adult 3 exam 1
a client has frequent bursts of ventricular tachycardia on the cardiac monitor. what should the nurse be most concerned about with this dysrhythmia? a. it can develop into ventricular fibrillation at any time b. it is almost impossible to convert to a normal rhythm c. it is uncomfortable for the client, giving a sense of impending doom d. it produces a high cardiac output that quickly leads to cerebral and myocardial ischemia
a
a client's electrocardiogram strip shows atrial and ventricular rates of 110 bpm. the PR interval is 0.14 seconds, the QRS complexes measure 0.08 seconds, and the PP and RR intervals are regular. how should the nurse currently interpret this rhythm? a. sinus tachycardia b. sinus bradycardia c. sinus dysrhythmia d. normal sinus rhythm
a
after teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says: a. I would like to add weight lifting to exercise program b. i can only keep my blood pressure normal with medication c. i can change my diet to decrease my intake of saturated fats d. i will change my lifestyle to reduce activities that increase my stress
a
during admission of a pt with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway b. presence of neck injury c. neurologic status with the glasgow coma scale d. cerebrospinal fluid leakage from the ears or nose
a
the nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. there are no P waves; instead there are fibrillatory waves before each QRS complex. how should the nurse correctly interpret the client's heart rhythm? a. atrial fibrillation b. sinus tachycardia c. ventricular fibrillation d. ventricular tachycardia
a
the nurse recognizes that primary manifestations of systolic failure include a. decreased EF(ejection fraction) and increased PAWP (pulmonary artery wedge pressure) b. decreased PAWP and increased EF c. decreased pulmonary HTN associated with normal EF d. decreased afterload and decreased left ventricular end-diastolic pressure
a
the nurse should evaluate that defibrillation of a client was most successful if which observation was made? a. arousable, sinus rhythm, BP 116/72 b. nonarousable, sinus rhythm, BP 88/60 c. arousable, marked bradycardia, BP 86/54 d. nonarousable, supraventricular tachycardia, BP 122/60
a
a pt with chronic HF and a-fib is treated with a digitalis glycoside and a loop diuretic. to prevent possible complications of this combination of drugs, what does the nurse need to do? select all that apply a. monitor serum potassium levels b. teach the pt how to take a pulse rate c. keep an accurate measure of intake and output d. teach the pt about dietary restriction of potassium e. withhold digitalis and notify the HCP if pulse is irregular
a,b
the nurse in a medical unit is caring for a client with heart failure. the client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. the nurse immediately asks another nurse to contact the HCP and prepares to implement which priority interventions? (select all that apply) a. administering oxygen b. inserting a foley catheter c. administering furosemide d. administering morphine sulfate IV e. transporting the client to the coronary unit f. placing the client in a low folwer's side-lying position
a,b,c,d
a nurse is completing an assessment of a client who has an increased ICP. which of the following are expected findings? (select all that apply) a. disoriented to time and place b. restlessness and irritability c. unequal pupils d. ICP 15 mm Hg e. headache
a,b,c,e
a nurse is preparing to care for a client following chest tube placement. which of the following items should be available in the clients room? (select all that apply) a. oxygen b. sterile water c. enclosed hemostat clamps d. indwelling urinary catheter e. occlusive dressing
a,b,c,e
a nurse is caring for a client who experienced defibrillation. which of the following should be included in the documentation of this procedure? select all that apply a. follow up ECG b. energy settings used c. IV fluid intake d. urinary output e. skin condition under electrodes
a,b,e
a nurse is planning care for a client following insertion of a chest tube and drainage system. which of the following should be included in the plan of care? (select all that apply) a. encourage the client to cough every 2 hours b. check for continuous bubbling in the suction chamber c. strip the drainage tubing every 4 hours d. clamp the chest tube once a day e. obtain a chest xray
a,b,e
a pt is admitted to the ICU with a diagnosis of unstable angina. which drug(s) would the nurse expect the pt to receive? select all that apply a. ACE inhibitor b. antiplatelet therapy c. thrombolytic therapy d. prophylactic abx e. intravenous nitroglycerin
a,b,e
a nurse on a cardiac unit is caring for a group of clients. the nurse should recognize which of the following clients as being at risk for development of a dysrhythmia? select all that apply a. a client who has metabolic acidosis b. a client who has a serum potassium level of 4.3 mEq/L c. a client who has an SaO2 of 96% d. a client who has COPD e. a client who underwent stent placement in a coronary artery
a,d,e
a client is admitted to the hospital with chest pain and a hx of type 2 DM is scheduled for cardiac catheterization. which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? a. glipizide b. metformin c. repaglinide d. regular insulin
b
a client with myocardial infarction is developing cardiogenic shock. because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? a. bradycardia b. ventricular dysrhythmias c. rising diastolic BP d. falling central venous pressure
b
a client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. which finding would the nurse anticipate when auscultating the client's breath sounds? a. stridor b. crackles c. scattered ronchi d. diminished breath sounds
b
a hospitalized patient with a hx of chronic stable angina tells the nurse that she is having chest pain. the nurse bases his actions on the knowledge that ischemia a. will always progress to myocardial infarction b. will be relieved by rest, nitroglycerin, or both c. indicates that irreversible myocardial damage is occurring d. is frequently associated with vomiting and extreme fatigue
b
a nurse is caring for a client who has a chest tube and drainage system in place. the nurse observes that the chest tube was accidentally removed. which of the following actions should the nurse take first? a. obtain a chest xray b. apply sterile gauze to the insertion site c. place tape around the insertion site d. assess respiratory status
b
a nurse on a cardiac unit is caring for a client who is on telemetry. the nurse recognizes the client's heart rate is 46 bpm and notifies the provider. the nurse should anticipate which of the following management strategies will be used for this client? a. defibrillation b. pacemaker insertion c. synchronized cardioversion d. administration of IV lidocaine
b
a nurse plans care for the pt with increased intracranial pressure with the knowledge that the best way to position the pt is to a. keep the HOB flat b. elevate the HOB to 30 degrees c. maintain the pt on the left side with the head supported on a pillow d. use a continuous-rotation bed to continuously change pt position
b
the nurse is caring for a patient who is 2 days post MI. the pt reports that she is experiencing chest pain. she states, "it hurts when i take a deep breath." which actions would be a priority? a. notify the physician STAT and obtain a 12-lead ECG b. obtain vital signs and auscultate for a pericardial friction rub c. apply high flow O2 by face mask and auscultate breath sounds d. medicate the pt with PRN analgesic and reevaluate in 30 minutes
b
the nurse is caring for the client increased ICP. the nurse would note which trend in vital signs if the ICP is rising? a. increasing temp, increasing pulse, increasing respirations, decreasing BP b. increasing temp, decreasing pulse, decreasing respirations, increasing BP c. decreasing temp, decreasing pulse, increasing respirations, decreasing BP d. decreasing temp, increasing pulse, decreasing respirations, increasing BP
b
the nurse is evaluating a client's response to cardioversion. which assessment would be the priority? a. blood pressure b. status of airway c. oxygen flow rate d. level of consciousness
b
the nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. which observation would indicate that the procedure was effective? a. muffled heart sounds b. a rise in blood pressure c. jugular vein distention d. client expressions of dyspnea
b
vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter b. altering endothelial lining of cerebral capillaries c. leaking molecules from the intracellular fluid to the capillaries d. altering the osmotic gradient flow into the intravascular component
b
a nurse is assessing a client who has a chest tube and drainage system in place. which of the following are expected findings? (select all that apply) a. continuous bubbling in the water seal chamber b. gentle constant bubbling in the suction control chamber c. rise and fall in the level of water in the seal chamber with inspiration and expiration d. exposed sutures without dressing e. drainage system upright and at chest level
b,c
in teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include: select all that apply a. diffuse involvement of plaque formation in coronary veins b. abnormal levels of cholesterol, especially LDLs c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina due to a decreased blood supply to the heart muscle e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm
b,c,d
which pt teaching points should the nurse include when providing discharge instructions to a pt with a new permanent pacemaker and the caregiver? (select all that apply) a. avoid or limit air travel b. take and record a daily pulse c. obtain and wear a medic alert ID at all times d. avoid lifting arm on the side of the pacemaker above the shoulder e. avoid microwave ovens because they interfere with pacemaker function
b,c,d
a client is having frequent premature ventricular contractions. the nurse should place priority on assessment of which item? a. sensation of palpitations b. causative factors, such as caffeine c. blood pressure and oxygen saturation d. precipitating factors, such as infection
c
a client is wearing a continuous cardiac monitor, which begins to sound its alarm. the nurse sees no ECG complexes on the screen. which is the priority nursing action? a. call a code b. call the HCP c. check the client's status and lead placement d. press the recorder button on the ECG console
c
a compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is a. ventricular dilation b. ventricular hypertrophy c. neurohormonal response d. sympathetic nervous system activation
c
a pt admitted with acute coronary syndrome (ACS) has continuous ECG monitoring. an examination of the rhythm strip reveals the following characteristics: atrial rate 74 bpm and regular, ventricular rate 62 bpm and regular, P wave normal shape, PR interval lengthens progressively until a P wave is not conducted, QRS normal shape. the priority nursing intervention would be to a. perform synchronized cardioversion b. administer epinephrine 1 mg IV push c. observe for symptoms of hypotension or angina d. apply transcutaneous pacemaker pads on the pt
c
a pt is recovering from an uncomplicated MI. which rehabilitation guideline is a priority to include in the teaching plan? a. refrain from sexual activity for a minimum of 3 weeks b. plan a diet program that aims for a 1 to 2 lb weight loss per week c. begin an exercise program that aims for at least five 30 min sessions per week d. consider the use of erectile agents and prophylactic NTG before engaging in sexual activity
c
important teaching for the pt scheduled for a radiofrequency catheter ablation procedure included explaining that a. vetnricular bradycardia may be induces and treated during the procedure b. a catheter will be placed in both femoral arteries to allow double-catheter use c. the procedure with destroy areas of the conduction system that are causing rapid heart rhythms d. a general anesthetic will be given to prevent the awareness of any "sudden cardiac death" experiences
c
the client has developed atrial fibrillation, with a ventricular rate of 150 bpm. the nurse should assess the client for which associated signs and/or symptoms? a. flat neck veins b. nausea and vomiting c. hypotension and dizziness d. hypertension and headache
c
the most common finding in individuals at risk for sudden cardiac death is a. aortic valve disease b. mitral valve disease c. left ventricular dysfunction d. atherosclerotic heart disease
c
the nurse is alerted to a possible acute subdural hematoma in the pt who a. has a linear skull fracture crossing a major artery b. has focal symptoms of brain damage with no recollection of a head injury c. develops decreased LOC and a headache w/in 48 hrs of a head injury d. has an immediate loss of consciousness with a brief lucid interval followed by decreased LOC
c
the nurse is monitoring the ECG of a patient admitted with ACS. which ECG characteristics would be most suggestive of myocardial ischemia? a. sinus rhythm with a pathologic Q wave b. sinus rhythm with an elevated ST segment c. sinus rhythm with a depressed ST segment d. sinus rhythm with premature atrial contractions
c
the nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. there are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 bpm. the nurse determines that the client is experiencing which dysrhythmia? a. sinus tachycardia b. ventricular fibrillation c. ventricular tachycardia d. PVCs
c
the nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. the client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. how should the nurse correctly interpret this rhythm? a. asystole b. atrial fibrillation c. ventricular fibrillation d. ventricular tachycardia
c
you are caring for a pt with ADHF (acute decompensated heart failure) who is receiving IV dobutamine (Dobutrex). you know that this drug is ordered because it (select all that apply) a. increases SVR (systemic vascular resistance) b. produces diuresis c. improves contractility d. dilates renal blood vessels e. works on the Beta receptors of the heart
c,e
a client has clear fluid leaking from the nose following a basilar skull fracture. which finding would alert the nurse that cerebrospinal fluid is present? a. fluid is clear and tests negative for glucose b. fluid is grossly bloody in appearance and has a pH of 6 c. fluid clumps together on the dressing and has a pH of 7 d. fluid separates into concentric rings and tests positive for glucose
d
a client in ventricular fibrillation is about to be defibrillated. to convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? a. 50 J b. 120 J c. 200 J d. 360 J
d
a client recovering from a head injury is participating in care. the nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? a. blowing the nose b. isometric exercises c. coughing vigorously d. exhaling during repositioning
d
a client with sinus bradycardia, with a heart rate of 45 bpm, complains of dizziness and has a BP of 82/60 mm Hg. which prescription should the nurse anticipate will be prescribed? a. administer digoxin b. defibrillate the client c. continue to monitor client d. prepare for transcutaneous pacing
d
a client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. which statement by the client indicates the need for further teaching? a. i should notify my doctor if my feet or legs start to swell b. my doctor told me to call his office if my pulse rate decreases below 60 c. avoiding grapefruit juice will definitely be a challenge for me, since i usually drink it every morning with breakfast d. my spouse told me that since i have developed this problem, we are going to stop walking in the mall every morning
d
a nurse is assisting a provider with the removal of a chest tube. which of the following should the nurse instruct the client to do? a. lie on his left side b. use the incentive spirometer c. cough at regular intervals d. perform Valsalva maneuver
d
a pt with intracranial pressure monitoring has a pressure of 12 mm Hg. the nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of cerebrospinal fluid c. the loss of autoregulatory control of intracranial pressure d. a normal balance between brain tissue, blood, and cerebrospinal fluid
d
the ECG monitor of a pt in the cardiac care unit after an MI indicates ventricular bigeminy with a rate of 50 bpm. the nurse would anticipate a. performing defibrillation b. treating with IV amiodarone c. inserting a temporary transvenous pacemaker d. assessing the patient's response to the dysrhythmia
d
the nurse is assisting to defibrillate a client in ventricular fibrillation. after placing the pad on the client's chest and before discharge, which intervention is a priority? a. ensure that the client has been intubated b. set the defibrillator to the 'synchronize' mode c. administer an amiodarone bolus IV d. confirm that the rhythm is actually ventricular fibrillation
d
the nurse is caring for a client who has just had an implantation of an automatic internal cardioverter-defibrillator. the nurse should assess which item based on priority? a. anxiety level of the client and family b. presence of a MedicAlert bracelet card for the client to carry c. knowledge of restrictions on postdischarge physical activity d. activation status of device, heart rate cutoff, and number of shocks it is programmed to deliver
d
the nurse is reviewing an ECG rhythm strip. the P waves and QRS complexes are regular. the PR interval is 0.16 seconds, and the QRS complexes measure 0.06 seconds. the overall heart rate is 64 bpm. which action should the nurse take? a. check vital signs b. check laboratory results c. notify the HCP d. continue to monitor for any rhythm change
d
the nurse prepares a pt for synchronized cardioversion knowing that cardioversion differs from defibrillation in that a. defibrillation requires a lower dose of electrical energy b. cardioversion in indicated to treat atrial bradydysrhythmias c. defibrillation is synchronized to deliver a shock during the QRS complex d. patients should be sedated if cardioversion is done on a non-emergency basis
d