AHIV Exam 3

A 19-year-old patient admitted with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock: i. Inspiratory crackles ii. Cool, clammy extremities iii. Apical heart rate 45 beats/min iv. Temperature 101.2 F (38.4 C)

iii. Apical heart rate 45 beats/min

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexa? i. Support selection of a high-protein diet ii. Discus options for sexuality and fertility iii. Assist in planning a prescribed bowel program iv. Use quad coughing to strengthen cough efforts

iii. Assist in planning a prescribed bowel program

When analyzing an electro cardio graphic (ECG) rhythm strip of a patient with a regular rhythm, the nurse counts 30 small blacks from one R wave to the next. The nurse calculates the patient's heart rate as:

50

A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate?(Select all that apply) A. Tachycardia B. Increased blood glucose level C. Decreased breath sounds D. Confusion E. Thick, tenacious bronchial secretions

A. Tachycardia C. Decreased breath sounds D. Confusion

A 22-year-old patient who experience a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? i. Auscultate heart sounds ii. Palpate peripheral pulses iii. Auscultate breath sounds iv. Check pupil reaction to light

iii. Auscultate breath sounds

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? i. Notify the patients HCP ii. Document the QRS interval measurement iii. Check the medical record for most recent potassium level iv. Check the chart for the patients current creatinine level

iii. Check the medical record for most recent potassium level

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as i. Flexion withdrawal ii. Localization of pain iii. Decorticate posturing iv. Decerebrate posturing

iii. Decorticate posturing

A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? i. Obtain 12-lead electrocardiogram (ECG) ii. Notify the healthcare provider of the change in rhythm iii. Give supplemental O2 at 2-3 L/min via nasal cannula iv. Assess the patient's vital signs including oxygen saturation

iii. Give supplemental O2 at 2-3 L/min via nasal cannula

The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and attempting to jump from a third-story window. Which nursing diagnosis should the nurse assign as the highest priority? i. Risk for injury to altered perception ii. Ineffective health maintenance related to drug use iii. Powerlessness related to loss of behavior control iv. Ineffective denial related to lack of control of life situation

i. Risk for injury to altered perception

A patient is brought to the emergency department after ingestion of an unknown substance. The patient has been vomiting and complains of abdominal pain. The nurse observes that the patient's oral mucous membranes are dry, the heart rate is 88 beats per minute, and the blood pressure is 90/60 mm Hg. The nurse will prepare to initially: A. administer an antiemetic. B. give activated charcoal. C. infuse normal saline as an IV bolus. D. obtain blood for toxicology testing.

C. infuse normal saline as an IV bolus.

A patient who is orally intubated and receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take next? i. Verbally coach the patient to breathe with the ventilator ii. Sedate the patient with ordered PRN lorazepam (Ativan) iii. Manually ventilate the patient with a bag-valve-mask device iv. Increase the rate for the ordered propofol (Diprivan) infusion

i. Verbally coach the patient to breathe with the ventilator

Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)? i. Withhold oral fluid or foods ii. Provide highly seasoned foods iii. Insert an oropharyngeal airway iv. Apply artificial tears every hour

i. Withhold oral fluid or foods

A patient who is admitted to the hospital for wound debridement admits to using fentanyl (Sublimaze) illegally. What finding does the nurse expect? i. Nausea and diarrhea ii. Tremors and seizures iii. Lethargy and disorientation iv. Delusions and hallucinations

i. Nausea and diarrhea

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patients i. P wave ii. Q wave iii. P-R interval iv. QRS complex

i. P wave

Which patient is most appropriate for the intensive care unit (ICU) charge nuse to assign to a registered nurse (RN) who has floated from the medical unit? i. A 45-year-old receiving IV antibiotics for meningococcal meningitis ii. A 25-year-old admitted with a skull fracture and craniotomy the previous day iii. A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy iv. A 35-year-old with ICP monitoring after a head injury last week

i. A 45-year-old receiving IV antibiotics for meningococcal meningitis

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse assess first? i. A patient with a red tag ii. A patient with a blue tag iii. A patient with a black tag iv. A patient with a yellow tag

i. A patient with a red tag

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? i. Apply external cooling device ii. Check mental status every 15 minutes iii. Avoid the use of sedative medications iv. Rewarm if temperature is <91 F (32.8 C)

i. Apply external cooling device

When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take? i. Ask family members about the patients' health history ii. Ask leading questions to assist in obtaining health data iii. Wait until the patient is better oriented to ask questions iv. Obtain only the physiologic neurologic assessment data

i. Ask family members about the patients' health history

As the nurse admits a patient in end-stage kidney disease to the hospital, the patient tells the nurse, if my heart or breathing stop, I do not want to be resuscitated. Which action is the best for the nurse to take? i. Ask if these wishes have been discussed with the HCP ii. Place a Do Not Resuscitate (DNR) notation in the patients care plan iii. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed iv. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently

i. Ask if these wishes have been discussed with the HC

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if take 1 hour after admission, will be of the most concern to the nurse. i. Blood pressure 154/68, pulse 56, respirations 12 ii. Blood pressure 134/72, pulse 90, respirations 32 iii. Blood pressure 148/78, pulse 112, respirations 28 iv. Blood pressure 110/70, pulse 120, respirations 30

i. Blood pressure 154/68, pulse 56, respirations 12

A 20-year-old patient arrives in the emergency department (ED) several hours after taking 25-30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? i. Give N-acetylcysteine (Mucomyst) ii. Discuss the use of chelation therapy iii. Start oxygen using a non-rebreather mask iv. Have the patient drink large amounts of water

i. Give N-acetylcysteine (Mucomyst)

The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid medications? i. Give around-the-clock routine administration of analgesics ii. Provide PRN doses of medication whenever the patient requests iii. Offer enough pain medication to keep the patient sedated and unawake stimuli iv. Suggest analgesic does that provide pain control without decreasing respiratory rate

i. Give around-the-clock routine administration of analgesics

A patient with a history of alcohol use is diagnosed with acute gastritis. Which statement by the patient indicates a willingness to stop alcohol use? i. I am older and wiser now, and I think I can change my drinking behavior ii. Alcohol has never bothered my stomach before. Think I likely have the flu iii. My drinking is affecting my stomach, but some drugs will help me feel better iv. People say that I drink too much, but I really feel pretty good most of the time

i. I am older and wiser now, and I think I can change my drinking behavior

Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? i. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia ii. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole iii. Turns the synchronizer switch to the on position before defibrillation a patient with ventricular fibrillation iv. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

i. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? i. Instruct the patient to call for assistance before getting out of bed ii. Explain the association between various dysrhythmias and syncope iii. Educate the patient about the need to avoid caffeine and other stimulants iv. Tell the patient about the benefits of implantable cardioverter-defibrillators

i. Instruct the patient to call for assistance before getting out of bed

A patient who has a history of ongoing opioid abuse is hospitalized for surgery. After a visit by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication will the nurse administer immediately? i. Naloxone (Narcan) ii. Diazepam (Valium) iii. Clonidine (Catapres) iv. Methadone (Dolophine)

i. Naloxone (Narcan)

An unconscious 39-year-old male patient I admitted to the emergency department (ED) with a head injury. The patients spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? i. Ask the family to stay in the waiting room until the initial assessment is completed ii. Allow the family to stay with the patient and briefly explain all procedures to them iii. Refer the family members to the hospital counseling service to deal with their anxiety iv. Call the family's pastor or spiritual advisor to take them to the chapel while care is given

ii. Allow the family to stay with the patient and briefly explain all procedures to them

A 19-year-old student comes to the student health center at the end of the semester complaining that, my heart is skipping beats. An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? i. Start supplemental O2 at 2-3 L/min via nasal cannula ii. Ask the patient about current stress level and caffeine use iii. Ask the patient about any history of coronary artery disease iv. Have the patient taken to the hospital emergency department (ED)

ii. Ask the patient about current stress level and caffeine use

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? i. Cardiac monitoring for bradycardia ii. Assessment of respiratory rate and effort iii. Application of pneumatic compression devices to legs iv. Administration of methylprednisolone (Solu-Medrol) infusion

ii. Assessment of respiratory rate and effort

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? i. Insert a large bore orogastric tube ii. Assist with intubation of the patient iii. Prepare a 60-mL syringe with saline iv. Give first dose of activated charcoal

ii. Assist with intubation of the patient

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? i. Have the patient gently blow the now ii. Check the drainage for glucose content iii. Teach the patient that rhinorrhea is expected after a head injury iv. Obtain a specimen of the fluid to send for culture and sensitivity

ii. Check the drainage for glucose content

Following a surgery for an abdominal aortic aneurysm, a patients central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? i. Administer IV diuretic medications ii. Increase the IV fluid infusion per protocol iii. Document the CVP and continue to monitor iv. Elevate the head of the patients bed to 45 degrees

ii. Increase the IV fluid infusion per protocol

The patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which actions will the nurse include in the plan of care? i. Teach the patient the Cred method ii. Instruct the patient how to self-catheterize iii. Catheterize for residual urine after voiding iv. Assist the patient to the toilet every 2 hours

ii. Instruct the patient how to self-catheterize

A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 162/98, heart rate 142 and irregular, and respirations 32. Which action by the nurse is most important? i. Reorient the patient at frequent intervals ii. Monitor the patients electrocardiogram (ECG) and vital signs iii. Keep the patient in a quiet and darkened room iv. Obtain a health history including prior drug use

ii. Monitor the patients electrocardiogram (ECG) and vital signs

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? i. Encourage the patient to cough and auscultate the lungs again ii. Notify the HCP and prepare for endotracheal intubation iii. Document the results and continue to monitor the patients respiratory rate iv. Reposition the patient in high-fowlers positions and reassess breath sounds

ii. Notify the HCP and prepare for endotracheal intubation

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of i. Persistent skin tenting ii. Rapid, deep respirations iii. Bounding peripheral pulses iv. Hot, flushed face and neck

ii. Rapid, deep respirations

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action the nurse should take? i. Perform synchronized cardioversion ii. Start cardiopulmonary resuscitation (CPR) iii. Administer atropine per agency dysrhythmia protocol iv. Provide supplemental oxygen via non-rebreather mask

ii. Start cardiopulmonary resuscitation (CPR)

When hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? i. Mean arterial pressure (MAP) ii. Systemic vascular resistance (SVR) iii. Pulmonary vascular resistance (PVR) iv. Pulmonary artery wedge pressure (PAWP)

ii. Systemic vascular resistance (SVR)

a. Appropriate treatment modalities for the management of cardiogenic shock include (Select all that apply). i. dobutamine to increase myocardial contractility ii. vasopressors to increase systemic vascular resistance iii. circulatory assist devices such as an intraaortic balloon pump iv. corticosteroids to stabilize the cell wall in the infarcted myocardium v. Trendelenburg positioning to facilitate venous return and increase preload

ii. vasopressors to increase systemic vascular resistance iii. circulatory assist devices such as an intraaortic balloon pump

After receiving change-of-shift report on four patients who are undergoing substance abuse treatment, which patient will the nurse assess first? i. A patient who has just arrived for alcohol abuse treatment and states that the last drink was 3 hours ago ii. A patient who is agitated and experiencing nausea, occasional vomiting, and diarrhea while withdrawing from heroin iii. A patient who has tremors secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago iv. A patient who is being treated for cocaine addiction and is irritable and disoriented, with a pulse rate of 112 beats/minute

iii. A patient who has tremors secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? i. Hyperactive reflex activity below the level of injury ii. Involuntary, spastic movements of the arms and legs iii. Hypotension, bradycardia, and warm, pink extremities iv. Lack of sensation or movement below the level of injury

iii. Hypotension, bradycardia, and warm, pink extremities

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which intervention will be included in the plan of care? i. Encourage coughing an deep breathing ii. Position the patient with knees and hips flexed iii. Keep the head of bed elevated to 30 degrees iv. Cluster nursing intervention to provide rest periods

iii. Keep the head of bed elevated to 30 degrees

The nurse is caring for a patient who has an intraortic balloon pump in place. Which action should be included in the plan of care? i. Position the patient supine at all times ii. Avoid the use of anticoagulant medications iii. Measure the patients urinary output every hour iv. Provide passive range of motion for all extremities

iii. Measure the patients urinary output every hour

Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? i. Decide whether a patient's heart rate of 116 requires urgent treatment ii. Monitor a patients level of consciousness during synchronized cardioversion iii. Observe cardiac rhythms for multiple patients who have telemetry monitoring iv. Select the best lead for monitoring a patient admitted with acute coronary syndrome

iii. Observe cardiac rhythms for multiple patients who have telemetry monitoring

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? i. Assess oral temperature ii. Check potassium level iii. Place on cardiac monitor iv. Assess for pain at contact points

iii. Place on cardiac monitor

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? i. The apical pulse is slightly irregular ii. The patient complains of a headache iii. The patient is more difficult to arouse iv. The blood pressure (BP) increases to 140/62 mm Hg

iii. The patient is more difficult to arouse

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? i. A 20-year-old patient whose cranial x-rays shows a linear skull fracture ii. A 30-year-old patient who has an initial Glasgow coma scale score of 13 iii. A 40-year-old patient who lost consciousness for a few seconds after a fall iv. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

iv. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? i. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago ii. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due iii. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating iv. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a doe of amiodarone (Cordarone) due

iv. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a doe of amiodarone (Cordarone) due

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? i. A patient with no pedal pulses ii. A patient with an open femur fracture iii. A patient with bleeding facial lacerations iv. A patient with paradoxic chest movements

iv. A patient with paradoxic chest movements

Which assessment finding would alert the nurse to ask the patient about alcohol use? i. Low blood pressure ii. Decreased heart rate iii. Elevated temperature iv. Abdominal tenderness

iv. Abdominal tenderness

A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? i. Recheck the heart rhythm and BP in 5 mins ii. Have the patient perform the Valsalva maneuver iii. Give the scheduled dose of diltiazem (Cardizem) iv. Apply the transcutaneous pacemaker (TCP) pads

iv. Apply the transcutaneous pacemaker (TCP) pads

A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? i. Place the transcutaneous pacemaker pads on the patient ii. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol iii. Document the patients rhythm and assess the patients response to the rhythm iv. Call the HCP before giving the next dose of metoprolol (Lopressor)

iv. Call the HCP before giving the next dose of metoprolol (Lopressor)

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H20 or peak end-respiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops i. Oxygen saturation of 93% ii. Respirations of 20 breaths/min iii. Green nasogastric tube drainage iv. Increased jugular venous distention

iv. Increased jugular venous distention

During the emergent phase of burn care, which assessment will be the most useful in determining whether the patient is receiving adequate fluid infusion? i. Check skin turgor ii. Monitor daily weight iii. Assess mucous membranes iv. Measure hourly urine output

iv. Measure hourly urine output

A patient admitted to the hospital after an automobile accident is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 100 mg/dL (0.11%). Which action by the nurse is most appropriate? i. Avoid the use of IV fluids ii. Maintain the patient on NPO status iii. Administer acetaminophen for headache iv. Monitor frequently for anxiety, hyperreflexia and sweating

iv. Monitor frequently for anxiety, hyperreflexia and sweating

After change-of-shift report, which patient should the progressive care nurse assess first? i. Patient who was extubated in the morning and has a temperature of 101.4 F (38.6 C) ii. Patient with bi-level positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16 iii. Patient with arterial pressure monitoring who is 2 hours pot percutaneous coronary intervention who needs to void iv. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

iv. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

After a change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? i. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator ii. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring iii. Patient with a central venous oxygen saturation (SevO2) of 69% while on bi-level positive airway pressure (BiPAP) iv. Patient who was successfully weaned and extubated 4 hours and now has no urine output for the last 6 hours

iv. Patient who was successfully weaned and extubated 4 hours and now has no urine output for the last 6 hours

The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is i. Reflex reaction time ii. Pupil reaction to light iii. Level of consciousness iv. Respiratory rate and rhythm

iv. Respiratory rate and rhythm

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? i. Send blood to the lab for CBC ii. Assess further for a cause of the decreased circulation iii. Finish the airway, breathing, circulation, disability survey iv. Start normal saline fluid infusion with a large-bore IV line

iv. Start normal saline fluid infusion with a large-bore IV line

The nurse caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important t report to the healthcare provider? i. Complaint of severe headache ii. Large contusion behind left ear iii. Bilateral periorbital ecchymosis iv. Temperature of 101.4 F (38.6 C)

iv. Temperature of 101.4 F (38.6 C)

Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the HCP? i. Blood pressure is 95/48 per arterial line ii. Serous exudate is leaking from the burns iii. Cardiac monitor shows a pulse rate of 108 iv. Urine output is 20 mL per hour for the past 2 hours

iv. Urine output is 20 mL per hour for the past 2 hours