Exam 2 part 1
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?
The P wave is before the QRS complex
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should thenurse take?
Have the client lie flat in bed.
1. 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 pressure should the nurse make?
Hypovolemia
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Increased respiratory rate
A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?
Increased urine output
the nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?
Metformin
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?
My vision seems yellow
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? (Select all that apply.)
Nausea Tachycardia Diaphoresis
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Oliguria
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 monitoring strip?
Pacemaker spikes before each QRS complex
A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?
QT interval
The nurse is evaluating a client who had a cardiac catheterization w/ a left antecubital insertion site. Which of the following pulses should the nurse palpate?
Radial pulse in the left arm
A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first?
Check for a carotid pulse
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider required clarification?
0.9% Normal saline IV at 50ml/hr continuousRationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift need in this client to reduce circulatory overload. This prescription requires clarification
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?
Epinephrine
A client has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin given due to whcih of the following actions of the medication?
Antiplatelet aggregate
A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave
Atrial depolarization The P wave reflects atrial depolarization, typically initiated in the sinoatrial node.
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
BP 115/68 mmHg
A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin?
Feverfew
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?
Frothy sputum
A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventionsshould the nurse include in the client's plan of care? (Select all that apply.)
Check peripheral pulses in the affected extremity. Keep the client's hip and leg extended. Have the client remain in bed up to 6 hr.
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?
Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
elective cardioversion
A nurse on a med-surg unit is caring for a client who reports pain in the jaw, back, and shoulder; shortness of breath and nausea. Which of the following actions should the nurse take?
obtain an EKG
A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?
to reduce the risk of stroke in clients who have atrial fibrillation.
