exam 3 nur212 mc3
A middle-aged man collapses in the emergency department waiting room. The triage nurse should first: a) Ask the client to state his name. b) Feel for any air movement from the victim's nose or mouth. c) Perform the chin-tilt to open the victim's airway. d) Watch the victim's chest for respirations.
A) Ask the client to state his name. Explanation: Calling the victim's name and gently shaking the victim is used to establish unresponsiveness. The head-tilt, chin-lift maneuver is used to open the victim's airway. Feeling for any air movement from the victim's nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victim's chest for respirations to see if the victim is breathing
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? a) The client demonstrates ability to tolerate more activity without chest pain. b) The client requests information regarding smoking cessation. c) The client exhibits a heart rate within normal limits. d) The client is able to verbalize the action of all his prescribed medications.
A) The client demonstrates ability to tolerate more activity without chest pain. Explanation: The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. A heart rate within the normal limits of 60-100 per minute does not necessarily indicate a favorable response to treatment. Smoking is a cardiovascular risk factor that the client would be wise to eliminate, but it does not indicate favorable response to treatment. Knowledge of prescribed meds is a good thing, but again does not impact response to treatment.
Before surgery to repair an aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for: a) loss of consciousness. b) headache. c) anxiety. d) disorientation.
A) loss of consciousness. Explanation: If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain. Anxiety is not a sign of aortic valvular insufficiency. The end result of decreased cerebral blood flow is loss of consciousness, not headache or disorientation.
A client is in hypovolemic shock. In which position should the nurse place the client? a) semi-Fowler's. b) supine c) supine with the legs elevated 15 degrees d) Trendelenburg's
C) supine with the legs elevated 15 degrees Explanation: A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation. Neither semi-Fowler's position nor the supine position by itself promotes venous return. Semi-Fowler's position would not facilitate venous return. Trendelenburg's position inhibits respiratory expansion and possibly causes increased intracranial pressure.
The nurse is caring for a client following a myocardial infarction and is aware that complications can occur due to damage to the myocardium. Which of the following interventions would be appropriate for this client? Select all that apply. a) Continuous cardiac monitoring via telemetry b) Ambulating length of hall in first 24 hours c) Maintaining bed rest for 72 hours d) Auscultating apical pulse every 2 hours e) Electrocardiogram with any chest pain
E) Electrocardiogram with any chest pain A) Continuous cardiac monitoring via telemetry D) Auscultating apical pulse every 2 hours Explanation: After a myocardial infarction it is important to monitor the client carefully for complications. An EKG should be done with any chest pain to assess for any changes that would indicate additional damage to the heart muscle. Auscultating the apical pulse and continuous cardiac monitoring would identify a change in status. Bed rest would be maintained for 24 hours, and ambulation would be added gradually, not in the first 24 hours.
A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? a) "A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" b) "It is due to severe hypersensitivity reaction resulting in massive systemic vasodilation." c) "Generally caused by decreased blood volume" d) "A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces"
a) "A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" Explanation: Shock may have different causes (e.g., hypovolemia, cardiogenic, septic), but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Movement of plasma into the interstitial spaces could reflect dependent edema and sepsis. Decreased blood volume is an example of hypovolemia. A hypersensitivity reaction is an example of anaphylactic shock or distributive shock
A nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he complains of dizziness. What is the nurse's priority action? a) Administer atropine 0.5 mg IV push as ordered. b) Administer lidocaine 100 mg IV push as ordered. c) Administer a 500 ml IV bolus of normal saline solution (0.9% NaCl). d) Notify the attending physician.
a) Administer atropine 0.5 mg IV push as ordered. Explanation: I.V. push atropine is used to treat symptomatic bradycardia. The attending physician should be notified after the patient is stabilized. A normal saline bolus will treat the hypotension, but will not address the underlying problem. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? a) Reduce pain and myocardial oxygen demand. b) Limit visitation by family and friends. c) Provide client education on medications and diet. d) Monitor daily weights and urine output.
a) Reduce pain and myocardial oxygen demand. Explanation: Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload? a) Myocardial infarction, fluid overload, and diuresis b) Hemorrhage, sepsis, and anaphylaxis c) Fluid overload, sepsis, and vasodilation d) Third spacing, heart failure, and diuresis
b) Hemorrhage, sepsis, and anaphylaxis Explanation: Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload increases with fluid overload and heart failure.
Which of the following is the best nursing response to make when a client who is experiencing an acute myocardial infarction (MI) asks why the nurse is administering intravenous morphine? a) "Morphine increases your heart's ability to stretch and squeeze and decreases pain." b) "Morphine decreases blood pressure and increases your heart's ability to stretch." c) "Morphine decreases the heart's need for oxygen and also makes your heart not work as hard." d) "Morphine is a medication that is commonly administered for pain control."
c) "Morphine decreases the heart's need for oxygen and also makes your heart not work as hard." Explanation: When given to treat acute MI, morphine eliminates pain, reduces preload and afterload, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine does not increase myocardial contractility, raise blood pressure, or increase preload or afterload
A nurse is preparing a client for cardiac catheterization. The nurse must provide which nursing intervention immediately when the client returns to his room after the procedure? a) Apply ice to the puncture site for 12 hours post procedure. b) Force fluids for 6 hours after the procedure. c) Administer the prescribed analgesia. d) Assess the puncture site frequently for hematoma formation or bleeding.
d) Assess the puncture site frequently for hematoma formation or bleeding. Explanation: Because the diameter of the catheter used for cardiac catheterization is large, the immediate priority is to assess the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as ordered and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client's system. Application of ice to the site is not required.
An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. Changes in which leads of a 12-lead ECG indicate damage to the left ventricular septal region? a) Leads I, aVL, V5, and V6 b) Leads V1 and V2 c) Leads II, III, and aVF d) Leads V3 and V4
d) Leads V3 and V4 Explanation: Leads V3 and V4 record electrical events in the septal region of the left ventricle. Leads I, aVL, V5, and V6 record electrical events on the lateral surface of the left ventricle. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle. Leads V1 and V2 record electrical events on the anterior surface of the right ventricle and the anterior surface of the left ventricle.
The nurse should complete which of the following assessments on a client who has received tissue plasminogen activator or alteplase recombinant therapy? a) Blood glucose level. b) Arterial blood gas values. c) Excessive bleeding every hour for the first 8 hours. d) Neurologic signs frequently throughout the course of therapy.
d) Neurologic signs frequently throughout the course of therapy. Explanation: The nurse needs to assess neurologic status throughout the therapy. Altered sensorium or neurologic changes may indicate intracranial bleeding for the client who has received tissue plasminogen activator or alteplase. The nurse should carefully check for bleeding every 15 minutes during the first hour of therapy, every 15 to 30 minutes during the next 9 hours, and at least every 4 hours during the duration of therapy. Bleeding may occur from sites of invasive procedures or from body orifices. The blood glucose level does not need to be evaluated. Arterial blood gas values relate to acid base status and oxygenation and are avoided due to the invasiveness of arterial puncture at this time. (less)
A client is in the compensatory stage of shock. Which finding indicates the client is entering the progressive stage of shock? a) temperature of 99° F b) blood pressure of 110/70 mm Hg c) heart rate of 110 bpm d) urinary output of 20 ml per hour
d) urinary output of 20 ml per hour Explanation: In the compensatory stage of shock, the client exhibits moderate tachycardia, but as the shock continues to the progressive stage the client will have a decreased urinary output, hypotension, and mental confusion as a result of failure to perfuse and ineffective compensatory mechanisms. The body temperature initially may remain normal. These findings are indications that the body's compensatory mechanisms are failing.
Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: (Select all that apply.) a) has not had an alcoholic beverage within the last 8 hours. b) does not have active internal bleeding. c) is older than 65 years. d) has a blood pressure within normal limits. e) has had symptoms of the stroke less than 3 hours.
e) has had symptoms of the stroke less than 3 hours. d) has a blood pressure within normal limits. b) does not have active internal bleeding. Explanation: Contraindications for t-PA or alteplase recombinant therapy include current active internal bleeding, 3 hours or longer since the onset of symptoms of a stroke, and severe hypertension. Age greater than 65 years or having had an alcoholic beverage are not contraindications for the therapy.