Exam 2 Sole Ch. 7, 12, 13, 17 IGGY 37, 38 FINAL

The nurse is assess clients in the ED. Which client is at highest risk for developing septic shock?

25 yr old man with IBS

The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient is asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient, the nurse should first:

Assess the patient's medication profile.

The nurse is caring for a pt with complete heart block (3rd degree AV block). What is the nurse's priority intervention?

Begin external pacing

A client who presented with an acute myocardial infarction is prescribed thrombolytic therapy. The client had a stroke 1 month ago. Which action does the nurse take?

Contact the health care provider to discontinue the prescribed therapy

While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process?

Death of cardiac muscle from lack of oxygen (tissue necrosis).

The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find?

Dyspnea and crackles

The nurse assessing a client who has L ventricular failure syndrome secondary to MI. Which clinical manifestations of poor organ perfusion does the nurse monitor client for?

Dyspnea crackles

The patient's heart rate is 165 beats per minute. His cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient's blood pressure has dropped from 124/62 to 78/30. His skin is cold and diaphoretic and he is complaining of nausea. The nurse prepares the patient for:

Emergent cardioversion.

The nurse administering thrombolytic therapy to a client who had MI. Which intervention does nurse implement to reduce the risk of complications in this client

Heparin (administration of Rx Heparin)

A pt with VT unresponsive and has no pulse. The nurse calls 4 assist and a defibrillator. What is the nurse's priority intervention while waiting for defibrillator to arrive?

Initiate CPR

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101 F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patients plan of care?

Insertion of an 18-gauge peripheral intravenous line

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first?

Isotonic fluid challenge

The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse?

My back is killing me!

The nurse assessing a client who was admitted for treatment of shock. Which manifestation the pt shock caused by sepsis?

Oozing blood from the IV site

The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock?

Severe head injury from a motor vehicle accident

The ICU nurse is educating the spouse of a client who is being treated for shock. The spouse states "The Dr. said she has shock. What is that?" What is the nurse best response?

Shock occurs when O2 to the body tissue and organs is impaired death

The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition?

Speech Alterations

The nurse is caring for a client with A. Fib. What manifestation most alert the nurse to the possibility of a serious of complications from this condition/

Speech alterations or Blood Clots

The nurse is assessing a client who has been prescribed a nonselective Beta-Blocking agent. Which adverse effect does the nurse monitor for this client?

Wheezing

The nurse is assessing a client who has been prescribed a nonselective beta-blocking agent. Which adverse effect does the nurse monitor for in this client?

Wheezing

The nurse is assessing a client at risk for shock. The client's systolic blood pressure is 20 mm Hg lower than baseline. Which intervention does the nurse perform first?

of OXYGEN,

Nurse assessing a client with hx of stable angina. The client describes increased number of attacks and intensity of the pain. Which question does the nurse as to assess client change in condition?

"Do you have pain when you are resting?"

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?

A patient with a 2-day history of nausea, vomiting, and diarrhea

The nurse is assessing the pt risk for shock. The pt systolic is 20 lower than baseline. Which intervention does nurse perform 1st?

Administer O2

The nurse is caring for a client with a complete heart block (third-degree atrioventricular [AV] block). What is the nurse's priority intervention?

Begin External Pacing

The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should:

Begin cardiopulmonary resuscitation and advanced life support.

Nurse teaching pt who is Rx calcium channel blocker after a percutaneous transluminal coronary angioplasty (PTCA). Which instruction does the nurse include in pt teaching?

Change positions slowly

A client who presents with AMI prescribed thrombolytic therapy. The client had stroke 1 yr ago. Which action does the nurse take?

Contact HC provider to DC Rx therapy

The patient presents to the ED with sudden severe sharp chest discomfort radiating to his back and down both arms, as well as numbness in his left arm. While taking the patients vital signs, the nurse notices a 30- point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should:

Contact the physician immediately and begin prepping the patient for surgery.

The patient presents to the ED with severe chest discomfort. He is taken for cardiac catheterization and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed?

Coronary artery bypass graft surgery

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patients care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team?

Enteral feedings

The ED triaging a pt which pt does the nurse assess most carefully for hypovolemic shock?

Greatest output pt

Which of the following are common causes of sinus tachycardia? (Select all that apply.)

Hyperthyroidism Hypovolemia Heart Failure

The nurse observes a prominent V wave on the client ECG tracing. What is the most appropriate action for the nurse to take?

Review the client daily electrolyte results

The nurse has administered Adenosine. What is the expected therapeutic response?

Short period of asystole

While eval pt ECG before surgery the preop nurse identifies large wide Q waves. What's the nurse best interpretation of finding?

The client had MI in past

The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the demand mode at a rate of 60 beats per minute. The nurse realizes that:

The pacemaker will pace only if the patients intrinsic heart rate is less than 60 beats per minute.

Which comment by the patient indicates a good understanding of her diagnosis of coronary heart disease?

The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on.

The nurse is caring for a patient who has undergone a splenectomy, and notices that the patients platelet count has increased. The nurse realizes that the increase is due to:

The patient's inability to store platelets.

When assessing the 12-lead electrocardiogram (ECG) or a rhythm strip, it is helpful to understand that the electrical activity is viewed in relation to the positive electrode of that particular lead. When an electrical signal is aimed directly at the positive electrode, the inflection will be:

Upright.

Right sided failure-

excessive volume (increased edema)

Left sided failure

lung pump poorly