exam 2 study guide

The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."

1. The full course of antibiotics must be taken to help ensure complete destruction of streptococcal infection. 2. Antibiotics kill bacteria but also destroy normal body flora in the vagina, bowel, and mouth, leading to a superinfection. 3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur. 4. A throat culture is taken to diagnose group A beta-hemolytic streptococcus and is positive in 25% to 40% of clients with acute rheumatic fever.

The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing? 1. The hypodynamic phase. 2. The compensatory phase. 3. The hyperdynamic phase. 4. The progressive phase.

1. The hypodynamic phase is the last and irreversible phase of septic shock, characterized by low cardiac output with vasoconstriction. It reflects the body's effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries. 2. In the compensatory phase of shock, the heart rate, blood pressure, and respiratory rate are within normal limits, but the skin may be cold and clammy and urinary output may be decreased. However, this is the first phase of all types of shock and is not specific to septic shock. 3. The hyperdynamic phase, the first phase of septic shock, is characterized by a high cardiac output with systemic vasodilation. The BP may remain within normal limits, but the heart rate increases to tachycardia and the client becomes febrile. 4. The progressive phase is the second phase of all shocks. It occurs when the systolic BP decreases to less than 80 to 90 mm Hg, the heart rate increases to greater than 150

The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges.

1. The nurse must obtain blood cultures prior to administering antibiotics. 2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify. 3. An echocardiogram allows visualization of vegetations and evaluation of valve function. However, antibiotic therapy is a priority before diagnostic tests, and blood cultures must be obtained before administering medication. 4. Bedrest should be implemented, but the first intervention should be obtaining blood cultures so that antibiotic therapy can be started as soon as possible.

The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position.

1. The nurse should monitor the vital signs for any client who has just undergone surgery. 2. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds allows assessment for cardiac failure. 3. The pericardial fluid is documented as output. 4. Evaluating the client's cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardiocentesis. 5. The client should be in the semi-Fowler's position, not in a flat position, which increases the workload of the heart.

The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter. 2. Administer dopamine intravenous infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter.

1. There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock. 2. This blood pressure does not require dopamine; fluid resuscitation is first. 3. The client may need ABGs monitored, but this is not the first intervention. 4. An indwelling catheter may need to be inserted for accurate measurement of output, but it is not the first intervention.

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4˚F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm3. 3. A urinary output of 90 mL in the last four (4) hours. 4. The client complains of being thirsty.

1. These vital signs are expected in a client with septic shock. 2. An elevated WBC count indicates an infection, which is the definition of sepsis. 3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last four (4) hours indicates impaired renal perfusion, which is a sign of worsening shock 4. The client being thirsty is not an uncommon complaint for a client in septic shock. This warrants immediate intervention.

A patient has a pulmonary artery (PA) catheter placed. What should the nurse recognize as the purpose of this catheter? 1. The patient cannot tolerate hemodynamic monitoring. 2. The patient requires a peripheral intravenous catheter for medication administration. 3. The patient would benefit from having the right ventricle pressures measured each shift. 4. The patient requires evaluation of left ventricular pressures each shift.

Answer 4 Explanation: 1. PA catheters are a form of hemodynamic monitoring. 2. The PA catheter would not be used to administer medications as it is a central arterial catheter, not a peripheral line. 3. The PA catheter does not measure right ventricular pressures. 4. The PA catheter is used to evaluate left ventricular and overall cardiac function.

A patient with injuries from a motor vehicle crash develops hypotension and severe jugular distension with a tracheal deviation. What should the nurse suspect is occurring in this patient? 1. Tension pneumothorax 2. Hemorrhage 3. Compensatory shock 4. Hypovolemic shock

Answer: 1 Explanation: 1. A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung. 2. The patient would not have jugular vein distention with a hemorrhage. 3. The patient would not have jugular vein distention with compensatory shock. 4. The patient would not have jugular vein distention with hypovolemic shock.

A trauma patient is experiencing ongoing progression of shock. What finding caused the nurse to come to this conclusion? 1. Decrease in serum glucose level 2. Drop in blood urea nitrogen level 3. Increased eosinophil level 4. Low serum cardiac enzyme level

Answer: 1 Explanation: 1. As shock progresses, liver functions are impaired, and hypoglycemia develops. 2. A drop in blood urea nitrogen level means the kidneys are receiving adequate blood flow. 3. An increase in eosinophils indicates an allergic response. 4. Low serum cardiac enzymes indicate there is no myocardial damage.

A patient admitted with multiple injuries is prescribed an intravenous colloid solution. Which solution would be appropriate for the nurse to infuse? 1. 25% albumin 2. 0.9% normal saline 3. Dextrose 5% and 0.45% normal saline 4. Dextrose 5% and water

Answer: 1 Explanation: 1. Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. Colloid solutions used to treat shock include 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran. 2. Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space. 3. Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space. 4. Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space.

A patient is admitted with acute pericarditis. When auscultating heart sounds, which action should the nurse ask the patient to perform? 1. Sit and lean forward while the nurse auscultates at the left lower sternal border. 2. Lie supine and breathe quietly while the nurse auscultates for expiratory wheezes. 3. Sit upright while the nurse auscultates the outer aspects of the upper lobes for vesicular breath sounds. 4. Sit and lean forward while the nurse auscultates at the second right intercostal space, near the sternal border.

Answer: 1 Explanation: 1. Pericardial friction rub is the characteristic sign of pericarditis and can be heard best at the left lower sternal border when the patient is sitting and leans forward. The rub is usually heard on expiration and may be constant or intermittent. 2. Expiratory wheezes are not a pericardial friction rub, the characteristic sign of pericarditis. 3. Auscultating lung sounds for vesicular breath sounds is done but does not focus on the pericardial friction rub, the characteristic sign of pericarditis. 4. Auscultating at the second right intercostal space near the sternal border will not help determine the presence of a pericardial friction rub, the characteristic sign of pericarditis

A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution should the nurse recognize would be best for this patient? 1. Ringer's lactate 2. Dextrose 5% and water 3. Dextrose 5% and 0.45% normal saline 4. Dextrose 5% and 0.9% normal saline

Answer: 1 Explanation: 1. Ringer's lactate and 0.9% saline are the fluids of choice in treating hypovolemic shock, especially in the emergency phase of care while blood is being typed and crossmatched. Large amounts of these solutions may be infused rapidly, increasing blood volume and tissue perfusion. 2. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. However, approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. 3. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. However, approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. 4. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. However, approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema.

The nurse is providing medications to increase a patient's systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion? 1. Mean arterial pressure reaches 60 mmHg. 2. Mean arterial pressure reaches 90 mmHg. 3. Blood pressure reaches 120/80 mmHg. 4. Urine output is 10 mL per hour.

Answer: 1 Explanation: 1. A mean arterial pressure of 60 mmHg is required to maintain adequate perfusion to the brain, heart, and kidneys. 2. A mean arterial pressure of 90 mmHg is considered within normal limits. 3. A blood pressure of 120/80 mmHg is considered normal. 4. A urine output of 10 mL per hour would not indicate adequate renal perfusion.

Home care teaching is being completed by the nurse for a patient recovering from rheumatic fever. Which patient statement indicates that the teaching has been effective? 1. "I will be sure to tell my dentist that I had rheumatic fever." 2. "I will try to focus on eating less protein and more fat so I will have more energy." 3. "I will avoid brushing my teeth so often and quit using mouth rinse because I have gingivitis." 4. "If my joints start to hurt again, I need to slow down, but I won't have to worry because I'm immune to rheumatic fever now."

Answer: 1 Explanation: 1. Antibiotic prophylaxis for invasive procedures such as dental care is important to prevent bacterial endocarditis in the patient recovering from rheumatic fever. 2. Dietary teaching focuses on a high-carbohydrate, high-protein diet to facilitate healing and combat fatigue. 3. Maintaining good oral hygiene and preventive dental care are important to preventing gingival infections, which can lead to recurrence of the disease. 4. Rheumatic fever is manifested by joint pain. One episode of rheumatic fever does not confer immunity to future episodes

An older patient is diagnosed with E. coli in the bloodstream. If not treated, this patient is at risk for developing which types of shock? 1. Distributive 2. Obstructive 3. Hypovolemic 4. Anaphylactic

Answer: 1 Explanation: 1. Distributive shock includes several types of shock that result from widespread vasodilatation and decreased peripheral resistance. As the blood volume does not change, relative hypovolemia results. One example of distributive shock is septic shock. Septic shock is a subset of sepsis where there are underlying circulatory and cellular/metabolic abnormalities that are profound enough to substantially increase mortality and is most often the result of gram-negative bacterial infections such as E. coli. 2. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. 3. Hypovolemic shock occurs with a decrease in circulating blood volume. 4. Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction.

A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which finding indicates this medication has been effective? 1. Increased heart rate 2. Reduced heart rate 3. Decreased respiratory rate 4. Decreased blood pressure

Answer: 1 Explanation: 1. Dobutamine (Dobutrex) is a medication that mimics the fight-or-flight response of the sympathetic nervous system. The physiologic effect is improved perfusion and oxygenation of the heart, with increased stroke volume and heart rate, and increased cardiac output. Increased cardiac output, in turn, increases tissue perfusion and oxygenation. 2. This medication will not reduce the heart rate. 3. This medication will not reduce the respiratory rate. 4. This medication will not reduce the blood pressure.

A patient who sustained a traumatic injury several days ago is hypotensive, oliguric, and has cool, pale skin and acidosis. For which type of shock should the nurse plan care for this patient? 1. Hypovolemic 2. Cardiogenic 3. Septic 4. Anaphylactic

Answer: 1 Explanation: 1. Hypovolemic shock is caused by a decrease in intravascular volume. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular fills drops. As a result, stroke volume, cardiac output, and blood pressure decrease. Hypovolemic shock affects all body systems. 2. Cardiogenic shock occurs when the heart's pumping ability is compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion. 3. Patients at risk for developing infections leading to septic shock include those who are hospitalized, have debilitating chronic illnesses, or have poor nutritional status. Septic shock does not usually present in a patient with a traumatic injury. 4. Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.

A patient has an estimated blood loss of 2 L and a mean arterial pressure ranging between 30 and 40 mmHg. If this patient's hemodynamic status is not corrected, what should the nurse realize can occur? 1. Failure of sodium-potassium pump 2. Cells shrinking 3. Full and bounding peripheral pulses 4. Metabolic alkalosis

Answer: 1 Explanation: 1. With a blood loss of 2 L and a mean arterial pressure below 60 mmHg, the body cells switch from aerobic to anaerobic metabolism. The lactic acid formed as a by-product of anaerobic metabolism contributes to an acidotic state at the cellular level. Adenosine triphosphate, the source of cellular energy, is produced inefficiently. Lacking energy, the sodium-potassium pump fails. Potassium moves out of the cells while sodium and water move inward. 2. As this process continues, the cells swell, not shrink. 3. Peripheral pulses may not be palpable. 4. The body develops acidosis, not alkalosis.

A patient with traumatic injuries has lost approximately 300 mL of blood. What should the nurse expect to assess in this patient? 1. Slight increase in heart rate 2. Nonpalpable peripheral pulses 3. Narrowing pulse pressure 4. Increase in blood glucose level

Answer: 1 Explanation: 1. With a slight decrease in circulating blood volume, usually less than 500 mL, the symptoms of shock are almost imperceptible. The pulse rate may be slightly elevated. If the injury is minor or of short duration, arterial pressure is usually maintained and no further symptoms occur. 2. Nonpalpable peripheral pulses are a sign of progressive shock. The patient is not in progressive shock. 3. Narrowing pulse pressure is a sign of progressive shock. The patient is not in progressive shock. 4. An increase in blood glucose level is a sign of progressive shock. The patient is not in progressive shock.

The nurse suspects that a patient has pericarditis. What did the nurse assess to make this clinical decision? Select all that apply. 1. Pericardial friction rub 2. Abdominal discomfort and nausea 3. Chest pain 4. Bradycardia 5. Distended neck veins

Answer: 1, 3 Explanation: 1. Pericardial friction is a hallmark sign of pericarditis. 2. Abdominal discomfort and nausea are not associated with pericarditis. 3. Chest pain is a hallmark sign of pericarditis. 4. Bradycardia is not associated with pericarditis. 5. Distended neck veins are not associated with pericarditis.

A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient? Place in order the steps of the process. Choice 1. Stop the transfusion and notify the healthcare provider Choice 2. Compare the blood slip with the unit of blood Choice 3. Assess vital signs and associated manifestations Choice 4. Save the blood bag and tubing for laboratory analysis Choice 5. Collect urine and venous blood samples according to policy

Answer: 1, 3, 2, 4, 5 Explanation: Choice 1. The first step is to immediately stop the infusion and notify the healthcare provider. Choice 2. The third step is to compare the blood slip with the unit of blood to ensure that an identification error was not made. Choice 3. The second step is to assess vital signs and assess for other manifestations. Choice 4. The fourth step is to save the blood bag and any remaining blood for return to the laboratory for testing to determine the cause of the reaction. Choice 5. The fifth step is to follow organizational policy for collecting urine and venous blood samples.

The nurse is caring for a patient who has invasive hemodynamic monitoring. What would be the highest priority of care for this patient? 1. Preventing infection at the catheter site by changing the dressing as prescribed 2. Setting alarm limits and turning monitor alarms on 3. Explaining to family members why the monitoring is in use 4. Coiling IV tubing on the bed

Answer: 2 Explanation: ' 1. Preventing infection by changing dressings is important but not the priority of care. 2. Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. Alarms should always be investigated because they are silenced only when blood is drawn or tubing changed. 3. Keeping family members informed about monitoring is important but is not the priority of care. 4. Coiling the IV tubing on the bed is contraindicated.

A patient has received 145 mL of blood and complains of chills. For what should the nurse assess this patient? Select all that apply. 1. Bradypnea 2. Urticaria 3. Fever 4. Hypertension 5. Lumbar pain

Answer: 2, 3, 5 Explanation: 1. Reduced respiratory rate is not a manifestation of a hemolytic blood reaction. 2. Urticaria is a manifestation of a hemolytic blood reaction. 3. Fever is a manifestation of a hemolytic blood reaction. 4. Hypertension is not a manifestation of a hemolytic blood reaction

A patient in hypovolemic shock is receiving an intravenous colloid solution (plasma expander). Which assessment finding indicates to the nurse that the infusion rate should be reduced? Select all that apply. 1. Prothrombin time of 13.5 seconds 2. Jugular vein distention 3. Tenting of the skin 4. Increased central venous pressure 5. Auscultation of crackles and wheezes

Answer: 2, 4, 5 Explanation: 1. A prothrombin time of 13.5 seconds is within normal range. 2. Jugular vein distention indicates circulatory overload and pulmonary edema. 3. Tenting of the skin would indicate dehydration and the need for more fluid replacement. 4. Increased central venous pressure indicates circulatory overload and pulmonary edema. 5. Crackles and wheezes indicate circulatory overload and pulmonary edema.

17) A patient is diagnosed with cardiac tamponade. What treatment should the nurse expect to be prescribed for this patient? 1. Antidysrhythmic drugs and oxygen 2. Oxygen and rest 3. Pericardiocentesis 4. Antibiotics

Answer: 3 Explanation: 1. Antidysrhythmic drugs and oxygen may be indicated after the pericardiocentesis is performed. 2. Oxygen and rest may be indicated after the pericardiocentesis is performed. 3. Cardiac tamponade is a medical emergency. Pericardiocentesis is performed to remove fluid or blood that has collected around the heart and is preventing the heart from pumping effectively. 4. Antibiotics may be indicated after the pericardiocentesis is performed.

The nurse is caring for a patient in the critical care area whose fluid volume status needs to be closely assessed. Which type of monitoring should the nurse expect for this patient? 1. Arterial pressure monitoring 2. Pulmonary artery pressure monitoring 3. Central venous pressure (CVP) monitoring 4. Intra-aortic balloon pump monitoring

Answer: 3 Explanation: 1. Arterial pressure monitoring would not measure central venous pressure. 2. Pulmonary artery pressure monitoring is used to evaluate left ventricular and overall cardiac function. 3. CVP is used to monitor fluid volume status. 4. An intra-aortic balloon pump is not used for pressure monitoring.

A patient with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. What should the nurse do first? 1. Notify the physician about these findings. 2. Elevate the leg above the level of the heart. 3. Wrap the extremity in a loose, warm blanket and apply a foot cradle. 4. Perform passive range of motion (PROM) exercises to stimulate circulation.

Answer: 3 Explanation: 1. The physician should be notified after the nurse performs another step. 2. Elevating the leg above the heart could worsen the ischemia. 3. The patient is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. Without immediate intervention, tissue ischemia and necrosis will develop, with ultimate loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain the temperature and protect the leg from injury, apply a foot cradle, then notify the physician. 4. Passive range of motion exercises will increase tissue demand for oxygen and increase ischemia.

The nurse is caring for patients on a cardiac unit. Which patient should the nurse assess first? 1. Patient with hypertrophic cardiomyopathy who is reporting dyspnea 2. Patient who had a cardiac catheterization and will be ambulating for the first time 3. Patient receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain 4. Patient recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101°F

Answer: 3 Explanation: 1. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment. However, another patient is the most emergent. 2. The patient ambulating for the first time will be assessed by a nurse. However, another patient is the most emergent. 3. The patient with bacterial endocarditis is at risk for thrombus formation. This patient requires immediate attention as chest pain and anxiety are signs of pulmonary embolism (PE), which is life-threatening. 4. A temperature of 101°F requires further assessment. However, another patient is the most emergent.

The nurse is reviewing medications prescribed for a patient with myocarditis. Which medication should the nurse question before administering to the patient? Select all that apply. 1. Antibiotic 2. Anticoagulant 3. Cardiac glycoside 4. Proton pump inhibitor 5. Antidysrhythmic agent

Answer: 3, 4 Explanation: 1. Myocarditis is an infection of the heart muscle. Antibiotics are indicated in the treatment of this condition. 2. Emboli can occur with myocarditis. Anticoagulants would be indicated in the treatment of this condition. 3. Patients with myocarditis often are particularly sensitive to the effects of digitalis, which is a cardiac glycoside, so it is used with caution. The nurse should question this medication. 4. Proton pump inhibitors are used for gastrointestinal disorders. The nurse should question this medication. 5. Dysrhythmias can occur with myocarditis. Antidysrhythmic agents are indicated in the treatment of this condition.

An adolescent is experiencing anaphylactic shock after being stung by a swarm of bees. Which medication should the nurse anticipate providing to this patient? Select all that apply. 1. Diuretics 2. Antibiotics 3. Epinephrine 4. Beta2-agonists 5. Antihistamine

Answer: 3, 4, 5 Explanation: 1. Diuretics are used to increase urine output after fluid replacement has been initiated. 2. Antibiotics are used to suppress organisms in septic shock. 3. Epinephrine is used to treat anaphylactic shock. 4. Beta2-agonists are used to treat anaphylactic shock. 5. Antihistamines are used to treat anaphylactic shock.

The nurse is caring for a patient with possible endocarditis. What is important for the nurse to consider when caring for this patient? 1. Endocarditis does not pose a high risk of damage to affected heart valves. 2. Patients with this disorder can be treated with open heart surgery to clean the heart valves. 3. The condition is unrelated to fever, so patients can be medicated with the prescribed antipyretic and observed. 4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures.

Answer: 4 Explanation: 1. Endocarditis carries serious risks of damage to heart valves. 2. Open heart surgery is not an appropriate treatment for this condition. 3. Fever may be present in endocarditis. 4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures.

The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement? 1. Ask the client about drug allergies. 2. Obtain a sterile sputum specimen. 3. Have the client wait for 30 minutes. 4. Place a warm washcloth on the client's left hip.

It is too late to ask the client about drug allergies because the medication has already been administered. 2. Obtaining a specimen after the antibiotic has been initiated will skew the culture and sensitivity results. It must be obtained before the antibiotic is started. 3. Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics. 4. The client is being discharged and the nurse can encourage the client to do this at home, but it is not appropriate to do in the emergency department.

The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? 1. Monitor the client's telemetry. 2. Turn the client every two (2) hours. 3. Administer oxygen via nasal cannula. 4. Place the client in the Trendelenburg position.

Monitoring the telemetry will not prevent cardiogenic shock. It might help identify changes in the hemodynamics of the heart, but it does not prevent anything from occurring. 2. Turning the client every two (2) hours will help prevent pressure ulcers, but it will do nothing to prevent cardiogenic shock. 3. Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock. 4. Placing the client's head below the heart will not prevent cardiogenic shock. This position can be used when a client is in hypovolemic shock.

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next? A. Lower the client's left foot below heart level. B. Administer oxygen at 4 L/min to the client. C. Notify the client's physician about the change in status. D. Reassure the client that embolization is common in endocarditis.

c

The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub.

1. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider. 2. Distended, not nondistended, jugular veins would warrant immediate intervention. 3. Decreasing quality of peripheral pulses, not bounding peripheral pulses, would warrant immediate intervention. 4. A pericardial friction rub is a classic symptom of acute pericarditis, but it would not warrant immediate intervention.

The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds.

1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade. 2. Cardiac enzymes may be slightly elevated because of the inflammatory process, but evaluation of these would not be ordered to treat or evaluate cardiac tamponade. 3. A 12-lead ECG would not help treat the medical emergency of cardiac tamponade. 4. Assessment by the nurse is not collaborative; it is an independent nursing action.

The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family history of carditis?" 4. "What over-the-counter (OTC) medications do you take?"

1. A sore throat in the last month would not support the diagnosis of carditis. 2. Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of people who develop it. 3. Carditis is not a genetic or congenital disease process. 4. This is an appropriate question to ask any client, but OTC medications do not cause carditis.

The nurse caring for a client with sepsis writes the client diagnosis of "alteration in comfort R/T chills and fever." Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift. 2. Monitor urinalysis, creatinine level, and BUN level. 3. Apply sequential compression devices to the lower extremities. 4. Administer an antipyretic medication every four (4) hours PRN.

1. Ambulating the client in the hall will not address the etiology of the client's chills and fever; in fact, this could increase the client's discomfort. 2. Monitoring these laboratory data does not address the etiology of the client's diagnosis. 3. Sequential compression devices help prevent deep vein thrombosis. 4. Antipyretic medication will help decrease the client's fever, which directly addresses the etiology of the client's nursing diagnosis.

Which nursing diagnosis would be priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function.

1. Anxiety is a psychosocial nursing diagnosis, which is not a priority over a physiological nursing diagnosis. 2. Antibiotic therapy does not result in injury to the client. 3. Myocarditis does not result in valve damage (endocarditis does), and there would be decreased, not increased, cardiac output. 4. Activity intolerance is priority for the client with myocarditis, an inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.

The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.

1. Cardiogenic shock occurs when the heart's ability to contract and pump blood is impaired and the supply of oxygen to the heart and tissues is inadequate, such as occurs in myocardial infarction or valvular damage. 2. These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging. 3. In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. It can result from the depressant action of medication or lack of glucose. 4. Septic shock is a type of circulatory shock caused by widespread infection.

The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse? 1. The UAP places a urine specimen in a biohazard bag in the hallway. 2. The UAP uses the alcohol foam hand cleanser after removing gloves. 3. The UAP puts soiled linen in a plastic bag in the client's room. 4. The UAP obtains a disposable stethoscope for a client in an isolation room.

1. Specimens should be put into biohazard bags prior to leaving the client's room. 2. This is the appropriate way to clean hands and does not warrant intervention. 3. This is the appropriate way to dispose of soiled linens and does not warrant intervention. 4. Taking a stethoscope from a client who is in isolation to another room is a violation of infection-control principles.

The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.

1. The client's diet is not priority when transcribing orders. 2. An IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order. 3. Diagnostic tests are important but not priority over intervening in a potentially lifethreatening situation such as septic shock. 4. There is no indication this client has diabetes in the stem of the question, and glucose levels are not associated with signs/symptoms of septicemia.

The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."

1. Steroids, such as prednisone, not NSAIDs, must be tapered off to prevent adrenal insufficiency. 2. NSAIDs will not make clients drowsy. 3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain. 4. NSAIDs should be taken regularly around the clock to help decrease inflammation, which, in turn, will decrease pain. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (p. 96). F A Davis Co. Kindle Edition.

The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? 1. Cool, moist skin. 2. Bradycardia. 3. Wheezing. 4. Decreased bowel sounds.

1. The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin as seen in hypovolemic shock. 2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock. 3. Wheezing is associated with anaphylactic shock. 4. Decreased bowel sounds occur

The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer.

1. Oxygen may be needed, but it is not the first intervention. 2. This would be appropriate to determine if the urine output is at least 30 mL/hr, but it is not the first intervention. 3. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider. 4. Using the incentive spirometer will increase the client's alveolar ventilation and help prevent atelectasis, but it is not the first intervention.

Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus (PE). 2. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis.

1. Pulmonary embolus would occur with an embolization of vegetative lesions from the tricuspid valve on the right side of the heart. 2. Bacteria enter the bloodstream from invasive procedures, and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys, or peripheral tissues. 3. Coughing up blood (hemoptysis) occurs when the vegetation breaks off the tricuspid valve in the right side of the heart and enters the pulmonary artery. 4. Deep vein thrombosis is a complication of immobility, not of a vegetative embolus from the left side of the heart.

The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.

1. Pulsus paradoxus is the hallmark of cardiac tamponade; a paradoxical pulse is markedly decreased in amplitude during inspiration. 2. Fatigue and arthralgias are nonspecific signs/symptoms that usually occur with myocarditis. 3. Petechiae on the trunk, conjunctiva, and mucous membranes and hemorrhagic streaks under the fingernails or toenails occur with endocarditis. 4. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements (deep inspiration, coughing), changes in body position, and swallowing.

The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic.

1. This is a normal potassium level (3.5 to 5.5 mEq/L); therefore, the nurse does not need to notify the HCP. 2. A culture result showing a high sensitivity to an antibiotic indicates this is the antibiotic the client should be receiving. 3. A pulse oximeter reading of greater than 93% indicates the client is adequately oxygenated. 4. A sensitivity report indicating a resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organism, and the HCP needs to be notified so the antibiotic can be changed.

The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer the client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery.

1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health. 2. Occupational therapy addresses activities of daily living. The client should be referred to physical therapy to develop a realistic and progressive plan of activity. 3. The client with pericarditis is not usually prescribed oxygen, and 2 L/min is a low dose of oxygen that is prescribed for a client with chronic obstructive pulmonary disease (COPD). 4. Endocarditis, not pericarditis, may lead to surgery for valve replacement.

The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. What should the nurse do when administering this medication? 1. Use an infusion pump. 2. Administer with PVC tubing. 3. Use within 8 hours of reconstitution. 4. Allow the patient to get out of bed only with assistance.

Answer: 1 Explanation: 1. Intravenous nitroglycerin must be mixed in glass bottles and infused through special, non-PVC tubing, because up to 40%-80% of nitroglycerin can be absorbed by PVC bags or tubing. 2. Intravenous nitroglycerin should not be administered with PVC tubing, because up to 40%-80% of nitroglycerin can be absorbed by PVC bags or tubing. 3. This medication must be used within 4 hours of reconstitution. 4. The patient receiving intravenous nitroglycerin should be on bed rest, not assisted out of bed.

The nurse suspects that a patient with a myocardial infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion? 1. Jugular vein distention 2. Warm extremities 3. Laryngospasm 4. Urticaria

Answer: 1 Explanation: 1. Jugular vein distention is seen in cardiogenic shock. 2. Warm extremities are seen in early septic shock and anaphylactic shock. 3. Laryngospasm is seen in anaphylactic shock. 4. Urticaria is seen in anaphylactic shock.

The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient's problem of anxiety? 1. Reducing stimuli and medicating for pain 2. Assessing blood pressure and heart rate 3. Monitoring central venous pressure 4. Assessing bowel sounds

Answer: 1 Explanation: 1. Interventions appropriate for the problem of anxiety include reducing stimuli, which is calming and facilitates rest, and medicating for pain because pain precipitates or aggravates anxiety. 2. Assessing blood pressure and heart rate would be appropriate for a problem with cardiac output. 3. Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. 4. Assessing bowel sounds would be appropriate for a problem with cardiac output.

A patient is diagnosed with a pneumothorax. Which type of shock is this patient at risk for developing? 1. Obstructive 2. Hypovolemic 3. Cardiogenic 4. Neurogenic

Answer: 1 Explanation: 1. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. One cause of obstructive shock is impaired diastolic filling, as seen in a pneumothorax. 2. Hypovolemic shock is seen in patients with a low circulating blood volume. 3. Cardiogenic shock can occur in patients who have experienced a myocardial infarction. 4. Neurogenic shock can occur in patients with spinal cord injuries.

A patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. Because there is not enough time for type and crossmatch, which type of blood will the patient likely receive? 1. O 2. A 3. B 4. AB

Answer: 1 Explanation: 1. Type O blood is the universal donor. ABO antibodies develop in the serum of people whose RBCs lack the corresponding antigen; these antibodies are called anti-A and anti-B. 2. The person with blood type A has B antibodies. 3. The person with blood type B has A antibodies. 4. The person with AB has no antibodies (called a universal recipient).