HCIV Unit 2 Exam
Which dysrhythmia is shown in the figure? A) Atrial flutter B) Atrial fibrillation C) Ventricular tachycardia D) Ventricular fibrillation
B) Atrial fibrillation
A patient who has cardiogenic shock is experiencing labored breathing and low oxygen levels. A STAT chest x-ray is ordered. The x-ray results show pulmonary edema. The physician orders Furosemide IV. What finding would require immediate nursing action? A) Blood pressure 98/54 B) Urinary output 45 mL/hr C) Potassium 1.8 mEq/L D) Heart rate 110 bpm
C) Potassium 1.8 mEq/L
A client receiving a blood transfusion reports itching and difficulty breathing. The heart rate has increased, and the blood pressure is falling. Which type of shock would the nurse suspect? A) Septic shock B) Cardiogenic shock C) Neurogenic shock D) Anaphylactic shock
D) Anaphylactic shock
Six hours after pacemaker insertion, a client reports sudden onset of chest pain and shortness of breath with a drop in SpO2 from 98% on 2L/min of oxygen to 90% on 2L/min on oxygen. Which action should the nurse take first? A) Assess the client's breath sounds and chest movement B) Notify the HCP to obtain a chest x-ray C) Check the client's blood pressure and heart rate D) Assess the incision site for redness, pain, drainage, and/or swelling
A) Assess the client's breath sounds and chest movement
Which electrical activity of the cardiac conduction system is reflected in the p-wave? A) Atrial depolarization B) Atrial repolarization C) Ventricular depolarization D) Ventricular repolarization
A) Atrial depolarization
A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action? A) Patient heart rate is 115 bpm B) Patient experiences dyspnea and crackles in lung fields C) Patient is anxious D) Patient's urinary output is 35 mL/hr
B) Patient experiences dyspnea and crackles in lung fields
Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the HCP? A) Irregular heartbeat B) Right arm weakness C) Client report of palpitations D) Client report of lightheadedness
B) Right arm weakness
The process that causes a heart cell to contract is known as? A) Repolarization B) Polarization C) Depolarization D) Neutral
C) Depolarization
The nurse is assessing an ECG strip and begins measuring at the beginning of the p-wave to the beginning of the QRS complex. What is the nurse measuring? A) P-wave B) ST segment C) PR interval D) PR segment
C) PR interval
The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What lab value will the nurse anticipate? A) pH 7.51 B) PaO2 100 C) PaCO2 49 D) Lactate 0.4
C) PaCO2 49
The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia, sensory loss, and cognitive dysfunction. During the client's first 72 hours of hospitalization, which is the priority nursing action? A) Teach the client how to transfer from bed to chair B) Use a picture board to help the client communicate C) Perform neurological assessments every 2 hours D) Assist the client to comb hair and brush teeth
C) Perform neurological assessments every 2 hours
The physician orders a Dobutamine IV drip on a patient in cardiogenic shock. After starting the IV drip, the nurse would make it priority to monitor for? A) Rebound hypertension B) Ringing in the ears C) Worsening hypotension D) Severe headache
C) Worsening hypotension
Which patient below is at most risk for developing cardiogenic shock? A) A 52-year-old male who is experiencing a severe allergic reaction from shellfish B) A 25-year-old female who has experienced an upper thoracic spinal cord injury C) A 72-year-old male who is post-op from a liver transplant D) A 49-year-old female who is experiencing an acute myocardial infarction
D) A 49-year-old female who is experiencing an acute myocardial infarction
The nurse provides care for a client at risk for an intracranial hemorrhage. Which are risk factors for an intracranial hemorrhage? A) Atherosclerosis and hypertension B) Anemia and kidney disease C) Hypothyroidism and glaucoma D) Arteriosclerosis and hypertension
D) Arteriosclerosis and hypertension
The nurse provides care for a client that is at high risk for a stroke. Which is a known risk factor for stroke? A) Atrial fibrillation B) Senile dementia C) Chronic constipation D) Coagulopathies
A) Atrial fibrillation
When a client's level of consciousness suddenly decreases or alters, the nurse should immediately determine if any of these conditions are present: SATA. A) Hypoglycemia B) Hypoxia C) Incontinence D) Hyperkalemia
A, B
Which of the following medications is used for early DIC? A) Labetalol B) Heparin C) Aspirin D) Furosemide
B) Heparin
Which dysrhythmia is shown in the figure? A) Atrial flutter B) Atrial fibrillation C) Ventricular tachycardia D) Ventricular fibrillation
A) Atrial flutter
Which of the following symptoms is a clinical manifestation of a PE? SATA. A) Bradycardia B) Distended neck veins C) Petechiae D) Diarrhea E) Dry cough
B, C, E
A client suddenly develops paroxysmal supraventricular tachycardia (PSVT) at a rate of 180 bpm. Current vital signs: BP 90/45, HR 180 bpm, respirations 30 breaths/min, O2 saturation 90% on room air. The client is diaphoretic and reports dizziness. What should the nurse do first? A) Ask the client about current caffeine use B) Administer atropine per agency protocol C) Prepare defibrillator for synchronized cardioversion D) Start CPR
C) Prepare defibrillator for synchronized cardioversion
Which clinical manifestation indicates a client may have an actively bleeding stress ulcer? A) Unexplained symptoms of shock B) Small amounts of melena for several days C) Sudden hematemesis and rectal blood D) A gradual drop in the hematocrit vale
C) Sudden hematemesis and rectal blood
A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A) Suspend the alarm B) Call the emergency response team C) Press the record button to get an ECG strip D) Assess the client and check lead placement
D) Assess the client and check lead placement
The nurse is caring for a client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse? A) Potassium 4.8 mEq/L B) Magnesium 2 mEq/L C) Heart rate 90 D) History of smoking
D) History of smoking
A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what next? A) IV corticosteroids B) Colloids C) Dobutamine D) Norepinephrine
D) Norepinephrine
A client has chest pain rated at 8 on a 10-point scale. The 12-lead EKG reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first? A) Monitor daily weights and urine output B) Limit visitation by family and friends C) Provide client education on medications and diet D) Reduce pain and myocardial oxygen demand
D) Reduce pain and myocardial oxygen demand
The client admitted with possible ischemic stroke has been aphasic for 3 hours and has a blood pressure of 220/120 mmHg. Which prescription by the HCP should the nurse question? A) Labetalol drip to keep the BP <120/80 B) Tissue plasminogen activator (tPA) per protocol C) Normal saline IV at 75 mL/hr D) Bed elevated at 30°
A) Labetalol drip to keep the BP <120/80 Rationale: Elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than 130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
The nurse provides care for a client diagnosed with stroke earlier that day. Which nursing assessment is priority? A) The client's ability to speak clearly B) The client's level of consciousness C) The color, temperature, and moisture of the client's skin D) The client's ability to follow simple commands
B) The client's level of consciousness
A QRS complex should measure no more than? A) 0.20 seconds B) 0.12 seconds C) 0.08 seconds D) 0.04 seconds
B) 0.12 seconds
A client who 3 days ago underwent extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and feeling very scared. After assessing the client, what is the nurse's best action or response to prevent harm? A) Ask the client about possible drug allergies B) Apply oxygen and initiate the Rapid Response Team C) Determine when she last received an opioid dose D) Check the oxygen saturation and encourage her to cough
B) Apply oxygen and initiate the Rapid Response Team
Atrial fibrillation is characterized by random p-waves on the EKG. True or False?
False
Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment. True or False?
False
P-Waves are absent in atrial flutter. True or False?
True
The hallmark of atrial flutter are "saw-tooth" waves, sometimes called F-waves. True or False?
True
Which acid-base imbalance would the nurse anticipate in a client in the progressive stage of shock? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
A) Metabolic acidosis
A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient? A) Modified Trendelenburg B) Trendelenburg C) High Fowler's D) Supine
A) Modified Trendelenburg
When heart muscle cells are in the resting state they have what type of charge? A) Negative B) Positive C) Neutral D) Depolarized
A) Negative
Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock? A) Oliguria B) Crackles D) Dyspnea E) Bounding pulse
A) Oliguria
Which part of the PQRST complex represents atrial depolarization? A) P-wave B) QRS complex C) T-wave D) ST segment
A) P-wave
When a heart muscle cell goes back into its negatively charged state, or in other words, when it relaxes this is known as? A) Repolarization B) Polarization C) Depolarization D) Neutral
A) Repolarization
A patient is on IV Norepinephrine for treatment of septic shock. Which statement is false about this medication? A) "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B) "This medication causes vasodilation and decreases systemic vascular resistance." C) "It is used when fluid replacement is not unsuccessful." D) "It is considered a vasopressor."
B) "This medication causes vasodilation and decreases systemic vascular resistance."
Which finding will the nurse expect when caring for a client who is in hypovolemic shock? A) Slow HR B) Cool skin temperature C) Bounding radial pulses D) Increased urine output
B) Cool skin temperature
Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment first? A) Low-dose corticosteroids B) Crystalloids IV fluid bolus C) Norepinephrine D) 2 units of Packed Red Blood Cells
B) Crystalloids IV fluid bolus
The nurse educator reviews ECGs with a group of new nurses. The QRS complex reflects which activity? A) Atrial depolarization B) Ventricular depolarization C) Ventricular repolarization D) Central venous pressure
B) Ventricular depolarization
A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it priority to? A) Rapidly infuse the fluids B) Warm the fluids C) Change tubing in between bags D) Keep the patient supine
B) Warm the fluids
The nurse is assessing an ECG strip and counts 30 large squares. How many seconds of time did the nurse count? A) 30 seconds B) 10 seconds C) 6 seconds D) 60 seconds
C) 6 seconds
Which part of PQRST complex represents ventricular repolarization? A) QRS complex B) ST segment C) T-wave D) P-wave
C) T-wave
On an EKG/ECG strip each small square represents how many seconds of time? A) 0.20 second B) 0.02 seconds C) 0.12 seconds D) 0.04 seconds
D) 0.04 seconds
The nurse assesses a client's EKG and counts 14 QRS complexes occurring on a 6 second rhythm strip. Which is the heart rate? A) 70 bpm B) 84 bpm C) 100 bpm D) 140 bpm
D) 140 bpm
Which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse? A) "I'm glad I can keep eating protein like red meat." B) "I'll try to walk 20-30 minutes each day." C) "I'm going to talk to my doctor about a weight loss plan." D) "I plan to include more fruits and vegetables in my diet."
A) "I'm glad I can keep eating protein like red meat."
The nurse is caring for clients on a med-surg unit and identifies which client has the highest risk for developing a PE? A) An obese client with leg trauma B) A pregnant client with acute asthma C) A client with diabetes who has cholecystitis D) A client with pneumonia who is immunocompromised
A) An obese client with leg trauma
The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate? A) Heart rate 118 bpm B) 2+ pedal pulses C) Bilateral fine crackles in the lung bases D) BP change from 100/60 to 100/40 mmHg
A) Heart rate 118 bpm
After a client sustains multiple internal injuries in a motor vehicle accident, the BP suddenly drops from 134/90 to 80/60 mmHg. What is the likely cause of this drop in BP? A) Reduction in the circulating volume B) Diminished vasomotor stimulation to the arterial wall C) Vasodilation resulting from diminished vasoconstrictor tone D) Cardiac decompensation resulting from electrolyte imbalance
A) Reduction in the circulating volume
The nursing instructor provides information about cardiac dysrhythmias to nursing students. Which cardiac dysrhythmia is the most life-threatening? A) Ventricular fibrillation (V-fib) B) Atrial fibrillation (A-fib) C) Ventricular tachycardia (V-tach) D) Atrial bradycardia
A) Ventricular fibrillation (V-fib)
You're providing an in-service to new nurse graduates on the fluid treatment for hypovolemic shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic shock. Which responses are incorrect? SATA. A) Albumin B) Lactated Ringer's C) Normal Saline D) Hetastarch
A, D
When a family member of a client with cardiogenic shock asks the nurse for more information about the condition, how would the nurse describe cardiogenic shock? A) An irreversible phenomenon B) A failure of the circulatory pump C) Usually a fleeting reaction to tissue injury D) Generally caused by decreased blood volume
B) A failure of the circulatory pump
The nurse provides care for a client after a total abdominal hysterectomy. The nurse notes the client's vital signs are apical pulse 102 and thready, respiration 28 per minute, and supine BP 88/50. The client is weak and restless with skin that is pale, moist, and cool to the touch. Which intervention should the nurse take to care for the client? A) Place the client in High Fowler's position and notify the HCP immediately B) Administer oxygen at 2-3 liters/min C) Decrease the rate of flow of the IV fluids D) Ambulate the client in the hallway
B) Administer oxygen at 2-3 liters/min
Which part of the PQRST complex represents ventricular depolarization? A) P-wave B) QRS complex C) T-wave D) ST segment
B) QRS complex
Which assessment finding by the nurse caring for a client with new-onset atrial fibrillation would be most important to communicate to the HCP? A) Irregular apical pulse B) Sudden vision change C) Exertional dyspnea D) Lower extremity edema
B) Sudden vision change
A patient is diagnosed with septic shock. As the nurse, you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock. A) obstructive; hypovolemic and anaphylactic B) distributive; anaphylactic and neurogenic C) obstructive; cardiogenic and neurogenic D) distributive; anaphylactic and cardiogenic
B) distributive; anaphylactic and neurogenic
The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A) "I need to go to the clinic once a week to have my blood level checked." B) "If my stools turn black, I will be sure to call my HCP." C) "I'm glad I don't need to change my diet. Salads are my favorite food." D) "I need to stop taking my herbal supplement."
C) "I'm glad I don't need to change my diet. Salads are my favorite food."
The office nurse prepares a client for a resting EKG. Which statement by the client indicates teaching is successful? A) "I will be asleep during the first part of the test." B) "I will be asked to look at flickering lights at one point in the test." C) "The more still I can lie, the better the results will be." D) "The shocks I will feel are very small and will feel like a tingle."
C) "The more still I can lie, the better the results will be."
A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the HCP if there is a rapid increase in which vital sign? A) Pulse B) Respirations C) Blood pressure D) Temperature
C) Blood pressure
Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? A) Urine output 1000 mL in 8 hours B) Oral temperature 101 F C) Client reports feeling very thirsty D) Bounding radial and femoral pulses
C) Client reports feeling very thirsty
The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient? A) Platelets B) Albumin C) Fresh Frozen Plasma D) Packed Red Blood Cells
C) Fresh Frozen Plasma
A nurse hears an irregular heart rate of 110 bpm when listening to a client's chest. After assessing the client and noting new onset shortness of breath, which action should the nurse take next? A) Check the availability of medication to relieve anxiety B) Recheck the pulse later in the shift C) Obtain a prescription for a stat EKG D) Call the radiology service to obtain a stat chest x-ray
C) Obtain a prescription for a stat EKG
Which nursing intervention would prevent septic shock in the hospitalized client? A) Maintain the client in a normothermic state B) Administer blood products to replace fluid losses C) Use aseptic technique during all invasive procedures D) Keep the critically ill client immobilized to reduce metabolic demands
C) Use aseptic technique during all invasive procedures
The nurse is caring for a client with hypovolemic shock who is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action? A) Insert a large-bore IV catheter B) Administer supplemental oxygen C) Elevate the client's feet, keeping the head flat D) Apply direct pressure to the area of overt bleeding
D) Apply direct pressure to the area of overt bleeding
Initially, after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic BP is rising. Which complication would the nurse plan to address? A) Spinal shock B) Hypovolemic shock C) Transtentorial herniation D) Increased intracranial pressure
D) Increased intracranial pressure
What is the point where the QRS complex meets the ST segment? A) R-point B) PR interval C) QT interval D) J-point
D) J-point
Which part of the electrical conduction system is located in the upper part of the right atrium and is responsible for atrial depolarization? A) AV node B) Bundle of His C) Purkinje Fibers D) SA node
D) SA node
Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. True or False?
False
The R-waves in atrial fibrillation are regular. True or False?
False
Once electrical signals pass through the Bundle of His, they next travel to? A) AV node B) Bundle branches C) SA node D) Purkinje Fibers
B) Bundle branches
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A) Cholesterol level B) Pupil size and pupillary response C) Bowel sounds D) Echocardiogram
B) Pupil size and pupillary response
A client who has been given CPR is transported by ambulance to the hospital's ED. What is the most effective way for the nurse to determine if this client has adequate oxygenation? A) There is a pulse B) Pupils are reacting to light C) Mucous membranes are pink D) Systolic BP is at least 80 mmHg
B) Pupils are reacting to light
A middle-aged client with a history of hypertension reports having "indigestion." The nurse connects the client to a cardiac monitor, which reveals eight premature ventricular contractions per minute. What should the nurse do next? A) Call the HCP B) Start an IV infusion C) Obtain a portable chest radiograph D) Draw blood for lab studies
B) Start an IV infusion
A normal PR interval should measure between? A) 0.04-0.12 seconds B) 0.20-0.36 seconds C) 0.12-0.20 seconds D) 0.35-0.40 seconds
C) 0.12-0.20 seconds
A client who had an MI has runs of ventricular tachycardia. Which medication will the nurse prepare to administer? A) Digoxin B) Furosemide C) Amiodarone D) Norepinephrine
C) Amiodarone
A client arrives in the ED with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (tPA)? A) Ask what medications the client is taking B) Complete a history and health assessment C) Identify the time of onset of the stroke D) Determine if the client is scheduled for any surgical procedures
C) Identify the time of onset of the stroke
The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20, QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? A) Sinus tachycardia B) Sinus bradycardia C) Normal sinus rhythm D) Sinus arrhythmia
C) Normal sinus rhythm
The nurse assesses a client's rhythm strip and interprets the rhythm to be atrial fibrillation. On which criteria does the nurse base this analysis? A) Normal and regular rate, normal P wave, PR interval greater than 0.20 seconds, and normal QRS B) Atrial rate 250-350 bpm, ventricular rate is irregular and greater than 100, sawtooth P wave, and variable PR interval C) Rate is regular and greater than 100 bpm, normal P wave, normal PR interval, and normal QRS D) Atrial rate is irregular and 350-600 bpm, ventricular rate is variable and irregular, P wave is chaotic, and PR interval is not measurable
D) Atrial rate is irregular and 350-600 bpm, ventricular rate is variable and irregular, P wave is chaotic, and PR interval is not measurable
The nurse is caring for a client with hypovolemic shock. Which new assessment finding indicates to the nurse that interventions are currently effective? A) Oxygen saturation remains unchanged B) Core body temperature has increased to 99°F C) The client correctly states the month and year D) Serum lactate and serum potassium levels are declining
D) Serum lactate and serum potassium levels are declining
A patient has lost 750 mL of blood volume. The MD orders Normal Saline infusion. Using the 3:1 rule, how much crystalloid solution should be prescribed by the doctor? A) 2,250 mL of Normal Saline B) 250 mL of Normal Saline C) 375 mL of Normal Saline D) 1,225 mL of Normal Saline
A) 2,250 mL of Normal Saline
Two hours after hip surgery, a client's vital signs are BP 100/60, pulse 104 bpm, RR 22, and O2 sat 95%. Which action would the nurse take first? A) Check the dressing on the incision B) Increase the IV flow rate C) Obtain the client's oral temp D) Monitor the vital signs every 15 minutes
A) Check the dressing on the incision
The nurse provides care for a client who reports, "It feels like my heart is missing a beat." Which is the most accurate way for the nurse to use an EKG tracing to calculate the heart rate of the client with an irregular heart rate? A) Count the number of QRS complexes in a 1-minute time interval B) Count the number of QRS complexes in a 6-second interval and multiply that number by 10 C) Count the number of small squares between two QRS complexes on the tracing and divide 1500 by that number D) Locate the R wave that falls on a heavy vertical line and count memorized landmarks at subsequent heavy lines to the next QRS complex
A) Count the number of QRS complexes in a 1-minute time interval
Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation? A) Take pulse apically for a full minute B) Monitor BP at least every 2 hours C) Ask the client to call for assistance when ambulating D) Teach client to avoid taking OTC aspirin
A) Take pulse apically for a full minute
The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A) The patient's blood pressure changes from 75/48 to 110/82 B) Patient's CVP 2 mmHg C) Patient's skin is warm and flushed D) Patient's urinary output is 20 mL/hr
A) The patient's blood pressure changes from 75/48 to 110/82
When a client presents with a PE, what should the nurse anticipate their lab values to look like? SATA. A) Alkalosis first, then acidosis from increased lactic acid B) Acidosis first, then alkalosis from decreased lactic acid C) Decreased D-Dimer D) Elevated D-Dimer
A, D
During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the nurse palpates the radial pulse and notices which signs? A) Two regular beats followed by one irregular beat B) An irregular rhythm with pulse rate >100 bpm C) Pulse rate below 60 bpm D) A weak, thready pulse
B) An irregular rhythm with pulse rate >100 bpm
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first? A) Activate the Rapid Response Team B) Assess the client's orientation and vital signs C) Call the HCP D) Administer a bolus of lidocaine
B) Assess the client's orientation and vital signs
Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A) Administer Norepinephrine before attempting a fluid resuscitation B) Collect cultures and then administer IV antibiotics C) Check blood glucose levels before starting any other treatments D) Administer Drotrecogin Alpha within 48-72 hours
B) Collect cultures and then administer IV antibiotics
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? A) BP 110/62, atrial fibrillation with heart rate 82 bpm, bilateral basilar crackles B) Confusion, urine output 15 mL over the last two hours, orthopnea C) SpO2 92 on 2 L nasal cannula, respirations 20, 1+ edema of lower extremities D) Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise
B) Confusion, urine output 15 mL over the last two hours, orthopnea
A client is diagnosed with a possible stroke. The client has a history of poorly controlled hypertension. The client takes antihypertensive medication and hormone replacement therapy. The client appears overweight and admits to mostly watching tv or working on the computer all day. The nurse identifies which risk factor as most significant for development of a stroke for this client? A) Obesity B) Hypertension C) Sedentary lifestyle D) Hormone replacement therapy
B) Hypertension Rationale: Hypertension is the leading major risk factor for developing a stroke because of damage to blood vessels.
A patient with cardiogenic shock has a blood pressure of 70/38. In addition, the patient is experiencing dyspnea with a respiratory rate of 32 breaths per minute and has an oxygen saturation of 82% on room air. On auscultation, you note crackles throughout the lung fields. You notify the physician. What order below would you ask for an order clarification? A) Dopamine IV stat B) Normal saline IV bolus stat C) Furosemide IV stat D) Place patient on CPAP (continuous positive airway pressure)
B) Normal saline IV bolus stat
A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to? A) An increase in cardiac preload B) An increase in stroke volume C) A decrease in cardiac preload D) A decrease in cardiac contractility
C) A decrease in cardiac preload
The nurse assesses a client diagnosed with a TIA. The nurse anticipates the client will report which symptom? A) Inability to speak for 7-10 days B) Intermittent sharp, stabbing pain on one side of the head C) Acute right lower extremity weakness that lasts about 15 minutes D) Bilateral upper extremity weakness that progresses downward
C) Acute right lower extremity weakness that lasts about 15 minutes
Which nursing intervention is the priority for a client with stroke who transitioned from the ED to other settings? A) Monitoring vital signs B) Reassuring the client and family C) Assessing the level of consciousness D) Monitoring specific client manifestations of stroke
C) Assessing the level of consciousness
A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to? A) Collect a urine sample B) Obtain an EKG C) Establish 2 large-bore IV access sites D) Place a warming blanket on the patient
C) Establish 2 large-bore IV access sites
During a client's paracentesis, 1500 mL of fluids are removed. Which assessment finding by the nurse is indicative of a potentially severe response? A) Abdominal girth decrease B) Mucous membranes becoming drier C) HR increases from 80 to 135 bpm D) BP rises from 130/70 - 190/80
C) HR increases from 80 to 135 bpm
A client is given amiodarone in the ED for a dysrhythmia. Which finding indicates the drug is having the desired effect? A) The ventricular rate is increasing B) The absent pulse is now palpable C) The number of premature ventricular contractions is decreasing D) The fine ventricular fibrillation changes to coarse ventricular fibrillation
C) The number of premature ventricular contractions is decreasing
A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? A) Bradycardia B) Flushed face C) Unilateral chest pain D) Decreased BP
C) Unilateral chest pain