2600 Exam 1

Which statement appropriately describes tidal volume? a. It is the volume of air inhaled and exhaled with each breath. b. It is the amount of air remaining in the lungs after forced expiration. c. It is the additional air that can be forcefully inhaled after normal inhalation. d. It is the additional air that can be forcefully exhaled after normal exhalation.

1. It is the volume of air inhaled and exhaled with each breath

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number. _____mL/min

5040

A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? a. Remain with the client to assess responses. b. Allow family members to participate in the process. c. Permit the client more extended times alone for independence. d. Observe monitoring devices at the control panel of the ventilator.

A. Remain with the client to assess responses

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? a. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. b. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. c. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. d. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.

B. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify? a. Tachycardia b. Hypoglycemia c. Constricted pupils d. Decreased blood pressure

a. Tachycardia

What is the priority nursing action when caring for a client with disseminated intravascular coagulation? a. Monitor for Homans sign. b. Avoid giving intramuscular injections. c. Take temperatures via the rectal route. d. Apply sequential compression stockings.

b. Avoid giving intramuscular injections

A client is considered to be in septic shock when what changes are assessed in the client's labwork? a. Blood glucose is 70-100 mg/dL b. An increased serum lactate level c. An increased neutrophil level d. A white blood count of 5000 cells/uL

b. An increased serum lactate level

What client response must the nurse monitor to determine the effectiveness of amiodarone? a. Absence of ischemic chest pain b. Decrease in cardiac dyshythmias c. Improvement in fasting lipid profile d. Maintenance of blood pressure control

b. Decrease in cardiac dysrhythmias

The nursing staff of a unit is frustrated and uncomfortable with the newly appointed nurse leader. Which role transition process is involved? a. Role exploration b. Role negotiation c. Role discrepancy d. Role internalization

c. Role discrepancy

Endotracheal intubation and positive-pressure ventilation are instituted because of a client's deteriorating respiratory status. What is the priority nursing intervention? a. Facilitate verbal communication b. Prepare the client for emergency surgery c. Maintain sterility of the ventilation system d. Assess the client's response to the mechanical ventilation

d. Assess the client's response to the mechanical ventilation

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? a. Chest tube insertion b. Aggressive diuretic therapy c. Administration of beta-blockers d. Positive end-expiratory pressure (PEEP)

d. Positive end-expiratory pressure (PEEP)

The nurse is interpreting an electrocardiogram rhythm. What part of the electrical pattern represents ventricular contraction? a. P wave b. T wave c. PR interval d. QRS interval

d. QRS interval

A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? a. Tetany b. Hypercapnia c. Metabolic acidosis d. Respiratory alkalosis

d. Respiratory alkalosis

What will the nurse include when developing a teaching plan for a client receiving digoxin for left ventricular failure? a. Sleep flat in bed b. Follow a low-potassium diet c. Take the pulse three times a day d. Rest periodically throughout the day

d. Rest periodically throughout the day

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? a. Administer sedatives around the clock b. Turn client every four hours c. Increase ventilator settings as needed d. Suction as needed

d. Suction as needed

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? a. 7.20 b. 7.35 c. 7.45 d. 7.48

a. 7.20

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? a. Aspirating gastric contents b. Getting an opioid overdose c. Experiencing an anaphylactic reaction d. Receiving multiple blood transfusions

a. Aspirating gastric contents

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis? a. Spiral (helical) computed tomographic angiography (CTA) b. D-dimer and arterial blood gas (ABG) laboratory tests c. Ventilation-perfusion (V/Q) scan d. Pulmonary angiography

a. Spiral (helical) computed tomographic angiography (CTA)

Which complication does the nurse prevent by addressing the needs of a hyperventilating client? a. Cardiac arrest b. Carbonic acid deficit c. Reduction in serum pH d. Excess oxygen saturation

b. Carbonic acid deficit

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of? a. Atrial fibrillation b. Cardiac irritability c. Impending heart block d. Ventricular tachycardia

b. Cardiac irritability

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, what should the nurse do? a. Notify a respiratory therapist. b. Drain the fluid from the tubing. c. Decrease the amount of humidity. d. Record the amount of fluid removed from the tubing.

b. Drain the fluid from the tubing

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? a. Fibrotic b. Exudative c. Reparative d. Proliferative

b. Exudative

A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? a. An elevated pH, elevated PCO2 b. A decreased pH, elevated PCO2 c. An elevated pH, decreased PCO2 d. A decreased pH, decreased PCO2

c. An elevated pH, decreased PCO2

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? a. Muscle twitching b. Mental instability c. Deep and rapid respirations d. Tachycardia and cardiac dysrhythmias

c. Deep and rapid respirations

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data? a. These findings are expected because infants with this disorder often have some degree of atelectasis. b. The inspiratory pressure on the ventilator is probably too low and needs to be increased for adequate ventilation. c. These findings indicate that the infant may have a pneumothorax and that the health care provider should be contacted immediately. d. The endotracheal tube needs to be pulled back to ventilate both lungs because it has probably slipped into the left main stem bronchus.

c. These findings indicate that the infant may have a pneumothorax and that the health care provider should be contacted immediately.

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? a. Bradycardia b. Flushed face c. Unilateral chest pain d. Decreased blood pressure

c. Unilateral chest pain

To prevent septic shock in the hospitalized client, what should the nurse do? a. Maintain the client in a normothermic state. b. Administer blood products to replace fluid losses. c. Use aseptic technique during all invasive procedures. d. Keep the critically ill client immobilized to reduce metabolic demands.

c. Use aseptic echnique during all invasive procedures

Which client would have relatively smaller tidal volumes due to limited chest wall movement? a. A client with asthma b. A client with pneumonia c. A client with pulmonary fibrosis d. A client with phrenic nerve paralysis

d. A client with phrenic nerve paralysis

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? a. A reduction of confusion b. An absence of ecchymotic areas c. A decreased viscosity of the blood d. An activated partial thromboplastin twice the usual value

d. An activated partial thromboplastin twice the usual value

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? a. Airway obstruction b. Inadequate nutrition c. Prolonged gastric suction d. Excessive mechanical ventilation

d. Excessive mechanical ventilation

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is most important for the nurse to take? a. Encourage the client to slow the breathing rate b. Auscultate the client's lungs and suction if indicated c. Advise the healthcare provider that the client needs supplemental oxygen d. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.

d. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure

A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first? a. Remove all jewelry b. Wash the chest area c. Use a grounded electrical source d. Remove medication patches on the chest

d. Remove medication patches on the chest

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client? a. This decreases catabolism to promote healing at the site of injury. b. This lowers the metabolic rate in an attempt to help reduce the fever. c. This reduces the energy demands on the body in the presence of infection. d. This limits muscle contractions that may force causative organisms into the bloodstream.

d. This limits muscle contractions that may force causative organisms into the bloodstream

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary, and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. - Insert the catheter without applying suction - Assess client's vital signs and lung sounds - Rotate the catheter while suction is applied - Activate the ventilator suction hyperoxygenation setting

- Assess client's vital signs and lung sounds - Activate the ventilator suction hyperoxygenation setting - Insert the catheter without applying suction - Rotate the catheter while suction is applied

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? a. Remove secretions by suctioning. b. Lower the setting of the tidal volume. c. Check that tubing connections are secure. d. Obtain a specimen for arterial blood gases (ABGs).

a. Remove secretions by suctioning

A healthcare provider orders heparin 6000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. How many milliliters of heparin should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL

0.6

A client is receiving heparin sodium intravenously at 1500 units/hour. The concentration in the bag is 25,000 units/500 milliliters. The nurse determines that how many milliliters will infuse during the nurse's 8-hour shift? Record your answer using a whole number. ___ mL

240

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? a. Pink b. Clear c. Green d. Yellow

a. Pink

To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? a. A change in the respiratory rate b. A tingling sensation in the hands c. Periodic changes in the fetal heart rate d. A pulse oximetry reading of less than 98%

b. A tingling sensation in the hands

A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates, and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant? a. Tachycardia b. Hypotension c. Respiratory arrest d. Central nervous system depression

a. Tachycardia

A client is taking warfarin. If an antidote is needed, which agent will the nurse anticipate being prescribed? a. Vitamin K b. Fibrinogen c. Prothrombin D. Protamine sulfate

a. Vitamin K

A client is admitted to the emergency unit after a fire. The nurse initiates continuous cardiac monitoring and maintains oxygen saturation and end-tidal carbon dioxide. Which type of emergency assessment is being performed? a. Focused adjuncts b. Full set of vital signs c. Comfort measures d. Family presence

a. focused adjuncts

The ventilator of a client has leakage of air from its tubing. Alveolar hypoventilation is suspected. What blood gas value does the nurse expect to see? a. pH of 7.32 b. Po2 of 95 mm Hg c. Pco2 of 30 mm Hg d. HCO3 of 20 mEq/L (20 mmol/L)

a. pH of 7.32

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume? a. 70 mL b. 60 mL c. 50 mL d. 40 mL

a. 70 mL

A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. What is an appropriate treatment plan? a. Amiodarone bolus b. Intracardiac epinephrine c. Insertion of a pacemaker d. Cardiopulmonary resuscitation (CPR)

a. Amiodarone bolus

A client has an endotracheal tube and is receiving mechanical ventilation. The nurse identifies that periodic suctioning may be necessary. The nurse follows a specific protocol when performing this procedure. Place the steps in the order that they should be performed. - Auscultate lung sounds. - Obtain the vital signs. - Suction for approximately 10 seconds. - Rotate the catheter during its withdrawal. - Hyperoxygenate for 30 seconds.

1. Obtain the vital signs 2. Auscultate lung sounds 3. Hyperoxygenate for 30 seconds 4. Suction for approximately 10 seconds 5. Rotate the catheter during its withdrawal

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? a. Oliguria b. Crackles c. Dyspnea d. Bounding pulse

a. Oliguria

Which mechanism of action does norepinephrine promote to manage anaphylaxis? a. Blocks the effects of histamine b. Inhibits mast cell degranulation c. Increases blood pressure and cardiac output d. Stimulates muscarinic and nicotinic receptors

c. Increases blood pressure and cardiac output

Which is the priority nursing action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation? a. Treating pain b. Assessing respirations c. Initiating defibrillation d. Monitoring blood pressure

c. Initiating defibrillation

A pregnant client is prescribed heparin to prevent the risk of thromboembolism. Which adverse effects should the nurse anticipate with this medication? Select all that apply. a. Osteoporosis b. Suppress contractions in labor c. Increased risk of serious bleeding d. Stimulation of uterine contraction e. Compression fractures of the spine

a. Osteoporosis e. Compression fractures of the spine

A client who is prescribed diuretic therapy develops metabolic alkalosis. To which intervention should the nurse give priority as the healthcare team corrects the alkalosis? a. Preventing falls b. Monitoring electrolytes c. Administering antiemetics d. Adjusting the diuretic therapy

a. Preventing falls

The nurse provides discharge medication education to a client who has been switched from a prescription for heparin to a prescription for warfarin sodium. Which client statement indicates to the nurse that teaching was effective? a. "I will avoid taking aspirin and NSAIDs." b. "I will avoid exercise and will spend most of the day working at my desk." c. "I will need to have regular complete blood counts to guide warfarin dosage." d. "Before going to the dentist, I will ask my healthcare provider for antibiotics."

a. "I will avoid taking aspirin and NSAIDs."

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? a. A 65-year-old with pulmonary fibrosis b. A 24-year-old with uncontrolled type 1 diabetes c. A 45-year-old who has been vomiting for 3 days d. A 54-year-old who takes sodium bicarbonate for indigestion

a. A 65-year-old wiht pulmonary fibrosis

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? a. An obese client with leg trauma b. A pregnant client with acute asthma c. A client with diabetes who has cholecystitis d. A client with pneumonia who is immunocompromised

a. An obese client with leg trauma

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? a. Arteriolar constriction occurs b. The cardiac workload decreases c. Contractility of the heart decreases d. The parasympathetic nervous system is triggered

a. Arteriolar constriction occurs

The client reports a "fluttering in my chest." The nurse analyzes the client's heart rhythm and notices that there are three P waves for each QRS complex. The waves have a sawtooth appearance. The atrial rate is 240 beats per minute, but the ventricular rate is only 80 beats per minute. The nurse notifies the primary healthcare provider for which rhythm? a. Atrial flutter b. Atrial fibrillation c. Ventricular fibrillation d. Atrial flutter with rapid ventricular response

a. Atrial flutter

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. a. Crackles b. Atelectasis c. Hypoxemia d. Severe dyspnea e. Increased pulmonary wedge pressure

a. Crackles B. Atelectasis C. Hypoxemia D. Severe dyspnea

A client is experiencing tachycardia. Which adverse hemodynamic effects will the nurse consider when planning care for this client? Select all that apply. a. Decreased ventricular filling time b. Increased coronary artery filling c. Decreased cardiac output d. Increased atrial kick e. Increased cardiac output

a. Decreased ventricular filling time c. Decreased cardiac output

The nurse is caring for a client with sepsis who is hemodynamically stable. The client is complaining of abdominal pain. Which of these primary health care provider prescriptions should the nurse do first? a. Draw peripheral blood cultures. b. Administer levofloxacin 500 mg intravenously over 30 minutes. c. Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. d. Take the client to x-ray for an abdominal computed tomography (CT) scan.

a. Draw peripheral blood cultures

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. a. Fever b. Tachypnea c. Hypertension d. Abdominal rigidity e. Increased bowel sounds

a. Fever b. Tachypnea d. Abdominal rigidity

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do? a. Hyperoxygenate with 100% oxygen before and after suctioning b. Suction two or three times in quick succession to remove secretions c. Use the technique of short, pushing movements when applying suction d. Apply suction for no more than 10 seconds while inserting the catheter

a. Hyperoxygenate with 100% oxygen before and after suctioning

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs? a. Increased restlessness b. No secretions when client is suctioned c. PaO2 of 93 d. Skin warm and dry

a. Increased restlessness

During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic acidosis

A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. a. Oliguria b. Bradypnea c. Diaphoresis d. Tachycardia e. Hypertension

a. Oliguria c. Diaphoresis d. Tachycardia

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? a. Poached eggs b. Spinach salad c. Sweet potatoes d. Cheese sandwich

b. Spinach salad

A client is on a ventilator. A nurse asks another nurse, "What should be done when condensation resulting from humidity collects in the ventilator tubing?" What is the nurse's best response? a. "Notify the respiratory therapist." b. "Empty the fluid from the tubing." c. "Decrease the amount of humidity." d. "Document the output on the record."

b. "Empty the fluid from the tubing."

To prevent excessive bruising when administering subcutaneous heparin, what technique will the nurse employ? a. Administer the injection via the Z-track technique b. Avoid massaging the injection site after the injection c. Use 2 mL of sterile normal saline to dilute the heparin d. Inject the drug into the vastus lateralis muscle in the thigh

b. Avoid massaging the injection site after the injection

A client develops ventricular fibrillation in a coronary care unit. Which action is priority? a. Administer oxygen b. Initiate defibrillation c. Initiate cardioversion d. Administer sodium bicarbonate intravenously

b. Initiate defibrillation

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? a. Hypokalemia b. Metabolic acidosis c. Respiratory alkalosis d. Decreased Pco2 levels

b. Metabolic acidosis

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? a. Hypokalemia b. Metabolic acidosis c. Respiratory alkalosis d. Decreased carbon dioxide level

b. Metabolic acidosis

The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for what? a. Respiratory acidosis b. Respiratory alkalosis c. Respiratory compensation d. Respiratory decompensation

b. Respiratory alkalosis

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion? a. Energy level is set at maximum level b. Synchronizer switch is in the "on" position c. Skin electrodes are applied after the T wave d. Alarm system of the cardiac monitor is functioning simultaneously

b. Synchronizer switch is in the "on" position

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? a. The body initially attempts to compensate by releasing more red blood cells b. The body initially attempts to compensate by maintaining peripheral vasoconstriction c. The body initially attempts to compensate by decreasing mineralocroticoid production d. The body initially attempts to compensate by producing less antidiuretic hormone (ADH)

b. The body initially attempts to compensate by maintaining peripheral vasoconstriction

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? a. Dyspnea b. Hyperpnea c. Kussmaul breathing d. Cheyne-Stokes breathing

c. Kussmaul breathing

What is a nursing priority to prevent complications in clients with respiratory acidosis? a. Assessing the nail beds b. Listening to breath sounds c. Monitoring breathing status d. Checking muscle contractions

c. Monitoring breathing status

The nurse is caring for a client who has a tracheostomy tube with a high-volume, low-pressure cuff. What does the cuff prevent? a. Leakage of air b. Lung infection c. Mucosal necrosis d. Tracheal secretion

c. Mucosal necrosis

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? a. Respiratory alkalosis b. Poor oxygen perfusion c. Normal acid-base balance d. Compensated metabolic acidosis

c. Normal acid-base balance

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic? a. International normalized ratio (INR) is between 2 and 3 b. Prothrombin time (PT) is 2.5 times the control value c. Activated partial thromboplastin time (APTT) is double the control value d. Activated clotting time (ACT) is in the range of 70 to 120

c. Activated partial thromboplastin time (APTT) is double the control value

An emergency nursing staff member is performing defibrillation/cardioversion and special resuscitation for clients who sustained injuries in a tsunami. Which certification does the emergency nursing staff member possess? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS)

c. Advanced Cardiac Life Support (ACLS)

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? a. Hypertension b. Tenacious sputum c. Altered mental status d. Slow rate of breathing

c. Altered mental status

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? a. Hypertension b. Tenacious sputum c. Altered mental status d. Slowed rate of breathing

c. Altered mental status

A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? a. Atropine b. Epinephrine c. Amiodarone d. Sodium bicarbonate

c. Amiodarone

A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time? a. Prepare the client for emergency surgery b. Facilitate the client's verbal communication c. Assess the client's response to the interventions d. Maintain sterility of the ventilation system that is being used

c. Assess the client's response to the interventions

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? a. Chronic pain b. Risk for injury c. Electrolyte imbalance d. Inadequate gas exchange

c. Electrolyte imbalance

The medical-surgical nurse called the code team for a client who is unresponsive and not breathing. Cardiopulmonary resuscitation and an ambu bag have been initiated. What is the next most appropriate action for the nurse to take? a. Contact the client's primary healthcare provider b. Move any other clients or visitors out of the room c. Get the client's record and have it available in the room d. Contact religious ministry

c. Get the client's record and have it available in the room

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? a. PO2 value is 80 mm Hg. b. PCO2 value is 60 mm Hg. c. HCO3 value is 50 mEq/L (50 mmol/L). d. Serum potassium value is 4 mEq/L (4 mmol/L).

c. HCO3 value is 50 mEq/L (50 mmol/L)

A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats per minute. Following treatment with diltiazem hydrochloride, what assessment indicates to the nurse that the diltiazem hydrochloride is effective? a. Increased urine output b. Blood pressure of 90/60 mm Hg c. Heart rate of 110 beats per minute d. No longer complaining of heart palpations

c. Heart rate of 110 beats per minute

A nurse is caring for a toddler with severe dehydration and its associated acid-base imbalance. What compensatory mechanism within the body is activated to counteract the effects of the child's acid-base imbalance? a. Profuse diaphoresis b. Increased temperature c. Increased respiratory rate d. Renal retention of hydrogen ions

c. Increased respiratory rate

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what? a. Providing more oxygen to lung tissue b. Forcing pressure into lung tissue, which improves gas exchange c. Opening collapsed alveoli and keeping them open d. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue

c. Opening collapsed alveoli and keeping them open

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is what? a. White blood cell (WBC) count of 8200/mm3 (8.2 X 109/L) b. Bilateral 3+ pitting pedal edema c. Oral temperature of 101.3° F (38.5° C) d. Pale skin and nail beds

c. Oral temperature of 101.3° F (38.5° C)

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? a. Skeletal and nervous b. Circulatory and urinary c. Respiratory and urinary d. Muscular and endocrine

c. Respiratory and urinary

A nurse on the Code Blue/Arrest team responds to a code that is called for a client with hyperkalemia who is experiencing cardiac standstill. What would an appropriate immediate treatment plan include? a. Defibrillation b. Furosemide c. Sodium bicarbonate d. Anticoagulation therapy

c. Sodium bicarbonate

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip is prescribed. Several hours later, vancomycin intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? a. Stop the heparin, flush the line, and administer the vancomycin. b. Use a piggyback setup to administer the vancomycin into the heparin. c. Start another IV line for the vancomycin and continue the heparin as prescribed. d. Hold the vancomycin and tell the healthcare provider that the drug is incompatible with heparin.

c. Start another IV line for the vancomycin and continue the heparin as prescribed.

While preforming nasotracheal suctioning, the nurse notices that the client has blood pressure of 90/70 and a heart rate of 50 beats per minute. What is the priority nursing intervention in this situation? a. Administering intravenous fluids to the client b. Reporting to the primary healthcare provider c. Stopping the suctioning procedure immediately d. Administering 100% oxygen manually to the client

c. Stopping the suctioning procedure immediately

In addition to atrial fibrillation, which cardiac dysrhythmia exhibited by a client does the nurse determine may be converted to sinus rhythm by cardioversion? a. Cardiac standstill b. First degree heart block c. Supraventricular tachycardia d. Frequent premature complexes

c. Superventricular tachycardia

The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? a. Boggy uterus b. Hypovolemic shock c. Multiple vaginal clots d. Bleeding at the venipuncture site

d. Bleeding at the venipuncture site

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? a. Gravida III with twins b. Gravida V with endometriosis c. Gravida II who had a 9-lb baby d. Gravida I who has had an intrauterine fetal death

d. Gravida I who has had an intrauterine fetal death