Exam 2 - EAQ

When discharging a client who has had insertion of a coronary artery stent, for which signs and symptoms will a nurse instruct the client to seek immediate medical attention? Select all that apply Dyspnea with vigorous exertion Unexplainable profuse diaphoresis Indigestion not relieved by antacids Fatigue the day after a rigorous walk Acute chest pain after rigorous exercise Continued chest pain after nitroglycerin use

- Unexplainable profuse diaphoresis - Indigestion not relieved by antacids - Acute chest pain after rigorous exercise - Continued chest pain after nitroglycerin use All are clinical indicators of inadequate oxygen to the heart -> needs to seek immediate medical intervention Dyspnea on vigorous exertion and fatigue the day after a rigorous walk are expected

Which diagnostic test is most important for the nurse to obtain rapidly when caring for a client who has just arrived in the ED with possible Acute Coronary Syndrome? Chest radiograph Troponin T CK-MB 12 Lead EKG

12 Lead EKG - EKG first to assess if pt has ST elevations - then chest radiograph, and later the cardiac biomarkers (as they take time to elevate)

Which explanation would the nurse give to the spouse of a client who had a CABG surgery when asked why there is a dressing on the client's left leg? This is the access site for the heart-lung machine A filter is inserted in the leg to prevent embolization A vein in the leg was used to bypass the coronary artery The arteries in the extremities are examined during surgery

A vein in the leg was used to bypass the coronary artery - greater saphenous vein

Which finding in a client with a dx of stable angina is most important for the nurse to communicate to the HCP? Anginal sxs are relieved by rest Discomfort is described as chest pressure Radiation to the left arm and back occurs Angina episodes are occurring more frequently

Angina episodes are occurring more frequently - this indicates unstable angina

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery? Assist client to use the incentive spirometer Admin prescribed IV ABX Take V/S every 4 hours Auscultate breath sounds every 4 hrs

Assist client to use the incentive spirometer

Which action by an UAP who is assisting with postprocedure care requires that the nurse intervene when caring for a client who has had cardiac catheterization using the femoral approach? Taking pulse Q15min Keeping client's legs extended Offering client a sandwich and apple juice Assisting the client to stand and void

Assisting the client to stand and void

Which assessment finding will the nurse expect when caring for a client right ventricular failure? Crackles throughout both lungs Substernal chest pressure Redness and swelling of calf Bilateral lower leg edema

Bilateral lower leg edema

When performing a focused respiratory assessment, which action would the nurse take first? Examine for any abnormal respiratory patterns Inspect for changes in skin color or temperature Check for any evidence of respiratory distress Determine the shape and symmetry of the chest

Check for any evidence of respiratory distress - the remaining choices may be sxs of respiratory distress

Which action will the nurse first when two hrs after a cardiac catheterization that was accessed through the right femoral route, a client reports numbness and pain in the right foot? Call the HCP Check client's pedal pulses bilaterally Take client's BP and a pulse Teach about postcatheterization embolus

Check the client's pedal pulses bilaterally

Which finding would the nurse expect when assessing a client with compensated metabolic acidosis? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias

Deep and rapid respirations

Which assessment finding indicates to the nurse that the client with COPD who is receiving oxygen is retaining CO2? Anxiety Drowsiness Irregular pulse Mental confusion Increased respirations

Drowsiness Irregular pulse Mental confusion This patient is experiencing respiratory acidosis (not blowing off enough CO2 and retaining instead) Anxiety and increased respirations would be seen in respiratory alkalosis (blowing off too much CO2)

A client's ABG report indicates as follows: pH 7.52 PCO2 32 HCO3 24 Which does the nurse identify as a possible cause of these results? Airway obstruction Inadequate nutrition Prolonged gastric suction Excessive mechanical ventilation

Excessive mechanical ventilation - ABG = respiratory alkalosis - can be caused by mechanical ventilation that is too aggressive Airway obstruction -> respiratory acidosis Inadequate nutrition -> metabolic acidosis Prolonged gastric suction -> metabolic alkalosis

Which factor would the nurse identify as the cause of the pain experienced by a client who is experiencing ACS? Arterial aneurysm Heart muscle ischemia Blocking of the coronary veins Irritation of nerve endings in the cardiac plexus

Heart muscle ischemia

Which complication is a priority for the nurse to prevent for a client who has just returned to the nursing unit after coronary artery stenting via access through the femoral artery? Infection Urinary retention Hematoma formation Orthostatic hypotension

Hematoma formation

Which statement explains why metabolic acidosis develops with kidney failure? Inability of the renal tubules to secrete hydrogen ions and conserve bicarb Depressed respiratory rate dt metabolic waste, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste products

Inability of the renal tubules to secrete hydrogen ions and conserve bicarb

Which physiological response explains why elevation in body temperature occurs in clients who experience ACS? Parasympathetic reflexes Inflammatory response Catecholamine release Peripheral vasoconstriction

Inflammatory response - response to tissue destruction and persist as long as a week

Which dx is suspected by the nurse when the laboratory date for a client with prolonged vomiting reveal ABG gases of the following: pH 7.51 PCO2 45 HCO3 58 K+ 3.8

Metabolic Alkalosis - dt vomiting, confirmed by ABG

Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis? Observing nail beds Listening to breath sounds Monitoring breathing status Checking muscle contractions

Monitoring breathing status

Which intervention will relieve chest pain of a client admitted to the cardiac care unit with a MI? Nitro SL O2 per NC Lidocaine hydrochloride 50-mg IV bolus Morphine sulfate 2 mg IV

Morphine

The nurse is caring for a client with the following ABG: PO2 89 PCO2 35 pH 7.37 These findings indicate the client is experiencing which condition?

Normal acid-base balance

A client with COPD has a blood pH of 7.25 and PCO2 of 60. These blood gas results require nursing attention because they indicate with condition?

Respiratory acidosis

Which finding for a client who has just returned to the nursing unit after an emergency cardiac catheterization would be most important to report to the HCP? Anxiety about the results of the procedure ST segment elevation on the ECG Pain at femoral artery catheter site Premature atrial contractions on the cardiac monitor

ST segment elevation on the ECG - sx of an acute myocardial injury -> emergency stent placement may be necessary

Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization? To obtain the pressures in the heart chambers To determine the existence of congenital heart disease To visualize the disease process in the coronary arteries To measure the oxygen content of various heart chambers

To visualize the disease process in the coronary arteries

Which laboratory value will be important for the nurse to monitor to determine whether a client with chest pain has ACS? Troponin (cTnT) C-reactive protein (CRP) Low-density lipoprotein (LDL) B-type natriuretic protein (BNP)

Troponin

Which ABGs are associated with DKA? pH 7.28, PCO2 28, HCO3 18 pH 7.30, PCO2 54, HCO3 28 pH 7.50, PCO2 49, HCO3 32

pH 7.28, PCO2 28, HCO3 18 - metabolic acidosis