17-Qs

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

1

When a patient requires defibrillation, in which order will the nurse accomplish the following steps? 1. Turn on the defibrillator 2. Deliver the electrical charge 3. Select the appropriate energy level 4. Place the paddles on the patient's chest 5. Check the location of other personnel and call out "all clear" 1, 4, 2. 3. 5 1, 5, 4, 3, 2 1, 2, 3, 4, 5 1, 3, 4, 5, 2

1, 3, 4, 5, 2

A nurse is caring for a client who has a chest tube in place due to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? 1. O2 sat 95% 2. no fluctuations in the water seal chamber 3. no reports of pleuritic chest pain 4. occasional bubbling in the water-seal chamber

2

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1. Call the health care provider 2. Place the tube in a bottle of sterile water 3. Immediately replace the chest tube system 4. Place a sterile dressing over the disconnection site

2

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr. 2. Continuous bubbling in the water seal chamber. 3. Reports of chest pain at the chest tube site. 4. Chest tube dressing dated yesterday.

2

A nurse is monitoring a client who has two chest tubes inserted for a right-sided pneumothorax. The client complains of chest burning. Which of the following is an appropriate nursing action? 1. increase the client's wall suction 2. strip the client's chest tube 3. clamp the client's chest tube 4. reposition the client

4

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A

A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? A. Arterial blood gases B. Urinary output C. Chest tube drainage D. Pain level

A

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side B. Bubbling of the water seal chamber with exhalation C. Crepitus in the area above and surrounding the insertion site. D.Eyelets are not visible

A

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

A

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber

A

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degrees. b. Suction the endotracheal tube every 2 to 4 hours. c. Limit the use of positive end-expiratory pressure. d. Give enteral feedings at no more than 10 mL/hr.

A

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? A. The client should hold his cell phone on the side opposite the ICD B. The client should avoid the use of small electric devices C. The client can carry his ICD in a small pocket D. The client cannot travel by air due to security screening

A

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm H C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg

A

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

A

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects.

A

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? A. Start CPR B. Provide supplemental O2 via non-rebreather mask C. Give atropine per agency dysrhythmia protocol D. Perform synchronized cardioversion

A

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each

A

The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patients PaO2 is 45 mm Hg. b. The patients PaCO2 is 33 mm Hg. c. The patients respirations are shallow. d. The patients respiratory rate is 32 breaths/minute.

A

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse? a. Only continuous IV opioids have been ordered. b. The patient does not respond to verbal stimulation. c. There is no cough or gag when the patient is suctioned. d. The patients oxygen saturation fluctuates between 90% to 93%.

A

. A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? SATA A. Elevate the HOB to at least 30 B. Administer pantoprazole as prescribed C. Reposition the endotracheal tube to the opposite side of the mouth daily D. Apply Restraints if the client becomes agitated. E. Verify the prescribed ventilator settings daily

ABC

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

ABCD

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.) A. Severe dyspnea B. Nausea C. Decreased level of consciousness D. Headache E. Hypotension

ACDE

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

AD

A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? a. Suction the tracheostomy before beginning care. b. Secure new tracheostomy ties before removing old ones. c. Remove soiled dressing with sterile gloves. d. Clean disposable inner cannula with hydrogen peroxide.

B

A nurse is caring for a client in the critical care unit follwoing a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following findings supports this suspicion? A. widening pulse pressure B. Muffled heart sounds C. Elevating systolic bp D. decresing venous pressure

B

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. give morphine IV B. administer oxygen therapy C. start an iv infusion of LR D. initiate cardiac monitoring

B

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? A. Pacemaker spikes after each QRS complex B. Pacemaker spikes before each QRS complex C. Pacemaker spikes before each p wave D. Pacemaker spikes with each t wave

B

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make? A. Fluid overload B. Hypovolemia C. Intracardiac shunt D. Left ventricular failure

B

A nurse is teaching a client who is scheduled for a cardiac catheterization. Which of the following statements should the nurse include in the teaching? A. You will be given general anesthesia during the procedure B. You will need to keep your affected leg straight following the procedure C. You should not have this procedure if you are allergic to eggs D. You should restrict fluids following the procedure

B

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

B

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

B

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)

B

The client sustained an injury to the chest in a motor vehicle accident. Which assessment finding 3 hours later alerts you to a possible pulmonary contusion? A. Dyspnea B. Hemoptysis C. Increased chest pain with movement D. Hyperresonance on percussion

B

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated? A. Insert the decannulation plug before removing the nonfenestrated inner cannula. B. Use a hand-held manometer to measure cuff pressure. C. Suction the patient through a fenestrated inner cannula to clear secretions. D. Review the health record for the prescribed cuff pressure.

B

​​Which patient is at highest risk for pulmonary embolism? A. A middle-ages patient awaiting surgery B An older adult patient with recent pelvic surgery C. A patient who had a tracheostomy tube inserted 1 week ago D. A patient with pneumonia on antibiotics

B

The low-pressure alarm sounds on a ventilator. The nurse assesses and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? a. Administer oxygen b. Check the client's vital signs c. Ventilate the client manually d. Start cardiopulmonary resuscitation

C

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis Postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis Older client prescribed antacids for gastroesophageal reflux disease

BCE

A nurse in an ICU is caring for a client who has a pulmonary artery catheter and a pressure monitoring system. The client has a central venous pressure (CVP) of 14 mmHg and a pulmonary artery wedge pressure (PAWP) of 17 mmHg. Which of the following findings should the nurse expect? (SATA) Dry mucous membranes Poor skin turgor Bilateral crackles in the lungs Lower extremity edema Jugular vein distension

Bilateral crackles in the lungs Lower extremity edema Jugular vein distension

A nurse reports on 4 clients on a telemetry unit. Which of the following rhythms indicates the need for a priority assessment? Atrial fibrillation with a rate of 80/minute in a client who is starting on warfarin and enoxaparin Bradycardia with a rate of 60 in a client with a demand pacemaker set at 70/minute Sinus tachycardia in a patient with pancreatitis and dehydration Tachycardia with a rate of 101/minute in a client who is complaining of pain

Bradycardia with a rate of 60 in a client with a demand pacemaker set at 70/minute

A nurse is caring for a client who has valvular heart disease and is at risk for developing left sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? Distended abdomen Breathlessness Weight gain Anorexia

Breathlessness

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A. First degree AV block B. Sinus tachycardia C. Atrial fibrillation D. Sinus bradycardia

C

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

C

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection B. Pulmonary edema C. Atelectasis D. Delayed gastric emptying

C

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Dexamethasone c. Heparin d. Atropine

C

A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patients heart rate is 97 beats/min. b. The patients oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patients spontaneous tidal volume is 450 mL.

C

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a.Leave the tracheostomy inner cannula inserted at all times. b.Place the decannulation cap in the tube before cuff deflation. c.Assess the ability to swallow before using the fenestrated tube. d.Inflate the tracheostomy cuff during use of the fenestrated tube.

C

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Arrange for arterial blood gases to be drawn immediately. b. Cover stoma with sterile gauze and ventilate through stoma. c. Attempt to reinsert the tracheostomy tube with the obturator in place. d. Assess the patient's oxygen saturation and notify the health care provider.

C

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

C

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? A. Sinus tachycardia at a rate of 110 beats/min B. Patient reports feeling tired C. Inversion of T waves on the electrocardiogram D. Blood pressure (BP) increases from 134/68 to 150/80

C

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patients oxygen saturation is 93%. b. The patient was last suctioned 6 hours ago. c. The patients respiratory rate is 32 breaths/minute. d. The patient has occasional audible expiratory wheezes.

C

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? a. Chest x-ray b. O2 saturation c. Arterial blood gas analysis d. Central venous pressure monitoring

C

While monitoring a patient post abdominal surgery, the nurse suspects hypoventilation. Which assessment finding best correlates with hypoventilation? A PH less than 7.35 Respiratory Rate less than 13 breaths/min A PaCO2 greater than 45 mmHg A Pao2 of less than 85mmHg

C

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department with back pain and absent pedal pulses. Which action should the nurse take first? Draw blood for CBC Assess for presence of an abdominal bruit Assess for family history of heart disease Check the patient's blood pressure

Check the patient's blood pressure

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department with severe back pain and absent pedal pulses. Which action should the nurse take first? Check the patient's blood pressure Assess the patient for an abdominal bruit Determine any family history of heart disease Draw blood for laboratory testing

Check the patient's blood pressure

. A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally. c. It will prepare the gastrointestinal tract for enteral feedings. d. It will prevent ulcers from the stress of mechanical ventilation.

D

A client is intubated and receiving mechanical ventilation. The physician has added 7cm of positive end expiratory pressure (PEEP) to the ventilator settings of the client. The nurse assesses for which of the following expected but adverse effects of PEEP? A. Decreased peak pressure on the ventilator B. Increased temperature from 98 to 100 F rectally C. Decreased heart rate from 78 to 64 beats per minute D. Systolic blood pressure decrease from 122 to 98 mmHg

D

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding. A. Hypertension B. Bradypnea C. Flushing of the skin D. CVP measurement shows -2 mmhg

D

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

D

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

D

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial damage? A. Homocysteine B. Creatine kinase-MB C. Myoglobin D. Troponins

D

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

D

The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holding the endotracheal tube (ET) in her hand. Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

D

To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds. b. obtain a portable chest x-ray to check tube placement. c. observe the chest for symmetric chest movement with ventilation. d. use an end-tidal CO2 monitor to check for placement in the trachea.

D

When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first? a. Notify the health care provider. b. Check pupils for reaction to light. c. Attempt to calm and reorient the patient. d. Assess oxygenation using pulse oximetry.

D

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm hg A. Provide assisted ventilations with a bag-valve mask device B. Set the defib/cardioverter energy to 360 joules C. Turn the synchronizer switch to the "off" position D. Give a sedative before cardioversion is implemented

D

A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. What finding should the nurse expect? Apical pulse rate is different than the radial pulse rate Drop in systolic BP by 20 mm Hg when changing positions Decrease in systolic pressure by more than 10 mm Hg during inspiration Increase in heart rate by 20% when moving from sitting to standing

Decrease in systolic pressure by more than 10 mm Hg during inspiration

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

Dyspnea

A patient is admitted to the hospital with possible acute pericarditis. What diagnostic test is most accurate? Blood cultures Echocardiography Cardiac catheterization 24-hour holter monitor

Echocardiography

A nurse in a cardiac unit is caring for a client with acute right-sided heart failure rel ?? which of the following findings should the nurse expect? Elevated CVP Decreased specific gravity Increased PAWP Decreased BNP

Elevated CVP

Where might a nurse expect to hear a bruit best in a client with sharp back pain and an abdominal aortic aneurysm??? Subrapubic region Right upper quadrant Epigastrium Flank

Epigastrium

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

Fatigue

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (SATA) Down syndrome History of smoking Frequent heartburn Atherosclerosis History of hypertension

History of smoking Atherosclerosis History of hypertension

Which statement by a patient with infective endocarditis indicates that the nurse's discharge teaching was effective? I will avoid taking aspirin or other antiinflammatory drugs I will take antibiotics before my teeth are cleaned at the dental office I will need to limit my intake of salt and fluids even in hot weather I can restart my exercise program that includes hiking and biking

I will take antibiotics before my teeth are cleaned at the dental office

Knowing that patients with restrictive cardiomyopathy are at risk for infective endocarditis, which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective? I will avoid taking aspirin or other anti inflammatory drugs I will need to limit my intake of salt and fluids even in hot weather I will take antibiotics when my teeth are cleaned at the dental office I should begin an exercise program that includes things like biking or swimming

I will take antibiotics when my teeth are cleaned at the dental office

Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the healthcare provider? Pulsus paradoxus 8 mm Hg Level 8 (0 to 10 scale) chest pain with depp breath Jugular venous distension to jaw level Blood pressure 100/44 mm Hg

Jugular venous distension to jaw level

A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? Biologic valves will require immunosuppressive drugs after surgery Ongoing cardiac care by a health care provider is not necessary after the valvuloplasty Mechanical mitral valves need to be replaced sooner than biologic valves Lifelong anticoagulant therapy is needed after mechanical valve replacement

Lifelong anticoagulant therapy is needed after mechanical valve replacement

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (SATA) Orthopnea Nausea Diaphoresis Tachycardia Headache

Nausea Tachycardia Diaphoresis

A nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has a intravenous infusion rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 is most recent). The client's blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority? Confirm that the intravenous line is in a pump so that the infusion rate stays the same Notify the physician Check to see if the client had a sample for serum albumin level drawn Check the urine specific gravity

Notify the physician

The nurse is caring for a patient immediately after the repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? Notify the surgeon and anesthesiologist Wrap both the legs in a warming blanket Document the findings and recheck in 15 minutes Compare findings to the postoperative assessment of the pulses

Notify the surgeon and anesthesiologist

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate which of the following management strategies will be used for this client? Defibrillation Administration of IV lidocaine Synchronized cardioversion Pacemaker insertion

Pacemaker insertion

Which of the following findings would indicate that a patient's systemic vascular resistance was increased? Faster than normal capillary refill time Increased venous engorgement with strong pulses Pale, cool extremities with decreased pulses Strong bounding pulse with deep red coloring

Pale, cool extremities with decreased pulses

The nurse is evaluating the condition of a patient after pericardiocentesis is performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? Jugular venous distension Patient expressions of dyspnea A rise in blood pressure Muffled heart sounds

Patient expressions of dyspnea

A nurse is caring for a client who was diagnosed with acute pericarditis yesterday. ???? Restenosis of the coronary artery Pericardial effusion Cardiac tamponade Congestive heart failure

Pericardial effusion

A transesophageal echocardiogram (TEE) is planned for a patient hospitalized with possible endocarditis. Which action included in the standard TEE will the nurse need to accomplish first. Start an IV line Give lorazepam (Ativan) 1 mg IV Start O2 per nasal cannula Place the patient on NPO status

Place the patient on NPO status

A patient undergoing hemodynamic monitoring after a myocardial infarction has a low central venous pressure. What action by the nurse is most appropriate? Lay the patient in the supine position Prepare to administer a fluid bolus Level the transducer at the phlebostatic axis Prepare to administer diuretics

Prepare to administer a fluid bolus

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? Prothrombin time (PT) Bleeding time Activated partial thromboplastin time (aPTT) Hemoglobin (Hgb)

Prothrombin time (PT)

The nurse is caring for a patient who is post-operative open aortic aneurysm repair. Which of the following should the nurse include in the plan of care? (SATA) Provide adequate pain management Clear incision with hydrogen peroxide Encourage use of incentive spirometer Assess pedal pulses bilaterally Maintain systolic BP greater than 145 mm Hg

Provide adequate pain management Encourage use of incentive spirometer Assess pedal pulses bilaterally

Which assessment finding in a patient who is admitted with infective endocarditis should be reported to the provider? Temperature 100.7 F Muscle aching Right flank pain Janeway's lesions on the palms

Right flank pain

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? First degree atrioventricular block ST-segment elevation Sinus tachycardia Inverted p wave

ST-segment elevation

While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to Teach the patient the need for anticoagulant therapy Teach the patient how to take sublingual nitroglycerin Teach the patient the importance of rest Raise the head of the bed 60 degrees

Teach the patient the importance of rest

A nurse is caring for a patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? The patient has a palpable thrill over the left anterior chest The patient has a loud systolic murmur across the precordium The patient has diffuse bilateral crackles The patient has 4+ peripheral edema

The patient has diffuse bilateral crackles

The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy. Which information obtained by the nurse is most important in planning care? The patient had a recent upper respiratory infection The patient has a family history of coronary artery disease The patient's 29-yr-old brother died from a sudden cardiac arrest The patient reports using cocaine "a few times" as a teenager

The patient's 29-yr-old brother died from a sudden cardiac arrest

A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about Abdominal tenderness Trouble swallowing Low back pain Changes in bowel habits

Trouble swallowing

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding? Increase in heart rate of 15 beats/minute with walking Fever, chills, and diaphoresis Petechiae on the inside of the mouth and conjunctiva Urine output less than 30 mL/hr

Urine output less than 30 mL/hr