Lesson 3 Perfusion Adaptive Quizzing

Which test result would the nurse use to determine whether the daily dose is therapeutic when a client with a venous thrombosis is receiving warfarin? A. International normalized ratio (INR) B. Accelerated partial thromboplastin time (APTT) C. Bleeding time D. Sedimentation rate

A. International normalized ratio (INR)

Which finding in a client who has just arrived in the cardiac ICU after having coronary artery bypass grafting(CABG) requires the most rapid action by the nurse? A. The serum potassium level is 3.1 mEq/L B. The client is confused about the date and time of day C. The client reports incisional pain at an 8 out of 10 D. The chest tube collection chamber has 150 ml of bloody fluid

A. The serum potassium level is 3.1 mEq/L

Which possible dysrhythmia would a nurse anticipate testing for after noting that a client in the clinic has an irregular pulse rhythm of 88 beats/min? A. Atrial fibrillation B. Ventricular tachycardia C. Complete heart block D. Supraventricular tachycardia

A. Atrial fibrillation

Which assessment finding will the nurse expect when caring for a client who has cardiogenic shock? A. Cold, clammy skin B. Slow, bounding pulse C. Increased blood pressure D. Hyperactive bowel sounds

A. Cold, clammy skin

Which response would the nurse give when a client is admitted with chest pain and a family member asks the purpose of the prescribed 12-lead electrocardiogram (ecg)? A. Indicates whether a heart attack is occurring B. Detects changes in the structures in the heart C. Shows whether the heart muscle is pumping D. Evaluates for prognosis after a heart attack

A. Indicates whether a heart attack is occurring

A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. A. Oliguria B. Bradypnea C. Diaphoresis D. Tachycardia E. Hypertension

A. Oliguria C. Diaphoresis D. Tachycardia

When a client with a heart murmur reports gaining weight in spite of nausea and anorexia, which additional information would be priority for the nurse to obtain? A. Presence of a cough and exertional dyspnea B. Dietary food and salt intake in the past 24 hours C. Changes in voiding and bowel patterns within the past month D. History of childhood streptococcal infection or rhematic fever

A. Presence of a cough and exertional dyspnea

How would the nurse describe cardiogenic shock when a family member of a client asks for more information about the condition? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume

B. A failure of the circulatory pump

Which medication prescribed for a client with an acute episode of heart failure would the nurse question? A. Diuretic B. Beta blocker C. Long acting nitrate D. Angiotensin receptor blocker

B. Beta blocker

Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider? A. Apical heart rate of 55 beats per minute B. Premature ventricular contractions (PVCs) C. Serum potassium level 3.9 mEq/L D. Bilateral swelling of the lower extremities

B. Premature ventricular contractions (PVCs)

Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the healthcare provider? A. Irregular heart beat B. Right arm weakness C. Client report of palpitations D. Client report of lightheadedness

B. Right arm weakness

Which topic is priority to include in teaching when a client with acute coronary syndrome is admitted to the cardiac ICU? A. Symptoms of worsening heart failure B. Use of daily low dose aspirin after discharge C. Need to report any chest discomfort to the nurse D. Importance of starting a walking and exercise program

C. Need to report any chest discomfort to the nurse

Which action would the nurse take next when a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 during a clinic appointment? A. Teach the client about the need for a low sodium diet B. Ask the client when blood pressure medications were taken last C. Question the client about symptoms such as headache or chest pain D. Call for an ambulance to transport the client to the emergency room

C. Question the client about symptoms such as headache or chest pain

Which finding in a client who has been admitted with myocardial infarction is most important to communicate to the health care provider? A. High anxiety level B. Elevated troponin C. Urine output 15 ml/hr D. Heart rate 58 beats/minute

C. Urine output 15 ml/hr

Which statement by a client is consistent with a diagnosis of heart failure? A. "I see spots before my eyes." B. " I am tired at the end of the day." C. "I feel bloated when I eat a large meal." D. "I have trouble breathing when I climb a flight of stairs."

D. "I have trouble breathing when I climb a flight of stairs."

After donning gloves, which action would the nurse take first after discovering a large amount of blood under the buttocks of a client would had a cardiac catherization through the femoral artery? A. Apply pressure to the site B. Obtain vital signs C. Change the client's gown and bed linens D. Assess the catheterization site

D. Assess the catheterization site

Which finding would the nurse expect when caring for a client with right-sided heart failure? A. Oliguria B. Pallor C. Cool extremities D. Distended neck veins

D. Distended neck veins

A healthcare provider prescribes administration of tissue plasminogen activator (t-PA) intravenously over 1 hour for a client experiencing a myocardial infarction. Which assessment component identifies problems caused by this medications effect? A. Respiratory rate B. Peripheral pulses C. Level of consciousness D. Intravenous insertion site

D. Intravenous insertion site

Which clinical manifestation would the nurse expect to find in a client who has had damage to major blood vessels caused by a fractured tibia? A. Increased blood pressure B. Extensive thigh edema C. Increased skin temperature of the foot D. Prolonged cap refill of the toes

D. Prolonged cap refill of the toes

A client with paroxysmal supraventricular tachycardia reports a mild "fluttering feeling" in their chest and has a blood pressure of 110/55. Which potential treatment by the health care provider would the nurse question? A. Intravenous adenosine B. Intravenous metoprolol C. Carotid sinus massage D. Synchronized cardioversion

D. Synchronized cardioversion

The nurse is caring for a client who is admitted to the hospital for medical management of heart failure and chronic peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess for? A. Proteinemia B. Contractures C. Tissue ischemia D. Thrombus formation

C. Tissue ischemia

The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock? A. Respirations of 10 B. Urine output of 30 ml/hr C. Lethargy D. Restlessness

D. Restlessness

When a client who experienced a myocardial infarction suddenly develops a heart rate of 120 beats/minute which action would the nurse take first? A. Offer reassurance B. Check blood pressure C. Call for an EKG D. Activate rapid response team

B. Check blood pressure

Which nursing action would be included in the plan of care when a client is admitted with thrombocytopenia? Select all that apply. A. Avoid IM injection B. Institute neutropenic precautions C. Monitor white blood count D. Administer prescribed anticoagulants E. Examine the skin for ecchymotic areas

A. Avoid IM injection E. Examine the skin for ecchymotic areas

Which action would the nurse perform with a client is in ventricular fibrillation? Select all that apply. A. Initiate CPR B. Assessing the EKG C. Using the defibrillator D. Obtaining electrolytes E. Administering epinephrine

A. Initiate CPR B. Assessing the EKG C. Using the defibrillator D. Obtaining electrolytes E. Administering epinephrine

An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In which position would the nurse place the infant to relieve the cyanosis and dyspnea? A. Knee-chest B. Orthopneic C. Lateral recumbent D. Semi-fowler

A. Knee-chest

When a client reports a sudden onset of chest pain that feels like a pressure or weight on their chest, which action would the nurse take first? A. Call the rapid response team B. Check blood pressure and heart rate C. Administer the prescribed as needed nitroglycerin 0.4 mg D. Ask whether there have been previous episodes of similar pain

B. Check blood pressure and heart rate

When a client's cardiac monitor indicates ventricular tachycardia, which action would the nurse take after identifying an increased apical pulse rate from 100 to 150 beats per minute? A. Administer amiodarone B. Administer epinephrine C. Assist with insertion of pacemaker D. Administer atropine

A. Administer amiodarone

Which clinical manifestation would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. A. Tachycardia B. Restlessness C. Warm, moist skin D. Decreased urinary output E. Bradypnea

A. Tachycardia B. Restlessness D. Decreased urinary output

Which information will the nurse include when explaining to a client with atrial tachycardia how the use of the valsala maneuver may decrease the client's heart rate? A. The vagus nerve is stimulated B. The glottis closes momentarily C. Thoracic pressure decreases D. Respiratory pattern is interrupted

A. The vagus nerve is stimulated

Which laboratory test is important for the nurse to monitor when a client is admitted with acute coronary syndrome? A. Troponin B. Myoglobin C. Homocysteine D. Creatine kinase (CK)

A. Troponin

Which would the nurse expect to see when reviewing the results of a CBC of an infant with tetralogy of Fallot? A. Anemia B. Polycythemia C. Agranulocytosis D. Thrombocytopenia

B. Polycythemia

Which clinical finding indicates compromised circulation for a client with a long leg cast? Select all that apply. A. Foul odor B. Swelling of the toes C. Drainage on the cast D. Increased temperature E. Prolonged capillary refill

B. Swelling of the toes E. Prolonged capillary refill

Which topic will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? Select all that apply. A. Need for daily aspirin B. Symptoms of infection C. Use of pain medications D. Wound care for leg incision E. Purpose of anticoagulant medications

B. Symptoms of infection C. Use of pain medications E. Purpose of anticoagulant medications

Which action would the nurse take first after obtaining a radial pulse rate of 136 beats/minute in a client with chronic atrial fibrillation? A. Ask about any new stressors in the client's life B. Take the client's apical pulse for a full minute C. Notify the healthcare provider about the heart rate D. Ask whether prescribed medications have been taken

B. Take the client's apical pulse for a full minute

Which mechanism of action would the nurse attempt to increase to prevent post operative deep vein thrombosis? A. Coagulability of the blood B. Velocity of venous return C. Effectiveness of internal respiration D. Oxygen carrying capacity of the blood

B. Velocity of venous return

Which action would the nurse take when a client who just returned from a cardiac catheterization reports that the pressure bandage on the right groin is tight? A. Loosen the dressing slightly B. Notify the primary health care provider C. Assess the circulatory status of the extremity D. Have the client flex the joints of the right leg.

C. Assess the circulatory status of the extremity

Which finding would be of most concern when the nurse is caring for a client who has just arrived in the ICU after coronary bypass graft surgery? A. Blood pressure 152/92 B. Blood glucose 120 C. Atrial fibrillation, rate 112 beats/minute D. 100 ml of blood in the chest drainage system

C. Atrial fibrillation, rate 112 beats/minute

Which modification in the plan of care would the nurse make because of the client's age when caring for an older adult with coronary artery disease (CAD)? A. Decrease warm up and cool down times around exercise B. Disregard arrhythmias because they are common in the aging adult C. Hold all anticoagulants because the older adult has an increased risk of side effects D. Assess for less common anginal symptoms like shortness of breath and gastric discomfort

D. Assess for less common anginal symptoms like shortness of breath and gastric discomfort

Which analgesic is the medication of choice for a client hospitalized with a myocardial infarction? A. Ketorolac B. Meperidine C. Flurazepam D. Morphine sulfate

D. Morphine sulfate

When the clinic nurse is teaching a group of clients with heart failure about dietary interventions to prevent fluid overload, which topic will be included? A. Fluid intake restrictions B. Low-calorie diet for weight loss C. Avoidance of high fat, high cholesterol foods D. Use fresh or frozen vegetables instead of canned ones

D. Use fresh or frozen vegetables instead of canned ones

Which clinical finding enables the nurse to conclude that the heparin therapy is effective in a client who has atrial fibrillation with rapid ventricular response and is started on a continuous heparin infusion? A. Atrial fibrillation converts to sinus rhythm B. The heart rate is stabilized at 70-90 beats per minute C. The INR is within normal range D. aPTT is twice the usual value

D. aPTT is twice the usual value