AMS 2024

A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? Low-sodium diet Serum cardiac enzyme levels MRI of the chest Physical therapy

MRI of the chest

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's IN is 5.2. Which of the following medications should the nurse prepare to administer? Epinephrine Atropine Vitamin K Protamine

Vitamin K

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication? "Take this medication after each meal and at bedtime." Take one tablet every 15 min during an acute attack." "Take one tablet at the first indication of chest pain." "Take this medication with 8 ounces of water."

"Take one tablet at the first indication of chest pain."

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make? "Try taking a mild analgesic to relieve the headache." Take only one dose of nitroglycerin to reduce the risk of getting a headache. "We will ask the provider to prescribe a different medication for you. "There's nothing that can be done to relieve the headaches that nitroglycerin causes."

"Try taking a mild analgesic to relieve the headache."

A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection?

"You seem upset about taking your blood pressure medication

A nurse is preparing to administer desipramine 150 mg PO daily to a client to treat diabetic neuropathy. The amount avallable is desipramine 100 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth)

1.5 tab

A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. )

3 Cap

A nurse is preparing to administer dopamine 2 mcg/kg/min via continuous IV infusion to a client who weighs 60 kg. Available is dopamine 400 mg/ 250 mL The nurse should set the IV pump to deliver how many mL/hr? (DO NOT ROUND the answer).

4.5 ml/hr

The nurse is performing a cardiac assessment and needs to locate the point of maximal impulse. Which location would the nurse choose to locate this? Second intercostal space, right sternal border Third intercostal space, left sternal border Second intercostal space, left sternal border 5th intercostal space, midclavicular line

5th intercostal space, midclavicular line

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge

A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

A patient reporting dizziness and shortness of breath is admitted with dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? Atropine sulfate Adenosine Digoxin Metoprolol

Adenosine

The nurse is completed AM care with a patient diagnosed with angina when the patient reports chest pain. The patient has a saline lack in the right forearm. Which intervention should the nurse at the bedside implement first? Administer IV morphine sulfate via a saline lock. Assess the client's vital signs. Administer oxygen via nasal cannula. Administer sublingual nitroglycerin.

Administer oxygen via nasal cannula.

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below.

Apical Pulse

During a cardiac examination, where can the nurse best hear the S2 heart sound? At the base of the heart At Erb's point. At the tricuspid location. At the apex of the heart.

At Erb's point.

The nurse is preparing to listen to a thin patient's apical aspect of the heart. The nurse will place the stethoscope. At the pulmonary artery located at the base. At the first heart sound is located at the apex At the carotid artery

At the first heart sound is located at the apex

In chronic atrial fibrillation, There is a 30% percent loss in cardiac output. This is due to the loss of which of the following: Atrial appendage Atrial Kick Carotid stenosis Ventricular hypertrophy

Atrial Kick

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? Atrial depolarization slow repolarization of ventricular Purkinje fibers Early ventricular repolarization Ventricular depolarization

Atrial depolarization

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia. Epinephrine Magnesium Sodium bicarbonate Atropine

Atropine

A nurse is teaching a client's family about lightning strike prevention following a lightning injury to the client. Which of the following information should the nurse include in the teaching? Lie down on the ground Seek safety in an isolated shed Avoid using a corded landline telephone. Move out of the open area by standing by a tree.

Avoid using a corded landline telephone.

Differentiating serous drainage from cerebral spinal fluld (CSF) leaking from a head injury is done by which of the following? Obtaining a non-contrast CT scan. Asking the patient to perform a Valsalva maneuver and noting any increase in drainage Determining the pil of the drainage Checking the fluid for glucose levels

Checking the fluid for glucose levels

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Cheyne-Stokes respirations Apneustic respirations Kussmaul respirations Stridor

Cheyne-Stokes respirations

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? Computed tomography (CT) scan Chest radiograph (chest x-ray) 12-Lead electrocardiogram (ECG) Complete blood count (CBC)

Computed tomography (CT) scan

A 73-year-old client was found wandering through traffic. She was struck by a car and brought to the emergency department. When stimulated with a sternal rub, she temporarily flickers her eyes open. When asked the date, she does not respond. The picture demonstrates her posture: Determine the client's Glasgow Coma Scale (GCS) rating. Highlight the text that corresponds with the assessment findings presented in the scenario tab.

Decorticate response. Flexion of arms, wrists, and fingers with adduction in upper extremities. Extension, internal rotation, and plantar flexion in lower extremities. GCS 8

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? Amiodarone administration Defibrillation Airway management Epinephrine administration

Defibrillation

A nurse is caring for a 74-year-old female client who reports experiencing Increased shortness of breath. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Elevate the head of the client's bed. Apply O, at 2 L/min nasal cannula <=Exacerbation of COPD=> Respiratory rate Oxygen saturation

Elevate the head of the client's bed. Apply O, at 2 L/min nasal cannula <=Exacerbation of COPD=> Respiratory rate Oxygen saturation

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the fallowing findings should the nurse expect? Decreased brain natriuretic peptide (BNP). Increased pulmonary artery wedge pressure (PAWP) Decreased specific gravity Elevated central venous pressure (CVP).

Elevated central venous pressure (CVP).

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? Heart rate is 58 beats/min. Mean arterial pressure is 62 mm Hg. Elevated systemic vascular resistance (SVR) Pulmonary artery wedge pressure (PAWP) Is low.

Elevated systemic vascular resistance (SVR)

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take? Discard the prepared medications and begin again after returning. Have another nurse finish preparing the medications Lock the medication in a room and finish preparing it after returning from the emergency. Have another nurse guard the medication preparations under the nurse's return.

Lock the medication in a room and finish preparing it after returning from the emergency.

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication? Orange juice Grapefruit juice Coffee

Grapefruit juice

A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating? Holistic health Disease prevention Health promotion Health education

Health promotion

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg. pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? Hemorrhagic stroke Thrombotic stroke Transient ischemic attack (TIA) Embolic stroke

Hemorrhagic stroke

The nurse is caring for a cardiac patient in the ICU with increased CVP pressure readings. The nurse is aware that increased CVP readings indicate? Hypervolemia sepsis Decreased fluids

Hypervolemia

The nurse is performing a neurological assessment on a client and needs to use stereognosis. Which of the following instructions would the nurse provide for the client? "Open and close your hand each time I tell you to." Tell me if you feel one or two objects touching you with your eyes closed." Identify the number being traced in your hand with your eyes closed. Identify the object in your hand with your eyes closed."

Identify the object in your hand with your eyes closed."

The nurse is teaching the patient diagnosed with angina about sublingual nitroglycerin (NTG). Which statement indicates the patient needs more medication teaching? If I have chest pain, I will put a tablet underneath my tongue." I should expect to get a headache after taking my nitroglycerin If my pain is not relieved with one tablet, will get medical help I will always carry my nitroglycerin in a dark-colored bottle."

If my pain is not relieved with one tablet, will get medical help

The nurse is administering adrenergic (SNS) medication to a patient. The nurse will expect the following effects on the circulatory system and VS? Increased heart rate no pulse no breathing

Increased heart rate

A female patient presents to the emergency department reporting the most severe headache of her life. Which type of stroke should the nurse anticipate? Intracerebral hemorrhage= subarachnoid Thrombotic stroke Transient ischemic attack (TIA) Embolic stroke

Intracerebral hemorrhage= subarachnoid

The nurse has administered the prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? Intracranial pressure Oxygen saturation Blood pressure Hemoglobin and hematocrit

Intracranial pressure

A 65 yr female patient has ST-segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? Lead II Lead I Lead V2 Lead V6

Lead II

Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? Administration of tissue plasminogen activator (PA) Positioning to promote cerebral perfusion Control of fluid and electrolyte imbalances Maintenance of patient's airway

Maintenance of patient's airway

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer? Mannitol 25% Hydroxyethyl glucose Dextran 70 Albumin 25%

Mannitol 25%

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? Offer the client a light snack. Measure the client's blood pressure. Weigh the client. Measure the client's apical pulse.

Measure the client's apical pulse.

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? Oxygen Morphine Aspirin Nitroglycerin

Morphine

A client presents to the emergency department complaining of chest pain. Which orders does the nurse anticipate? Morphine Oxigen Aspiring 325mg adenosine 12 mg IVP 12 lead EKG Nitroglycerine 0.4 mg SL Troponin 1

Morphine Oxigen Aspiring 325mg adenosine 12 mg IVP 12 lead EKG Nitroglycerine 0.4 mg SL Troponin 1

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? Myocardial infarction Myocardial injury Myocardial ischemia Normal pacemaker function

Myocardial ischemia

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

P wave

A nurse is caring for a client who has had a spinal cord injury at the level of the T2 - T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paraplegia Paresthesia Hemiplegia Quadriplegia

Paraplegia

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 it the client is experiencing a myocardial infarction? Check the client's blood pressure. Auscultate heart tones. Determine if the pain radiates to the left arm. Perform a 12-lead ECG

Perform a 12-lead ECG

A nurse is caring for a client who is diagnosed with a cerebrovascular accident (CA, stroke), Which of the following actions should be implemented to prevent deep-vein thrombosis (DVT)? Place sequential compression devices bilaterally Monitor the client's level of consciousness Massage lower extremities daily. Check for positive Homans' sign.

Place sequential compression devices bilaterally

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? Place the client in a high-Fowler's position. Administer a nitrate antihypertensive. Assess the client for bladder distention. Obtain the client's heart rate.

Place the client in a high-Fowler's position.

A nurse is caring for a client who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? Place the client in contact isolation. Prepare the client for a lumbar puncture Administer an intravenous antibiotic. Obtain blood cultures.

Place the client in contact isolation.

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? Centers the cuff bladder over the client's brachial artery Wraps the blood pressure cuff snugly around the client's arm Places the client's arm above the level of the client's heart Checks the instrument gauge to ensure the reading starts at zero

Places the client's arm above the level of the client's heart

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects? Vitamin K Protamine sulfate Acetylcysteine Deferasirox

Protamine sulfate

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose? Vitamin K Glucagon Protamine sulfate Acetylcysteine

Protamine sulfate

The nurse is preparing a medication for a client and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take? Notify the provider. Return the medication to the pharmacy. Discard the medication. Give the medication.

Return the medication to the pharmacy.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? Impaired physical mobility Disturbed sensory perception Impaired skin integrity Risk for aspiration

Risk for aspiration

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEg/L. Which of the following medications should the nurse plan to administer? Sevelamer Sodium polystyrene Darbepoetin alfa Lactulose

Sodium polystyrene

A patient whose heart monitor shows asystole. The patient is apneic, and has no palpable pulses. What action should the nurse take next? Perform synchronized cardioversion Provide supplemental 02 via a non-rebreather mask. Start cardiopulmonary resuscitation (CPR) Give atropine per agency dysrhythmia protocol.

Start cardiopulmonary resuscitation (CPR)

When reviewing the 12-lead EKG for a healthy 69 yr old patient who is having an annual physical examination, what will be of most concern to the nurse? The QRS duration is 0,13 seconds. There is a right bundle-branch block The heart rate (HR) is 42 beats/minute The PR interval is 0,21 seconds.

The heart rate (HR) is 42 beats/minute

While reading a client's ECG tracing, the nurse should understand that the PR interval reflects which of the following cardiac electrical activities? The length of time it takes for the electrical impulse to travel from the SA node to the AV node The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers The length of time it takes for the atria to depolarize and depolarize The length of time it takes to depolarize the atrium

The length of time it takes for the electrical impulse to travel from the SA node to the AV node

The elderly patient diagnosed with coronary artery disease has been taking aspirin daily far more than a year, Which data warrants notifying the HCP? The patient has trouble bearing low tones. The patient has hard, dark, tarry stools The patient has lost 5 pounds in the last month. The patient reports having a funny taste in the mouth.

The patient has hard, dark, tarry stools

A patient who is recovering from an acute myocardial infarction (MI) asks the nurse when sexual intercourse can be resumed. Which response by the nurse is best? a. The sexual activity uses about as much energy as climbing two flights of stairs. b. "The doctor will provide sexual guidelines when your heart is strong enough" c. "Most patients are able to enjoy intercourse without any complications." d. Holding and cuddling are good ways to maintain intimacy after a heart attack."

The sexual activity uses about as much energy as climbing two flights of stairs.

The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt on their face. Which cranial nerve is the nurse assessing? Abducens nerve (cranial nerve VI) Facial nerve (cranial nerve VIl) Optic nerve (cranial nerve lI) Trigeminal nerve (cranial nerve V)

Trigeminal nerve (cranial nerve V)

The nervous system is concerned with the regulation and coordination of the body activities True False

True

For which dysrhythmia is defibrillation primarily indicated as the treatment? Ventricular fibrillation. Third-degree AV block. Uncontrolled fibrillation Ventricular tachycardia with a pulse.

Ventricular fibrillation.

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tab. The client's current vital signs are: blood pressure 144/96, heart rate 54/min, respirations 18/min, and temperature 98.6° F. Which of the following actions should the nurse take? Withhold the digoxin dose for elevated blood pressure. Administer digoxin 0,125 mg. Withhold the digoxin dose for decreased pulse rate. Administer digoxin 0.25 mg.

Withhold the digoxin dose for decreased pulse rate.

Nurse is caring for a client. The client is admitted following a cerebrovascular accident. (CVA). The client is alert and oriented. Heart rate regular. Respirations are rapid and non-labored. Wheezing auscultated in the upper lobes of the lungs. The client is receiving 2 Unit of oxygen via nasal cannula. Right upper and lower extremities flaccid with decreased muscle tone and strength. 1200: Client sitting up in a chair for lunch. Client states they are right-handed and are having difficulty feeding themselves For which of the following interprofessional team members should the nurse anticipate a provider's referral? Select all that apply. a. Case manager b. Respiratory Therapist c. Diabetes nurse educator d. Physical therapist e. Occupational therapist f. Enterostomal therapy nurse

a. Case manager b. Respiratory Therapist d. Physical therapist e. Occupational therapist f

A nurse is caring for a client who was recently admitted and has symptomatic bradycardia. The nurse is caring for the client immediately following the insertion of the permanent pacemaker. Complete the following sentence by using the list of options. The nurse should monitor the client for _________ and _________ following permanent pacemaker placement.

incisional site bleeding and Bradycardia

While assisting with a lumbar puncture, the nurse notes that the cerebrospinal fluid returning is cloudy. This is a symptom of: subdural hematoma. traumatic tap. cerebral edema. infection

infection

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? Ask the client to shrug his shoulders against passive resistance. instruct the client to look up and down without moving his head. Observe the client's ability to smile and frown. Have the client stand with eyes his closed and touch his nose.

instruct the client to look up and down without moving his head.

The nurse is concerned about a sustained elevation in heart rate because sinus tachycardia causes increased oxygen demand and: causes reflex hypotension may lead to ventricular arrhythmias. decreases cardiac output.

may lead to ventricular arrhythmias.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots,

most distal pulse on the affected side

The nurse is assessing a patient with a head injury due to a MA who is experiencing temporary blindness to the left eye. This abnormal assessment finding is due to injury to which cerebral lobe? occipital ear temporal

occipital

A client has an oral intake of 1500 ml and a urine output of 350 ml in a 24-hour period. The nurse can correctly chart that the client is polyuric. diaphoretic anuric. oliguric.

oliguric

While auscultating the heart sounds of a patient with mitral insufficiency, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this heart sound as: fourth heart sound S4 third heart sound (S3). a first heart sound S1

third heart sound (S3).