Exam 1
The client asks the nurse what urine output has to do with cardiac function. What is the best response by the nurse?
"Poor urine output may indicate inadequate blood flow to the kidneys."
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilator tubing
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?
Assessing the client's respiratory status, orientation, and skin color
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?
Call for a chest x-ray.
The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse?
Call for help and begin chest compressions.
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
Continues assessing the client's respiratory status frequently
The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)
Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP)
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death?
Increased restlessness
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication?
N-acetylcysteine
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space
The nurse is proving discharge instructions for a client with a new arrhythmia. Which statement should the nurse include?
Your family and friends may want to take a CPR class.
Which set of arterial blood gas (ABG) results requires further investigation?
pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L
The nurse is administering metoprolol to a client. What type of medication should the nurse educate the client about?
Beta blocker
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding?
Document that the chest drainage system is operating as it is intended.
The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade? Select all that apply.
Dyspnea Tachycardia Distant heart sounds Jugular vein distention
A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis?
Echocardiography
The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?
Ensure no one is touching the client at the time shock is delivered.
The pathophysiology of pericardial effusion is associated with all of the following except:
Increased venous return.
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this?
Maintaining a patent airway
A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?
Measure blood glucose concentration every 4 to 6 hours
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the drainage in the collection chamber
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of dysrhythmia would the cardiologist likely diagnose?
Sinus tachycardia
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:
Symmetry of the client's chest expansion
While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach?
The system has an air leak.
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells
Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:
cannot tolerate high-glucose concentration.
What is the major clinical use of dobutamine?
increase cardiac output. Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient?
"Are you hearing anything that is disturbing you?"
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."
A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the client's cardiopulmonary status, the nurse should prepare to perform what intervention?
Administer naloxone hydrochloride (Narcan).
The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem?
Air leak
A family member brings a client to the ED following an apparent oxycodone overdose. The client is experiencing severe respiratory depression. Which medication will the nurse administer?
Naloxone hydrochloride
A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess?
Pinpoint pupils
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation. Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?
Pulmonary edema
Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions?
Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care
A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for?
Removing excess air and fluid
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
See if there are leaks in the system.
The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse's pressing the discharge button?
Shouting "Clear!"
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply.
dobutamine dopamine epinephrine
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
pH, 7.25; PaCO2 50 mm Hg
The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
ABG Findings
A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?
Administer epinephrine.
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?
Bilateral lower lobes Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.
The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient?
Decreases the sinoatrial node automaticity Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect).
A novice hospice nurse is reviewing the orders of several clients. Which orders will the nurse most likely have to clarify? Select all that ap
Infuse two units PRBC PRN for hemoglobin <7 g/dL. Infuse TPN at 80 mL/hr via central line.
The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?
Levophed The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.
The nurse is caring for a client who has a suspected dysrhythmia. What most appropriate intervention should the nurse use to help detect dysrhythmias?
Monitor cardiac rhythm continuously.
A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply.
P wave P-R interval T wave
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage.
The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter?
Sawtooth
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-seal chamber
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross?
Anger
Which medication reverses severe respiratory depression and coma?
Naloxone hydrochloride
A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action?
Report possible signs of aspiration pneumonia to the primary provider.
A client who is frightened of needles has been told that the client will have to have an intravenous (IV) line inserted. The client's blood pressure and pulse rate increase, and the nurse observes the pupils dilating. What does the nurse recognize has occurred with this client?
The client is showing the fight-or-flight response.
The ECG of a new patient shows a P wave slightly different than normal. The nurse is considering the possibility of premature atrial contractions (PAC). The nurse will ask about which factors when taking this client's history?
There are a number of causes of premature atrial contractions (PAC), which is why it is so important to know and review a patient's complete history when examining for dysrhythmias.
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart?
There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart, including fever, shock, and strenuous exercise.
A 60-year-old client who has been fighting cancer for more than 20 years has just been diagnosed with metastases to the brain. The client finds it difficult to get out of bed in the morning, has no interest in eating, and no longer finds fulfillment in favorite hobbies. Within which emotional reaction is the client functioning?
depression
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.
pH PaCO2 HCO3
The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition?
reduced blood supply to the heart
Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as
sodium nitroprusside. Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.
The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour?
2.7 ml/hr
A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.
70 ml
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
Which of the following responses is most helpful to the client when in an emergency situation?
A response by the sympathetic nervous system
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
ABG Analysis
You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
Arterial blood gas (ABG) findings
Which medication is the drug of choice for sinus bradycardia?
Atropine Atropine is the medication of choice in treating symptomatic sinus bradycardia. Lidocaine treats ventricular dysrhythmias. Pronestyl treats and prevents atrial and ventricular dysrhythmias. Cardizem is a calcium channel blocker and treats atrial dysrhythmias.
Which is a late sign of hypoxia?
Cyanosis Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.
A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline arterial blood gas (ABG) levels
The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition?
Catheter-related bloodstream infections
The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts?
Treat pulseless ventricular tachycardia.
A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply.
Dopamine, Dobutamine, Nitroglycerin, and Vasopressin
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client?
alerting the healthcare provider of the third-degree heart block
The nurse is assessing a client with symptomatic bradycardia. What medication does the nurse anticipate will be ordered by the healthcare provider to treat the bradycardia?
atropine
The nurse witnesses a client experiencing ventricular fibrillation. What is the nurse's priority action?
defibrillation
A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize?
Risk for infection related to the presence of a subclavian catheter
The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation?
Sit with the client's daughter privately and encourage her to express her feelings frankly.
A client has been placed on a ventilator, and the spouse begins to cry during the initial visit. What is the best therapeutic statement for the nurse to communicate?
"Tell me what you are feeling."
When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?
A systolic blood pressure that is lower during inhalation Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.
The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. What order does the nurse describe?
Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers
A nurse is caring for a client who has premature ventricular contractions. What sign would the nurse assess in this client?
Fluttering/heart skipping Premature ventricular contractions usually cause a flip-flop sensation in the chest, sometimes described as "fluttering" or "skipping a beat." Associated signs and symptoms include pallor, nervousness, sweating, and faintness. Symptoms of premature ventricular contractions are not nausea, hypotension, and fever.
What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?
Friction rub
A nurse enters a client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?
Immediate CPR Immediate CPR is used during pulseless ventricular tachycardia and ventricular fibrillation.
Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?
Monitor vital signs and cardiac rhythm
Acetaminophen overdose is treated with administration of which medication?
N-acetylcysteine
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
Pneumothorax
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
Reduced cardiac output PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.
It is important for a nurse to be aware of the normal hemodynamics of blood flow to recognize and understand pathology when it occurs. The nurse should know that incomplete closure of the tricuspid valve results in a backward flow of blood from the:
Right ventricle to the right atrium.
It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur:
Right ventricular pressure must be higher than pulmonary arterial pressure.
The nurse assessing a patient with pericardial effusion at 0800 notes the apical pulse is 74 and the BP is 140/92. At 1000, the patient has neck vein distention, the apical pulse is 72, and the BP is 108/92. Which action would the nurse implement first?
Stay with the patient, use a calm voice, and ask for assistance via call light.
A client needs additional information about a heart condition. The client asks the nurse, "What is considered the pacemaker of the heart?"
The SA node
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?
The client requires total parenteral nutrition
A client with heart failure asks the nurse how dobutamine affects the body's circulation. What is the nurse's best response?
The medication increases the force of the myocardial contraction. A positive inotropic medication increases the force of the myocardial contraction. The inotropic medication decreases heart rate; it does not cause the kidneys to retain fluid or produce more urine.
During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?
The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact.
A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:
Wipes catheter ports from distal end to insertion site
