NUR 213 test 2

2 A child with severe diaper rash has potential for infection if the interventionist makes the standard groin approach.

A 1-year-old child is being prepared for a cardiac catheterization procedure. Which of the following findings about the child might delay the procedure? 1. 30th percentile for weight. 2. Severe diaper rash. 3. Allergy to soy. 4. Oxygen saturation of 91% on room air.

2 The nurse should assess the client's blood pressure.

A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Assess the woman's fundal height. 4. Ask the woman about stressors at work.

1 The pressures in the left side of the heart are greater, causing the flow of blood to be from an area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood flow with the extra blood.

A 3-month-old has been diagnosed with a VSD. The flow of blood through the heart with this type of defect is: 1. Right to left. 2. Equal between the two chambers. 3. Left to right. 4. Bypassing the defect.

2 Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

4 Discontinuing the blood at the hub of the intravenous catheter is the first intervention because the client is exhibiting signs of an anaphylactic reaction, which can lead to anaphylactic shock if the allergen (blood) is not stopped immediately. Many different allergens can cause anaphylactic shock, including medications, blood administration, latex, foods, snake venom, and insect stings.

During the first 15 minutes of administering blood to a client, the client complains of shortness of breath, low back pain, and itching all over the body. Which action should the nurse implement first? 1. Administer 0.5 mL of epinephrine, an adrenergic, intravenously. 2. Assess the client's temperature, pulse, and blood pressure. 3. Infuse normal saline at 125 mL an hour via a peripheral IV. 4. Discontinue the blood at the hub of the intravenous catheter.

1 This is the correct statement explaining what an AED does when used in a code.

The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED? 1. It analyzes the rhythm and shocks the client in ventricular fibrillation. 2. The client will be able to have synchronized cardioversion with the AED. 3. It will keep the health-care provider informed of the client's oxygen level. 4. The AED will perform cardiac compressions on the client.

2 A condition in which there are localized edematous areas (wheals), accompanied by intense itching of the skin and mucous membranes, is called angioedema. This is an adverse reaction to an ACE inhibitor and should be reported to the HCP.

The HCP prescribed an angiotensin-converting enzyme (ACE) inhibitor for a client diagnosed with congestive heart failure (CHF). Which instruction should the nurse provide? 1. Eat a banana or drink orange juice at least twice a day. 2. Notify the HCP if you develop localized edematous areas that itch. 3. A dry cough is expected early in the morning on arising. 4. The symptoms of CHF should improve rapidly.

1 This is a major surgery but has a predictable course with no complications identified in the stem, and a colostomy is expected with this type of surgery. The graduate nurse could be assigned this client.

The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation? 1. The client with an abdominal peritoneal resection who has a colostomy. 2. The client diagnosed with pneumonia who has acute respiratory distress syndrome. 3. The client with a head injury developing disseminated intravascular coagulation. 4. The client admitted with a gunshot wound who has an H&H of 7 and 22.

3 A new graduate should be able to complete a preprocedure checklist and get this client to the catheterization laboratory.

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

3 This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough.

2 Because this client is being discharged, it would be an appropriate assignment for the new graduate.

The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor? 1. The client admitted for diagnostic tests to rule out valvular heart disease. 2. The client three (3) days post-myocardial infarction being discharged tomorrow. 3. The client exhibiting supraventricular tachycardia (SVT) on telemetry. 4. The client diagnosed with atrial fibrillation who has an INR of five (5).

1 The signs/symptoms of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from every body orifice and into the tissues.

The client admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site. 2. Sudden onset of chest pain and frothy sputum. 3. Foul-smelling, concentrated urine. 4. A reddened, inflamed central line catheter site.

3 This medication causes orthostatic hypotension, and the client should be instructed to rise slowly from lying to sitting to standing position to prevent falls and injury.

The client being discharged after sustaining an acute myocardial infarction is prescribed the ACE inhibitor lisinopril (Zestril). Which instruction should the nurse include when teaching about this medication? 1. Instruct the client to monitor the blood pressure weekly. 2. Encourage the client to take medication on an empty stomach. 3. Discuss the need to rise slowly from lying to a standing position. 4. Teach the client to take the medication at night only.

4 Because the client has had one myocardial infarction, the client may have sublingual NTG in a pocket and can take it immediately. If the client does not have any on the body, then the nurse should determine if there is anyone in the home that can help the client.

The client calls the clinic and says, "I am having chest pain. I think I am having another heart attack." Which intervention should the nurse implement first? 1. Call 911 emergency medical services. 2. Instruct the client to take an aspirin. 3. Determine if the client is at home alone. 4. Ask if the client has any sublingual nitroglycerin.

1 The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

3 The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring.

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move legs. 4. Take no action concerning the UAP's behavior.

2 Any bleeding from the intravenous site, gums, rectum, or vagina should be reported to the HCP. The HCP may not be able to take action to prevent the bleeding during therapy, but it warrants notifying the HCP.

The client diagnosed with a myocardial infarction is receiving thrombolytic therapy. Which data would warrant immediate intervention by the nurse? 1. The client's telemetry has reperfusion dysrhythmias. 2. The client is oozing blood from the intravenous site. 3. The client is alert and oriented to date, time, and place. 4. The client has no signs of infiltration at the insertion site.

3 Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

1 Life-threatening hypotension can result with concurrent use of nitroglycerin and sildenafil (Viagra).

The client diagnosed with angina is prescribed nitroglycerin (Nitrobid) and tells the nurse, "I don't understand why I can't take my Viagra. I need to take it so that I can make love to my wife." Which statement is the nurse's best response? 1. "If you take the medications together, you may get very low blood pressure." 2. "You are worried your wife will be concerned if you cannot make love." 3. "If you wait at least 8 hours after taking your NTG, you can take your Viagra." 4. "You should get clarification with your HCP about your taking Viagra."

1, 2 1. If the nurse does not wear the gloves, the nurse can absorb the medication and get a headache. 2. The old nitroglycerin paste must be removed because it could cause an overdose of the medication.

The client diagnosed with angina must receive a two (2)-inch nitroglycerin paste (Nitro-Bid) application. Which interventions should the nurse implement? Select all that apply. 1. Wear gloves when administering. 2. Remove the old Nitro-Bid paper. 3. Apply the paper on a hairy spot. 4. Put medication only on the legs. 5. Report any headache to the HCP.

2 By reducing the levels of angiotensin II, ACE inhibitors dilate blood vessels, reduce blood volume, and prevent or reverse angiotensin II pathologic changes in the heart and kidneys.

The client diagnosed with congestive heart failure (CHF) is prescribed the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec). Which statement explains the scientific rationale for administering this medication? 1. ACE inhibitors increase the levels of angiotensin II in the blood vessels. 2. ACE inhibitors dilate arteries, which reduces the workload of the heart. 3. ACE inhibitors decrease the effects of bradykinin in the body. 4. ACE inhibitors block the action of antidiuretic hormone in the kidney.

3 When a baby aspirin is taken daily, it helps prevent platelet aggregation, which, in turn, helps the blood pass through the narrowed arteries more easily.

The client diagnosed with coronary artery disease is instructed to take 81 mg of aspirin ("children's aspirin" or "adult low-dose aspirin") daily. Which statement best describes the scientific rationale for prescribing this medication? 1. This medication will help thin the client's blood. 2. Daily aspirin will decrease the incidence of angina. 3. This medication will prevent platelet aggregation. 4. Baby aspirin will not cause gastric distress.

2 Statins can cause muscle injury, which can lead to myosititis, fatal rhabdomy- olysis, or myopathy. Muscle pain or tenderness should be reported to the HCP immediately; usually the medica- tion is discontinued.

The client diagnosed with coronary artery disease is prescribed atorvastatin (Lipitor), an HMG-CoA reductase inhibitor. Which statement by the client would warrant the nurse notifying the health-care provider? 1. "I really haven't changed my diet, but I am taking my medication every day." 2. "I am feeling pretty good except I am having muscle pain all over my body." 3. "I am swimming at the local pool about three times a week for 30 minutes." 4. "I am taking this medication first thing in the morning with a bowl of oatmeal."

1 Antihypertensive medications ingeneral cause orthostatic hypotension. Therefore, the client should be taught to get up slowly from lying to sitting and sitting to a standing position to help prevent dizziness and lightheadedness.

The client diagnosed with high blood pressure is ordered the angiotensin-converting enzyme inhibitor captopril (Capoten). Which statement by the client indicates to the nurse that the discharge teaching has been effective? 1. "I should get up slowly when I am getting out of my bed." 2. "I should check and record my blood pressure once a week." 3. "If I get leg cramps, I should increase my potassium supplements." 4. "If I forget to take my medication, I will take two doses the next day."

3 Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs.

2 An IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order.

The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.

4. A sensitivity report indicating a resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organ- ism, and the HCP needs to be notified so the antibiotic can be changed.

The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic.

1 A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

3 If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

3 Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock.

The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? 1. Monitor the client's telemetry. 2. Turn the client every two (2) hours. 3. Administer oxygen via nasal cannula. 4. Place the client in the Trendelenburg position.

3 Extravasation of dopamine causes severe, localized vasoconstriction, resulting in a slough of the tissue and tissue necrosis if not reversed with the antidote phentolamine (Regitine) injections at the site of the infiltration.

The client in cardiogenic shock is receiving dopamine, a beta and alpha agonist. The peripheral intravenous site becomes infiltrated. Which action should the nurse implement? 1. Assess the client's blood pressure and apical pulse. 2. Elevate the arm and apply ice to the infiltrated area. 3. Inject phentolamine (Regitine) at the site of infiltration. 4. Discontinue the IV and take no other action.

4 Norepinephrine is a powerful vasoconstrictor; therefore, continuous monitor- ing of the blood pressure is required to avoid hypertension.

The client in cardiogenic shock is receiving norepinephrine (Levophed), a sympathomimetic. Which priority intervention should the nurse implement? 1. Do not abruptly discontinue the medication. 2. Administer medication on an infusion pump. 3. Check the client's creatinine level and BUN. 4. Monitor the client's blood pressure continuously.

3 Because of the ability of all colloids, including dextran, to pull fluid into the vascular space, circulatory overload is a serious adverse outcome. Crackles in the lungs reflect pulmonary congestion, a sign of fluid-volume overload.

The client in hypovolemic shock is receiving dextran, a nonblood colloid. Which assessment data would warrant immediate intervention by the nurse? 1. The client's blood pressure is 102/78. 2. The client's pulse oximeter reading is 95%. 3. The client's lung sounds reveal bilateral crackles. 4. The client's urine output is 120 mL in 3 hours.

1 There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock.

The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter. 2. Administer dopamine intravenous infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter.

2 Morphine sulfate is the drug of choice for chest pain, and it is administered intravenously so that it acts as soon as possible, within 10-15 minutes. Intravenous push medications should be diluted to help decrease the pain when it is administered and to prevent irritation to the vein. An intravenous push also allows the nurse to inject the medication more accurately over the 5-minute administration time.

The client is complaining of severe chest pain radiating down the left arm and is nauseated and diaphoretic. The HCP suspects the client is having a myocardial infarction (MI) and has ordered morphine sulfate (MS), a narcotic analgesic, for the pain. Which intervention should the nurse implement? 1. Administer the morphine intramuscularly in the ventral gluteal muscle. 2. Dilute the MS to a 10-mL bolus with normal saline and administer intravenous push. 3. Question the order because MS should not be administered to a client with an MI. 4. Assess the client's pain prior to administering the medication orally.

3 The client is symptomatic and will require a pacemaker.

The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

3 The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular fibrillation. If the client's heart is beating, the nurse would then administer lidocaine.

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.

1 Lidocaine suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias.

The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health-care provider to order for this client? 1. Lidocaine. 2. Atropine. 3. Digoxin. 4. Adenosine.

1, 3, 4, 5 Ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted. Defibrillation is the treatment of choice for ventricular fibrillation. The crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation. Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias.

The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

2 The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

2 The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor.

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.

4 Assessment is the first part of the nursing process, and determining if the client is taking any antiulcer medication is the first question the nurse should ask the client.

The client newly diagnosed with coronary artery disease is being prescribed a daily aspirin. The client tells the nurse, "I had a bad case of gastritis last year." Which action should the nurse implement first? 1. Ask the client if he or she informed the HCP of the gastritis. 2. Explain that regular aspirin could cause gastric upset. 3. Instruct the client to take an enteric-coated aspirin. 4. Determine if the client is taking any antiulcer medication.

2 Subcutaneous heparin is used prophylactically to prevent deep vein thrombosis. Symptoms of a DVT include calf edema, redness, warmth, and pain on dorsiflexion. Lack of these symptoms indicates the client does not have a DVT and that, therefore, the medication is effective.

The client on strict bed rest is prescribed subcutaneous heparin. Which data indicates the medication is effective? 1. The client's current PT is 22, the INR is 2.4, and the PTT is 70. 2. The client's calves are normal size, are normal skin color, and are nontender. 3. The client performs active range-of-motion exercises every 4 hours. 4. The client's varicose veins have reduced in size and appearance.

3 The nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol.

The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation.

3 Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors.

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.

4 In this invasive procedure, performed in a cardiac catheterization laboratory, the client has a catheter inserted into the femoral artery. Therefore, the client must keep the leg straight to pre- vent hemorrhaging at the insertion site.

The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the recovery room nurse implement? 1. Assess the client's chest tube output. 2. Monitor the client's chest dressing. 3. Evaluate the client's endotracheal (ET) lip line. 4. Keep the client's affected leg straight.

4 Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia.

The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.

1 Ginkgo, an herb, can increase bleeding when taken with an antiplatelet medication such as aspirin or Plavix. Therefore, this statement warrants intervention and the nurse should encourage the client to quit taking ginkgo. Ginkgo has been shown to have a beneficial effect of increasing blood flow to the brain, but in this case, the risk of bleeding warrants the nurse's intervention.

The client with arterial occlusive disease is taking clopidogrel (Plavix), an antiplatelet medication. Which statement by the client would warrant intervention by the nurse? 1. "I am taking the herb ginkgo to help improve my memory." 2. "I am a vegetarian and eat a lot of green, leafy vegetables." 3. "I have not had any blood drawn in more than a year." 4. "I always use a soft-bristled toothbrush to brush my teeth."

1 This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1 The P wave represents atrial contraction, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.

The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.

4 A complication of long-term aspirin use is gastric bleeding, which could result in dark, tarry stools. This data would warrant further intervention.

The elderly client diagnosed with coronary artery disease has been taking aspirin daily for more than a year. Which data would warrant notifying the health-care provider? 1. The client has lost 5 pounds in the last month. 2. The client has trouble hearing low tones. 3. The client reports having a funny taste in the mouth. 4. The client has hard, dark, tarry stools.

2 These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of develop- ing ulcers, which can erode the stomach lining and lead to hemorrhaging.

The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.

4. Hawthorn dilates the peripheral blood vessels, increases coronary circulation, improves cardiac oxygenation, acts as an antioxidant, has a mild diuretic effect, and is used to treat CHF and HTN. Doses of ACE inhibitors, cardiac glycosides, and beta blockers may need to be modified if taken in combination with hawthorn.

The female client diagnosed with congestive heart failure (CHF) tells the nurse that she has been taking hawthorn extract, an over-the-counter medication, since the HCP told her that she had heart problems. Which statement by the nurse would be appropriate? 1. "You need to take garlic supplements with hawthorn for it to be effective." 2. "You should stop taking this herb immediately because it can cause more prob- lems." 3. "This herb can cause bleeding if you take it with your other medications." 4. "Some clients find this is helpful, but make sure your HCP is aware of the medication."

1 This is the correct scientific rationale for administering this medication.

The health-care provider prescribed a beta blocker for the client diagnosed with arte- rial hypertension. Which is the scientific rationale for administering this medication? 1. This medication decreases the sympathetic stimulation to the heart, thereby decreasing the client's heart rate and blood pressure. 2. This medication prevents the calcium from entering the cell, which helps decrease the client's blood pressure. 3. This medication prevents the release of aldosterone, which deceases absorption of sodium and water, which, in turn, decreases blood pressure. 4. This medication will cause an increased excretion of water from the vascular system, which will decrease the blood pressure.

1. A symptom of CHF is shortness of breath. The fact that the client can ambulate without being short of breath is an improvement of symptoms, which shows that the medications are effective.

The home health nurse is caring for a client diagnosed with congestive heart failure (CHF) who has been prescribed the cardiac glycoside digoxin (Lanoxin) and the loop diuretic furosemide (Lasix). Which statement by the client indicates the medications are effective? 1. "I am able to walk next door now without being short of breath." 2. "I keep my feet propped up as much as I can during the day." 3. "I have gained 3 pounds since my last visit here." 4. "I am staying on my diet, and I don't salt my foods anymore."

1 An S3 indicates left ventricular failure and should be reported to the health- care provider. It is a potential life- threatening complication of a myocardial infarction.

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

4 The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

1 Specimens should be put into biohazard bags prior to leaving the client's room.

The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse? 1. The UAP places a urine specimen in a biohazard bag in the hallway. 2. The UAP uses the alcohol foam hand cleanser after removing gloves. 3. The UAP puts soiled linen in a plastic bag in the client's room. 4. The UAP obtains a disposable stethoscope for a client in an isolation room.

4 The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment.

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done.

3 This is the first intervention the nurse should implement after finding the client unresponsive on the floor.

The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? 1. Check the client for breathing. 2. Assess the carotid artery for a pulse. 3. Shake the client and shout. 4. Notify the Rapid Response Team.

1 The client receiving a calcium channel blocker (CCB) should avoid grapefruit juice because it can cause the CCB to rise to toxic levels.

The nurse is administering 0900 medications to the following clients. To which client would the nurse question administering the medication? 1. The client receiving a calcium channel blocker who drank a glass of grapefruit juice. 2. The client receiving a beta blocker who has an apical pulse of 62 beats per minute. 3. The client receiving a nitroglycerin patch who has a blood pressure of 148/92. 4. The client receiving an antiplatelet medication who has a platelet count of 150,000.

4 The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62.

2, 3 The client's potassium level, as well as the digoxin level, is monitored because high levels of potassium impair therapeutic response to digoxin and low levels can cause toxicity. The most common cause of dysrhythmias in clients receiving digoxin is hypokalemia from diuretics that are usually given simultaneously. Yellow haze indicates the client may have high serum digoxin levels. The therapeutic range for digoxin is relatively small (0.5 to 1.2), and levels of 2.0 or greater are considered toxic.

The nurse is administering digoxin (Lanoxin), a cardiac glycoside, to a client diagnosed with congestive heart failure (CHF). Which interventions should the nurse implement? Select all that apply. 1. Assess the client's carotid pulse for 1 full minute. 2. Check the client's current potassium level. 3. Ask the client if he or she is seeing a yellow haze around objects. 4. Have the client squeeze the nurse's fingers. 5. Teach the client to get up slowly from a sitting position.

2 Usually a VSD will close on its own within the first year of life.

The nurse is caring for a 3-month-old with a VSD. The physicians have decided not to repair it surgically. The parents express concern that this is not best for their child and ask why their daughter will not have an operation. The nurse's best response to the parents is: 1. "It is always helpful to get a second opinion about any serious condition like this." 2. "Your daughter's defect is small and will likely close on its own by the time she is 2 years old." 3. "It is common for the physicians to wait until an infant develops respiratory distress before they do the surgery because of the danger." 4. "With a small defect like this, we will wait until the child is 10 years old to do the surgery."

4 Applying direct pressure 1 inch above the puncture site will localize pressure over the vessel site.

The nurse is caring for a child who has undergone cardiac catheterization. During the recovery phase, the nurse notices the dressing is saturated with bright red blood and a 6-inch circle of blood on the crib sheet. The nurse's first action is to: 1. Call the interventional cardiologist. 2. Notify the cardiac catheterization laboratory that the child will be returning. 3. Apply a bulky pressure dressing over the present dressing. 4. Apply direct pressure 1 inch above the puncture site.

2, 3 Aspirin is an antiplatelet medication and should be administered orally. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.

2, 3, 4 Sympathomimetics are incompatible with sodium bicarbonate or alkaline solutions.The client in hypovolemic shock isin critical condition, and a thorough assessment must be completed on the client frequently. This intervention is not specific for the dopamine administration, but a client in cardiogenic shock taking dopamine is in critical condition. An advance directive would be an appropriate intervention for this client.

The nurse is caring for a client diagnosed with cardiogenic shock who is receiving a dopamine drip, a sympathomimetic. Which interventions should the nurse implement? Select all interventions that apply. 1. Aspirate the injection site to avoid injecting directly into the vein. 2. Do not administer any alkaline solutions in the same tubing as dopamine. 3. Assess the client's lung sounds, vital signs, and hemodynamic parameters. 4. Ask if the client has a living will or durable power of attorney for health care. 5. Administer the dopamine via a Y-tubing along with normal saline (0.9%).

1 The hypodynamic phase is the last and irreversible phase of septic shock, characterized by low cardiac output with vasoconstriction. It reflects the body's effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries.

The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing? 1. The hypodynamic phase. 2. The compensatory phase. 3. The hyperdynamic phase. 4. The progressive phase.

3 The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last four (4) hours indicates impaired renal perfusion, which is a sign of worsening shock and warrants immediate intervention.

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4 ̊F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm3. 3. A urinary output of 90 mL in the last four (4) hours. 4. The client complains of being thirsty.

3. Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death; ventricular fibrillation is responsible for 65% to 85% of sudden cardiac deaths.

The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? 1. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. The 60-year-old client exhibiting asymptomatic sinus bradycardia. 3. The 53-year-old client exhibiting ventricular fibrillation. 4. The 65-year-old client exhibiting supraventricular tachycardia.

1 Septic shock is secondary to an infection of the blood and a broad-spectrum antibiotic (such as Rocephin) is prescribed until cultures and sensitivity results are obtained. The antibiotic that is specific to the bacteria causing the septic shock— in this case, vancomycin—should be administered as soon as possible.

The nurse is caring for the client in septic shock. The nurse administered the twice-a- day, intravenous, broad-spectrum antibiotic ceftriaxone (Rocephin) at 0900. At 1100 the health-care provider prescribed daily intravenous vancomycin, an aminoglycoside antibiotic. Which action should the nurse implement? 1. Administer the vancomycin within 2 hours. 2. Notify the HCP and question the antibiotic order. 3. Schedule the vancomycin to be administered at 2100. 4. Assess the client's white blood cell count.

3 A platelet count of less than 100,000 per cubic millimeter of blood indicates thrombocytopenia.

The nurse is caring for the following clients. Which client should the nurse assess first? 1. The client whose partial thromboplastin time (PTT) is 38 seconds. 2. The client whose hemoglobin is 14 g/dL and hematocrit is 45%. 3. The client whose platelet count is 75,000 per cubic millimeter of blood. 4. The client whose red blood cell count is 4.8 × 106/mm3.

4 The nurse would have oxygen at the bedside, and applying it would be the first intervention the nurse could implement at the bedside.

The nurse is completing A.M. care with a client diagnosed with angina when the client complains of chest pain. The client has a saline lock in the right forearm. Which intervention should the nurse at the bedside implement first? 1. Assess the client's vital signs. 2. Administer sublingual nitroglycerin (NTG). 3. Administer intravenous morphine sulfate via saline lock. 4. Administer oxygen via nasal cannula.

2 Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain).

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

2 The nurse should determine if the client is in a depressed state or if the medication is effective, so the nurse should ask the client to rate the depression on a 1-to-10 scale, with 1 being no depression and 10 being the most depressed.

The nurse is evaluating the client's home medications and notes the client with angina is taking an antidepressant. Which intervention should the nurse implement since the client is taking this medication? 1. Ask the client if there is a plan for suicide. 2. Assess the client's depression on a 1-to-10 scale. 3. Explain this medication cannot be taken because of the angina. 4. Request a referral to the hospital psychologist.

2 These medications all work in different parts of the body to help decrease the client's blood pressure. The nurse should realize the HCP is having difficulty controlling the client's blood pressure and should monitor the client's blood pressure prior to administering.

The nurse is preparing to administer a calcium channel blocker, a loop diuretic, and a beta blocker to a client diagnosed with arterial hypertension. Which action should the nurse implement? 1. Hold the medication and notify the HCP on rounds. 2. Check the client's blood pressure. 3. Contact the pharmacist to discuss the medication. 4. Double-check the health-care provider's orders.

2 These drugs must be protected from light. They must be protected in the package that is provided or wrapped in tin foil.

The nurse is preparing to administer a nitroglycerin (Tridil) drip to a client in cardiogenic shock. Which intervention should the nurse implement? 1. Mix the nitroglycerin in 500 mL of lactated Ringer's. 2. Wrap the intravenous bag and tubing in a foil package. 3. Use regular intravenous tubing when administering Tridil. 4. Ensure that the client's nitroglycerin patch is in a nonhairy area.

3 This is the scientific rationale for administering a colloid solution. They are blood volume expanders that promote circulatory volume and tissue perfusion.

The nurse is preparing to administer albumin 5% (Albuminar-5), a colloid solution. Which statement is the scientific rationale for administering this medication? 1. Albumin acts directly on the smooth muscles to cause vasodilatation. 2. Albumin mimics the fight-or-flight response of the sympathetic nervous system. 3. Albumin is a blood volume expander that promotes circulatory volume. 4. Albumin contains dextrose and increases fluid volume in the interstitial space.

3 This medication works in the arteries to prevent platelet aggregation and is prescribed for a client diagnosed with arteriosclerosis.

The nurse is preparing to administer clopidogrel bisulfate (Plavix), an antiplatelet medication, to the client with coronary artery disease. The client asks the nurse, "Why am I getting this medication?" Which statement by the nurse would be most appropriate? 1. "It will help decrease your chance of developing deep vein thrombosis." 2. "Plavix will help decrease your LDL cholesterol levels in about 1 month." 3. "This medication will help prevent your blood from clotting in the arteries." 4. "The medication will help decrease your blood pressure if you take it daily."

1 Clients must be connected to a cardiac monitor prior to and during the infusion of cardiotonic drugs. The client in cardiogenic shock will be in the inten- sive care department.

The nurse is preparing to administer dopamine, a beta and alpha agonist, to a client in cardiogenic shock. Which intervention should the nurse implement? 1. Ensure the client is on a cardiac monitor. 2. Assess the blood pressure every 4 hours. 3. Evaluate the intake and output every shift. 4. Explain that burning at the intravenous site may occur.

3 The nurse should remove the old patch, wash the client's skin, note the date and time the new patch is applied, and apply it in a new area that is not hairy.

The nurse is preparing to administer nitroglycerin, a coronary vasodilator transdermal patch, to the client diagnosed with a myocardial infarction. Which intervention should the nurse implement? 1. Question applying the patch if the client's B/P is less than 110/70. 2. Use nonsterile gloves when applying the transdermal patch. 3. Date and time transdermal patch prior to applying to client's skin. 4. Place the transdermal patch on the site where the old patch was removed.

1 The client with SVT must be continuously monitored on telemetry when this medication is being administered. When the SVT converts to normal sinus rhythm, the nurse knows the medication has been effective.

The nurse is preparing to administer the antidysrhythmic adenosine (Adenocard) for the client diagnosed with supraventricular tachycardia (SVT). Which assessment finding would indicate the effectiveness of the medication? 1. The client's ECG tracing shows normal sinus rhythm. 2. The client's apical pulse is within normal limits. 3. The client's blood pressure is above 100/60. 4. The client's serum adenosine level is 1.8 mg/dL.

1 The therapeutic range for most clients' INR is 2 to 3, but for a client with a mechanical valve replacement it is 2 to 3.5. The medication should be given as ordered and not withheld.

The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's international normalized ratio (INR) is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Prepare to administer vitamin K (AquaMephyton). 3. Hold the medication and notify the HCP. 4. Assess the client for abnormal bleeding.

3 Unexpected death occurring within one (1) hour of the onset of cardiovas- cular symptoms is the definition of sudden cardiac death.

The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? 1. Cardiac death occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time the HCP officially declares the client dead. 3. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms. 4. The death is caused by myocardial ischemia resulting from coronary artery disease.

3 The client should put one tablet under the tongue every 5 minutes and, if the chest pain is not relieved after taking three tablets, the client should seek medical attention. This statement indi- cates the client needs more teaching about the medication.

The nurse is teaching the client diagnosed with angina about sublingual nitroglycerin (NTG), a coronary vasodilator. Which statement indicates the client needs more medication teaching? 1. "I will always carry my nitroglycerin in a dark-colored bottle." 2. "If I have chest pain, I will put a tablet underneath my tongue." 3. "If my pain is not relieved with one tablet, I will get medical help." 4. "I should expect to get a headache after taking my nitroglycerin."

4. The problem is addressing the potential for hemorrhage, and a urine output of greater than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not in shock.

The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with disseminated intravascular coagulation (DIC). Which would be an appropriate goal for this client? 1. The client's clot formations will resolve in two (2) days. 2. The saturation of the client's dressings will be documented. 3. The client will use lemon-glycerin swabs for oral care. 4. The client's urine output will be >30 mL per hour.

4 The chart is a legal document, and the code must be documented in the chart and provide information needed in the intensive care unit.

The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? 1. A person is ventilating with an Ambu bag. 2. A person is performing chest compressions correctly. 3. A person is administering medications as ordered. 4. A person is keeping an accurate record of the code.

1 An infusion pump should be used when administering dobutamine because an overdose, which could occur if a drip via gravity is used, could cause death in the client. This action by the primary nurse would warrant immediate intervention by the charge nurse.

The primary nurse is preparing to administer dobutamine (Dobutrex), a beta1- adrenergic agonist, to a client in cardiogenic shock. Which action by the primary nurse would warrant intervention by the charge nurse? 1. The primary nurse is administering the dobutamine drip via gravity. 2. The primary nurse attaches a urometer to the client's Foley catheter. 3. The primary nurse applies a pulse oximeter to the client's finger. 4. The primary nurse checks the client for any medication allergies.

3. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the monitor.

The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.

3 The sternum should be depressed one and one-half (1.5) to two (2) inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP.

The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse? 1. The UAP has hand placement on the lower half of the sternum. 2. The UAP performs cardiac compressions and allows for rescue breathing. 3. The UAP depresses the sternum 0.5 to one (1) inch during compressions. 4. The UAP asks to be relieved from performing compressions because of exhaustion.

4 The nurse should not administer this medication if the client's blood pressure is less than 90/60 because it will further decrease the blood pressure, resulting in the brain not being perfused with oxygen.

Which assessment data should the nurse obtain prior to administering a calcium channel blocker? 1. The serum calcium level. 2. The client's radial pulse. 3. The current telemetry reading. 4. The client's blood pressure.

3 Troponin is the enzyme that elevates within 1 to 2 hours.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).

2 Any abnormal electrical activity of the heart causes decreased cardiac output.

Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.

4 DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC.

Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? 1. A 35-year-old pregnant client with placenta previa. 2. A 42-year-old client with a pulmonary embolus. 3. A 60-year-old client receiving hemodialysis 3 days a week. 4. A 78-year-old client diagnosed with septicemia.

3 Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets.

Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC? 1. Administer oral anticoagulants. 2. Prepare for plasmapheresis. 3. Administer frozen plasma. 4. Calculate the intake and output.

2 A cholesterol level less than 200 mg/dL is desirable and indicates the medication is effective.

Which data would indicate to the nurse that simvastatin (Zocor), an HMG-CoA reductase inhibitor, is effective? 1. The client's blood pressure is 132/80. 2. The client's cholesterol level is 180 mg/dL. 3. The client's LDL is 180 mg/dL. 4. The client's HDL is 35 mg/dL.

2 The crash cart is the mobile unit with the defibrillator and all the medications and supplies needed to conduct a code.

Which equipment must be immediately brought to the client's bedside when a code is called for a client who has experienced a cardiac arrest? 1. A ventilator. 2. A crash cart. 3. A gurney. 4. Portable oxygen.

1 The chaplain should be called to help address the client's family or significant others. A small community hospital does not have a 24-hour on-duty pastoral service. A chaplain is part of the code team in large medical center hospitals.

Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital? 1. The hospital chaplain. 2. The social worker. 3. The respiratory therapist. 4. The director of nurses.

3 This is the most important interven- tion. The nurse should always treat the client based on the nurse's assessment and data from the monitors; an inter- vention should not be based on data from the monitors without the nurse's assessment.

Which intervention is most important for the nurse to implement when participating in a code? 1. Elevate the arm after administering medication. 2. Maintain sterile technique throughout the code. 3. Treat the client's signs/symptoms; do not treat the monitor. 4. Provide accurate documentation of what happened during the code.

4 Nurses should protect themselves against possible communicable dis- ease, such as HIV and hepatitis, and should be protected if the client vomits during CPR.

Which intervention is the most important for the nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation? 1. Perform the jaw thrust maneuver to open the airway. 2. Use the mouth to cover the client's mouth and nose. 3. Insert an oral airway prior to performing mouth-to-mouth. 4. Use a pocket mouth shield to cover client's mouth.

4 If any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. Therefore, the nurse should shout "all clear."

Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client.

2 Without a heart transplant, this client will end up in end-stage heart failure. A transplant is the only treatment for a client with dilated cardiomyopathy.

Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? 1. Keep the client in the supine position with the legs elevated. 2. Discuss a heart transplant, which is the definitive treatment. 3. Prepare the client for coronary artery bypass graft. 4. Teach the client to take a calcium channel blocker in the morning.

2 The fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.

Which laboratory result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time (PT). 2. A low fibrinogen level. 3. An increased platelet count. 4. An increased white blood cell count.

1 Medical client problems indicate the nurse and the HCP must collaborate to care for the client; the client must have medications for heart failure.

Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure. 2. Activity intolerance. 3. Paralytic ileus. 4. Atelectasis.

1 Medical client problems indicate the nurse and the physician must collaborate to care for the client; the client must have medications for heart failure.

Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure. 2. Activity intolerance. 3. Powerlessness. 4. Anticipatory grieving.

4 Leg cramps may indicate a low blood potassium level; the nurse shouldhold the medication until the potas- sium level can be checked. Loop diuretics cause the kidneys to excrete potassium. Hypokalemia can cause life- threatening dysrhythmias.

Which medication would the nurse question administering? 1. Lisinopril (Zestril), an ACE inhibitor, to a client with a BP of 118/84. 2. Carvedilol (Coreg), a beta blocker, to a client with an apical pulse of 62. 3. Verapamil (Calan), a calcium channel blocker, to a client with angina. 4. Furosemide (Lasix), a loop diuretic, to a client complaining of leg cramps.

1 This primigravid client—age 44 and with a history of diabetes—is very high risk for preeclampsia.

Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy? 1. G1 P0000, age 44 with history of diabetes mellitus. 2. G2 P0101, age 27 with history of rheumatic fever. 3. G3 P1102, age 25 with history of scoliosis. 4. G3 P1011, age 20 with history of celiac disease.

1 Gastric distention occurs from over- ventilating clients. When compressions are performed, the pressure will cause vomiting which may cause aspiration into the lungs.

Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts? 1. Gastric distention can occur as a result of ventilation. 2. It is needed to assist when intubating the client. 3. This equipment will ensure a patent airway. 4. It keeps the vomitus away from the health-care provider.