SARF 2
The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?
"A pulmonary artery pressure provides information about pressure on the left side of the heart."
The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home?
"I cut back on going up the steps during the day."
The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective? Select all that apply.
"I will watch my urine output to be sure that the medication is not affecting my kidneys." "If I take my digoxin I should have limited episodes of shortness of breath."
The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.)
-A heart rate >100bpm -Crackles -Lethargy and mental confusion
A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply.
-Use an intravenous controller or pump. -Verify dosage and pump settings with another RN. - Measure urine output every hour.
Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply.
1. Acid-base imbalance 2. Decreased capillary permeability and fluid and electrolyte shifts 3. Increased blood urea nitrogen and serum creatinine says increase i put it anyway idk
A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order.
1. Place the client in the modified Trendelenburg position. 2. Initiate an intravenous (IV) site and prescribed IV fluids. 3. Assess the capillary blood glucose level. 4. Collect a stool specimen for culture.
The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate?
3:1
The nurse is administering colloids to a client during the first 6 hours of septic shock. What is the client's central venous pressure reading goal?
8 to 12 mm Hg
En route to the emergency room, a client's systolic blood pressure (BP) was 96 mm Hg and falling. Which systolic BP supports the diagnosis of septic shock? Select all that apply.
80 & 72
A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?
A partial rebreathing mask
A client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply.
A. Wear appropriate protective equipment when around airborne irritants and dusts. C. Do not smoke, or quit smoking if currently smoking.
A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The clients reports that these symptoms came on suddenly. The nurse knows that these are symptoms of what condition?
Acute pulmonary edema
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered.
A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?
Anemic hypoxia
The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause increased preload. Which response by the student indicates understanding?
Application of antiembolic stockings
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?
At bedtime
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. The ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Select all that apply.
At bedtime When secretions have mobilized idk tho
A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as
COMPENSATORY
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?
Chest tube drainage, 190 mL/hr
The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)?
Cleaning the client's mouth with chlorhexidine daily
A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse
Consults with the physician about substituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix)
An emergency room nurse is assessing a client who is complaining of dyspnea. Which sign would indicate the presence of a pleural effusion?
Decreased chest wall excursion upon palpation
The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs?
Dopamine
The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS?
Elevated B-type natriuretic peptide (BNP) levels
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?
Encourage coughing to mobilize secretions.
The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply.
Encouraging a liberal fluid intake Applying a sequential compression device Using elastic stockings, especially when decreased mobility would promote venous stasis Instructing the client to move the legs in a "pumping" exercise
A nurse finds a client with absent breathing and prepares to begin one-person cardiopulmonary resuscitation. What will the nurse do first?
Establish unresponsiveness.
The nurse should monitor a client receiving mechanical ventilation for which of the following complications?
Gastrointestinal hemorrhage
The triage nurse in the emergency department is performing a rapid assessment of a client with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, which action would the nurse take first?
Gently shake and shout, "Are you OK?"
The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)
Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress.
The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.)
Hypoperfusion of tissues Must produce energy through anaerobic metabolism Activation of the inflammatory response
A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply.
Increased paCO² levels Ecchymoses and petechiae Loss in consciousness Reports of chest pain
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?
Increased pulmonary artery diastolic pressure
A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?
Intubation and mechanical ventilation
The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?
Levophed
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Select all that apply.
Manual resuscitation bag pulse ox rat
When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?
Myocardial depression
The nurse is caring for a client with severe compensated heart failure. What human brain natriuretic peptide (BNP) medication may be used in a critical care unit with hemodynamic monitoring?
Natrecor
A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?
Partial pressure of arterial oxygen (PaO2)
A nurse is transporting a client with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?
Place the chest tube in sterile water
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. Which intervention may improve oxygenation and provide comfort for the client?
Position the client in the prone position
The nurse is caring for a client with heart failure who has been prescribed digoxin. What laboratory value for the client can precipitate digoxin toxicity?
Potassium 3.0 milliequivalents per liter
The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?
Production of antidiuretic hormone and corticosteroid hormones
The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?
Progressive
Following thoracic surgery, what should the nurse include in the care plan for a client at risk for impaired gas exchange? Select all that apply.
Reinforce preoperative breathing exercises. Monitor vital signs frequently. Elevate head of bed 30 to 40 degrees as tolerated.
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?
Respiratory alkalosis
The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines?
Sodium and glucose levels
The nurse is discussing cardiac terms with a client who was doing some reading on the Internet. What is the correct response for the nurse when the client asks what affects stroke volume?
Stroke volume is affected by temperature and heart rate.
A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure?
Sudden onset of lung impairment in a client who had normal lung function
A patient in cardiogenic shock after a myocardial infarction is placed on an intra-aortic balloon pump (IABP). What does the nurse understand is the mechanism of action of the balloon pump?
The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart
A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse?
The employee enters the room wearing a gown, gloves, and a mask.
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?
The patient has developed a stress ulcer that is bleeding.
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?
The tissues give a crackling sensation when palpated.
A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply.
Tracheal ischemia Pressure necrosis Tracheal bleeding
When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?
Treat the oxygenation needs of the heart muscle
Which comfort technique does a nurse teach to a client with pleurisy to assist with splinting the chest wall?
Turn onto the affected side
A nurse is aware that the diagnostic feature of ARDS is sudden:
Unresponsive arterial hypoxemia.
Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply.
Vital capacity of 13 mL/kg PaO2 of 64 mm Hg Tidal volume of 8.5 mL/kg
The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?
administration of a vasodilating drug (as ordered by a health care provider)
A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply.
antacids H2 blockers proton pump inhibitors
The nurse is admitting a client with heart failure. What factor will worsen the client's myocardial function?
arterial pH 7.28
The critical care nurse is caring for a client with cardiogenic shock. What is the premise for inserting an intra-aortic balloon pump?
inadequate tissue perfusion
A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure?
low urine output
A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply.
norepinephrine epinephrine vasopressin phenylephrine
A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?
Pulmonary hypertension
A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?
pulmonary crackles
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:
synchronized intermittent mandatory ventilation (SIMV).
A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.
• Substernal pain • Dyspnea • Fatigue
The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply.
• obtaining a urine specimen for culture • administering pantoprazole (Protonix) IV daily • monitoring urine output every hour
A client with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this client?
Calcium channel blockers
A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication should the nurse monitor for? Select all that apply.
cardiac dysrhythmias, respiratory arrest, cardiac arrest
A client has been diagnosed with right-sided heart failure based on symptomology. The cardiologist will confirm this suspicion through diagnostics. Which diagnostics are used to reveal right ventricular enlargement? Select all that apply.
echocardiography chest radiograph electrocardiogram
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:
empyema
A client is believed to be in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse?
"The healthcare team needs room to do procedures to help your family member, so it would be best if you stayed in the waiting area."
The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range?
2.0 to 2.5
A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client?
<180 mg/dL
A nurse is discussing cardiac hemodynamics with a client and explains the concept of afterload. What are other preexisting medical conditions to discuss that may increase afterload? Select all that apply
Aging Hypertension Aortic Valve Stenosis
A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?
Apply airtight dressing.
The nurse is providing care for a client with pulmonary edema. Which assessment method should the nurse prioritize to monitor the respiratory status of this individual?
Arterial blood gas (ABG) analysis
The nurse knows that a sputum culture is necessary to identify the causative organism for acute tracheobronchitis. What causative fungal organism would the nurse suspect?
Aspergillus
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?
Assess for elevated blood urea nitrogen levels.
A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?
Negative-pressure ventilator
A client continues to report dyspnea on exertion and overall weakness. A pulmonary artery catheter is placed and the mean pulmonary arterial pressure is 35 mm Hg. What condition is the client experiencing?
Pulmonary arterial hypertension
The triage nurse in the Emergency Department (ED) is admitting a client with a history of Class III heart failure. What symptoms would the nurse expect the client to exhibit?
The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea.
A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock?
The client with testicular cancer who is receiving intravenous chemotherapy
A client receives alteplase (t-PA). It is most important for the nurse to intervene when
The client's Glasgow Coma Score changes from 15 to 13.
The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?
Unresponsive arterial hypoxemia
A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?
Venous thromboemboli
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
Ventricular assist device (VAD)
A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit?
compensatory respiratory alkalosis
A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing?
decompensation stage
The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?
decreased left ventricular workload
A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels?
distributive
A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply.
dobutamine dopamine epinephrine
The nurse is receiving a client from the emergency in cardiogenic shock. What mechanical device does the nurse anticipate will be inserted into the client?
intra-aortic balloon pump
The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival?
lisinopril
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what actions should the nurse perform? Select all that apply.
place the client in an upright position administer oxygen have the client take deep breaths perform chest physiotherapy
