodium, fluid restricted B) regular diet, no added salt C) low carbohydrate, low protein diet D) low protein, low potassium diet
A) low sodium, fluid restricted This will prevent complications
A 48 YO patient is in the ICU following CABG surgery for treatment of an MI. 36 hours after the procedure, the patient's O2 saturation drops to 90% and he has developed crackles in the lungs. The nurse suspects cardiogenic shock. Which of the following symptoms would the nurse expect from a patient experiencing cardiogenic shock? Select all that apply. A) tachycardia B) confusion C) bounding pulse D) hypertension E) bradycardia
A, B (tachycardia & confusion) Cardiogenic shock severely impairs the pumping function of the heart, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia and weak pulse. Cardiogenic shock is a serious complication of MI with a high mortality rate.
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (select all that apply) A. Troponin I B. Troponin T C. Plasma low-density lipoproteins (LDL) D. CPK E. Myoglobin
A, B, D, E Troponin I & T :a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hours following a myocardial infarction CPK: creatine phosphokinase, is an enzyme that is elevated in the presence of muscle injury. Although CPK is not specific for myocardial damage, it is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction; A CPK isoenzyme, CK-MB is specific to cardiac muscle and a significant elevation in this isoenzyme indicates a myocardial infarction has occurred. Myoglobin: elevation of myoglobin indicates myocardial injury. Myoglobin levels will significantly increase with approximately 3 hours following myocardial infarction. This test is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction
Healthy and normal coping mechanisms utilized by parents of children with congenital heart disease include what? Select all that apply. A) Initially denying seriousness of the child's condition. B) Exhibiting overly protective behaviors toward the child. C) Seeking detailed information about the defect. D) Requesting reassurance and support.
A, C, D
A nurse is completing a history and physical on a 3 YO child who is admitted for surgical repair of tetralogy of fallot (TOF). WHich of the following manifestations of the condition should the nurse expect. Select all that apply. A) polycythemia B) hypertension C) clubbing of the nail beds D) failure to thrive E) pallor F) murmur
A, C, D, and F Polycythemia results as a compensatory measure when the child's blood supply produces extra RBC's in an attempt to increase the oxygen carrying capacity of the blood. Clubbing of the nail beds results from chronic hypoxia of the distal extremities. Failure to thrive and difficulty feeding may result from the child expending more energy to eat than what is being taken in. Murmur is correct, a loud, long systolic murmur is associated with TOF.
A nurse is reinforcing teaching with a client regarding reduction of risk factors for CAD. Which of the following statements by the client indicates an understanding of the teaching? A. "i must stop smoking" B. "I should limit my exercise" C. "I will stop consuming alcohol" D. "I need to monitor my weight" E. 'I am limiting my intake of fast foods"
A, D, E Nicotine in tobacco causes peripheral vasoconstriction, which increases blood pressure, cardiac afterload, and oxygen consumption. Alterations in blood vessels contribute to atherosclerosis and the formation of clots. Smoking cessation can decrease the risk of coronary artery disease by as much as 80%. Clients also should avoid secondhand smoke Obesity or an increase in weight is a significant factor in developing coronary artery disease. Weight management is vital to decreasing the risk of coronary artery disease. Fast foods typically are prepared with high sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease. An elevated cholesterol and serum lipid level predisposes a client to coronary artery disease. To promote cardiovascular health, clients should select healthier food options, such as fruits and vegetables, or foods prepared by baking or broiling
A school nurse is speaking to the mother of a 16 year old male. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide? A. "His favorite teacher committed suicide a few weeks ago" B. "He has slept 9 hours each night for the past 2 years" C: "He is very religious and attends services twice a week" D. "He spends much of his time with his two school friends"
A. "His favorite teacher committed suicide a few weeks ago" Adolescents are at risk for a "copycat" suicide if a peer or a significant role model has recently committed suicide. Adolescents often act impulsively and can be easily frustrated. The fact that an admired person committed suicide is a stressor that could put the adolescent at risk for suicide
A nurse is planning care for a patient who has acute glomerulonephritis related to a streptococcal infection. Which of the following interventions is appropriate to include in the plan of care? A. Administer prescribed antibiotics B. Encourage increased fluid intake C. Obtain weekly weight D. Encourage frequent ambulation
A. Administer prescribed antibiotics Acute glomerulonephritis related to a streptococcal infection is treated with antibiotic therapy including penicillin and erythromycin
A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A. Confusion B. Blood pressure 84/50 mmHg C. Anuria D. Petechiae
A. Confusion Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis
A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching? A) "i will feed my baby on a schedule every 4 hours" B) "i will add polycose to each of my baby's bottles" C) "i will allow my baby to take as much time as needed to finish the bottle" D) "I will limit my babies crying to 15 min. prior to each feeding"
B) "i will add polycose to each of my baby's bottles" The parent should add polycose to the formula to increase the number of calories per ounce, allowing the infant to consume more calories in less volume.
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue and dyspnea. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A) first-degree AV block B) A-fib C) sinus bradycardia D) sinus tachycardia
B) A-fib A fib causes disorganized twitching of the atrial muscles. The rate is irregular with no P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.
A 57-year-old male is admitted to your unit following a coronary artery bypass graft (CABG). AT 0400 he is alert and oriented and is extubated without difficulty. At 0500 he is lethargic despite not receiving analgesics. He has a mediastinal chest tube that has drained 500ml in the last hour. He is receiving 40% oxygen via mask. Pulmonary artery catheter and blood gas information are listed below: 0400 0500 blood pressure 100/70 100/66 pulse 100 116 PCWP 15 10 CVP 10 7 CO 4.3 4.0 SaO2 0.96 0.95 PaO2 82 77 PaCO2 37 39 pH 7.37 7.35 HCO2- 24 23 Based on the preceding information, the patient is probably developing which of the following disease processes? A) Tension pneumothorax. B) Mediastinal bleeding. C) Acute respiratory distress syndrome. D) Heart failure.
B) Mediastinal Bleeding Yes! Good job! Because of the hemodynamic deterioration that we are seeing here, there is probably bleeding occurring. And since there is 500 ml of drainage from his chest tube, bleeding at the surgical site is most likely. Bleeding from mediastinal chest tube in excess of 150 ml/hour needs to be reported. This is a life-threatening situation that must to be investigated and treated.
A nurse is providing teaching to a client who is postoperative following CABG surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications would the nurse identify as most important for the client's recovery? A) it decreases the client's level of anxiety B) it facilitates the clients deep breathing C) it enhances the client's ability to sleep D) it reduces the client's BP
B) it facilitates the clients deep breathing When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief.
A nurse is assessing an infant. Which of the following is a clinical manifestation of a large patent ductus arteriosus? A) cyanosis with crying B) machinery-like murmur C) weak pulses D) chronic hypoxemia
B) machinery-like murmur A PDA is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a L to R shunt. A machinery-like murmur is a clinical manifestation of a large PDA.
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the patient is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? A) sudden lethargy B) muffled heart sounds C) flattened neck veins D) bradycardia
B) muffled heart sounds This is a key indicator of cardiac tamponade because of the excess fluid surrounding the heart.
A nurse is obtaining vital signs from a 2 MO infant. The infant's heart rate is 190/min. and his temperature is 104 degrees. The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate? A) this is within the expected range for your baby B) the fever is causing an increase in your baby's heart rate C) as your baby begins to fall asleep, his heart rate will decrease D) your baby's heart is beating fast in an attempt to cool down his body
B) the fever is causing an increase in your baby's heart rate Expected temperature is 97.7 to 98.9F. This infant has a fever that is causing the infant's heart rate to increase. The expected reference range for heart rate in a 2 month old infant is 121 to 179/min.
The philosophy of family-centered care represents a paradigm shift for some pediatric nurses. Mark all of the following basic concepts included in the philosophy of family centered care. A) Family dependence B) Collaboration with family C) Paraprofessional teams D) Promotion of family strengths E) Medical control of care
B, C, D
A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? A. "A headache is an indication of an allergy to the medication" B. "A headache is an expected adverse effect of the medication" C. " A Headache indicates tolerance to the medication" D. "A headache is likely due to the anxiety about the chest pain
B. "A headache is an expected adverse effect of the medication" The vasodilation nitroglycerin induces increased blood flow to the head and typically results in a HA
A nurse is teaching a group of postmenopausal women about activities to reduce the risk of developing coronary artery disease. Which of the following statements by a client requires clarification? A. "A weight loss program can increase the LDL cholesterol levels" B. "Increasing the intake of foods containing trans-fatty acids in my diet can lower my risk." C. "Exercising regularly will lower my HDL cholesterol levels." D. "Adding foods containing omega-3 fatty acids to my diet can lower my risk."
B. "Increasing the intake of foods containing trans-fatty acids in my diet can lower my risk." Increasing dietary intake of foods containing trans-fatty acids increases the risk of developing coronary artery disease
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? A. Place the child on a no-salt added diet B. Check the child's daily weight C. Educate the parents about potential complications D. Maintain a saline-lock
B. Check the child's daily weight The first action the nurse should take using the nursing process is to assess the child. Therefore, checking the child's daily weight is the priority.
A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? A. Polyuria B. Facial Edema C. Smokey brown urine D. Hypertension
B. Facial Edema The glomerular membrane is permeable to albumin, which is excreted and changes the colloidal osmotic pressure. Therefore, facial edema is a manifestation of nephrotic syndrome
A nurse is caring for an infant who has congestive heart failure (CHF) secondary to a ventricular septal defect (VSD) and was brought to the clinic by the parent with a report of poor feeding. After instructing the parent about NG tube feedings, the nurse evaluates that teaching has been effective when the parent states, "I will A. give every other feeding by NG tube" B. nurse my baby for 20 minutes then give the rest by NG tube" C. administer all of my baby's feedings through the NG tube" D. Let my baby suck until tired"
B. nurse my baby for 20 minutes then give the rest by NG tube" Nursing the infant for 20 minutes allows the baby gratification from sucking, and the limited time frame does not place great exertion on the heart nor does it cause excessive fatigue. Using the NG tube to administer the additional feeding ensures adequate calorie and fluid intake
A nurse is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following statements indicates the nurse has an understanding of the condition? A. "DIC is controllable with lifelong heparin usage." B. DIC is characterized by an elevated platelet count." C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving a vitamin K deficiency."
C. "DIC is caused by abnormal coagulation involving fibrinogen" DIC ic caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address? A. "My parents treat me like a baby sometimes" B. "I haven't gotten my periods yet, and all my friends have theirs." C. "none of the kids at this school like me, and I don't like them either" D. "There is a big pimple on my face, and I worry everyone will notice it"
C. "none of the kids at this school like me, and I don't like them either" This comment indicates the client may be at risk for depression, an eating disorder, or self-harm. Therefore, this comment is the priority for the nurse to address
A nurse in an emergency department is caring for an adolescent who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take? A. Discuss self-defense techniques with the client B. Inform the client photographs of injuries are required for a police report C. Ask the client to describe the situation D. Give the client a bed bath prior to physical examination
C. Ask the client to describe the situation During the acute phase following assault, the nurse should encourage the client to provide information which may be helpful with treatment and to reduce the client's anxiety
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Oliguria D. Bradypnea
C. Oliguria Oliguria is present in hypovolemic shock as a result of decreased blood flow
A preschooler's response to hospitalization includes the fear of bodily injury or mutilation. How can the nurse best reduce this fear? A. Avoid any discussion of impending procedures with the child B. Give detailed and thorough explanations to the child C. Use band-aids or bandages after invasive procedures to reassure the child that his body will not leak and the body parts or blood will not come out D. Ask parents to retrain the child since the child trusts them
C. Use band-aids or bandages after invasive procedures to reassure the child that his body will not leak and the body parts or blood will not come out Children have very concrete thinking at this age. They don't want holes or openings in their bodies, because they don't know what will happen
A 68-year-old female is admitted to your unit after a CABG (coronary artery bypass graft). Eight hours following surgery, she is extubated and experiences only mild chest discomfort. Over the next hour, she begins to complain of vaguely increasing discomfort. Her pleural tube is bubbling in the water seal chamber. No drainage is present from the mediastinal tube. Her blood pressure fluctuates with respiration, decreasing by 20 mm Hg during inspiration. Her lung sounds are clear; heart sounds are normal but distant. Based on the preceding information, which condition is most likely to be developing? A) Tension pneumothorax. B) Pneumonia. C) Left ventricular failure. D) Cardiac tamponade.
D) Cardiac tamponade Signs and symptoms of cardiac tamponade to watch out for include decreasing pulse pressure, sudden decrease in chest tube output, decreased heart sounds, and widened mediastinum on chest x-ray.
How do older infants generally perceive pain? A) They may feel as though they are being punished. B) The are generally stoic and do not show emotions. C) They don't have a perception of pain since they have most likely not experienced pain. D) Their perceptions are influenced by previous perceptions and how the parent responded.
D) Their perceptions are influenced by previous perceptions and how the parent responded A is the perception of a toddler
The nurse is teaching a mother of an infant with tetralogy of fallot (TOF). The nurse instructs the mother to place the infant in which of the following positions if the infant suddenly becomes cyanotic and dyspnic? A) semi-fowlers in an infant seat B) supine, with the head turned to one side C) prone, making sure the infant can breathe easily D) in a knee-chest position
D) in a knee-chest position Placing the infant in knee-chest position reduces the venous return from the legs (which is desaturated) and increases systemic vascular resistance, which diverts more blood into the pulmonary artery.
A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. This nurse should recognize this finding as a manifestation of which of the following conditions? A) aortic regurgitation B) mitral stenosis C) aortic stenosis D) mitral valve prolapse
D) mitral valve prolapse Although many clients who have mitral valse prolapse are asymptomatic, others report atypical chest pain, palpitations, exercise intolerance, dizziness, and syncope. Auscultation of a client who has mitral valve prolapse reveals a systolic click that is caused by a valve leaflet prolapsing into the left atrium.
A nurse is assessing a toddler who has HF. Which of the following findings should the nurse expect? A) weight loss B) increased urine output C) bradycardia D) orthopnea
D) orthopnea A toddler who has HF has increased venous return to the heart and lungs, which leads to pulmonary congestion. The congestion causes orthopnea (difficulty breathing while lying down). Having the toddler sit up decreases venous return, as well as pressure the abdominal organs have on the diaphragm. THis decreases the pressure and improves breathing and oxygenation.
A client is requesting information regarding a serum troponin test. Which of the following is the nurse's best response? A) "it is a protein found in the serum of healthy clients" B) "lab results are used alone to diagnose heart disease" C) "troponin levels have a narrow time frame, so it is important to obtain this test now" D) "the slightest elevation in troponin levels will prompt treatment to prevent complications of cardiovascular disease"
D) the slightest elevation in troponin levels will prompt treatment to prevent complications of cardiovascular disease. LOw levels of troponin are treated aggressively due to the increased risk of death from CV disease. The more damage there is to the heart, the greater the amount of troponin will be in the blood. The most common reason to perform this test is to confirm diagnosis of an MI.
A premature infant has a PDA. What are the expected effects after administration of indomethacin (Indocin)? A. Ductus arteriosus remains open B. Ventricular septal defect closes C. Atrial septal defect remains open D. Ductus arteriosus closes
D. Ductus arteriosus closes
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16/min B. Decrease in the urinary output from 50 mL to 30 mL per hour C. Increase in the temperature from 37.5 (99.5 F) to 38.6 (101.5 F) D. Increase in the heart rate from 88 to 110/min
D. Increase in the heart rate from 88 to 110/min Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. in the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole
A client comes to the emergency department via ambulance to report severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4L/min, cardiac enzyme levels, IV fluids, and a 12-lead ECG stat. Which of the following actions should the nurse take first. A. Obtain the blood sample B. Attach the leads for a 12-lead ECG C. Insert the IV catheter D.Initiate oxygen therapy
D. Initiate oxygen therapy The greatest risk to the client's safety is myocardial ischemia. Thus the priority is to administer oxygen to help minimize this
In shock, blood supply to the kidney is __________________
decreased
which medication administration improves myocardial contractility?
digoxin
