PCC3 Unit 1 Practice Questions
Medication and electrical management for bradycardia?
*only treat if symptomatic* Med: atropine, dopamine, or epinephrine infusion if unresponsive to atropine Electrical: pacemaker
A nurse is assessing a client following a gunshot wound to the chest. For which of the following finders should the nurse monitor to detect a pneumothorax? (Select all that apply) a. tachypnea b. deviation of the trachea c. bradycardia d. decreased use of accessory muscles e. pleuritic pain
A, B, E a. tachypnea b. deviation of the trachea e. pleuritic pain: due to inflammation of pleura of the lung caused by injury
A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis
A. CORRECT: Splinter hemorrhages in nail beds and a report of fever are findings associated with infective endocarditis.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration D. Exposed sutures without dressing E. Drainage system upright at chest level
B, C Gentle bubbling in the suction control chamber is an expected finding as air is being removed A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that the drainage system is functioning properly
A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply) a. bradycardia b. cyanosis c. hypotension d. dyspnea e. paradoxic chest movement
B, C, D, E b. cyanosis c. hypotension d. dyspnea e. paradoxic chest movement tachycardia not bradycardia!!
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Place the tubing in sterile water to restore the water seal B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess the client's respiratory status
B. Using ABC priority framework, the application of a sterile gauze to the site should be the first action for the nurse to take. This allows the air to escape and reduces the risk of the tension pneumothorax
A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A. "I will be glad to get back to my exercise routine right away." B. "I will have my prothrombin time checked on a regular basis." C."I will talk to my dentist about no longer needing antibiotics before dental exams." D."I will continue to limit my intake of foods containing potassium."
B. "I will have my prothrombin time checked on a regular basis."
A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk of acquiring rheumatic endocarditis? A. Older adult who has chronic obstructive pulmonary disease B. Child who has streptococcal pharyngitis C. Middle-age adult who has lupus erythematosus D. Young adult who recently received a body tattoo
B. CORRECT: A child who has streptococcal pharyngitis is at risk for developing rheumatic fever which could result in rheumatic endocarditis.
A nurse on a cardiac unit a caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/minute and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client. A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine
B. Pacemaker insertion For bradycardia!
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.
B. Place a sterile dressing over the site and tape it on three sides and notify the physician
A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.
B. The lung may have re-expanded or there is a kink in the system.
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium (Norcuron) to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. This medication is given to treat infection B. This medication is given to facilitate ventilation C. This medication is given to decrease inflammation D. This medication is given to reduce anxiety
B. Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption
A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.
C. When a patient is receiving mechanical ventilation the water in the water seal chamber will oscillate oppositely than if the patient were breathing on their own. Therefore, the water in the chamber will decrease during inspiration and increase during expiration.
A nurse is completing the admission physical assessment of client who has a history of mitral valve insufficiency. Which of the following findings should the nurse expect? A. S4 heart sound B. Petechiae C. Neck vein distension D. Splenomegaly
C. Neck vein distension
A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A. Diet medication B. Relaxation exercises C. Smoking cessation D. Taking omega-3 capsules
C. Smoking cessation
A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub
D. CORRECT: A friction rub can be heard during auscultation of a client who has pericarditis.
A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture
D. CORRECT: A throat culture can reveal the presence of streptococcus, which is the leading cause of rheumatic endocarditis.
Medication and electrical management for afib, SVT, and vtac w/ pulse
Med: amiodarone, adenosine, and verapamil Electrical: Synchronized cardioversion
Medication and electrical management for vfib or vtac w/out a pulse
Med: amiodarone, lidocaine, and epinephrine Electrical: Defibrillation
A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? A. Intermittent bubbling may be noted in the water seal chamber. B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. C. The chest tube is positioned at the patient's chest level to facilitate drainage. D. All of these options are appropriate findings.
The answer is A. It is normal to find intermittent (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing intermittent bubbles.
Which statement is CORRECT about a tension pneumothorax? A. This condition happens when an opening to the intrapleural space creates a two-way valve which causes pressure to build up in the space leading to shifting of the mediastinum. B. A tension pneumothorax is a medical emergency and is treated with needle decompression. C. Tracheal deviation is an early sign of a tension pneumothorax D. An open pneumothorax is the only cause of a tension pneumothorax.
The answer is B. The only correct statement about a tension pneumothorax is option B. Option A is wrong because this condition happens when an opening to the intrapleural space creates a ONE-way (not two-way) valve which causes pressure to build up in the space leading to shifting of the mediastinum. Option C is wrong because tracheal deviation is a LATE (not early) sign of a tension pneumothorax. Option D is wrong because not only can an open pneumothorax cause a tension pneumothorax but a closed or spontaneous pneumothroax can as well.
Which of the following is a LATE sign of the development of a tension pneumothorax? A. Hypotension B. Tachycardia C. Tracheal deviation D. Dyspnea
The answer is C. With a tension pneumothorax, you will quickly see hypotension, tachycardia, and dyspnea as the mediastinum shifts from the extra pressure in the intrapleural space on the affected side. A late sign of a tension pneumothorax is that the trachea will eventually shift to the unaffected side.
A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition: A. Hypotension B. Jugular Venous Distention C. Bradycardia D. Tracheal deviation E. Hyperemia F. Tachypnea
The answers are A, B, D, and F. Hypotension, JVD, tracheal deviation, and tachypnea can all be present in a tension pneumothorax. The other options are not usually present.
A nurse preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing
A, B, C, E Oxygen should be readily available in case the client develops respiratory distress following chest tube placement. If the chest tube becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal Hemostat clamps should be available for the nurse to use to check air leaks Immediately place an occlusive dressing over the chest tube insertion site if becomes disconnected. This allows air to escape and reduces the risk for a tension pneumothorax
A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? (Select all that apply) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced a drug overdose
A, B, D, E A client who experienced a near-drowning incident has had trauma to the lungs and cerebral edema A client following coronary artery bypass graft surgery has had trauma to the chest A client who has dysphagia has difficulty swallowing and is at a risk for aspiration A client who experienced a drug overdose has damage to the central nervous system
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply) A. Encourage the client to cough every 2 hours B Check for continuous bubbling in the suction chamber C. Strip the drainage tubing every 4 hours D. Clamp the tube once a day E. Obtain a chest x ray
A, B, E Cough every 2 hours to promote oxygenation and lung reexpansion Check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level A chest x ray is obtained following the procedure to verify chest tube placement
A nurse is caring for a client who is receiving vecuronium (Norcuron) for acute respiratory distress syndrome (ARDS). Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply) A. Fentanyl (Duragesic) B. Furosemide (Lasix) C. Midazolam (Versed) D. Famotidine (Pepcid) E. Dexamethasone (Decadron)
A, C Fentanyl is a pain medication used to treat clients who has ARDS when a neuromuscular blocking agent us administered Midazolam (Versed) is a sedative medication used when a neuromuscular blocking agent is administered
A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (Select all that apply.) A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for 5 years D. Weight gain of 10 lb in past year E. Diastolic murmur present
A, C, E
A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. Which of the following is an appropriate response but he nurse? A. "Aspirin reduces the formation of blood clots that could cause a heart attack." B. "Aspirin relives the pain dye to myocardial ischemia." C. "Aspirin dissolves clots that are forming in your coronary arteries." D. "Aspirin relives headaches that are caused by other medications."
A. "Aspirin reduces the formation of blood clots that could cause a heart attack."
A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery.
A. A client who has metabolic alkalosis D. A client who has COPD E. A client who underwent stent placement in a coronary artery. at risk for dysrhythmias!
A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 minutes. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 minutes.
A. Angina can be relieved with rest and nitroglycerin.
5. A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema
A. Dyspnea B. Client report of fatigue E. Peripheral edema
A nurse is caring for a client who experience defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply) A. Follow up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes
A. Follow up ECG B. Energy settings used E. Skin condition under electrodes
A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.
B, C, D, E Option A: is wrong because this is not how the Valsalva Maneuver is performed (the correct way is detailed in option D). Option F: is wrong as well because this position would not faciltate breathing...Fowler's position is best after removal.
A nurse is planning care for a client who has severe acute respiratory distress syndrome (SARS). Which of the following should be included in the plan of care for this client? (Select all that apply) A. Administration of antibiotics B. Providing supplemental oxygen C. Administration of antiviral medications D. Administration of bronchodilators E. Maintaining ventilatory support
B, D, E Oxygen is administered to treat hypoxemia Bronchodilators are given to vasodilate the airway Intubation may be required to maintain a patent airway
A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? A. "This will improve blood flow in your mother's coronary arteries." B. "This will permit your mother to resume her activities of daily living." C."This will prolong your mother's life." D."This will reverse the effects to the damaged area."
B. "This will permit your mother to resume her activities of daily living."
What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system
B. Dry suction chest tube system
A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? a. assess patient's pain b. obtain a large-bore IV needle for decompression c. administer lorazepam d. prepare for chest tube insertion
B. obtain a large-bore IV needle for decompression priority is ABC!
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath in the left lower lobe with dyspnea, blood pressure 118/68, HR 124/min, RR 38/min, temp 38.6 (101.4), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x ray B. Prepare for chest tube insertion C. Administer oxygen via a high flow mask D. Initiate IV access
C. According to ABCs, administering oxygen via high flow mask is priority.
A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that... A. the cardioverter is being charged to the appropriate setting B. they should initiate CPR due to pulseless electrical activity C. They cant be in contact with equipment connected to the client D. A time-out is being called to verify correct protocols
C. They cant be in contact with equipment connected to the client
A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the infarction occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin
C. Troponin T Troponin T will still be evident 10-14 days following an MI
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side B. Use the incentive spirometer C. Cough at regular intervals D. Perform the Valsalva maneuver
D. The client should be instructed to take a deep breath, exhale, and bear down as the chest tube is being removed. This increases intrathoracic pressure and reduces the risk of an air embolism
You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.
D. Continuous bubbling in the water seal chamber is NOT normal and indicates there is an air leak. However, oscillation of the water in the water seal chamber is normal.
A nurse is instructing a client who has angina about a new prescription for metaprolol tartrate (Lopressor). Which of the following statements by the client indicates understanding of the teaching? A. "I should place the tablet under my tongue." B. "I should have my clotting time checked weekly." C. "I will report any ringing in my ears." D. "I will call my doctor if my pulse rates less than 60."
D. "I will call my doctor if my pulse rates less than 60."
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
Option D is the best choice. A new system needs to be obtained, however, in order to maintain a water seal until the new system arrives you will need to place the tubing 1 inch in sterile water or sterile saline to regain a water seal.
A patient has a chest tube for treatment of a pneumothorax in the left lung. Which finding during your assessment requires immediate nursing intervention? A. The water seal chamber has intermittent bubbling. B. The patient has slight tracheal deviation to the right side. C. The water seal chamber fluctuates while the patient inhales and exhales. D. The patient complains of tenderness at the chest tube insertion site.
The answer is B. A patient with a chest tube is at risk for a tension pneumothorax due to the risk of pressure building up in the intrapleural space. Therefore, the nurse would want to monitor the patient for this and if tracheal deviation is present this is a major sign a tension pneumothorax. All the other options are normal findings. The water seal chamber will have intermittent (not excessive) bubbling because of the air that will be leaving the intrapleural space. The water seal chamber will flucutate up and down when the patient breathes in and out, and it is normal for the patient to have tenderness at the insertion site of the chest tube.
A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as? A. Closed pneumothorax B. Open pneumothorax C. Tension pneumothorax D. Spontaneous pneumothorax
The answer is B. This description is of an open pneumothorax. An open pneumothorax happens when there is an opening in the chest wall ( from a gun shot, stabbing etc.) that creates a passage between the outside air and intrapleural space. This allow air to pass back and forth during inspiration and expiration. The body will shunt air through the opening in the chest well instead of the trachea (if the opening on the chest is large enough) which will create a "sucking" sound.
You're providing care to a patient with a pneumothorax who has a chest tube. On assessment of the chest tube system, you note there is no fluctuation of water in the water seal chamber as the patient inhales and exhales. You check the system for kinks and find none. What is your next nursing action? A. Keep monitoring the patient because this is a normal finding. B. Increase wall suction to the system until the water fluctuates in the water seal chamber. C. Assess patient's lung sounds to assess if the affected lung has re-expanded. D. Notify the physician.
The answer is C. It is normal for the water seal chamber to tidal up and down as the patient breathes in and out. If there is no fluctuation of water in the water seal chamber there may be a kink in the tubing or the lung has re-expanded. Therefore, it is important to check the system for kinks and if there are none then check the patient's lung sounds to see if lung sounds are present on the affected side (hence the lung has re-expanded).
In regards to the patient in the question above, which of the following options below is a nursing intervention you would provide to this patient? A. Place the patient in supine position B. Place a non-occlusive dressing over the chest wound C. Place a sterile occlusive dressing over the chest wound and tape it on three sides D. Prepare the patient for a thoracentesis
The answer is C. The nursing intervention would be to place a sterile occlusive dressing over the wound and tape it on 3 sides (leaving one side NOT taped). This will allow exhaled air to leave the opening but seal over the opening when inhaling (hence not letting pressure build in the intrapleural space and prevent a tension pneumothorax).
While caring for a patient with a suspected pneumothorax, you note there are several areas on the patient's skin that appear to be "bulging" out. These "bulging" areas are located on the patient's neck, face, and abdomen. On palpation on these areas, you note they feel "crunchy". When charting your findings you would refer to this finding as? A. Subcutaneous paresthesia B. Pigment molle C. Subcutaneous emphysema D. Veisalgia
The answer is C. This known as subcutaneous emphysema or subcutaneous crepitation.
A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side, and there is a large crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
The answer is D. A new system needs to be obtained, however, in order to maintain a water seal until the new system arrives you will need to place the tubing 1 inch in sterile water or sterile saline to regain a water seal.
A patient is diagnosed with a primary spontaneous pneumothorax. Which of the following is NOT a correct statement about this type of pneumothorax? A. It can be caused by the rupture of a pulmonary bleb. B. It can occur in patients who are young, tall and thin without a history of lung disease. C. Smoking increases the chances of a patient developing a spontaneous pneumothorax. D. It is most likely to occur in patients with COPD, asthma, and cystic fibrosis.
The answer is D. All options are correct about primary spontaneous pneumothorax EXCEPT D. This describes SECONDARY spontaneous pneumothorax not primary.
A nurse is reviewing discharge instructions for a client who has experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? a. notify your provider if you experience weakness b. you should be able to return to work in 1 week c. you need to wear a mask when in crowded areas d. notify your provider if you experience a productive cough
d. notify your provider if you experience a productive cough Could mean respiratory infection?