in class quizzes

A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client? A. "Turn head to the right." B. "Sit in semi-Fowler's position." C. "Bear down while holding breath." D. "Exhale slowly."

C. "Bear down while holding breath. The client should perform a Valsalva maneuver by holding a breath and bearing down while the nurse disconnects the old set and reconnects the new set. This action prevents air from entering the lumen, the heart, and pulmonary circulation.

A client who experienced a myocardial infarction (MI) 48 hours ago is most at risk for developing: A. cardiogenic shock B. heart failure C. arrhythmias D. pericarditis

C. arrhythmias Feedback: caused by oxygen deprivation to the myocardium is the most common complication of MI

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. A friction rub B. A split second heart sound S2 C. The third heart sound (S3) D. The fourth heart sound (S4)

D. The fourth heart sound (S4) Feedback: S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle.

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action? A. Notify the provider of the client's allergy. B. Attach a wrist band indicating the client's allergy. C. Ask the client if any other foods cause such a reaction. D. Notify the dietary department of the client's allergy.

A. Notify the provider of the client's allergy. Feedback: The greatest risk to the client is an allergic reaction to the iodine-containing contrast agent the client will receive IV for the procedure, because shellfish also contains iodine. A steroid and/or antihistamine will be given to a client with an iodine allergy to prevent or minimize a reaction.

A nurse is caring for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take? A. Provide humidified air for the client. B. Position the head of the client's bed in the flat position. C. Suction the client's mouth toward the surgical side. D. Clean the client's sutures every 8 hr.

A. Provide humidified air for the client. Feedback: The nurse should provide humidification to loosen secretions and prevent crust formation.

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? A. Attending a class given about tracheostomy care B. Verbalizing all steps in the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning

C. Performing the procedure independently Feedback: The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Keep the affected leg slightly flexed. C. Elevate the head of the bed 45°. D. Keep the client NPO for 4 hr.

A. Have the client lie flat in bed. Feedback: The nurse should have the client on lie flat in bed. Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.

A nurse in an 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? A. First-degree AV block B. Atrial fibrillation C. Sinus bradycardia D. Sinus tachycardia

B. Atrial fibrillation Feedback: Atrial fibrillation causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations? A. Increased urine output B. Rapid pulse C. Fatigue D. Sneezing

C. Fatigue Feedback: Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness.

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

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

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? A. To convert atrial fibrillation to sinus rhythm B. To dissolve clots in the bloodstream C. To slow the response of the ventricles to the fast atrial impulses D. To reduce the risk of stroke in clients who have atrial fibrillation

D. To reduce the risk of stroke in clients who have atrial fibrillation Feedback: Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as dabigatran, help prevent thrombus formation.

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be A. infertility B. diarrhea. C. dyspnea. D. dysphagia.

D. dysphagia. Feedback: Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness.

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. B. Remove the PICC line. C. Apply a cold pack to the client's upper arm. D. Notify the provider who inserted the PICC line.

A. Measure the circumference of both upper arms. The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.

A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter? A. Use a 10-mL syringe to flush the catheter. B. Flush the lumen with sterile water after each use. C. Use clean technique when accessing the catheter. D. Apply firm pressure to the syringe plunger when flushing the lumen.

A. Use a 10-mL syringe to flush the catheter During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Prepare to insert a central line. B. Administer oxygen via nasal cannula. C. Raise the foot of the bed to a 90° angle. D. Remove the dressing to inspect the wound.

B. Administer oxygen via nasal cannula. The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues.

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? A. Auscultate breath sounds. B. Clamp the catheter. C. Position the client in left lateral Trendelenburg. D. Initiate oxygen therapy.

B. Clamp the catheter. The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise

B. Dyspnea Feedback: When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization.

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the client's ability to sleep. D. It reduces the client's blood pressure.

B. It facilitates the client's deep breathing. Feedback: When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client's has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize 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? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet

B. MRI of the chest Feedback: A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction.

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury? A. Atorvastatin B. Metformin C. Nitroglycerin D. Carvedilol

B. Metformin Feedback: Metformin interacts with contrast dye and can cause acute kidney damage.

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A. Decrease chest wall compliance B. Suppress respiratory effort C. Induce sedation D. Decrease respiratory secretions

B. Suppress respiratory effort Feedback: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor lung compliance.

A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching? A. "I will take my pulse weekly." B. The pacemaker can be checked from home by using the telephone." C. "My pacemaker will need reprogramming if I stand too close to a microwave oven." D. "The next pacemaker check will be when the batteries need to be replaced."

B. The pacemaker can be checked from home by using the telephone." Feedback: The initial pacemaker check is performed at the clinic. Following this initial examination, follow-up pacemaker checks can happen remotely from the client's home. Using a telephone transmitting device, the client can transmit basic information electronically from the pacemaker to the clinic. The client will return to the clinic annually for a more thorough pacemaker check.

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? A. Airway management B. Amiodarone administration C. Defibrillation D. Epinephrine administration

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

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue B. Passage of the ET tube into the esophagus C. Movement of the ET tube into the right main bronchus D. Infection of the vocal cords

C. Movement of the ET tube into the right main bronchus Feedback: During intubation, the staff can misplace the ET tube in the right mainstem bronchus. The nurse should identify absence of chest wall movement or breath sounds on a single side as indicating ET tube displacement, and should notify appropriate personnel to reposition the tube.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. D. Limit each suction pass to 25 seconds.

C. Preoxygenate the client with 100% oxygen for up to 3 min. Feedback: To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm

C. Radial pulse in the left arm Feedback: Palpating the client's pulse distal to the insertion site is essential for evaluating possible thrombophlebitis and vessel occlusion. The left radial pulse should be strong and essentially equal to the right radial pulse.

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? A. Different blood pressures in the upper limbs. B. Differences between oral and axillary temperatures. C. Differences in upper and lower lung sounds. D. Different apical and radial pulses.

D. Different apical and radial pulses. Feedback: Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the atrium depolarizes too quickly and sends erratic impulses to the ventricles. The presence of a pulse deficit between the apical and radial pulses is an indication of atrial fibrillation. The nurse should assess further by obtaining an ECG or telemetry reading.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Allergic B. Febrile C. Acute pain D. Hemolytic

D. Hemolytic

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care? A. Patency of the intravenous line. B. Level of pain. C. Integrity of the dressing. D. Need for suctioning.

D. Need for suctioning. Feedback: Using the airway, breathing, circulation (ABC) priority-setting framework, confirming a patent airway is the priority observation for a postoperative client after a total laryngectomy.

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The QRS duration is 0.20 seconds. B. The P-R interval measures 0.22 seconds. C. The T wave is in the inverted position. D. The P wave falls before the QRS complex.

D. The P wave falls before the QRS complex. Feedback: The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave.

A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will need to hold my breath when they first put the needle in." B. "I will call the clinic if I have persistent hiccups." C. "I will have to stay in bed for several hours after the procedure." D. "I will turn my head in the opposite direction during insertion."

D. "I will turn my head in the opposite direction during insertion." The client should turn his head away from the insertion site to allow optimal accuracy in placing the catheter.

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult. B. Suction the client less frequently. C. Administer an antidysrhythmic medication. D. Perform pre-oxygenation prior to suctioning.

D. Perform pre-oxygenation prior to suctioning. Feedback: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first? A. Prepare the client for reintubation. B. Assess the client's airway. C. Suction the client's mouth. D. Elevate the client's head of bed.

B. Assess the client's airway. Feedback: The first action the nurse should take using the nursing process is to assess the client's airway for obstruction, listen to the client's lungs for air movement, and provide mechanical ventilation with a bag-valve-mask device to reduce the risk for hypoxia.

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? A. Pacemaker spikes after each QRS complex B. Pacemaker spikes before each P wave C. Pacemaker spikes before each QRS complex D. Pacemaker spikes with each T wave

C. Pacemaker spikes before each QRS complex Feedback: The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred.

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Administer an antidysrhythmic medication. B. Obtain a cardiology consult. C. Perform pre-oxygenation prior to suctioning. D. Suction the client less frequently.

C. Perform pre-oxygenation prior to suctioning. Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. D. Limit each suction pass to 25 seconds.

C. Preoxygenate the client with 100% oxygen for up to 3 min. To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula. B. Encourage oral intake of at least 3,000 mL of fluids per day. C. Offer high-protein and high-carbohydrate foods frequently. D. Place in a prone position.

D. Place in a prone position. Feedback: Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds.

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? A. Replace the infusion system. B. Prepare for chest tube insertion. C. Remove the catheter. D. Place the client on his left side in Trendelenburg position.

D. Place the client on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system.