HCC Exam 2-Remediation

A nurse is caring for a client who has schizophrenia. The nurse is reviewing the client's medical record. Select the "3" findings that require immediate follow-up by the nurse.

-Blood pressure -Hallucinations -Delusions

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

-Blood pressure 115/68 mmHg

A nurse is providing care for a client experiencing obstructive shock. Which of the following diagnoses should the nurse expect?

-Cardiac tamponade

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

-Elective cardioversion

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

-Epinephrine

Which of the following are risk factors for abdominal aortic aneurysm (AAA)? (Select all that apply.)

-Family history of aneurysm -Smoking cigarettes

A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave?

-Far right

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

-Give the child acetaminophen for discomfort.

A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?

-Heart rate 46/min

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

-Hypovolemia

A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client's blood pressure has been steadily decreasing over the past 2 hr. Which of the following categories of shock should the nurse recognize is occuring?

-Hypovolemic shock

A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

-Increased blood pressure in the arms with decreased blood pressure in the legs

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

-Increased respiratory rate

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching?

-"I'll take my heart medications the morning of my test."

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

-"Increasing my intake of foods containing trans-fatty acids can lower my risk."

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition?

-"Postpartum depression is more likely to occur in women who have a history of depression."

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

-"These tests help determine the degree of damage to the heart tissues."

A nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include?

-"You should avoid grapefruit juice."

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

-Assess the apical pulse for a full minute.

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?

-Atrial depolarization

Based upon this information, the nurse should interpret the client's rhythm as indicating which of the following?

-Atrial fibrillation

A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit?

-Disorientation and depression

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse reactions?

-Dysrhythmias

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take?

-Initiate oxygen therapy.

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? (Select all that apply.)

-Inspect the electrode pad -Instruct the client not talk during the test

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

-Irregular

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client feeling 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?

-Irregular pulsations

A nurse is caring for a client who is diagnosed with schizophrenia. Which of the following manifestations should the nurse identify as a negative symptom?

-Lack of emotions

A nurse is admitting a client to an inpatient mental health unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to take: -Determine if the client is experiencing command hallucinations. -Clearly explain expectations for daily hygiene. Potential Complication: -Schizophrenia Parameters to Monitor: -Suicidal ideation -Daily weight

NOT CORRECT! A nurse is caring for a client in the emergency department. For each manifestation, click to specify if the assessment finding is consistent with brain herniation, subarachnoid hemorrhage, or chronic traumatic encephalopathy. Each finding may support more than 1 disease process.

Brain herniation: -Pupil asymmetry -Lower limb weakness -Loss of gag reflex -Decorticate posturing TBI: -Hemiparesis -Memory difficulties -Aggressive behavior Chronic traumatic encephalopathy: -Aggressive behavior -Memory difficulties When analyzing cues, the nurse should recognize that manifestations of brain herniation include pupil asymmetry, lower limb weakness, low brainstem reflexes, and decorticate or decerebrate posturing. Pupil asymmetry is a sign when one pupil might be dilated while the other is not and is a result of high pressure within the skull, squeezing the brain and vital areas of the brain across structures within the skull leading to brain herniation. Brain herniation might lead to lower limb weakness as motor control is affected. If too much pressure is put on the brainstem, loss of brainstem reflexes will occur. A disrupted brainstem can also lead to posturing. When analyzing cues, the nurse should recognize that manifestations of traumatic brain injury (TBI) include hemiparesis, memory difficulties, and aggressive behavior. TBIs occur from a disruption in the cellular function of the brain from an outside mechanical force. The types of mechanical forces can be direct, rotational, or shear, and can result in mild, moderate, or severe injuries. When analyzing cues, the nurse should recognize that manifestations of chronic traumatic encephalopathy (CTE) include broad and nonspecific cognitive changes, such as increased aggression and memory difficulties. CTE is a type of brain degeneration that typically occurs due to repeated head trauma. Symptoms develop over years after repeated brain injuries. These are nonspecific and might include increased aggression and memory issues.

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex?

Far left

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?

-Abnormally prominent U wave

A nurse in an emergency department is preparing to administer alteplase accelerated therapy to a client who is having a myocardial infarction. Which of the following actions should the nurse plan to take? (Select all that apply.)

-Administer the medication within 30 min of the client's arrival to the department -Reconstitute the medication with sterile water is correct -Administer the medication in a 15 mg IV bolus -Assess the client for back pain

A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

-An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?

-Apex of the heart

A nurse is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

-Ask the client if she has considered harming her newborn.

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

-Hypotension

A nurse is planning care for a client who has neurogenic shock following a spinal cord injury. Which of the following provider prescriptions should the nurse anticipate? (Select all that apply.)

-Lactated Ringers intravenous fluid -Dopamine -Epinephrine

A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following is an early manifestation of an AAA?

-Lower back or groin pain

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

-MRI of the chest

A nurse is caring for a client in the emergency department. Which of the following interventions should the nurse expect when planning care for this client?

-Monitor client for back pain -Monitor CBC results -Administer an antihypertensive agent -Provide education regarding smoking cessation -Provide education regarding manifestations of increasing aneurysm

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

-Oliguria

A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?

-Summon the code team.

A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect?

-Systolic murmur

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?

-The P wave falls before the QRS complex.

A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

-The client has hypotension and is confused

A nurse in a n urgent care center is assessing 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 deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

-Atrial fibrillation

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

-Atropine

A nurse is teaching a client at a prenatal clinic. The client shares that they have family members diagnosed with schizophrenia and wants to know how they can reduce their baby's risk of developing schizophrenia. Which of the following information should the nurse include?

-Avoid contracting a viral infection.

A nurse is reviewing the medical record of a client who recently has been diagnosed with schizophrenia. Which of the following finding is a genetic risk factor associated with the development of schizophrenia?

-Biologic parent with schizophrenia

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

-Call the emergency response team.

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

-Carotid

A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?

-Carotid

A nurse is preparing to begin chest compressions on an infant. The nurse should perform compressions using which of the following techniques?

-Deliver compressions at ⅓ the depth of the chest.

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

-Different apical and radial pulses.

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

-Morphine

A nurse is caring for a client in critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

-Muffled heart sounds.

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

-Troponin I

A nurse is providing care for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

-Troponin T test

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?

-Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

-antiplatelet aggregate

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

-0.9% normal saline IV at 50 mL/hr continuous

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further?

-A history of left-sided heart failure

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

-Obtain an EKG.

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

-Pacemaker spikes before each QRS complex

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?

-Packed RBCs

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow?

-Patent ductus arteriosus

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

-Perform a 12-lead ECG

A nurse is caring for a client who has a new prescription for propranolol. The nurse should monitor the client for which of the following adverse reactions to the medication?

-Postural hypotension

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider?

-Potassium 2.3 mEq/L

A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?

-Prevents dysrhythmias

A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

-QT interval

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

-Reduce the client's intake of protein.

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

-The client should hold his cell phone on the side opposite the ICD.

The nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

-Troponin