exam 1 MSG3

a nurse is providing care for a client who was involved in a motor vehicle crash complete the following sentence by using the list of options. client admitted following head on motor vehicle crash with a tree. the client was found unconscious in the vehicle.

Guess is *** circulatory status LOC

11. Physical assessment of the patient with disseminated intravascular coagulation (DIC) may show which of the following? a. Crackles throughout bilateral lung fields b. Hypertension, headache c. Increased urinary output, fluid overload d. Peripheral cyanosis, oozing from puncture sites

d. Peripheral cyanosis, oozing from puncture sites

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? -Establish the ability to communicate effectively. -Compensate for loss of depth perception. -Learn to control impulsive behavior. -Improve left side motor function.

-Establish the ability to communicate effectively.

A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

2

A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 ML

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: 1. Sinus tachycardia 2. Atrial fibrillation 3. Ventricular tachycardia 4. Ventricular fibrillation

2. Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

" I shouldnt drink liquids while I have food in my mouth" " i will have to stop watching television while I eat" " i can have cream soups on this diet" "I wont be able to eat nuts anymore" "my food will have to be the consistency of pudding" "I will look up at the ceiling when i swallow"

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A nurse in an urgent care center is a client who reports a sudden onset of irregular palpitations, fatigue and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse defect. Which of the following dysrhythmias to the nurse expect to find on EKG a. first degree heart block b. atrial fibrillation c. sinus bradycardia d. sinus tachycardia

A fib

A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: A. Vagus nerve to slow the heart rate B. Vagus nerve to increase the heart rate; over driving the rhythm C. Diaphragmatic nerve to slow the heart rate D. Diaphragmatic nerve to overdrive the rhythm

A. Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm.

nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate (Kayexalate). If this medication is effective, the nurse should expect which of the following corrections on the client's ECG? a. reduction of t-wave amplitude b. shortening of P-wave duration c. widening of the QRS complex d. Restoration of QRS complex amplitude

A. Reduction of T-wave amplitude

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A- DIC is controllable with lifelong heparin usage B- DIC is caused by abnormal coagulation involving fibrinogen C- DIC is a genetic involving a vitamin K deficiency D- DIC is characterized by an elevated platelet count

B- DIC is caused by abnormal coagulation involving fibrinogen

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Oliguria D. Bradypnea

C. Oliguria

A nurse is caring for a client who returns tot he nursing unit forms the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A) Decrease in the respiratory rate from 20 to 16/min B) Decrease in the urinary output from 50 mL to 30 mL per hour C) Increase in the temperature from 37.5 to 38.6 D) Increase in the heart rate from 88 to 110/min

D) Increase in the heart rate from 88 to 110/min Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increase steadily. In the first stage of shock (compensatory), the heart rate is >100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole.

A nurse is caring for a client who reports heart palpitation. An EKG confirms the client is experiencing ventricular tachycardia. The nurse should anticipate the need for taking which of the following actions a. defibrillation b. elective cardioversion c. CPR d. radiofrequency catheter ablation

Elective cardioversion

.A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? hemolytic 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? a. transient ischemic attack (TIA) b. Hemorrhagic stroke c. Thrombotic stroke d. Embolic stroke

Hemorrhagic stroke

the nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? a. difficulty reading b. inability to recognize his family members c. right hemiparesis d. aphasia

Inability to recognize his family members

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse? a. bounding pulsations b. irregular pulsations c. tachycardia d. bradycardia

Irregular pulsations

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? a. Provide the client with water to test the gag reflex b. perform carotid massage c. notify EMS d. drive the client to the nearest medical facility

Notify EMS

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? a.Cryoprecipitates b.Platelets c.Albumin d.Packed RBCs

Packed RBCs

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? a. poor impulse control b. unable to discriminate words and letters c. deficits in the right visual field d. motor retardation

Poor impulse control A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? a. Bradycardia b. Pulmonary embolism c. Peripheral vascular isease d. Hypertension

Pulmonary embolism Altered atrial contractions can cause blood pooling and thrombus formation. The client is at risk for developing a pulmonary embolism or embolic stroke. The client should monitor and report immediately manifestations, such as shortness of breath, or neurological changes.

A nurse i s caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? a. preform passive range of motion on each extremity b. monitor the client's electrolyte levels c. suction saliva from the clients mouth d. record the client's intake and output

Suction saliva from the client's mouth.

An older adult client in a long term care facility had a stroke 4 weeks ago and has been unable to move independently since that time period. The nurse caring for her should observe for which other following findings that indicates a complication of immobility a. reddened area over the sacrum b. Stiffness in the lower extremities c. difficulty moving the upper extremities d. difficulty hearing some types of sounds

a reddened area over the sacrum

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? a. Defibrillation b. Airway management c. Epinephrine administration d. Amiodarone administration

a. Defibrillation The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? a. the p wave falls before the qrs complex b. the t wave is in the inverted postion c. the P-R interval measures 0.22 seconds d. the QRS duration is 0.20 seconds

a. the p wave falls before the qrs complex

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation Which of the following actions should the nurse take? (SATA) A. Keep the client NPO after midnight B. Inspect the electrode pads C. Wash the skin with plain water before placing the electrodes D. Instruct the client not talk during the test E. Administer an analgesic prior to the procedure

b. inspect the electrode pads C. Wash the skin with plain water before placing the electrodes D. Instruct the client not talk during the test

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? a." you might feel a slight tingling while the test is being done" b. " the test will be complete in 30-60 minutes" c. " i will need to apply electrodes to your chest and extremities" d. " the radioactivity from the dye lasts only a few hours"

c. " i will need to apply electrodes to your chest and extremities

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? a. Slow b. Not palpable c. Irregular d. Bounding

c. Irregular With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.

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 clients restored rhythm is symptomatic bradycardia? a. Epinephrine b. Magnesium c. Atropine d. Sodium bicarbonate

c. atropine

A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication? a. the antidote for warfarin is protamine b. the client's aptt should be monitored c. the client should be observed for manifestations of hemorrhage d. warfarin can be administered along with nsaids

c. the client should be observed for manifestations of hemorrhage

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 A. ventricular Depolarization B. Slow repolarization of venticular purkinje Fibers c. Atrial depolarization D. early ventricular repolarization

c.Atrial depolarization The P wave reflects atrial depolarization, typically initiated in the sinoatrial node.

7. A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of thefollowing should the nurse expect in the findings? a. Excessive thrombosis and bleeding b. Progressive increase in platelet production c. immediate sodium and fluid retention d. Increased clotting factors

d. increased clotting factors

A nurse is preparing to administer Warfarin to a client who has a new onset of atrial fibrillation. The client asks the nurse, "What should this medication do?" Which of the following responses should the nurse make? a. to convert atrial fibrillation to sinus rhythm b. to dissolve clots in the bloodstream c. to slow the response of the ventricles to the fast atrial impulses d. to reduce the risk of stroke to clients who has atrial fib

d. to reduce the risk of stroke to clients who has atrial fib Rationale:The nurse should identify that atrial fibrillation increases the client's risk of having a stroke due to clot formation in the atrium. Warfarin can prevent clot formation when used long-term, which will reduce the client's risk of having a stroke

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? a. flattening of t waves b. Elevated ST segment c. Wide QRS d. Peaked T waves

flatten of T wave

A nurse is teaching about risk factors of developing a stroke to a group of older adults. which of the following nonmodifable risk factors should the nurse include a. history of smoking b. obesity c. History of hypertension d. Genetics

genetics

a nurse is caring for a client who is at risk for shock which of the following finding is the earliest indicator that this complication is developing a. hypotension b. anuria c. increased respiratory rate d. decreased level of consciousness

increased respiratory rate

hot spot click where the t wave is

last bump

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? a. mottled skin b. blood pressure 115/68 mmhg c. HR 160/min d. hypokalemia

mottled skin

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. Sinus Tachycardia D. First-degree heart block.

normal sinus rhythm

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a."the medication you are talking about dissolves clots and could cause more bleeding in your husband's brain" b. " not everyone is eligible for this drug. has he had surgery lately?" c. " he didn't arrive within the time frame for therapy" d." you should discuss the treatment of your husband with his doctor"

the medication you are talking about dissolves clots and could cause more bleeding in your husbands brain