midterm medsurg IV
The nurse is caring for a client with a closed head injury. Which of the following is a consequence of sustained elevated intracranial pressure (ICP)? A. Heart failure B. Dementia C. Uremia D. Brainstem herniation
D. Brainstem herniation
Which diagnostic test is most useful in differentiating the dyspnea related to the pulmonary effects of heart failure from the dyspnea related to chronic pulmonary disease? A. Blood urea nitrogen (BUN). B. Cardiac catheterization. C. B-type natriuretic peptide (BNP). D. Exercise stress testing.
C. B-type natriuretic peptide (BNP).
Match these cranial nerves to whether they control sensory, motor or both reception: - I, II, VIII - III, IV, VI, XI, XII - V, VII, IX, X
- I, II, VIII - SENSORY - III, IV, VI, XI, XII - MOTOR - V, VII, IX, X - BOTH
A client being treated for acute exacerbation of asthma has been converted from a theophylline (Aminophylline) intravenous solution to metered-dose inhaler management. The amount of infused intravenous solution was 250 mL. The pharmacy provided 450 mg of theophylline mixed in 1000 mL of 5% dextrose in water. How much of the theophylline did the patient receive in milligrams (mg)? Enter the correct numeric response only. Round the answer to the first decimal place.
112.5
On making hourly rounds at 0700, the day shift nurse observes the infusion pump infusing a maintenance IV solution at 80 mL/hour. During change of shift report, the night shift nurse states that 80 mL/hour is the rate the pump has been infusing all night (previous 12 hours). The day nurse checks the orders during the 12-hour chart check and finds that the original order was for the IV to infuse at a rate of 1 liter every 8 hours. For the previous 12 hours, what was the client's IV fluid deficit in milliliters? Enter the correct numeric response only. Round the answer to the first decimal place
540
A client diagnosed with acute ischemic stroke is a candidate for thrombolytic therapy. The client is to receive a total of 0.9 mg/kg of Activase (alteplase), a tissue plasminogen activator (tPA), intravenously. Ten percent (10%) of the dose is to be delivered as a bolus. The client weighs 152 pounds. The dose is supplied as 90 mg in 100 mL normal saline solution. How many milliliters (mL) of tPA will the nurse administer for the bolus dose? Enter a numeric value only. Do not include units of measurement. Round the answer to the first decimal place.
6.9
The nurse is assessing a patient's level of consciousness following a motor vehicle accident using the Glasgow Coma Scale. He withdraws to pain and will only open his eyes when sternal rubbed. He mumbles incomprehensibly when asked orientation questions. The nurse calculates his GCS at _____. A. 8 B. 6 C. 3 D. 4
A. 8
A patient is admitted in acute respiratory distress. The patient is awake and anxious. Symptoms include marked shortness of breath and circumoral cyanosis. Past medical history includes chronic obstructive pulmonary disease (COPD). Arterial blood gases on a FiO2 of 0.30 via mask reveal: pH 7.22 paO2 90 mmHg paCO2 62 mmHg SaO2 88% HCO3 25 mEq/L Based on the data provided, what condition has most likely developed? A. Acute hypercapnic respiratory failure. B. Acute respiratory distress syndrome. C. Acute hypoxic respiratory failure. D. Acute decompensated heart failure.
A. Acute hypercapnic respiratory failure.
A client with Guillain-Barré syndrome (GBS) has been hospitalized for 3 days. Which assessment finding indicates a need for more frequent monitoring? A. Ascending weakness. B. Hyperactive reflexes. C. Focal seizures. D. Descending weakness.
A. Ascending weakness.
A patient with swallowing deficits following a stroke is preparing to eat. Which intervention(s) would the nurse employ to ensure the patient is safely swallowing during food ingestion? (Select all that apply). *ADP* A. Assess the patient for coughing after oral intake. B. Flex patient's head backwards slightly. C. Position the patient in an upright position (preferably 90 degrees if able). D. Determine if patient can sip water without choking. E. If patient exhibits no cough or choking, drooling is acceptable.
A. Assess the patient for coughing after oral intake. C. Position the patient in an upright position (preferably 90 degrees if able). D. Determine if patient can sip water without choking.
Which mode of mechanical ventilation is used with critically ill patients that provides the patient with a preset tidal volume or pressure at a preset rate while also allowing the patient to initiate an "extra breath"? The extra breath would provide the patient with the preset tidal volume or pressure. A. Assist-Control Ventilation B. Synchronized Intermittent Mandatory Ventilation C. Pressure Support Ventilation D. Controlled Mandatory Ventilation
A. Assist-Control Ventilation (ACV)
During the initial period of spinal shock, the nurse should expect the client's bladder function to be which of the following? A. Atonic B. Spastic C. Uncontrolled D. Normal
A. Atonic
A client admitted with a head injury has the following admission vital signs: temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respiratory rate 26. Which of the following vital signs, if taken 1 hour after admission, suggest impending herniation of the brain? A. Blood pressure 176/60, pulse 52, respiratory rate 10 B. Blood pressure 110/70, pulse 120, respiratory rate 20 C. Blood pressure 130/72, pulse 90, respiratory rate 32 D. Blood pressure 118/64, pulse 72, respiratory rate 22
A. Blood pressure 176/60, pulse 52, respiratory rate 10
Massive. atelectasis occurs in the client with acute respiratory distress syndrome (ARDS). What are the major causes of this alveolar collapse? (Select all that apply). *SIBI* A. Bronchospasm. B. Mucous plugging. C. Increased pulmonary vascular resistance. D. Increased pulmonary compliance. E. Interstitial pulmonary edema. F. Surfactant deficiency.
A. Bronchospasm. C. Increased pulmonary vascular resistance. E. Interstitial pulmonary edema. F. Surfactant deficiency.
What is the most important modifiable risk factor to overall stroke prevention? A. Controlling hypertension B. Preventing AFIB C. Smoking cessation D. Managing diabetes
A. Controlling hypertension
All of the following are causes of postrenal acute kidney injury (AKI) except: A. Decreased cardiac output B. Calculi C. Benign prostatic hyperplasia (BPH) D. Prostate cancer
A. Decreased cardiac output
A patient in the ICU floor is being monitored after a cardiac event of which they underwent a percutaneous coronary intervention. The monitor shows the rhythm below with a blood pressure of 70/36. Patient complaints of dizziness associated with shortness of breath. The team had given the patient 0.5 mg of Atropine IV and was repeated up to a total of 3mg. The patient still complains of shortness of breath, feeling faint and dizziness. You are waiting for a cardiologist to come bedside. According to the AHA, what medication are you anticipated to start to get the patient's heart rate within normal limits? A. Dopamine 2-20 mcg/kg/min B. Atropine 3-20 mg/min C. Noriepinephrine 20-200mcg/kg/min D. Epinephrine 10-30 mcg/min
A. Dopamine 2-20 mcg/kg/min
A patient who is orally intubated and mechanically ventilated has a nursing diagnosis of "Risk for Aspiration related to Artificial Airway". Which nursing interventions are appropriate to decrease the risk for aspiration in this patient? (Select all that apply). *EPE* A. Elevate head of bed to at least 30 degrees. B. Ensure proper endotracheal tube cuff inflation. C. Clear ventilator tubing of water condensation. D. Assess for presence of gag reflex. E. Provide oropharyngeal suctioning every hour.
A. Elevate head of bed to at least 30 degrees. B. Ensure proper endotracheal tube cuff inflation. E. Provide oropharyngeal suctioning every hour.
Medications sometimes given to help decrease ICP include which of the following? (Select all that apply) *HMC* A. Hypertonic 3% saline B. IV fluids C. Mannitol D. Corticosteroids
A. Hypertonic 3% saline C. Mannitol D. Corticosteroids
The nurse monitors for which of the following clinical manifestations in the client who has experienced a stroke resulting in damage to Wernicke's area of the brain? A. Inability to comprehend spoken or written words. B. Slurred, inarticulate speech. C. Communication with repetitive speech. D. Inability to make sounds
A. Inability to comprehend spoken or written words.
A nurse admits a patient from the emergency department with a diagnosis of acute coronary syndrome (ACS) due to unstable angina and possible non-ST segment elevation myocardial infarction (NSTEMI). The healthcare provider prescribes oxygen and nitroglycerin. By which mechanisms are these therapies thought to reduce or relieve chest pain? A. Increasing oxygen delivery and decreasing oxygen demand. B. Minimizing plaque formation and preventing vasospasm. C. Preventing dysrhythmias and decreasing cardiac contractility. D. Increasing preload and decreasing afterload.
A. Increasing oxygen delivery and decreasing oxygen demand
Hyperkalemia is one of the most serious complications in acute kidney injury because it can cause life-threatening cardiac dysrhythmias. Which of the following are modalities of correcting hyperkalemia? (select all that apply) *HIK* A. Kayexalate B. IV insulin & glucose C. Sodium phosphate D. Hemodialysis
A. Kayexalate B. IV insulin & glucose D. Hemodialysis
The nurse is assessing a newly admitted client. The client displays a right facial droop and has difficulty following commands. The client also presents with right homonymous hemianopsia, eyes deviated to the left, left pupil dilation, and right-sided upper and lower extremity hemiparesis. The client most likely has sustained which of the following conditions? A. Left-sided brain attack. B. Bacterial meningitis. C. Right temporal lobe tumor. D. Right-sided brain attack
A. Left-sided brain attack.
A client is admitted with a C7 ASIA "D" incomplete spinal transection. What priority must the nurse plan for in the immediate post-injury period? A. Optimization of perfusion. B. Autonomic dysreflexia complications. C. Bowel and bladder training. D. Mechanical ventilatory support.
A. Optimization of perfusion
A nurse cares for a patient with burn injuries during the resuscitation phase. Which actions are priorities during this phase? *PAP* A. Prevent wound infections B. Administer analgesics C. Decrease core temperature D. Provide fluid replacement E. Initiate physical therapy
A. Prevent wound infections B. Administer analgesics D. Provide fluid replacement
A client is demonstrating dysarthria following a stroke. The nurse understands that the client will have difficulty with which of the following activities? A. Slow, mumbling speech quality. B. Comprehending spoken words. C. Carrying out purposeful motor activity. D. Verbal expression of a thought.
A. Slow, mumbling speech quality.
Which cardiac biomarker rises the earliest and is the most specific for diagnosing myocardial infarction (MI)? A. Troponin I. B. B-Type natriuretic peptide (BNP). C. Creatinine phosphokinase (CPK)-MB. D. Lactic acid dehydrogenase (LDH).
A. Troponin I.
A client with a C6 spinal cord injury 2 months ago now complains of a pounding headache. The heart rate is 58 bpm, with blood pressure 220/110 mmHg. Which of the following actions should the nurse take? (Select all that apply) *URA* A. Urinary catheterization for distended bladder B. Position the client in a flat, supine position C. Arterial vasodilator after visceral causes eliminated D. Administer atropine for symptomatic bradycardia E. Rectal digital stimulation with disimpaction of bowel
A. Urinary catheterization for distended bladder C. Arterial vasodilator after visceral causes eliminated E. Rectal digital stimulation with disimpaction of bowel
When planning to move a client with a possible spinal cord injury, how should the nurse direct the activities of the healthcare team? A. Immobilize client head and neck while log-rolling the body. B. Cushion the client's back with pillows to provide comfort. C. Move client gently to avoid causing pain. D. Limit movement of client arms by wrapping them next to the body.
A. immobilize the clients head and neck while log-rolling the body.
A patient is admitted with an acute anterior wall myocardial infarction (MI). While the nurse is preparing the patient for transport to the cardiac catheterization lab, the patient becomes unresponsive and the monitor shows the following rhythm: High quality CPR is started, followed by defibrillation with 200 joules, and epinephrine is administered. Which anti-arrhythmic drug may be considered to help treat this rhythm if defibrillation and epinephrine remain ineffective? A. Epinephrine (Adrenalin). B. Amiodarone (Cordarone). C. Adenosine (AdenoCard). D. Atropine sulfate (Atropine).
B. Amiodarone (Cordarone.)
Which of the following actions is an important part of oral care for an intubated patient? (Select all that apply). *PUB* A. Using lemon glycerin swabs on the patient's lips and gums. B. Brushing the teeth and tongue with a soft-bristled toothbrush. C. Using alcohol-based mouthwash every 2 hours. D. Providing lip moisturizer as needed. E. Using tonsil suction to keep secretions cleared out of the mouth.
B. Brushing the teeth and tongue with a soft-bristled toothbrush. D. Providing lip moisturizer as needed. E. Using tonsil suction to keep secretions cleared out of the mouth.
The charge nurse is discussing various dialysis techniques with the graduate nurse on the unit. Which statement best reflects how continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis? A. CRRT does not use a hemofilter to facilitate ultrafiltration. B. CRRT removes solutes and water slowly. C. CRRT does not allow diffusion to occur. D. CRRT provides faster removal of solute and water
B. CRRT removes solutes and water slowly.
Intracranial pressure (ICP) is influenced by which of the following? (select all that apply) *TIPC* A. Deep tendon reflexes B. Carbon dioxide C. Posture D. Pedal pulses E. Temperature F. Intrathoracic pressure
B. Carbon dioxide C. Posture E. Temperature F. Intrathoracic pressure
According to the 2020 American Heart Association Basic Life Support (BLS) Guidelines, which actions by the graduate nurse demonstrate that high quality CPR is being performed on an adult that has sustained cardiopulmonary arrest? (Select all that apply). *TIPC* A. The cycle of compressions to breaths is 5 to 1. B. Compressions are occurring at a rate of 100-120 bpm. C. Depth of compressions is 1 and ½ inches. D. Interruptions in compressions are 10 seconds or less. E. The chest rises and falls with each breath delivered. F. Pulse checks lasts no more than 5-10 seconds
B. Compressions are occurring at a rate of 100-120 bpm. D. Interruptions in compressions are 10 seconds or less. E. The chest rises and falls with each breath delivered. F. Pulse checks lasts no more than 5-10 seconds
The nursing management plan for a patient with full-thickness burns includes which intervention? A. Surgical skin graf B. Daily wound care with premedication C. Weekly wound care until all eschar is debrided D. Daily replacement of autografts
B. Daily wound care with premedication
A patient is admitted with traumatic brain injury to the intensive care unit. Which nursing measure(s) will help control intracranial pressure (ICP)? (Select all that apply) A. Reposition patient from side-to-side every hour. B. Decrease environmental stimuli. C. Perform neurological assessment with noxious stimuli every hour. D. Maintain patient's head in a neutral position.
B. Decrease environmental stimuli. D. Maintain patient's head in a neutral position.
The nurse interprets which of the following clinical manifestations as an EARLY sign of acute respiratory distress syndrome (ARDS) in a patient? A. Metabolic acidosis. B. Decreasing carbon dioxide levels. C. Refractory hypotension. D. Severe electrolyte disturbance.
B. Decreasing carbon dioxide levels.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? A. Right-sided neglect B. Difficulty comprehending instructions C. Impulsive behavior D. Hyperactive left-sided tendon reflexes
B. Difficulty comprehending instructions
In the "hand-off" report the nurse is told the patient is in the early stages of Acute Respiratory Distress Syndrome (ARDS). Based on this information, what will the nurse anticipate as the patient's primary problem? A. Decreased lung compliance and fibrotic scarring. B. Diffusion defect and hypoxemia. C. Hypoventilation and carbon dioxide retention. D. Pulmonary fibrosis and pulmonary hypertension.
B. Diffusion defect and hypoxemia.
Which phase in the acute kidney injury is a patient MOST at high risk for dehydration? A. Oliguric Phase B. Diuretic Phase C. Pre-renal Phase D. Recovery Phase
B. Diuretic Phase
A nurse cares for a patient with burn injuries from a house fire. The patient is not consistently oriented and reports a headache. What action would the nurse take? A. Increase the patient's intravenous fluid rate. B. Draw blood for a carboxyhemoglobin level. C. Increase the patient's oxygen and obtain blood gases. D. Perform a thorough Mini-Mental State Examination.
B. Draw blood for a carboxyhemoglobin level.
The nurse is planning care for a client 24 hours after spinal cord injury at the C4-5 level. Which nursing action has the HIGHEST priority? A. Administration of methylprednisolone (Solu-Medrol). B. Evaluating inspiratory effort. C. Fluid volume expansion. D. Continuous cardiac monitoring for bradycardia.
B. Evaluating inspiratory effort.
A patient with a T1 spinal cord injury is admitted to the intensive care unit. What will the nurse will teach the patient and family about functional ability? A. Elevations in the HR are common B. Full function of the patient's arms will be retained C. Only use of the shoulders will be preserved D. Loss of respiratory function may occur temporarily
B. Full function of the patient's arms will be retained
The nurse administers atropine intravenously to a patient with a heart rate of 46 bpm due to symptomatic second-degree atrioventricular (AV) block, Type II. Which finding indicates that the medication has been effective? A. Decrease in premature ventricular contractions (PVCs). B. Increase in the patient's heart rate. C. Increase in peripheral pulse volume. D. Decrease in ventricular ectopic beats.
B. Increase in the patient's heart rate.
A patient is admitted with exacerbation of chronic obstructive pulmonary disease (COPD) and worsening dyspnea with slightly labored breathing. The admitting vital signs are: Temperature 38.1 C (100.6 F), HR 120 beats/min, RR 35 breaths/min, BP 180/80 mmHg. The patient was initially placed on a 2 liter/min nasal cannula. Arterial blood gases are: pH 7.34 paCO2 48 mmHg HCO3 35 mEq/L paO2 61 mmHg SaO2 87% Which intervention would the nurse anticipate performing FIRST based on this data? A. Provide sedation. B. Increase oxygen amount. C. Aggressive diuresis. D. Rapid sequence intubation.
B. Increase oxygen amount.
Peritoneal dialysis (PD) has several advantages over hemodialysis. Which of the following is a disadvantage of PD? A. May cause hemodynamic instability. B. Increases risk of infection and peritonitis. C. PD can be done at home. D. Requires a less restrictive diet.
B. Increases risk of infection and peritonitis.
A client with traumatic brain injury is at risk for increased intracranial pressure (ICP). Which of the following trends is a priority nursing assessment that needs to be reported to the healthcare provider? A. Normal systolic blood pressure. B. Increasing inequality of pupil size. C. Increasing heart rate to 100 bpm. D. Decreasing body temperature to 97.9F.
B. Increasing inequality of pupil size.
The rhythm is of acute onset (less than 48 hours) with a heart rate of 144 beats/minute and a blood pressure of 132/96. Which initial orders would the nurse expect the healthcare provider to prescribe to be implemented immediately? A. Prepare for elective cardioversion. B. Medication to decrease the ventricular heart rate. C. Draw labs for a baseline Prothrombin Time (PT)/INR. D. Transport patient for a surgical Maze procedure
B. Medication to decrease the ventricular heart rate.
Which of the following lab values is seen in the oliguric phase of acute kidney injury? (Select all that apply) *HUME* A. Hypokalemia. B. Metabolic acidosis. C. Hyperkalemia. D. Urine output less than 400 mL in 24 hours. E. Metabolic alkalosis. F. Elevated BUN and creatinine.
B. Metabolic acidosis. C. Hyperkalemia. D. Urine output less than 400 mL in 24 hours. F. Elevated BUN and creatinine.
A client with chronic obstructive pulmonary disease (COPD) is admitted. The client has been febrile for three days and is complaining of increasing shortness of breath and new production of thick yellow sputum. Home medications include a long acting beta agonist and a steroid inhaler. The arterial blood gases (ABGs) on admission are: pH 7.38 paCO2 59 mmHg, HCO3 32, PaO2 49 mmHg. What client needs would the registered nurse anticipate? A. Intravenous steroids and antibiotic therapy. B. Oxygen support and antibiotic therapy. C. A short-acting beta agonist and mucolytic therapy. D. Intubation and mechanical ventilation.
B. Oxygen support and antibiotic therapy.
Intrapulmonary shunt is a diagnosis on a mechanically ventilated patient with acute respiratory distress syndrome (ARDS). The nurse would expect which of the following conditions? A. Clear chest x-ray. B. Refractory hypoxemia. C. Metabolic acidosis. D. Refractory hypercapnia.
B. Refractory hypoxemia
A client admitted with a spinal cord injury is experiencing spinal shock. The nurse understands that planning care for the client must take into consideration which of the following aspects of the condition? A. Continuous monitoring for hypotension, bradycardia, and hypoxemia is required. B. Resolution is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. C. There is complete loss of motor/sensory functions below the level of injury, but autonomic functions are unaffected. D. Rehabilitation measures cannot be initiated until spinal shock has resolved.
B. Resolution is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder.
The nurse is suctioning a patient's endotracheal tube and notices that the heart rate is dropping from 100 to 52 beats/min. What is the nurse's next priority action? A. Decrease the FiO2 on the ventilator to 21%. B. Stop suctioning and give patient extra breaths. C. Administer atropine 0.5 mg intravenously (IV). D. Increase the rate of the patient's IV fluids.
B. Stop suctioning and give patient extra breaths.
The charge nurse observes an inexperienced staff nurse caring for a client who has had a craniectomy. Which action by the inexperienced nurse requires intervention by the charge nurse? A. The nurse suggests a rehabilitation referral during interdisciplinary rounds with the physician. B. The nurse assists the client to the bedside chair without the use of a helmet. C. The nurse perform a thorough neurologic assessment of the patient at time intervals specified by the physician. D. The nurse performs diligent hand washing.
B. The nurse assists the client to the bedside chair without the use of a helmet.
When admitting a somnolent patient in possible respiratory failure with a high PaCO2, which assessment information will be of MOST concern to the nurse? A. The patient complains of weakness. B. The patient is difficult to arouse. C. The patient's blood pressure is 162/94 mmHg. D. The patient's SpO2 is 90%.
B. The patient is difficult to arouse.
Which of the following foods should the nurse educate a patient being discharged with heart failure limit? A. Apples B. Tomato Juice C. Whole wheat bread D. Beef rib eye steak
B. Tomato Juice
The arterial blood gases (ABGs) listed below represent which of the following acid-base imbalances? pH 7.19 paCO2 69 mmHg HCO3 23 mEq/L paO2 46 mmHg A. Compensated Metabolic Alkalosis. B. Uncompensated Respiratory Acidosis. C. Compensated Respiratory Acidosis. D. Uncompensated Respiratory Alkalosis.
B. Uncompensated Respiratory acidosis.
The registered nurse assigns a patient who has an open burn wound to a licensed practical nurse (LPN). Which instruction would the nurse provide to the LPN when assigning this patient? A. "Administer the prescribed tetanus toxoid vaccine." B. "Wash your hands on entering the patient's room." C. "Assess the patient's wounds for signs of infection." D. "Encourage the patient to breathe deeply every hour."
B. Wash your hands on entering the patient's room
The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? A. Give the digoxin with extra fluids to dilute the sodium level. B. Withhold the dose and report the potassium level C. Give the digoxin with a salty snack, such as crackers. D. Withhold the daily dose until the following day.
B. Withhold the dose and report the potassium level
A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A. pH 7.40 paCO2 40 B. pH 7.25 paCO2 52 C. pH 7.35 paCO2 45 D. pH 7.50 paCO2 20
B. pH 7.25 paCO2 52
A client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome (GBS). Which question should the nurse ask during the nursing admission interview? A. "Were you diagnosed with meningitis within the last five years?" B. "Did you have a back injury to the spinal cord in the past year?" C. "Have you had a respiratory or a gastrointestinal infection lately?" D. "Have you experienced a seizure or trauma to the brain recently?"
C. "Have you had a respiratory or a gastrointestinal infection lately?"
A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? A. ask the practicioner to order a STAT chest radiograph B. apply a pulse oximeter to one of his unburned fingers C. administer 100% oxygen via NRB D. Call the local hyperbaric chamber to check on its availability
C. Administer 100% oxygen via nonrebreathing mask
During the change-of-shift "hand-off" report, the nurse learns that a client with a large myocardial infarction has been having frequent premature ventricular contractions (PVCs). How will the nurse assess the effects of PVCs on adequacy of peripheral perfusion? A. Most recent electrolyte values. B. Oxygen saturation. C. Apical-radial pulse difference. D. Efficacy of medications.
C. Apical-radial pulse difference.
A nurse cares for a patient with a burn injury who presents with drooling and difficulty swallowing. What action would the nurse take first? A. Ascertain the time food or liquid was last consumed. B. Measure abdominal girth and auscultate bowel sounds. C. Auscultate breath sounds over the trachea and bronchi D. Assess the level of consciousness and pupillary reactions.
C. Auscultate breath sounds over the trachea and bronchi
While caring for a client receiving mechanical ventilation, the nurse notices that the client suddenly becomes hypoxemic and the ventilator begins to alarm. The nurse is unable to identify immediately why the ventilator is alarming. Which of the following interventions is the priority action for the nurse to take to prevent further complications? A. Call for the respiratory therapist to evaluate the problem. B. Administer 100 percent oxygen via the ventilator to reverse hypoxemia. C. Detach client from the ventilator and deliver manual ventilations. D. Silence alarm on the ventilator and continue troubleshooting.
C. Detach the client from the ventilator and deliver manual ventilations.
When using the NIH Stroke Scale to assess a client exhibiting the signs of a brain attack, the nurse shows the picture below. By asking the client questions about this picture, the nurse is able to assess which of the following? A. Dysarthria. B. Dysphagia. C. Dysphasia D. Level of consciousness.
C. Dysphasia.
An electrocardiogram (ECG) is ordered for a client who reports chest pain. What finding does the nurse expect to discover on the ECG that represents an area of acute myocardial infarction (MI)? A. Depressed ST segments. B. Flattened T waves. C. Elevated ST segments. D. Absence of P waves
C. Elevated ST segments.
A client is admitted for worsening heart failure (HF) symptoms. While administering the prescribed medications, the nurse assesses the client's response. The nurse understands that medications used to alleviate the symptoms of worsening HF focus on which of the following goals of therapy? A. Maximizing systemic vascular resistance (SVR) to decrease cardiac workload. B. Increasing preload while decreasing afterload. C. Managing fluid overload to improve cardiac output D. Enhancing the renin-angiotensin-aldosterone system (RAAS) to promote vasodilation.
C. Managing fluid overload to improve cardiac output
Refer to the diagram below. During synchronized cardioversion, the equipment is set so that the electrical impulse will discharge during which part of the electrocardiographic tracing? A - P wave of the PR interval. B - Q wave of the QRS complex. C - R wave of the QRS complex. D - T wave of ventricular repolarization.
C. R wave of the QRS complex.
A client is found at the scene of an automobile accident in a state of emotional distress. The client tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34 breaths/minute. For which primary acid-base disturbance is the client at risk if medical attention is not provided? A. Metabolic acidosis. B. Respiratory acidosis. C. Respiratory alkalosis. D. Metabolic alkalosis
C. Respiratory alkalosis.
A client who experienced a small hemorrhagic stroke from an aneurysm 1 week ago reports a severe headache accompanied by an episode of nausea and vomiting. Which conclusion can the nurse make based on this information? A. The client is experiencing a mild, transient vasospasm. B. The client is experiencing stroke-related psychological stress. C. The aneurysm is rebleeding. D. The warfarin dose is inadequate.
C. The aneurysm is re-bleeding.
The nurse is explaining the client's new diagnosis of heart failure during an educational session. How does the nurse best describe heart failure as a result of systolic left ventricular dysfunction? A. The left ventricle causes elevation in systolic blood pressure when contracting. B. The left ventricle ceases to contract during systole. C. The left ventricle is unable to contract effectively during systole. D. The left ventricle is unable to relax and fill during systole.
C. The left ventricle is unable to contract effectively during systole.
The charge nurse is observing a graduate nurse insert a nasopharyngeal airway into a patient's right nare. The charge nurse would intervene if the graduate nurse did which of the following? A. Checks both nares for septal deviation. B. Lubricates airway with water-soluble lubricant prior to insertion. C. Uses an airway slightly larger than the nare. D. Inserts airway along contour of nasopharyngeal passage.
C. Uses an airway slightly larger than the nare.
A patient who has been receiving mechanical ventilation for three days develops a fever of 101.0°F (38.3°C), green secretions, and right lower lobe crackles. The nurse contacts the healthcare provider regarding the possible development of which complication? A. Pneumothorax. B. Pulmonary edema. C. Ventilator-associated pneumonia. D. Stress Ulcer.
C. Ventilator-associated pneumonia.
The nurse is assisting a patient with a stroke who has homonymous hemianopsia. What will the nurse understand about the patient with this condition? A. Forgets the names of foods. B. Will not be able to swallow liquids. C. Will eat food on only half the plate. D. Preference for foods high in sodium.
C. Will eat food only half the plate.
In an otherwise uncomplicated client presenting with C6 complete quadriplegic, what would be the highest functional potential the client could attain? A. Self-propel a manual wheelchair uphill for long distances. B. Transfer floor to chair independently. C. Write a letter using a computer, not with pen and paper. D. Transfer wheelchair to bathtub independently.
C. Write a letter using a computer, not with pen and paper.
A client with diabetes is known for not following the medical regimen. The client is admitted with a diagnosis of diabetic ketoacidosis, and the nurse is awaiting treatment orders. Which of the following arterial blood gas results are expected for this patient? A. pH 7.25; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 78 mm Hg B. pH 7.37; PaCO2 60 mm Hg; HCO3 39 mEq/L; PaO2 78 mm Hg C. pH 7.25; PaCO2 40 mm Hg; HCO3 17 mEq/L; PaO2 90 mm Hg D. pH 7.42; PaCO2 48 mm Hg; HCO3 35 mEq/L; PaO2 98 mm Hg
C. pH 7.25; PaCO2 40 mm Hg; HCO3 17 mEq/L; PaO2 90 mm Hg
Which clinical manifestation is the nurse likely to see in a patient with third-degree AV (complete) heart block with a ventricular rate of 38 bpm? A. Tachycardia. B. Hemiparesis. C. Syncope. D Headache.
C. syncope
A 70 kg patient with acute respiratory distress syndrome (ARDS) is intubated and mechanically ventilated on the following settings: Assist/control (A/C) mode, rate 12 breaths/min, tidal volume (TV) 700 mL, FiO2 1.00, and PEEP 15 cmH2O. The peak inspiratory pressure is 50 cmH2O with a plateau pressure of 40 cmH2O. The paO2 is 60 mmHg. The patient is receiving a continuous vecuronium (Norcuron) intravenous infusion. What will the nurse conclude on the basis of the information provided? A. the mode should be changed to allow for spontaneous breathing B. the PEEP should be decreased to improve oxygenation C. the tidal volume needs to be decreased to avoid volutrauma D. the plateau pressure is appropriate given the PEEP setting
C. the tidal volume needs to be decreased to avoid volutrauma
Match the term on the left to the definition on the right. Cerebral perfusion pressure (CPP) Cerebral blood flow Intracranial pressure Herniation
Cerebral perfusion pressure (CPP) - pressure needed to Cerebral blood flow - the amount of blood Intracranial pressure - the hydrostatic force Herniation - intense pressure
Which location of a myocardial infarction (MI) poses the greatest risk of heart failure and cardiogenic shock? A. Right ventricle B. Lateral wall C. Inferior wall D. Anterior wall
D. Anterior wall
Diuretic therapy with furosemide (Lasix) is ordered for a client with left-sided heart failure. The nurse compares assessment data obtained three days earlier with today's data. How would the nurse determine the medication is having its intended effect? A. Urinary output has decreased. B. Temperature has decreased. C. Appetite has improved. D. Breath sounds have improved.
D. Breath sounds have improved.
Which assessment finding indicates that administration of mannitol (Osmitrol) for increased cerebral edema is effective in a client with increased intracranial pressure (ICP)? A. Decreased pulse rate. B. Increased urine output. C. Increased blood pressure. D. Decreased ICP
D. Decreased ICP
What common sign helps to differentiate intracerebral hemorrhage from ischemic stroke? A. Expressive aphasia B. Right side paralysis C. Left side neglect D. Early loss of consciousness
D. Early loss of consciousness
All these complications pertaining to peritoneal dialysis are correct EXCEPT for: A. Inguinal hernia B. S. aureus peritonitis C. Hemoglobin level of 9.0 dL/mg D. Fewer dietary restrictions
D. Fewer dietary restrictions
The resuscitation team has completed a 2-minute period of highquality CPR. During the rhythm check, an organized, non-shockable rhythm is observed on the monitor. What is the nurse team leader's next action? A. Obtain a blood pressure and oxygen saturation. B. Administer a fluid bolus of normal saline at 20 mg/kg. C. Administer 1 mg epinephrine 1:10,000 intravenously. D. Have a team member check a carotid pulse.
D. Have a team member check a carotid pulse.
Which of the following interventions is MOST important for a client in the oliguric phase of acute kidney injury (AKI)? A. Ensure potassium replacement supplements. B. Promote intake of carbohydrates. C. Encourage coughing and deep breathing. D. Limit oral and intravenous fluid intake.
D. Limit oral and intravenous fluid intake.
A client is hospitalized with initial onset of Guillain-Barré syndrome (GBS). During this phase of the client's illness, which is the MOST essential assessment for the nurse to carry out? A. Determining level of consciousness. B. Monitoring cardiac rhythm. C. Assessing strength of the extremities. D. Observing respiratory effort.
D. Observing respiratory effort.
The code team completed 2 minutes of compressions on a patient in cardiopulmonary arrest. The ECG monitor displays the rhythm below. A member of the team reports the patient has no pulse. What is the assessment of the rhythm? A. Idioventricular rhythm B. Sinus rhythm C. Sinus bradycardia D. PEA
D. PEA
When caring for a client who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions. What should be the initial intervention by the nurse? A. Suction the oropharyngeal secretions hourly. B. Administer oxygen at 7 to 9 Liters/min via face mask. C. Encourage use of incentive spirometer every 2 hours while awake. D. Place hands on epigastric area and push upward when client coughs.
D. Place hands on epigastric area and push upward when client coughs
A client who experienced a severe hypotensive event after being involved in a motor vehicle accident earlier that day is found to be in acute renal failure. Which type of acute kidney injury has likely developed? A. Chronic kidney disease. B. Postrenal failure. C. Intrarenal failure. D. Prerenal failure.
D. Prerenal failure.
During a routine check of the cuff pressure of an endotracheal tube inserted in a patient who is receiving mechanical ventilation, the pressure is measured at 38 cmH2O. The nurse should anticipate the respiratory therapist doing which of the following? A. Injecting more air through the pilot balloon. B. Inserting a new endotracheal tube. C. Documenting the reading as acceptable. D. Releasing some of the air from the cuff.
D. Releasing some of the air from the cuff.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is MOST important to report to the healthcare provider? A. Pulse oximetry indicates O2 saturation of 92%. B. The patient is sitting up in chair in the tripod position. C. Auscultation of basilar lung crackles bilaterally. D. Respiratory rate decreased from 30 to 10 breaths/min
D. Respiratory rate decreased from 30 to 10 breaths/min
When the charge nurse is evaluating the care that a new RN staff member provides to a client receiving mechanical ventilation, which action by the new RN indicates the need for more education? A. The RN provides oral hygiene with chlorhexidine rinse once per shift. B. The RN asks for assistance to turn the client to the side-lying position. C. The RN provides 100% oxygen before suctioning. D. The RN positions the client with the head of bed at 15 degrees.
D. The RN positions the client with the head of the bed at 15 degrees.
When caring for a patient who has Guillain-Barré syndrome (GBS), which assessment data obtained by the nurse will require the most immediate action? A. The patients quadriceps and triceps reflexes are absent B. The patient c/o severe tingling pain in feet C. The patient's bp is 100/50 mmHg. D. The patient has continuous drooling of saliva
D. The patient has continuous drooling of saliva
A client with a history of stable angina suddenly wakes up from a sound sleep experiencing diaphoresis, nausea and lightheadedness, and chest pain (8 out of 10 on a 1-to-10 pain scale) that is unrelieved by 3 nitroglycerin (NTG). Which condition is the client most likely experiencing? A. Silent ischemia. B. Prinzmetal's angina. C. Stable angina. D. Unstable angina.
D. Unstable angina.
Following a stroke, a patient is experiencing expressive aphasia. Which nursing intervention is most helpful in promoting communication? A. Writing directions so the patient can read them. B. Speaking in short sentences to the patient. C. Speaking loudly to the patient. D. Using a "picture board" so the patient can point to pictures.
D. Using a "picture board" so the patient can point to pictures.
The nurse is caring for a trauma patient 36 hours following a transection of the cervical spine at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is now the priority nursing action? A. pad all bony prominences B. maintain body temperature C. Use proper hand washing D. monitor blood pressure
D. monitor blood pressure
The way to decipher between unstable angina (UA) and a non-ST elevation myocardial infarction (NSTEMI) is through assessing for ST changes on the electrocardiogram (ECG). True False
FALSE
True or False: A patient who has experienced an anterior wall myocardial infarction is at high risk for developing heart failure and cardiogenic shock. True False
TRUE
