Exam 3 Perfusion & Protection

client who develops ventricular fibrilation rhythm. Client is unresponsive pulseless, and apneic. Which is the nurses priority Defibrilation Airway managment Epinephrine administration Amiodarone administration

Defibrilation * we should administer epinephrine, a first line med, since it's a cardiac stimulant followed by amiodarone but these arent first priorities.

Discharge instructions for a client who has CHF. Which client statements indicates teaching was effective? " I will read food labels and limit sodium to 4g per day" "I should use naproxen to manage discomfort" "I plan to slow down if i am tired the day after exercising" "i will take my diuretic before sleep and drink fluids during the day"

"I plan to slow down if i am tired the day after exercising" * no more than 2g sodium a day * no naproxen. avoid NSAIDS bc they can cause sodium retention

Admitting client who has acute heart failure following an MI. The nurse recognizes that which of the following prescriptions by the provider requires clarification? Morphine sulfate 2 mg IV bolus every 2 hr PRN pain Lab testing serum potassium upon administration 0.9% normal saline IV at 50ml/hr continuous Bumetanide 1 mg IV bolus every 12 hours

0.9% normal saline IV at 50 ml/ hr continuous

A nurse is preparing to administer digoxin to a 6month old infant. prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infants heart rate is less than what rate

60 and below for adult 70 or below for child 90 and below for infant

While auscultating a clients heart sounds, the nurse hears turbulence between S1 and S2 heart sounds, the nurse should document this finding as which of the following? A systolic murmur A third heart sound An expected heart sound A Fourth heart sounds

A systolic murmur

A nurse is caring for a client who received an injection of penicillin G procaine. The client begins to experience dyspnea and tongue swelling. Which of the following actions should the nurse perform first? Obtain intravenous fluids for administration Record observed data in medical record Deliver a dose of aminophylline by inhalation Administer epinephrine subcutaneously

Administer epinephrine subcutaneously

which is manifestation of digoxin toxicity? Anorexia Ataxia Photosensitivity Jaundice

Anorexia ** As well as confusion, vomiting, headache, vision changes.

Nurse is caring for a client who has cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia? Epinephrine Magnesium Atropine Sodium Bicarbonate

Atropine is administered during CPR if the client has symptomatic bradycardia or is hemodynamically unstable

Caring for an 8 year old who has acute rheumatic fever. Which of the following assessments is the nurses priority immediately after admission Auscultating the rate and characteristic of the child's heart sounds Using a pain rating tool to determine the severity of the joint pain Identifying the degree of parental anxiety related to the diagnosis Assessing the clients erythematous rash

Auscultating the rate and characteristic of the child's heart sounds Rheumatic fever is a condition that can inflame or make the heart, joints, brain, and skin swell. Rheumatic fever is thought to be an immune response to an earlier infection

Assessing client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the med. Heart rate 46/min O2 95% RR 18 BP 160/94

HR 46

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? A) "I am gaining weight." B) "I am constipated." C) "My vision seems yellow. "D) "My tongue is red and beefy."

Blurred and yellow vision Other side effects: - Diarrhea - Weight loss

A client with HIV, which lab value is priority Positive western blot test CD4-T-cell count 180 cells/mm3 Platelets 150,000 mm3 WBC 5,000 mm3

CD4-T-Cell count 180 cells/mm3. 180 and less indicates client is severely immunocompromised and is at high risk for infection.

Client with CHF taking digoxin daily. Client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first. Check vitals Request dietician consult Suggest that the client rests before eating the meal Request an order for an antiemetic

Check vitals

Discharge teaching to client with implantable cardioverter / Defibrilator (ICD). Which of the following information should the nurse include? Client cannot travel by air due to security screening Client should hold his cell phone on the side opposite the ICD The client should avoid the use of small electric devices The client can carry his ICD in a small pocket

Client should hold his cell phone on the side opposite the ICD phone could interfere with phone function

What instructions should we provide to an RA patient beginning methotrexate Expect to feel fx immediately? Do not drink alc while taking this med Report unexplained bruising avoid people w/ infections Take NSAIDS to help minimize the adverse effects of the medication

Do not drink alc while taking this med Report unexplained bruising avoid people w/ infections

Physical assessment of client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? Grey colored non purpuric papular rash Dry, red rash across the bridge of the nose and on the cheeks Pitting Edema of the hands and fingers Subcutaneous nodules on the ulnar side of the arm

Dry red rash across bridge of nose and on the cheeks

A nurse is preparing to administer a transfusion of RBC's to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply) Dyspnea GI Bloating Jugular vein distention Confusion Hypotension

Dyspnea JVD Confusion

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? Defibrilation Elective cardioversion CPR Radiofrequency catheter ablasion

Elective Cardioversion since client is awake and responsive

Client has acute right sided heart failure. Which of the following should the nurse expect? Decreased Brain natriuretic peptide (BNP) Elevated Central venous Pressure (CVP) Increased Pulmonary artery wedge Pressure (PAWP) Decreased Specific Gravity

Elevated Central Venous Pressure. This is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure * BNP will be elevated * Specific Gravity will be increased

Older adult with RA taking asprin 650mg every 4 hours. Which diagnostic tests should the nurse monitor to evaluate the effectivness of this med? WBC Rheumatoid factor (RF) Antinuclear antibody Erythrocyte sedimentation rate (ESR)

Erythrocyte sedimentation rate (ESR) this monitors tissue inflammation

Teaching female client who has new diagnosis of systemic lupus erythematosus (SLE). Nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? Sunlight Pregnancy infection Exercise

Exercise. deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurse should encourage exercise. Pregnancy, sunlight and infection can all exacerbate SLE

Assessing client for early signs of RA. Which of the following changes is an early manifestation of RA Morning Stiffness Fatigue Temporomandibular joint pain Bakers cysts

Fatigue * as well as weakness and anorexia

Older adult with L sided heart failure. Which of the following assessment findings should the nurse expect? Frothy sputum Dependent edema Nocturnal polyuria Jugular distention

Frothy sputum ** As well as hacking cough, wheezing, fatigue, and weakness.

A nurse is assessing a client who has left sided heart failure. Which of the following findings should the nurse expect? Jugular venous distention Abdominal distention Dependent Edema Hacking cough * which of these are manifestations of Right sided heart failure?

Hacking cough - Dependent edema, abdominal distention, and jugular vein distention are all a manifestation of right sided heart failure

client reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? Asthma Aortic valve regurgitation Heart Failure Aortic stenosis

Heart Failure

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions? Febrile Hemolytic Allergic Bacterial

Hemolytic.

What should we expect with right ventricular failure? Dry hacking cough Hepatomegaly Dizziness Crackles in the lungs

Hepatomegaly (Liver enlargement)

Caring for client who has heart failure and prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication. I can walk a mile a day Ive had a backache for several days I am urinating more frequently I feel nauseated and have no appetite

I feel nauseated and have no appetite.

Client has heart failure and is taking dobutamine drip. The nurse should identify that which of the following findings indicates that the med is effective? Increased heart rate Increased urine output decreased blood pressure decreased blood glucose levels

Increased urine output. Dobutamine is administered to clients who have heart failure to improve their hemodynamic status - Tachycardia is an adverse effect of dobutamine - an increased blood pressure is a sign the med is working

Client presents with manifestations that indicate an MI. Which of the following prescriptions should the nurse take first? Attach the leads for a 12-lead ECG Obtain a blood sample Initiate oxygen therapy Insert the IV catheter

Initiate oxygen therapy because the greatest risk to the clients safety is myocardial ischemia and cellular death all the others are important too but not first priorities.

Assessing a client with AIDS, and multiple widespread raised purplish-brown skin lesions. What does this finding indicate? Actinic keratosis Kaposi's sarcoma Toxic epidermal necrosis Basal cell carcinoma

Kaposi's sarcoma

A nurse is collecting med history from a client scheduled to have cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client as risk for AKI Atorvastatin Metformin Nitroglycerin Carvedilol

Metformin

A nurse in a providers office is assessing a client who reports occasional atypical chest pain, palpations, and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following conditions?

Mitral valve prolapse

Nurse should plan to administer which of the following meds after the initial acute phase of MI to manage clients pain and anxiety? Nitro Aspirin Oxygen Morphine

Morphine. reduces preload and afterload

A nurse in an emergency department is assessing a client who is having suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? Select all that apply. Orthopnea Headache Nausea Tachycardia Diaphoresis

Nausea Tachycardia Diaphoresis

Caring for a client who reports pain in the jaw, back and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? Obtain an EKG Administer eneteric-coated acetaminophen Administer ibuprophen Maintain O2 sats greater than or equal to 92%

Obtain an EKG to detect heart rhythm abnormalities. also keep O2 above 95%

Assessing a toddler who has heart failure. Which of the following findings should the nurse expect? Weight loss Increased urine output Bradycardia Orthopnea

Orthopnea - This is difficulty breathing while laying down and it is because the toddler has increased venous return to the heart and lungs which leads to pulmonary congestion. Sitting up decreases venous return as well as pressure the abdominal organs have on the diaphragm.

lab result from a fib patient that should be reported to provider? PT 45 seconds Hgb 16 g/dL Hct 44% Platelets 190,000mm3

PT 45 sec. Should be 11-12.5

Nurse is planning to administer digoxin to heart failure patient. Which lab result is priority for nurse to review before administration? Hemoglobin Potassium Creatinine Blood urea nitrogen

Potassium because hypokalemia increases the risk of digitalis toxicity

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? Feelings of depression Dry, raised rash on the face presence of peripheral edema joint pain in hands and knees

Presence of peripheral edema. An SLE patient is at greatest risk of death from lupus nephritis. findings that indicate impairment of renal function are highest priority.

Teaching a client who has Rheumatoid Arthritis about self care strategies for managing disease. which of the following activities should the nurse include in the teaching? Press water form a sponge rather than wringing it Turn doorknobs using a clockwise motion Finish weekly household tasks within 1-2 days Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile.

Press water form a sponge rather than wringing it Turn doorknobs counterclockwise to avoid twisting the arm which promotes ulnar deviation.

Client has had CPR following cardiac arrest. Client is receiving lidocaine IV at 2mg/min when the client asks why they're receiving it, the nurse explain that it has which of the following actions? Prevents dysrhythmias slows intestinal motility dissolves blood clots relieves pain

Prevents dysrhythmias lidocaine is an antidysrhythmic can also help with pain but thats not the use for this situation

Teaching a client w Rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client? Reduced joint stress Maintainence of joint function Suppression of the inflammatory process Decreased stiffness

Reduced joint stress.

which instructions should be included for a prescription of bumetanide? Report changes in hearing Avoid foods high in potassium Take the prescribed second dose at nighttime Limit your fluid intake to no more than 1.5 L a day

Report changes in hearing

A nurse is reviewing lab values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the clients renal function? Serum creatinine Blood urea nitrogen (BUN) Serum sodium Urine specific gravity

Serum creatinine

client has a-fib and is receiving heparin. Which finding is the nurses priority? - ECG tracing shows irregular heart rate without P waves - Client has aPTT of 80 seconds - Client experiences sudden weakness of one arm and one leg - Urine output is cloudy and odorous

Sudden weakness of one arm and one leg can indicate stroke or stroke risk. * 80 sec aPTT is normal for those on heparin * This ECG reading is expected for someone with a-fib

A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? These tests help determine the degree of damage to the heart tissues Cardiac enzymes will identify the location of the MI These tests will enable the provider to determine the heart structure and mobility of the heart valves Cardiac enzymes assist in diagnosing the presence of pulmonary congestion

These tests help determine the degree of damage to the heart tissues

Nurse is assessing client who is to have IV urography. which of the following data should indicate to the nurse that this procedure is contraindicated for this client? Presence of a metal rod in her tibia Allergy to shellfish history of claustrophobia Prescribed rosiglitazone

This procedure requires contrast die which contains iodine and an Allergy to shellfish (which have iodine) is a contraindication to this procedure.

Client has delayed hypersensitivity reaction. Nurse should expect which manifestation Bronchospasm Serum Sickness Tissue damage at the site Excessive mucus secretion

Tissue damage at the site. This looks like edema, induration, ischemia, and tissue damage at the site occuring hours to days after exposure. - Bronchospasm is a Type 1 rxn - Serum sickness is Type 3 rxn - Excessive mucus secretion is type 1 rxn

A nurse in the ED is caring for a client who reports chest pressure and SOB. Which lab tests should the nurse anticipate? Troponin I Lipase B-type natriuretic peptide (BNP) Aspartate aminotransferase (AST)

Troponin I. These proteins only exist in cardiac muscle and enter the bloodstream within a few hours of an MI. They are the most specific indicator or myocardial damage. - Lipase identifies pancreatic disease - BNP used to identify heart failure - AST enzyme used to identify liver disease

Client reports chest pain. Provider suspects myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show- which of the following explainations should the nurse provide the client? Troponin is an enzyme that indicates damage to the brain, heart, and skeletal muscle tissues Troponin is a lipid whose levels reflect the risk for coronary artery disease Troponin is a heart muscle protein that appears in the bloodstream where there is damage to the heart Troponin is a protein that helps transport oxygen throughout the body

Troponin is a heart muscle protein that appears in the bloodstream where there is damage to the heart

What are the 4 kinds of hypersensitivity reactions?

Type I: reaction mediated by IgE antibodies. Type II: cytotoxic reaction mediated by IgG or IgM antibodies. Type III: reaction mediated by immune complexes. Type IV: delayed reaction mediated by cellular response.

Providing discharge teaching to a client who has systemic lupus erythematosus (SLE) which of the following instructions should the nurse include? Avoid using moisturizing lotions on the skin Wash the hair with a mild protein shampoo Apply powder liberally to sensitive skin areas Use a sun blocking agent with a sun protection factor of at least 15

Wash the hair with mild protein shampoo SLE patients are prone to hair loss. avoid treatments that can damage the hair and scalp such as dyes and permanents.

What discharge teaching should be included for a patient with SLE Avoid using moisturizing lotions on your skin Wash hair with mild protein shampoo Apply powder liberally to sensitive skin areas Use sun blocking agent with a sun protection of at least 15

Wash with mild protein shampoo

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that after the lab has the enzyme linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm diagnosis? CD4+ T-Cell count Western blot analysis Quantitative RNA assay Viral load test

Western Blot analysis Used to confirm seropositivity when the ELISA test has a positive result.

Client has heart failure and a potassium of 2.4 mEq/L. What med may have caused this Furosemide Nitroglycerin Metoprolol Spironolactone

furosemide- potassium wasting diuretic.

client calls in and reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which is an appropriate response from the nurse?

instruct the client to call 911 The client is having unstable angina or an acute MI

What pulse characteristic is expected with Afib Slow Not palpable irregular bounding

irregular

What is a late manifestation of RA Anorexia Knuckle deformity Low grade fever Weight loss

knuckle deformity

A nurse is caring for a client who is prescribed diphenhydramine to releive pruritus. The client asks the nurse how he can minimize the daytime sedation he is experieincing. Which of the following responses should the nurse give? Gradually decrease the dose once tolerance to the effect is reached Distribute the doses evenly throughout the day Take most of the daily dose at bedtime Take the medication with meals

take most of the daily dose at bedtime