Complex II Exam 1

A patient who has a diagnosis of atrial fibrillation has a heart rate of 152 beats per minute. The healthcare provider should assess for which of these problems related to the dysrhythmia? A. Hypotension B. Dizziness C. Headache D. Pulse deficit E. Chest pain

A, B, D, E

A client has just been treated with cardioversion. What should the nurse assess first? A. Blood pressure B. Status of airway C. Oxygen flow rate D. Level of consciousness

B. Status of airway Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority.

A client is diagnosed with acute inferior myocardial infarction and is placed on bedrest. The nurse includes measures in the plan of care to avoid which potential complication related to bedrest? A. Diarrhea B. Arthritis C. Constipation D. Increased chest pain

C. Constipation Constipation occurs as a result of inactivity and is an undesirable complication for cardiac clients because straining or bearing down triggers the Valsalva maneuver, which increases cardiac workload. Options 1, 2, and 4 are unrelated to bedrest.

A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the following conditions? A.Hypovolemic shock B. Cardiac tamponade C. Wound dehiscence D. Atelectasis

B. Cardiac tamponade All of the client's symptoms are found in both cardiac tamponade and hypovolemic shock except the increase in urinary output.

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Check all that apply. A. Tachycardia B. Hypertension C. Increased CVP D. Increased urine output E. Jugular vein distention

A, C, E

A patient diagnosed with heart failure has a pulmonary artery catheter (PAC) in place. What information about the patient's hemodynamic functioning will the healthcare provider obtain from this monitoring device? A. Left ventricular functioning B. Pulmonary valve function C. Coronary artery patency D. Stroke volume

A. Left ventricular functioning

The healthcare provider is reviewing risk factors for the development of an abdominal aortic aneurysm (AAA). Which of these inherited disorders in a patient's history is most likely related to the development of an AAA? A. Marfan syndrome B. Klinefelter syndrome C. Trisomy 21 D. Sickle cell anemia

A. Marfan syndrome

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: A. Normal sinus rhythm B. Sinus bradycardia C. Sick sinus syndrome D. First-degree heart block

A. Normal sinus rhythm measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively.

While caring for a patient who is experiencing a postoperative hemorrhage, the healthcare provider notes the rhythm observed on the electrocardiogram (EKG) does not produce a pulse. Which actions should the healthcare provider initiate to resolve this patient's problem? (Select all that apply) A. Defibrillation B. Administration of IV crystalloid (blood products) C. Administration of epinephrine D. Cardiopulmonary resuscitation (CPR) E. Administration of vasoconstrictors F. Synchronized cardioversion

B, C, D, E

The nurse is monitoring a client who is receiving a blood transfusion when the client complains of diaphoresis, warmth, and a backache. The nurse suspects a transfusion reaction and should take which actions? Select all that apply. A. Remove the IV catheter. B. Document the occurrence. C. Stop the blood transfusion. D. Contact the health care provider. E. Hang 0.9% sodium chloride solution.

B, C, D, E If a client experiences a transfusion reaction, the nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. The health care provider is notified, as is the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response. To preserve the IV access, the nurse should not remove the catheter and discontinue the IV site.

A client with unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine (Xylocaine) intravenously. Which item should the nurse caring for the client immediately obtain? A. A pacemaker B. A defibrillator C. A second dose of lidocaine D. An electrocardiogram machine

B. A defibrillator

The nurse is assessing a client hospitalized with infective endocarditis. The nurse determines that which assessment finding is unrelated to possible cardiac tamponade? A. Distended jugular neck veins B. Pulse rate of 58 beats per minute C. Muffled and distant heart sounds D. Systolic blood pressure (BP) of 110 mm Hg, dropping to 94 mm Hg on inspiration

B. Pulse rate of 58 beats per minute Assessment findings with cardiac tamponade include jugular vein distention, tachycardia, distant or muffled heart sounds, and a falling BP, accompanied by pulsus paradoxus (a drop in inspiratory BP by greater than 10 mm Hg). Bradycardia is the symptom that is unrelated.

A client with myocardial infarction is developing cardiogenic shock. Because of myocardial ischemia that occurs with this complication, for which finding should the nurse monitor the client? A. Bradycardia B. Ventricular dysrhythmias C. Rising diastolic blood pressure D. Falling central venous pressure (CVP)

B. Ventricular dysrhythmias Signs of cardiogenic shock include tachycardia and low blood pressure. Dysrhythmias commonly occur as a result of decreased oxygenation to the myocardium. The central venous pressure (CVP) would rise as the backward effects of the left ventricular failure became apparent.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? A Immediately defibrillate B Prepare for pacemaker insertion C Administer amiodarone (Cordarone) intravenously D Administer epinephrine (Adrenaline) intravenously

C. Administer amiodarone (Cordarone) intravenously

A client has an inoperable abdominal aortic aneurysm (AAA). Which intervention should the nurse anticipate will be prescribed? A. Bedrest B. Restricting fluids C. Antihypertensives D. Maintaining a low-fiber diet

C. Antihypertensives he medical treatment for AAA is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to be on bedrest or restrict fluids. A low-fiber diet is not helpful and will cause constipation.

A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120 beats/minute, blood pressure 80/55mmHg, and urine output 20mL/hr. After administering an IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion? A. Right atrial pressure increases B. Systolic blood pressure increases to 85mmHg. C. Urine output increases to 30mL/hour. D. Heart rate drops to 100 beats/minute

C. Urine output increases to 30mL/hour.

Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following? A. Intake and output. B. NPO standing order. C. Vital signs. D. Skin turgor

C. Vital signs. The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening.

A client is preparing for discharge following coronary artery bypass graft surgery (CABG). The client asks the nurse if sexual activity is permitted after discharge. Which statement should the nurse make to the client? A. "No; after open heart surgery, sexual activity is not recommended." B. "No; sexual activity can cause rupture of your cardiac suture lines." C. "I do not know; wait and discuss this with your health care provider." D. "Sexual activity will be allowed, and the health care provider will tell you when you can resume sexual activity."

D. "Sexual activity will be allowed, and the health care provider will tell you when you can resume sexual activity."

What is the primary reason for administering morphine to a client with an MI? A. To sedate the client B. To decrease the client's pain C. To decrease the client's anxiety D. To decrease oxygen demand on the client's heart

D. To decrease oxygen demand on the client's heart Morphine is administered because it decreases myocardial oxygen demand. Morphine will also decrease pain and anxiety while causing sedation, but it isn't primarily given for those reasons.

Which of the following types of angina is most closely related with an impending MI? A. Angina decubitus B. Chronic stable angina C. Nocturnal angina D. Unstable angina

D. Unstable angina Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months.

The nurse has provided instructions to a client being discharged from the hospital to home after an abdominal aortic aneurysm (AAA) resection. The nurse determines that the client understands the instructions if the client states that which would be an appropriate activity? A. Mowing the lawn B. Playing a game of 18-hole golf C. Lifting objects up to 30 pounds D. Walking as tolerated, including outdoors

D. Walking as tolerated, including outdoors

The nurse provides discharge instructions to a client after implantation of a permanent pacemaker. The nurse should tell the client to avoid exposure to which item? A. Hair dryers B. Electric blankets C. Electric toothbrushes D. Airport metal detectors

D. Airport metal detectors

The nurse is monitoring a client hospitalized with acute pericarditis for signs of cardiac tamponade. Which finding is associated with cardiac tamponade? A. Bradycardia B. Hypertension C. Bounding heart sounds D. Distended jugular veins

D. Distended jugular veins

A client is diagnosed with angina. The nurse reviews the client's diagnostic and laboratory result for which diagnostic finding that is indicative of ischemia? A. Increased serum potassium levels B. Decreased serum phosphorus levels C. Electroencephalogram (EEG) wave increases D. ST segment depression on electrocardiogram (ECG)

D. ST segment depression on electrocardiogram (ECG)

Nurse Jay is caring for a client with an ongoing transfusion of packed RBC's when suddenly the client is having difficulty of breathing, skin is flushed and having chills. Which action should nurse jay take first? A. Administer oxygen. B. Place the client on droplight. C. Check the client's temperature. D. Stop the transfusion.

D. Stop the transfusion. The client in this situation is experiencing transfusion reaction so the priority action of the nurse is to first stop the transfusion.

A client with coronary artery disease is admitted to the medical nursing unit after experiencing an episode of dizziness and shortness of breath. The nurse suspects that the client is experiencing decreased cardiac output, dyspnea, and syncopal episodes related to possible dysrhythmias. Which action should the nurse take in the care of the client? A. Place the client on a cardiac monitor. B. Check capillary refill at least once per shift. C. Monitor oxygen saturation levels every 4 hours. D. Measure the client's blood pressure every 4 hours.

A. Place the client on a cardiac monitor.

A 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 or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A Ventricular tachycardia B Ventricular fibrillation C Atrial fibrillation D Asystole

B. Ventricular fibrillation

A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI). The nurse should monitor the client for which most common complication of MI? A. Heart failure B. Cardiogenic shock C. Cardiac dysrhythmias D. Recurrent myocardial infarction

C. Cardiac dysrhythmias Dysrhythmias are the most common complication and cause of death after an MI. Heart failure, cardiogenic shock, and recurrent MI are also complications but occur less frequently.

The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2 mmHg, blood pressure is 90/50mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? A. Slow the IV infusion rate B. Administer dopamine C. No interventions are needed at this time D. Increase the IV infusion rate

D. Increase the IV infusion rate

A paradoxical pulse occurs in a client who had a coronary artery bypass graft (CABG) surgery 2 days ago. Which of the following surgical complications should the nurse suspect? A. Left-sided heart failure B. Aortic regurgitation C. Complete heart block D. Pericardial tamponade

D. Pericardial tamponade (Cardiac Tamponade) A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (pulse amplitude alternation from beat to beat, with a regular rhythm). Aortic regurgitation may cause bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).

The nurse is reviewing a rhythm strip obtained from the cardiac monitor. The strip shows complexes that are premature and have no P wave, and the QRS complexes are wide and bizarre. There is a compensatory pause. How should the nurse interpret these ectopic beats? A. Atrial fibrillation B. Ventricular fibrillation C. Premature atrial contractions D. Premature ventricular contractions

D. Premature ventricular contractions

A client who is unresponsive and pulseless and who has a possible neck injury is brought into the emergency department after a motor vehicle crash. What should the nurse do to open the client's airway? A. Insert oropharyngeal airway. B. Tilt the head and lift the chin. C. Place in the recovery position. D. Stabilize the skull and push up the jaw.

D. Stabilize the skull and push up the jaw. the health care team uses the jaw-thrust maneuver to open the airway until a radiograph confirms that the client's cervical spine is stable to avoid potential aggravation of a cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and option 3 can be ineffective for opening the airway.

The nurse in the emergency department is assessing a client with chest pain. Which finding should help the nurse determine that the pain is caused by myocardial infarction (MI)? A. The client experienced no nausea or vomiting. B. The pain was described as burning and gnawing. C. The client reports that the pain began while pushing a lawnmower. D. The pain, unrelieved by nitroglycerin, was relieved with morphine sulfate.

D. The pain, unrelieved by nitroglycerin, was relieved with morphine sulfate.

When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse's first action should be to a. suction the mouth and oropharynx. b. immobilize the cervical spine. c. administer supplemental oxygen. d. obtain venous access

b. immobilize the cervical spine When there is a risk of spinal cord injury, the nurse's initial action is immobilization of the cervical spine during positioning of the head and neck for airway management. Suctioning, supplemental oxygen administration, and venous access are also necessary after the cervical spine is protected by immobilization.

A 67-year-old patient who has fallen from a ladder is transported to the emergency department by ambulance. The patient is unconscious on arrival and accompanied by family members. During the primary survey of the patient, the nurse should a. assess a full set of vital signs. b. obtain a Glasgow Coma Scale score. c. attach a cardiac ECG monitor. d. ask about chronic medical conditions.

b. obtain a Glasgow Coma Scale score. The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

The healthcare provider is caring for a patient who has a diagnosis of cardiogenic shock secondary to left ventricular dysfunction. The goals of pharmacotherapy for this patient include which of these outcomes? Select all that apply. A.Decreased preload B. Increased contractility C. Decreased cardiac output D. Increased after load E. Increased peripheral resistance

A and B

A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to? A. Black. B. Green. C. Red. D. Yellow.

D. Yellow. The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is YELLOW.

A client newly diagnosed with angina pectoris asks the nurse how to prevent angina attacks. Which instruction should the nurse incorporate in a teaching session? A. Avoid straining during bowel movements. B. Plan all activities for early in the morning. C. Eat fewer, larger meals for more efficient digestion. D. Adjust medication doses freely until symptoms do not recur.

A. Avoid straining during bowel movements.

A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? A. Blood pressure and peripheral perfusion B. Sensation of palpitations C. Causative factors such as caffeine D. Precipitating factors such as infection

A. Blood pressure and peripheral perfusion Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output.

A client has just been admitted to the emergency department with chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis? A. Stable angina B. Unstable angina C. Prinzmetal's angina D. New-onset myocardial infarction (MI)

D. New-onset myocardial infarction (MI)

What is the most important nursing action when measuring a pulmonary artery wedge pressure (PAWP)? A. Have the client bear down when measuring the PAWP B. Deflate the balloon as soon as the PAWP is measured C. Place the client in a supine position before measuring the PAWP D. Flush the catheter with heparin solution after the PAWP is determined.

B. Deflate the balloon as soon as the PAWP is measured While the balloon must be inflated to measure the PAWP, leaving the balloon inflated will interfere with blood flow to the lung.

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

A and B

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

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

A client recovering from cardiogenic shock is experiencing an alteration in the level of consciousness. The nurse suspects that the client's decreased level of consciousness results from a decrease in cardiac output. What other finding would support this nurse's analysis? A. Pedal pulses faintly palpable B. Blood pressure of 118/70 mm Hg C. Urinary output of 60 mL per hour D. Lung fields clear with respirations of 22 breaths per minute

A. Pedal pulses faintly palpable In cardiogenic shock, the client's heart is unable to generate cardiac output to meet the body's demand. A major role for the nurse caring for the client experiencing cardiogenic shock is assessing and monitoring the client's hemodynamic status in response to treatment. If the client is experiencing a decrease in cardiac output, the nurse would expect to see a decrease in the strength and quality of peripheral pulses; a decrease in urinary output (less than 30 mL per hour in an adult); a decrease in blood pressure; adventitious breath sounds; and cool, pale skin.

A client is brought to the emergency department having experienced blood loss due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered. The nurse determines that the reason behind this order is to: A. Provide clotting factors and volume expansion. B. Increase hemoglobin, hematocrit, and neutrophil levels. C. Treat platelet dysfunction. D. Treat thrombocytopenia.

A. Provide clotting factors and volume expansion. Fresh-frozen plasma may be used to provide clotting factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away. Option B is incorrect since it will not specifically increase the hemoglobin, hematocrit, and neutrophil level. Options C and D are incorrect since FFP does not contain any platelet.

You have a patient who is in atrial fibrillation and going to be cardioverted. You set the monitor to sync to which wave? A. R wave B. Q wave C. T wave D. S wave

A. R wave

Which of the following conditions is most commonly responsible for myocardial infarction? A. Aneurysm B. Heart failure C. Coronary artery thrombosis D. Renal failure

C. Coronary artery thrombosis Coronary artery thrombosis causes an inclusion of the artery, leading to myocardial death. An aneurysm is an outpouching of a vessel and doesn't cause an MI. Renal failure can be associated with MI but isn't a direct cause. Heart failure is usually a result from an MI.

The nurse is assessing a client with a diagnosis of abdominal aortic aneurysm (AAA). Which assessment findings are most likely related to the AAA? Select all that apply. A. Headache B. Pulsatile abdominal mass C. Hyperactive bowel sounds D. Systolic bruit over the area of the mass E. Subjective sensation of the heart beating in the abdomen

B, D, E

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Irregular pulse. B. Ecchymosis in the flank area. C. A deviated trachea. D. Unequal pupils

C. A deviated trachea. A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated.

The healthcare provider is caring for a patient with a diagnosis of hypomagnesemia and a QT interval of 0.50 seconds. Which of these, if noted on the cardiac monitor, is an indication the patient's condition is worsening? A. Premature ventricular contractions B. Narrow QRS complexes C. An R-R interval of 1 second D. A polymorphic ventricular tachycardia

D. A polymorphic ventricular tachycardia -An R-R interval of 1second translates to a heart rate of 60 beats per minute, which is a normal finding. -Narrow QRS complexes are associated with a variety of tachycardias, but is not expected in this situation. -The patient's history of hypomagnesemia and prolonged QT interval puts the patient at risk of developing torsades de pointes, a polymorphic ventricular tachycardia that can potentially degenerate into a ventricular fibrillation.

Nurse Rick is administering a 2 unit packed RBC's on a client with a low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood? A. Microfusion set. B. Polyvol Pro Burette Set. C. Photofusion set. D. Tubing with an in-line filter

D. Tubing with an in-line filter The in-line filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused with the client. Option A is incorrect since the tubing that should be used is a macro drip. Option B is used for administration of IV medication infusion. Option C is incorrect since blood does not need any protection from light.

The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions. 1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant. 2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week. 3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days. 4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night. 5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour. A. 2,5,3,4,1 B. 3,1,4,5,2 D. 2,5,1,4,3

The client with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate easily. The woman with lower left quadrant pain is at risk for a life-threatening ectopic pregnancy. The 15-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. Lastly, the woman with mid epigastric pain is suffering from an ulcer, but follow-up diagnostic testing can be scheduled with a primary care provider.

A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen? A. 15 minutes. B. 30 minutes. C. 45 minutes. D. 60 minutes

A. 15 minutes.

You are caring for a patient with a hypertensive crisis. The patient is in an emergent hypertensive crisis if they start to show which signs or symptoms? Select all that apply. A. Facial drooping B. Chest pain C. Loss of consciousness D. Headache E. Epistaxis

A, B, C

The nurse is developing a plan of care for a client with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply. A. Assess peripheral circulation. B. Monitor for abdominal distention. C. Tell the client that abdominal pain is expected. D. Turn the client to the side to look for ecchymoses on the lower back. E. Perform deep palpation of the abdomen to assess the size of the aneurysm.

A, B, D If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected. Doing so could place the client at risk for rupture.

The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply. A. Headache B. Tachycardia C. Hypertension D. Apprehension E. Distended neck veins F. A sense of impending doom

A, B, D, F Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood containing antigens different from the client's own antigens are infused, antigen-antibody complexes are formed in the client's blood. These complexes destroy the transfused cells and start inflammatory responses in the client's blood vessel walls and organs. The reaction may include fever and chills or may be life threatening with disseminated intravascular coagulation and circulatory collapse. Other manifestations include headache, tachycardia, apprehension, a sense of impending doom, chest pain, low back pain, tachypnea, hypotension, and hemoglobinuria. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins and hypertension are characteristics of circulatory overload.

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Check all that apply. A. Tachycardia B. Hypertension C. Increased CVP D. Increased urine output E. Jugular vein distention

A, C, E Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid thready pulse. Tamponade causes hypotension and a narrowed pulse pressure. As the tamponade increases, pressure on the heart interferes with the ejection of blood from the left ventricle, resulting in an increased pressure in the right side of the heart and the systemic circulation. As the heart because more inefficient, there is a decrease in kidney perfusion and therefore urine output. The increased venous pressure caused JVD.

A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which actions should the nurse implement in the postprocedure period? Select all that apply. A. Restricting visitors B. Checking the client's groin for bleeding C. Encouraging the client to increase fluid intake D. Placing the client's bed in the high Fowler's position E. Instructing the client to move the toes when checking circulation, motion, and sensation

A, C, E Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high Fowler's position (flexion) increases the risk of occlusion or hemorrhage.

When developing a teaching plan for a client with endocarditis, which of the following points is most essential for the nurse to include? A. "Report fever, anorexia, and night sweats to the physician." B. "Take prophylactic antibiotics after dental work and invasive procedures." C. "Include potassium rich foods in your diet." D. "Monitor your pulse regularly."

A. "Report fever, anorexia, and night sweats to the physician." The most essential teaching point is to report signs of relapse, such as fever, anorexia, and night sweats, to the physician. To prevent further endocarditis episodes, prophylactic antibiotics are taken before and sometimes after dental work, childbirth, or GU, GI, or gynecologic procedures. A potassium-rich diet and daily pulse monitoring aren't necessary for a client with endocarditis.

A client has an order to receive a one unit of packed RBC's. The nurse make sure which of the following intravenous solutions to hang with the blood product at the client's bedside? A. 0.9% sodium chloride. B. 5% dextrose in 0.9% sodium chloride. C. Balanced Multiple Maintenance Solution with 5% Dextrose. D. 5% dextrose in 0.45% sodium chloride.

A. 0.9% sodium chloride. 0.9% sodium chloride is a standard solution used to follow infusion of blood products. Options B, C, and D: IV solution containing dextrose in water will hemolyze red cells.

A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. 1. Assess for spontaneous respirations. 2. Give supplemental oxygen per mask. 3. Insert a Foley catheter if not contraindicated. 4. Obtain a full set of vital signs. 5. Remove patient's clothing. 6. Secure/start two large-bore IVs with normal saline. 7. Use the chin lift or jaw thrust method to open the airway. A. 1, 7, 2, 6, 4, 5, 3 B. 7, 1, 4, 2, 3, 5, 6 C. 4, 1, 5, 7, 6, 3, 2 D. 5, 4, 1, 7, 2, 6, 3

A. 1, 7, 2, 6, 4, 5, 3 For multiple trauma victims, a lot of interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are a priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.

The healthcare provider is assessing a patient with a diagnosis of an abdominal aneurysm (AAA). Which of these assessment findings will the healthcare provider anticipate? A. A bruit auscultated over the periumbilical area B. A friction rub auscultated in the right upper abdominal quadrant C. A venous hum auscultated in the epigastric area. D. Tenderness felt over the costovertebral angle (CVA)

A. A bruit auscultated over the periumbilical area

A client is admitted to a telemetry unit with a potassium (K+) level of 6.3 mEq/L. In analyzing the cardiac rhythm, which electrocardiogram (ECG) changes should the nurse anticipate? A. A sinus rhythm with a peaked T wave B. A sinus tachycardia with an extra U wave C. A sinus rhythm with a depressed ST segment D. A sinus tachycardia with a prolonged QT interval

A. A sinus rhythm with a peaked T wave

Which of the following terms describes the force against which the ventricle must expel blood? A. Afterload B. Cardiac output C. Overload D. Preload

A. Afterload Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled by the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole.

A client is scheduled for a cardiac catheterization. Which data, if noted in the client's health record, should the nurse report to the health care provider before the catheterization? A. Allergy to shellfish B. History of hypertension C. Client slept poorly through the night D. History of coronary artery disease (CAD)

A. Allergy to shellfish

A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. A - Secure/start two large-bore IVs with normal saline B - Use the chin lift or jaw thrust method to open the airway. C - Assess for spontaneous respirations D - Give supplemental oxygen per mask. E - Obtain a full set of vital signs. F - Remove patient's clothing. G - Insert a Foley catheter if not contraindicated. A. C, B, D, A, E, F, G B. B,C,A,D,E,F,G C. C,B,A,D,G,F,E D. C,B,A,D,E,F,G

A. C, B, D, A, E, F, G For a multiple trauma victim, many interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.

A client with infective endocarditis is at risk for heart failure. What should the nurse monitor the client for on an ongoing basis? A. Crackles, peripheral edema, and weight gain B. Confusion, decreasing level of consciousness, and aphasia C. Respiratory distress, chest pain, and use of accessory muscles D. Flank pain with radiation to the groin, accompanied by hematuria

A. Crackles, peripheral edema, and weight gain The client with infective endocarditis may experience both left- and right-sided heart failure, and thus the nurse assesses the client for both pulmonary and peripheral symptoms, such as crackles, peripheral edema, and weight gain. Option 3 contains symptoms that occur with pulmonary embolism, which is not related to the question. Options 2 and 4 relate to emboli to the brain and kidney, respectively. The vegetation around the infected cardiac area could travel as emboli to these areas, but they are a less common complication of this disorder.

The health care nurse plans a visit to a client who has just been discharged from the hospital after receiving a permanent pacemaker. What priority items should the nurse check the client's home for in order to maintain a safe environment for the client? A. Electrical items that have strong electric currents or magnetic fields B. Hair dryers and electric blankets, which can cause electromagnetic interference C. Electrical items such as a personal computer or security device, which can cause failure to pace D. Electric toothbrushes that, even if used by other family members, can cause microshock to occur

A. Electrical items that have strong electric currents or magnetic fields

The nurse has just received a transfer client from the postanesthesia care unit (PACU) who has just had a right femoral-popliteal bypass graft. How often should the nurse plan to assess the client's neurovascular status to the leg? A. Every hour B. Every 2 hours C. Every 4 hours D. Every 5 minutes

A. Every hour After the return of the client from PACU, neurovascular status (color, temperature, peripheral pulses, motion, and sensitivity) are checked every hour. Adverse changes are reported to the health care provider immediately because they could indicate graft occlusion. The time frame in option 4 is unnecessary. Options 2 and 3 are too infrequent for the immediate postoperative period.

Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? A. Heart failure B. Diabetes C. MI D. Pericardial effusion

A. Heart failure Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with pericarditis.

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: A. Hypotension and dizziness B. Nausea and vomiting C. Hypertension and headache D. Flat neck veins

A. Hypotension and dizziness The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

The nurse is caring for a client admitted to the hospital with chest pain and possible myocardial infarction (MI). The health care provider has prescribed laboratory studies to evaluate the client's progress. Which laboratory test result should the nurse specifically monitor because it is related to the presence of MI? A. Increased troponin levels B. Increased hematocrit (Hct) C. Decreased white blood cell (WBC) count D. Increased creatine kinase (CK-MM) levels

A. Increased troponin levels

A client's electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is: A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia D. Sinus dysrhythmia

A. Normal sinus rhythm

The physician orders continuous intravenous nitroglycerin infusion for the client with MI. Essential nursing actions include which of the following? A. Obtaining an infusion pump for the medication B. Monitoring BP q4h C. Monitoring urine output hourly D. Obtaining serum potassium levels daily

A. Obtaining an infusion pump for the medication IV nitro infusion requires an infusion pump for precise control of the medication. BP monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). Which observation in the PVCs would indicate to the nurse that this therapy is ineffective? A. Occur in pairs B. Be unifocal in appearance C. Be fewer than six per minute D. Fall after the end of the T wave

A. Occur in pairs

The nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. What should the nurse do? A. Return the bag to the blood bank. B. Infuse the blood using filter tubing. C. Add 10 mL normal saline to the bag. D. Agitate the bag to mix contents gently.

A. Return the bag to the blood bank.

Which of the following results is the primary treatment goal for angina? A. Reversal of ischemia B. Reversal of infarction C. Reduction of stress and anxiety D. Reduction of associated risk factors

A. Reversal of ischemia Reversal of the ischemia is the primary goal, achieved by reducing oxygen consumption and increasing oxygen supply. An infarction is permanent and can't be reversed.

A client, without history of respiratory disease, has experienced sudden onset of chest pain and dyspnea and is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescription for this client? A. Semi-Fowler's position, oxygen, and morphine sulfate intravenously (IV) B. Supine position, oxygen, and meperidine hydrochloride (Demerol) intramuscularly (IM) C. High Fowler's position, oxygen, and two tablets of acetaminophen with codeine (Tylenol #3) D. High Fowler's position, oxygen, and meperidine hydrochloride (Demerol) intravenously (IV)

A. Semi-Fowler's position, oxygen, and morphine sulfate intravenously (IV) Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. The supine position will increase the dyspnea that occurs with pulmonary embolism. High Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered IV. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.

Which of the following interventions should be the first priority when treating a client experiencing chest pain while walking? A. Sit the client down B. Get the client back to bed C. Obtain an ECG D. Administer sublingual nitroglycerin

A. Sit the client down The initial priority is to decrease the oxygen consumption; this would be achieved by sitting the client down. An ECG can be obtained after the client is sitting down. After the ECGm sublingual nitro would be administered. When the client's condition is stabilized, he can be returned to bed.

A young woman has just been diagnosed with rheumatic heart disease. The client's husband asks the nurse why the client must tell the dentist about this condition before dental cleaning or other work. The nurse tells the client's husband that this should be done for which reason? A. To allow for prophylactic antibiotic therapy B. To prevent the client from going into heart failure C. To ensure that the dentist uses a lower-speed drill when doing dental work D. To ensure that the dentist uses a type of lidocaine that doesn't contain epinephrine

A. To allow for prophylactic antibiotic therapy The client with a history of rheumatic heart disease is at risk for developing infective endocarditis. The client should notify all health care providers and dentists about this past health problem. The health care provider or dentist will then initiate prophylactic antibiotic therapy before any procedure that is invasive or that could result in bleeding. The other options are not related to the question.

Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client should expect that which medication specific for chemical cardioversion would be needed? A. Lidocaine (Xylocaine) B. Nifedipine (Procardia) C. Amiodarone (Cordarone) D. Nitroglycerin (Nitro-Bid, Nitrostat, others)

C. Amiodarone (Cordarone)

The nurse is preparing to administer amiodarone (Cordarone) intravenously. To provide a safe environment, the nurse should ensure that which specific item is in place for the client before administering the medication? A. Oxygen therapy B. Oxygen saturation monitor C. Continuous cardiac monitoring D. Noninvasive blood pressure cuff

C. Continuous cardiac monitoring

The nurse is admitting a client suspected of having myocardial infarction (MI) to the hospital. The nurse anticipates which laboratory test will be prescribed to definitively diagnose MI? A. Lipid panel B. B-natriuretic peptide (BNP) C. Creatinine kinase (CK-MB [CK2]) D. Comprehensive metabolic panel (CMP)

C. Creatinine kinase (CK-MB [CK2])

During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the client's lung bases. On further assessment, the nurse notes that the client has distended neck veins and an increase in central venous pressure. Which complication of the blood transfusion should the nurse suspect the client is experiencing? A. Sepsis B. Circulatory overload C. Mild allergic reaction D. Anaphylactic reaction

B. Circulatory overload

A patient is being discharged after the insertion of a permanent pacemaker. Which statement made by the patient indicates an understanding regarding appropriate self-care? A. "Every morning I will perform arm and shoulder stretches." B. "Each day I'll take my pulse and record it in a log." C. "I'll have to get rid of my microwave oven." D. "I won't be able to use my electric blanket anymore."

B. "Each day I'll take my pulse and record it in a log."

In a multiple-trauma victim, which assessment finding signals the most serious and life-threatening condition? A. Gross deformity in a lower extremity B. A deviated trachea C. Decreased bowel sounds D. Hematuria

B. A deviated trachea A deviated trachea is a symptoms of tension pneumothorax. All of the other symptoms need to be addressed, but are of lesser priority.

What is the first intervention for a client experiencing MI? A. Administer morphine B. Administer oxygen C. Administer sublingual nitroglycerin D. Obtain an ECG

B. Administer oxygen Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they're more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI.

The nurse is caring for a client with a diagnosis of angina, when the client requests something to drink. Which beverage should the nurse give to the client? A. Cola B. Juice C. Coffee D. Iced tea

B. Juice Clients experiencing angina should not consume caffeinated beverages because of the vasoconstrictive effect associated with caffeine. Options 1, 3, and 4 are items that contain caffeine.

A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client complains of feeling lightheaded. Which finding should the nurse anticipate on auscultation of the heartbeat? A. A regular apical pulse B. An irregular apical pulse C. A very slow regular apical pulse D. A very rapid regular apical pulse

B. An irregular apical pulse The most accurate means of assessing pulse rhythm is by auscultation of the apical pulse. When a client has PVCs, the rate is irregular and if the radial pulse is taken, a true picture of what is occurring is not obtained. A very slow regular apical pulse indicates bradycardia. A very rapid regular apical pulse indicates tachycardia.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: A. Sinus tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation

B. Atrial fibrillation

Nurse Amanda is caring for a client with severe blood loss who is prescribed with multiple transfusion of blood. Nurse Amanda obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias? A. Cardiac monitor. B. Blood warmer. C. ECG machine. D. Infusion pump

B. Blood warmer. Rapid transfusion of cool blood put the client at risk for cardiac dysrhythmias. Options A and C are used to assess for any blood transfusion-related complication but they do not prevent the occurrence of cardiac dysrhythmia. Option D is not beneficial in this case since the infusion must be given rapidly

The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. Which action should the nurse take? A. Prepare for defibrillation. B. Continue to monitor the rhythm. C. Notify the health care provider immediately. D. Prepare to administer lidocaine hydrochloride (Xylocaine).

B. Continue to monitor the rhythm. -As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. -Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the health care provider needs to be notified. -Defibrillation is done to treat ventricular fibrillation. -Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output.

What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)? A. Have the client bear down when measuring the PCWP B. Deflate the balloon as soon as the PCWP is measured C. Place the client in a supine position before measuring the PCWP D. Flush the catheter with heparin solution after the PCWP is determined.

B. Deflate the balloon as soon as the PCWP is measured While the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lung. Bearing down will increase intrathoracic pressure and alter the reading. While a supine position is preferred; it is not essential. Agency protocols relative to flushing of unused ports must be followed.

n unconscious patient arrives at the emergency department. Periumbilical (Cullen's sign) and flank ecchymosis (Grey Turner's sign) is noted , and a ruptured abdominal aortic aneurysm (AAA) is suspected. Which of these additional assessment findings will the healthcare provider anticipate? A. Decorticate posturing B. Expiratory wheezes C. Pale, clammy skin D. Pinpoint pupils

C. Pale, clammy skin

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? A. Breathe deeply, regularly, and easily B. Inhale deeply and cough forcefully every 1 to 3 seconds C. Lie down flat in bed D. Remove any metal jewelry

B. Inhale deeply and cough forcefully every 1 to 3 seconds Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: A. Increase the IV infusion rate B. Notify the physician promptly C. Increase the oxygen concentration D. Administer a prescribed analgesic

B. Notify the physician promptly PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

The nurse is assessing a client who has been hospitalized with acute pericarditis for signs of complications. For which manifestation of cardiac tamponade should the nurse monitor the client? A. Bradycardia B. Paradoxical pulse C. Flattened jugular veins D. Bounding heart sounds

B. Paradoxical pulse

The nurse admits a client with myocardial infarction (MI) to the coronary care unit (CCU). What should the nurse plan to do in delivering care to this client? A. Begin thrombolytic therapy. B. Place the client on continuous cardiac monitoring. C. Infuse intravenous (IV) fluid at a rate of 150 mL per hour. D. Administer oxygen at a rate of 6 L per minute by nasal cannula

B. Place the client on continuous cardiac monitoring. Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring. Thrombolytic therapy may or may not be prescribed by the health care provider. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event. The nurse should ensure there is an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep-vein-open rate to prevent fluid overload and heart failure. Oxygen should be administered at a rate of 2 to 4 liters per minute unless otherwise prescribed

After terminating a blood transfusion during a reaction, which action should the nurse immediately be taken next? A. Run a solution of 5% dextrose in water. B. Run normal saline at a keep-vein-open rate. C. Remove the IV line. D. Fast drip 200ml normal saline.

B. Run normal saline at a keep-vein-open rate. The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. Option A: IV solution containing dextrose will hemolyze the red cells. Option C: The nurse will not remove the IV line because then there would be no IV access route. Option D: Doing a fast drip will potentially lead to congestion and is not done without the physician order.

When caring for a patient with a cardiac dysrhythmia, which laboratory value is a priority for the healthcare provider to monitor? A. BUN and creatinine B. Sodium, potassium, and calcium C. Hemoglobin and hematocrit D. PT and INR

B. Sodium, potassium, and calcium

The nurse is monitoring a client who had a myocardial infarction for signs of cardiogenic shock. The nurse checks the client for which signs that are indicative of cardiogenic shock? A. Oliguria, bradypnea, and warm dry skin B. Tachycardia, confusion, and hypotension C. Bradycardia, hypertension, and a pale appearance D. Peripheral edema, distended neck veins, and hepatic engorgement

B. Tachycardia, confusion, and hypotension The nurse is monitoring a client who had a myocardial infarction for signs of cardiogenic shock. The nurse checks the client for which signs that are indicative of cardiogenic shock? Rationale: Classical clinical manifestations of cardiogenic shock include tachycardia; altered sensorium (confusion); hypotension; tachypnea; oliguria; and cold, clammy, cyanotic skin. Options 1, 3, and 4 are incorrect. Option 4 identifies manifestations of right-sided heart failure, not cardiogenic shock.

A client is admitted to the cardiac intensive care unit after coronary artery bypass graft surgery (CABG). The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets that which may be the reason? A. This is normal. B. The tube may be occluded. C. The lung has fully reexpanded. D. The client needs to cough and deep breathe.

B. The tube may be occluded. After coronary artery bypass graft surgery, chest tube drainage should not exceed 100 to 150 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after coronary artery bypass graft surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse. Options 1, 3, and 4 are incorrect interpretations.

A 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 or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial fibrillation D. Asystole

B. Ventricular fibrillation Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

A 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 over 100. The nurse determines that the client is experiencing: A. Premature ventricular contractions B. Ventricular tachycardia C. Ventricular fibrillation D. Sinus tachycardia

B. Ventricular tachycardia Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

After cardiac surgery, a client's blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following? A. 46 mm Hg B. 80 mm Hg C. 95 mm Hg D. 90 mm Hg

C. 95 mm Hg MAP: [systolic pressure - diastolic pressure]/3 + diastolic pressure

The home health nurse is performing an initial assessment on a client who has arrived home after insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident? A. "I will never be able to operate a microwave oven again." B. "I should expect occasional feelings of dizziness and fatigue." C. "I will take my pulse in the wrist or neck daily and record it in a log." D. "Moving my arms and shoulders vigorously helps check pacemaker functioning."

C. "I will take my pulse in the wrist or neck daily and record it in a log." The home health nurse is performing an initial assessment on a client who has arrived home after insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident? Rationale: Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately so as to note any variation in the pulse rate or rhythm that may need to be reported to the health care provider. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the health care provider is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? A. Immediately defibrillate B. Prepare for pacemaker insertion C. Administer amiodarone (Cordarone) intravenously D. Administer epinephrine (Adrenaline) intravenously

C. Administer amiodarone (Cordarone) intravenously First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated.

You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. a - An ambulatory, dazed 25-year-old male with a bandaged head wound b - An irritable infant with a fever, petechiae, and nuchal rigidity c - A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d - A 50-year-old female with moderate abdominal pain and occasional vomiting A. B,C,D,A B. A,B,D,C C. B, A, D, C D. B,A,C,D

C. B, A, D, C An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary

A patient is diagnosed with an abdominal aortic aneurysm (AAA). Which of the patient's vital signs will be a priority for the healthcare provider to monitor? A. Pulse rate B. Respiratory rate C. Blood pressure D. Core temperature

C. Blood pressure

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Palpation and auscultation of the abdomen B. Initiation of pulse oximetry C. Brief neurologic assessment D. Complete set of vital signs

C. Brief neurologic assessment A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey

The nurse suspects that a client who had a myocardial infarction is developing cardiogenic shock. The nurse should assess for which peripheral vascular manifestation of this complication? A. Flushed, dry skin with bounding pedal pulses B. Warm, moist skin with irregular pedal pulses C. Cool, clammy skin with weak or thready pedal pulses D. Cool, dry skin with alternating weak and strong pedal pulses

C. Cool, clammy skin with weak or thready pedal pulses Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin.

A client is receiving transfusion of one unit of cryoprecipitate. The nurse will review which of the following laboratory studies to assess the effectiveness of the therapy? A. Serum electrolytes. B. White blood cell count. C. Coagulation studies. D. Hematocrit count

C. Coagulation studies. The evaluation of an effective response of a cryoprecipitate transfusion is assessed by monitoring coagulation studies and fibrinogen levels. Options A, C, and D are reviewed after transfusion of packed reb blood cells.

A nurse is caring for a client requiring surgery and is ordered to have a standby blood secured if in case a blood transfusion is needed during or after the procedure. The nurse suggest to the client to do which of the following to lessen the risk of possible transfusion reaction? A. Request that any donated blood be screened twice by the blood bank. B. Take iron supplement prior the surgery and eat green leafy vegetables. C. Do an autologous blood donation. D. Have a family member donate their own blood.

C. Do an autologous blood donation. A donation of the own blood is autologous. Doing this will prevent the risk of transfusion reaction.

If medical treatments fail, which of the following invasive procedures is necessary for treating cardiomyopathy? A. Cardiac catheterization B. Coronary artery bypass graft (CABG) C. Heart transplantation D. Intra-aortic balloon pump (IABP)

C. Heart transplantation The only definitive treatment for cardiomyopathy that can't be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.

A client has developed atrial fibrillation and has a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? A. Flat neck veins B. Nausea and vomiting C. Hypotension and dizziness D. Hypertension and headache

C. Hypotension and dizziness The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

A patient is being treated for hemorrhagic shock secondary to multiple rib fractures and a lacerated liver. Two units of packed red blood cells have been administered. Which of these measurements is an indication the patient has received adequate volume replacement? A. Oxygen saturation 90% B. Increased serum creatinine C. Decreased right atrial pressure D. Decreased serum lactate

D. Decreased serum lactate

The nurse has given a client with myocardial infarction (MI) simple instructions on preventing some of the complications of bedrest. The nurse should intervene and determine the client needs further teaching if the client were performing which activity, which is contraindicated? A. Deep breathing and coughing B. Repositioning self from side to side C. Isometric exercises of the arms and legs D. Ankle circles and plantar and dorsiflexion exercises

C. Isometric exercises of the arms and legs The client with MI should avoid activities that tense the muscles, such as isometric exercises. These increase intra-abdominal and intrathoracic pressures and can decrease the cardiac output. They can also trigger vagal stimulation, causing bradycardia. The exercises in options 1, 2, and 4 are acceptable

The nurse is caring for a client with a diagnosis of suspected myocardial infarction. The client has been experiencing chest pain unrelieved by nitroglycerin. The nurse administers morphine sulfate 5 mg intravenously as prescribed. Which nursing action has the highest priority following the administration of the morphine sulfate? A. Monitor urinary output. B. Increase the oxygen flow rate. C. Monitor respirations and blood pressure. D. Place the client in Trendelenburg

C. Monitor respirations and blood pressure. Morphine sulfate is administered to control pain in cardiac clients. The nurse assesses the client's heart rhythm and vital signs, especially noting the client's respirations. Signs of morphine sulfate toxicity include respiratory depression and hypotension. Urinary output is monitored but is not a primary concern with administration of this medication. The oxygen flow rate is not increased without a health care provider's prescription to do so. The client would be placed in Trendelenburg's position if a sudden drop in blood pressure occurs.

The nurse notes ventricular fibrillation on the client's cardiac monitor. What assessment finding should the nurse anticipate noting in the client? A. Dizzy and nauseated B. Hypotensive and pale C. Pulseless and unresponsive D. Complaining of severe palpitations

C. Pulseless and unresponsive

A client is being brought into the emergency department after suffering a head injury. Which should the nurse assess first? A. Level of consciousness B. Pulse and blood pressure C. Respiratory rate and depth D. Ability to move extremities

C. Respiratory rate and depth The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option 2), followed by evaluation of the neurological status (options 1 and 4).

The nurse should expect a client experiencing an acute myocardial infarction to manifest which pattern first on the electrocardiogram? A. Absent P waves B. T wave elevation C. ST segment elevation D. An abnormal Q wave

C. ST segment elevation

Which of the following blood tests is most indicative of cardiac damage? A. Lactate dehydrogenase B. Complete blood count (CBC) C. Troponin I D. Creatine kinase (CK)

C. Troponin I Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren't detectable in people without cardiac injury. Lactate dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse reviews the postprocedure prescriptions expecting to note a prescription that the client should remain on bedrest in which position? A. In the high Fowler's position B. With the head of the bed elevated at least 60 degrees C. With the head of the bed elevated no more than 30 to 45 degrees D. With the foot of the bed elevated as much as tolerated by the client

C. With the head of the bed elevated no more than 30 to 45 degrees Following cardiac catheterization, the affected leg is kept straight and the head is elevated no more than 30 to 45 degrees until hemostasis is adequately achieved. The extremity in which the catheter was inserted is usually kept straight for 4 to 6 hours unless a vascular closure device is used. If the femoral artery was used, strict bedrest is usually enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The nurse always checks the cardiologist's postprocedure activity prescription.

Which of the following tests is used most often to diagnose angina? A. Chest x-ray B. Echocardiogram C. Cardiac catheterization D. 12-lead electrocardiogram (ECG)

D. 12-lead electrocardiogram (ECG) The 12-lead ECG will indicate ischemia, showing T-wave inversion. In addition, with variant angina, the ECG shows ST-segment elevation. A chest x-ray will show heart enlargement or signs of heart failure, but isn't used to diagnose angina.

You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 1. Call for help and activate the code team. 2. Instruct a nursing assistant to get the emergency cart. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Perform the chin lift or jaw thrust maneuver. 5. Establish unresponsiveness. A. 5, 2, 4, 3, 1 B. 1, 5, 2, 4, 3 C. 1, 2, 5, 4, 3 D. 5, 1, 4, 3, 2

D. 5, 1, 4, 3, 2 Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.8 °F. Which action should the nurse take? A. Give an antipyretic and begin the transfusion. B. Proceed with the transfusion. C. Administer an antihistamine and begin the transfusion. D. Delay hanging the blood and inform the physician.

D. Delay hanging the blood and inform the physician. If the client has a temperature higher than 100 ° F, the unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further order. Options A and C are incorrect since the administration of the medicine will need the physician's prescription. Option B: The decision to administer the blood is not within the scope of nurse practice.

A client is hospitalized with chest pain and suspected myocardial infarction. The client has return of chest pain, and the nurse administers one 0.4-mg nitroglycerin tablet sublingually as prescribed. Which nursing action should the nurse implement next if the chest pain is not relieved? A. Administer morphine sulfate B. Increase the oxygen flow rate. C. Place the client in Trendelenburg's position. D. Administer a second sublingual nitroglycerin tablet in 5 minutes.

D. Administer a second sublingual nitroglycerin tablet in 5 minutes.

Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A. Complete history taking. B. Put the client on ECG monitoring. C. Notify the physician. D. Administer oxygen therapy via nasal cannula.

D. Administer oxygen therapy via nasal cannula. The priority goal is to increase myocardial oxygenation. Options A, B, and C: These actions are also appropriate and should be performed immediately.

A client with a diagnosis of angina pectoris who has been pain free for 2 days now complains of recurrent chest pain. The nurse notes a sinus tachycardia on the cardiac monitor. Based on this information, the nurse reviews the standing health care provider prescriptions and institutes which action initially? A. Obtains an ECG B. Notifies the health care provider C. Establishes an intravenous access D. Administers oxygen by nasal cannula

D. Administers oxygen by nasal cannula Myocardial ischemia is expressed symptomatically as angina (chest pain). The pain is related to an imbalance of myocardial oxygen supply and demand. Oxygen administration would help correct this imbalance. Oxygen administration can be accomplished quickly and can be working to provide relief while the other nursing actions (options 1, 2, and 3) are being implemented.

A client with myocardial infarction is exhibiting a cardiac rhythm that indicates premature ventricular contractions (PVCs).. The nurse ensures that which medication is available for use if prescribed? A. Digoxin (Lanoxin) B. Lisinopril (Prinivil) C. Verapamil (Calan SR) D. Amiodarone (Cordarone)

D. Amiodarone (Cordarone)

A client who developed complete heart block has been admitted to the telemetry unit from the postanesthesia care unit after insertion of a permanent demand ventricular pacemaker. As part of initial assessment, the nurse looks for a pacemaker spike after which occurrence if the client is reported to have a totally paced rhythm? A. Before each P wave B. Just after each P wave C. Just after each T wave D. Before each QRS complex

D. Before each QRS complex

The nurse is assigned to care for a client who had a permanent-demand ventricular pacemaker inserted. After the procedure, the nurse determines that there is good pacemaker function by noting that the pacemaker spike is present where? A. Before each P wave B. Just after each P wave C. Just after each T wave D. Before each QRS complex

D. Before each QRS complex

The healthcare provider is caring for a patient on a telemetry unit. The patient loses consciousness, and the healthcare provider notes ventricular fibrillation on the patient's cardiac monitor. Which intervention should the healthcare provider do first? A. Administer 100% oxygen via face mask at 8 liters/minute. B. Document the findings and continue to monitor. C. Ask the unit secretary to call the cardiologist. D. Begin cardiopulmonary resuscitation (CPR) and call for a defibrillator.

D. Begin cardiopulmonary resuscitation (CPR) and call for a defibrillator.

To verify the age of blood cells in a blood, the nurse will check which of the following? A. Blood type. B. Blood group. C. Blood identification number. D. Blood expiration date.

D. Blood expiration date. The safe storage of blood usually takes 35 days. Examining the expiration date is an important responsibility of a nurse prior hanging the blood.

The nurse is assigned to care for a client with coronary artery disease (CAD) who is scheduled for a cardiac catheterization. Which is the priority nursing action to assess after a cardiac catheterization? A. Temperature B. Urine output C. Potassium level D. Catheter insertion site

D. Catheter insertion site

A client remains in atrial fibrillation with rapid ventricular response despite pharmacological intervention. Synchronous cardioversion is scheduled to convert the rapid rhythm. What action should the nurse plan to take to ensure safety and prevent complications of this procedure? A. Cardiovert the client at 360 joules. B. Sedate the client before cardioversion. C. Ensure that emergency equipment is available. D. Check that the defibrillator is set on the synchronous mode

D. Check that the defibrillator is set on the synchronous mode Cardioversion is similar to defibrillation with two major exceptions: the countershock is synchronized to occur during ventricular depolarization (QRS complex), and less energy is used for the countershock. The rationale for delivering the shock during the QRS complex is to prevent the shock from being delivered during repolarization (T wave), often termed the "vulnerable period." If the shock is delivered during this period, the resulting complication is ventricular fibrillation. It is crucial that the defibrillator is set on the "synchronous" mode for a successful cardioversion. Cardioversion usually begins with 50 to 100 joules. Options 2 and 3 will not prevent complications.

When working with a client with cardiomyopathy, the nurse is careful to instruct the client not to bear down when having a bowel movement. The nurse explains to the client that avoiding this action is necessary to prevent which occurrence? A. Tachycardia B. Exercise tolerance C. Increased venous return D. Decreased cardiac output

D. Decreased cardiac output Bearing down while defecating causes a Valsalva effect that decreases cardiac output and venous return and puts the client at risk for syncope and dysrhythmias. Tachycardia is incorrect because Valsalva effect will cause bradycardia. Exercise tolerance and increased venous return do not occur with the Valsalva maneuver.

An infant brought to the emergency department is unresponsive and in respiratory distress. The nurse opens the infant's airway by which method? A. Flexion B. Jaw thrust C. Forward lift D. Head tilt-chin lift

D. Head tilt-chin lift The head tilt-chin lift is used to open the airway. The jaw thrust maneuver is used if neck trauma is suspected. There is no information in the question that indicates that neck trauma is present. Flexion and a forward lift would not open the airway.

When attending a client with a head and neck trauma following a vehicular accident, the nurse's initial action is to? A. Do oral and nasal suctioning. B. Provide oxygen therapy. C. Initiate intravenous access. D. Immobilize the cervical area.

D. Immobilize the cervical area. Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs. Options A, B, and C: Suctioning, oxygen therapy, and intravenous access are also done after the cervical spine is immobilize.

Which of the following conditions is the predominant cause of angina? A. Increased preload B. Decreased afterload C. Coronary artery spasm D. Inadequate oxygen supply to the myocardium

D. Inadequate oxygen supply to the myocardium Inadequate oxygen supply to the myocardium is responsible for the pain accompanying angina. Increased preload would be responsible for right-sided heart failure. Decreased afterload causes increased cardiac output. Coronary artery spasm is responsible for variant angina.

Which of the following is a compensatory response to decreased cardiac output? A. Decreased BP B. Alteration in LOC C. Decreased BP and diuresis D. Increased BP and fluid retention

D. Increased BP and fluid retention The body compensates for a decrease in cardiac output with a rise in BP, due to the stimulation of the sympathetic NS and an increase in blood volume as the kidneys retain sodium and water. Blood pressure doesn't initially drop in response to the compensatory mechanism of the body. Alteration in LOC will occur only if the decreased cardiac output persists.

Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion? A. Warming the blood prior transfusion. B. Informing the client that the transfusion usually takes 4 to 6 hours. C. Documenting blood administration in the client chart. D. Instructing the client to report any itching, chest pain, or dyspnea.

D. Instructing the client to report any itching, chest pain, or dyspnea. This will help the nurse take immediate action in case a reaction happens during a transfusion.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is most concerned with this dysrhythmia because: A. It is uncomfortable for the client, giving a sense of impending doom. B. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia. C. It is almost impossible to convert to a normal sinus rhythm. D. It can develop into ventricular fibrillation at any time

D. It can develop into ventricular fibrillation at any time Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Client's frequently experience a feeling of impending death. Ventricular tachycardia is treated with antiarrhythmic medications or magnesium sulfate, cardioversion (client awake), or defibrillation (loss of consciousness), Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: A. Stroke volume B. Cardiac output C. Venous pressure D. Left ventricular functioning

D. Left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.

The nurse is teaching a client with cardiomyopathy about home care safety measures. Which most important instruction should the nurse provide? A. Reporting pain B. Taking vasodilators C. Avoiding over-the-counter medications D. Moving slowly from a sitting to a standing position

D. Moving slowly from a sitting to a standing position Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Reporting pain, while important, is not directly related to the issue of safety. Vasodilators are not normally prescribed for the client with cardiomyopathy. Option 3, although important, is not directly related to the issue of safety

A client who is 36 hours post-myocardial infarction (MI) has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation were made? A. Skin cool but slightly diaphoretic B. Dyspnea noted only at the end of the exercise C. Preactivity blood pressure (BP) 140/84 mm Hg, postactivity BP 110/72 mm Hg D. Preactivity pulse rate 86 beats per minute, postactivity pulse rate 94 beats per minute

D. Preactivity pulse rate 86 beats per minute, postactivity pulse rate 94 beats per minute The nurse assesses vital signs and the level of fatigue with each activity. The client is not tolerating the activity if there is a drop in systolic BP greater than 20 mm Hg, changes in pulse rate of greater than 20 beats per minute, dyspnea, or chest pain. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise.

A client with a history of an abdominal aortic aneurysm suddenly complains of severe back and flank pain, accompanied by nausea. The client's pulse has increased from 80 to 94 beats per minute, and the blood pressure has dropped from 124/78 to 106/70 mm Hg. What should the nurse interpret that the client is experiencing? A. Renal calculi B. Appendicitis C. Sudden arterial embolus D. Rupture of the aneurysm

D. Rupture of the aneurysm

A client with a history of angina pectoris complains of acute midsternal chest discomfort. After assessment of the client, which medication should the nurse administer? A. Intravenous (IV) nitroglycerin B. IV morphine sulfate C. Sublingual nifedipine (Procardia) D. Sublingual nitroglycerin (Nitrostat)

D. Sublingual nitroglycerin (Nitrostat)

The nurse learns that an assigned client with cardiac tamponade is about to have a pericardiocentesis performed. In preparation for this procedure, how should the nurse position the client? A. Supine with slight Trendelenburg's position B. Lying on the right side with a pillow under the head C. Lying on the left side with a pillow under the chest wall D. Supine with the head of bed elevated at an angle of 45 to 60 degrees

D. Supine with the head of bed elevated at an angle of 45 to 60 degrees

The nurse has heard in intershift report that a client with a permanent ventricular demand pacemaker had an episode of "failure to capture." The nurse assesses the client's rhythm periodically during the day, looking for the pacemaker spikes that fall at which interval? A. After every other P wave B. After every fourth T wave C. Regularly across the strip, despite an underlying client rhythm D. Systematically across the strip with no QRS complexes following

D. Systematically across the strip with no QRS complexes following The term capture refers to the electrical and mechanical response of the heart to pacemaker stimulation. The pacemaker spike indicates pacemaker firing. The client should have a QRS complex that follows the spike. Failure to capture then would be the absence of a QRS after a pacemaker spike on the client's rhythm strip. Options 1 and 2 are incorrect, because ventricular pacemakers do not fire after P waves or T waves. Option 3 describes a pacemaker that has failure to sense. The sensing device of a demand pacemaker senses the heart's own electrical activity and allows the pacemaker to fire only when the client rate is less than the preset rate. Therefore, for the portion of time that the client's rhythm is adequate, no pacemaker spikes should appear on the ECG. Failure to sense occurs when regular pacing artifact appears on the ECG regardless of the client's own inherent rhythm.

During the primary assessment of a trauma victim, the nurse determines that the patient has a patent airway. The next assessment by the nurse should be to a. check the patient's level of consciousness. b. examine the patient for any external bleeding. c. observe the patient's respiratory effort. d. palpate for the presence of peripheral pulses

c. observe the patient's respiratory effort. Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but are not accomplished as rapidly as the assessment of breathing.