Nursing 211 Exam 1

The nurse is performing CPR on an adult patient who has an endotracheal tube in place. At what rate does the nurse, who is alone, administer breaths? a. 8 per minute b. 12 per minute c. 20 per minute d. 24 per minute

A

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. I can use a heating pad on my legs if its set on low. b. I should not cross my legs when sitting or lying down. c. I will go out and buy some warm, heavy socks to wear. d. Its going to be really hard but I will stop smoking.

A

A patient is receiving a nutritional supplement via an enteral feeding tube. The nurse will monitor for which common adverse effect? a. Diarrhea b. Constipation c. Fluid overload d. Heartburn

A

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

B

Hypertension is common in some ethnic groups, including a. Europeans. b. Asians. c. African Americans. d. Native Americans.

C

A patient is taking procainamide (Pronestyl) for a cardiac dysrhythmia. The nurse will monitor the patient for which possible adverse effect? a. Bradycardia b. Shortened QT interval c. Dyspnea d. Diarrhea

D

The nurse is using the Centers for Disease Control and Prevention (CDC) growth chart for an African-American child. Which statement should the nurse consider? a. This growth chart should not be used. b. Growth patterns of African-American children are the same as for all other ethnic groups. c. A correction factor is necessary when the CDC growth chart is used for non-Caucasian ethnic groups. d. The CDC charts are accurate for US African-American children.

D

The nurse will monitor a patient for signs and symptoms of hyperkalemia if the patient is taking which of these diuretics? a. Hydrochlorothiazide (HydroDIURIL) b. Furosemide (Lasix) c. Acetazolamide (Diamox) d. Spironolactone (Aldactone)

D

What should the nurse do when discontinuing a peripheral IV? a. Withdraw the catheter quickly. b. Keep the hub perpendicular to the skin. c. Apply pressure to the site for 1 minute. d. Inspect the catheter for intactness after removal.

D

When assessing a patient who is receiving a loop diuretic, the nurse looks for the manifestations of potassium deficiency, which would include what symptoms? (Select all that apply.) a. Dyspnea b. Constipation c. Tinnitus d. Muscle weakness e. Anorexia f. Lethargy

D,E,F

Nutrition therapy for those with heart failure restricts sodium to a. 1.0 gram per day. b. 1.5 grams per day. c. 2.0 grams per day. d. 2.5 grams per day

C

Protection against coronary heart disease is associated with a high-density lipoprotein (HDL) value of at least _____ mg/dL. a. 30 b. 40 c. 60 d. 80

C

The Dietary Approaches to Stop Hypertension (DASH) diet encourages intake of a. foods high in monounsaturated fats. b. foods high in soluble fiber. c. fruits, vegetables, and low-fat dairy products. d. breads, cereals, rice, and pasta.

C

The diagnosis of stages 1 and 2 hypertension is based on the _____ blood pressure. a. systolic b. diastolic c. systolic and diastolic d. resting

C

The function of lipoproteins is to carry a. proteins to the liver for metabolism. b. proteins to the cells for metabolism. c. fat and cholesterol to the cells for energy and metabolism. d. cholesterol to adipose tissue for storage.

C

The greatest proportion of dietary fatty acids should be a. saturated. b. polyunsaturated. c. monounsaturated. d. fish oil.

C

The nurse administering the phosphodiesterase inhibitor milrinone (Primacor) recognizes that this drug will have a positive inotropic effect. Which result reflects this effect? a. Increased heart rate b. Increased blood vessel dilation c. Increased force of cardiac contractions d. Increased conduction of electrical impulses across the heart

C

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond? a. Substance abuse puts clients at risk for many health issues. b. The hospital requires that I ask you about cocaine use. c. Clients who use cocaine are at risk for fatal dysrhythmias. d. We can provide services for cessation of substance abuse.

C

The nurse caring for a patient receiving IV fluids knows that the current recommendation for changing the tubing on a continuously running IV is: a. at least every 48 hours. b. every 24 hours. c. no more often than every 96 hours. d. with each IV solution bag change.

C

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

B

A patient is in the emergency department with a new onset of rapid-rate atrial fibrillation, and the nurse is preparing a continuous infusion. Which drug is most appropriate for this dysrhythmia? a. Diltiazem (Cardizem) b. Atenolol (Tenormin) c. Lidocaine d. Adenosine (Adenocard)

A

The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born preterm." This information should be recorded under which of the following headings? a. Past history b. Present illness c. Chief complaint d. Review of systems

A

The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school-age child. What is the purpose of doing this? a. To measure body fat b. To measure muscle mass c. To determine arm circumference d. To determine accuracy of weight measurement

A

The nurse is preparing for a community education program on hypertension. Which of these parameters determine the regulation of arterial blood pressure? a. Cardiac output and systemic vascular resistance b. Heart rate and peripheral resistance c. Blood volume and renal blood flow d. Myocardial contractility and arteriolar constriction

A

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

B

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? A. Amount of pressure in fluid container B. Date of catheter tubing change C. Percent of heparin in infusion container D. Presence of an ulnar pulse

D

The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. How should this action be interpreted? a. Appropriate because of child's age b. Appropriate because mother would be uncomfortable making decisions for child c. Inappropriate because of child's age d.

A

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? a. Introduce self. b. Make family comfortable. c. Explain purpose of interview. d. Give assurance of privacy.

A

.A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications? A. Initiate a dedicated team to insert access devices. B. Require additional education for all nurses. C. Limit the use of peripheral venous access devices. D. Perform quality control testing on skin preparation products.

A

A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. How should the nurse interpret this action? a. Normal development b. Significant developmental lag c. Slightly delayed development due to prematurity d. Suggestive of a neurologic disorder such as cerebral palsy

A

A 62-year-old man is to receive lidocaine as treatment for a symptomatic dysrhythmia. Upon assessment, the nurse notes that he has a history of alcoholism and has late-stage liver failure. The nurse will expect which adjustments to his drug therapy? a. The dosage will be reduced by 50%. b. A diuretic will be added to the lidocaine. c. The lidocaine will be changed to an oral dosage form. d. An increased dosage of lidocaine will be prescribed so as to obtain adequate blood levels.

A

A 74-year-old professional golfer has chest pain that occurs toward the end of his golfing games. He says the pain usually goes away after one or two sublingual nitroglycerin tablets and rest. What type of angina is he experiencing? a. Classic b. Variant c. Unstable d. Prinzmetal's

A

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the clients temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the clients daily white blood cell count

A

A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the clients blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

A

A client has Crohns disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconis anemia c. Hemolytic anemia d. Vitamin B12 anemia

A

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a. Calling the Rapid Response Team b. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest

A

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition? a. Bence-Jones protein in urine b. Epstein-Barr virus: positive c. Hemoglobin: 18 mg/dL d. Red blood cell count: 8.2/mm3

A

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best? a. Assess the reason behind the clients fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

A

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful? a. Assist the client to make sick day plans for household responsibilities. b. Determine if there are family members or friends who can help the client. c. Help the client inform friends and family that they will have to help out. d. Refer the client to a social worker in order to investigate respite child care.

A

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication.

A

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringers solution

A

A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best? a. Assess client fears and coping mechanisms. b. Reassure the client this is a common test. c. Sedate the client prior to the procedure. d. Tell the client he or she will be asleep.

A

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best?a. Do you have any concerns about sexuality? b. Im glad to hear you are sleeping well now. c. Sleep near your spouse in case of emergency. d. Why would you move into the guest room?

A

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the clients vital signs. d. Obtain consent for a central line.

A

A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best? a. It inhibits thrombin. b. It inhibits fibrinogen. c. It thins your blood. d. It works against vitamin K.

A

A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What response by the nurse is best? a. No, it may interfere with the warfarin. b. There isnt any information about that. c. Why would you want to take that? d. Yes, it is a good supplement for you.

A

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV line.

A

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the clients lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

A

A food choice that may be limited in a meal plan controlling fat and cholesterol is a. pork sausage. b. baked beans. c. broiled fish. d. glazed carrots.

A

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the clients respiratory status. b. Draw blood to assess the clients serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications.

A

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

A

A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.

A

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

A

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

A

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use? a. Standard Precautions b. Bleeding precautions c. Reverse isolation d. Contact isolation

A

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond? a. Weight is the best indication that you are gaining or losing fluid. b. Daily weights will help us make sure that youre eating properly. c. The hospital requires that all inpatients be weighed daily. d. You need to lose weight to decrease the incidence of heart failure.

A

A nurse cares for an older adult client with heart failure. The client states, I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond? a. Would you like to talk more about this? b. You are lucky to have such a devoted daughter. c. It is normal to feel as though you are a burden. d. Would you like to meet with the chaplain?

A

A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3

A

A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age? a. 6 to 8 weeks b. 10 to 12 weeks c. 4 to 6 months d. 8 to 10 months

A

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. Could you walk further than that a few months ago? b. Do you walk mostly uphill, downhill, or on flat surfaces? c. Have you ever considered swimming instead of walking? d. How much pain medication do you take each day?

A

A nurse is assessing a dark-skinned client for pallor. What action is best? a. Assess the conjunctiva of the eye. b. Have the client open the hand widely. c. Look at the roof of the clients mouth. d. Palpate for areas of mild swelling.

A

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the clients favorite channel. d. Speak loudly to the client in case of hearing problems.

A

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

A

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? a. Client who had two bloody diarrhea stools this morning b. Client who has been premedicated for nausea prior to chemotherapy c. Client with a respiratory rate change from 18 to 22 breaths/min d. Client with an unchanged lesion to the lower right lateral malleolus

A

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Womens health clinics

A

A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child? a. Focus communication on child. b. Explain experiences of others to child. c. Use easy analogies when possible. d. Assure child that communication is private.

A

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching? a. Avoid using salt substitutes. b. Take your medication with food. c. Avoid using aspirin-containing products. d. Check your pulse daily.

A

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. No, women should only have one beer a day as a general rule. b. No, you should not drink any alcohol with hypertension. c. Yes, since you are larger, you can have more alcohol. d. Yes, two beers per day is an acceptable amount of alcohol.

A

A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

A

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

A

A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? A. Check for kinking of the catheter. B. Flush the catheter with a thrombolytic enzyme. C. Get a new infusion pump. D. Remove the IV catheter.

A

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. Clean the skin and clip hairs if needed. b. Add gel to the electrodes prior to applying them. c. Place the electrodes on the posterior chest. d. Turn off oxygen prior to monitoring the client.

A

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching? a. Minimize or abstain from caffeine. b. Lie on your side until the attack subsides. c. Use your oxygen when you experience PACs. d. Take amiodarone (Cordarone) daily to prevent PACs.

A

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching? a. Avoid carrying your grandchild with the arm that has the central catheter. b. Be sure to place the arm with the central catheter in a sling during the day. c. Flush the peripherally inserted central catheter line with normal saline daily. d. You can use the arm with the central catheter for most activities of daily

A

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. Continue to educate the client on possible healthy changes. b. Emphasize complications that can occur with noncompliance. c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.

A

A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? a. Blood pressure of 88/62 mm Hg b. Apical pulse rate of 110 beats/min c. History of renal disease d. History of a myocardial infarction 2 years ago

A

A patient is being discharged to home on a single daily dose of a diuretic. The nurse instructs the patient to take the dose at which time so it will be least disruptive to the patient's daily routine? a. In the morning b. At noon c. With supper d. At bedtime

A

A patient is taking digoxin (Lanoxin) and a loop diuretic daily. When the nurse enters the room with the morning medications, the patient states, "I am seeing a funny yellow color around the lights." What is the nurse's next action? a. Assess the patient for symptoms of digoxin toxicity. b. Withhold the next dose of the diuretic. c. Administer the digoxin and diuretic together as ordered. d. Document this finding, and reassess in 1 hour.

A

A patient with a partial bowel obstruction will be given a 1-week course of enteral tube feeding via a nasogastric tube. Which formulation is appropriate for this patient? a. Vivonex Plus, an elemental formulation b. Osmolite, a polymeric formulation c. Glucerna, a formulation for impaired glucose tolerance d. Polycose, a modular formulation that contains carbohydrates

A

A patient with elevated lipid levels has a new prescription for nicotinic acid (niacin). The nurse informs the patient that which adverse effects may occur with this medication? a. Pruritus, cutaneous flushing b. Tinnitus, urine with a burnt odor c. Myalgia, fatigue d. Blurred vision, headaches

A

A patient's blood pressure elevates to 270/150 mm Hg, and a hypertensive emergency is obvious. He is transferred to the intensive care unit and started on a sodium nitroprusside (Nipride) drip to be titrated per his response. With this medication, the nurse knows that the maximum dose of this drug should be infused for how long? a. 10 minutes b. 30 minutes c. 1 hour d. 24 hours

A

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. I get short of breath when I climb stairs. b. I see halos floating around my head. c. I have trouble remembering things. d. I have lost weight over the past month.

A

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

A

An older adult patient needs to receive an enteral supplement to improve her overall nutritional status. When considering enteral supplements, the nurse notes that which formulation provides complex nutrients? a. Ensure Plus b. Moducal c. Propac d. Microlipid

A

Heart failure results in a. difficulty breathing. b. anemia. c. dehydration. d. myocardial infarction.

A

In assessing a patient before administration of a cardiac glycoside, the nurse knows that which lab result can increase the toxicity of the drug? a. Potassium level 2.8 mEq/L b. Potassium level 4.9 mEq/L c. Sodium level 140 mEq/L d. Calcium level 10 mg/dL

A

In terms of fine motor development, what should the infant of 7 months be able to do? a. Transfer objects from one hand to the other and bang cubes on a table. b. Use thumb and index finger in crude pincer grasp and release an object at will. c. Hold a crayon between the fingers and make a mark on paper. d. Release cubes into a cup and build a tower of two blocks.

A

Mannitol (Osmitrol) has been ordered for a patient with acute renal failure. The nurse will administer this drug using which procedure? a. Intravenously, through a filter b. By rapid intravenous bolus c. By mouth in a single morning dose d. Through a gravity intravenous drip with standard tubing

A

The Therapeutic Lifestyle Changes (TLC) diet recommends limiting daily cholesterol intake to no more than _____ mg daily. a. 200 b. 300 c. 400 d. 600

A

The health care provider tells the nurse that a client is to be started on a platelet inhibitor. About what drug does the nurse plan to teach the client?a. Clopidogrel (Plavix) b. Enoxaparin (Lovenox) c. Reteplase (Retavase) d. Warfarin (Coumadin)

A

The main source of dietary sodium in food is a. processed foods. b. found naturally in foods. c. found in cooking compounds. d. found as a mineral in drinking water.

A

The nurse enters the patients room and finds that the patient is not breathing and has no pulse. The patient does not have a do-not-resuscitate order. What would the nurses most immediate action be? a. Call the cardiac/respiratory arrest team. b. Begin CPR. c. Call a co-worker for help. d. Get the crash cart.

A

The nurse is assessing a client on admission to the hospital. The clients leg appears as shown below: What action by the nurse is best? a. Assess the clients ankle-brachial index. b. Elevate the clients leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

A

The nurse is assisting the physician during the insertion of a central line into the subclavian vein. How should the nurse cleanse the area? a. With chlorhexidine in a back and forth scrubbing motion b. With chlorhexidine followed by alcohol in a back and forth scrubbing motion c. With alcohol in a circular motion for 5 minutes d. With antimicrobial solution that must be dabbed dry with a sterile towel

A

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued

A

The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider? a. Hypotonic or isotonic solutions b. Hypertonic or isotonic solutions c. Hypertonic solutions only d. Whole blood

A

The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

A

The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding? a. Normal finding b. Finding requiring a referral c. Abnormal finding d. Normal finding, but requires rechecking in 1 month

A

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

B

The nurse must assess a 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate? a. Initiate a game of peek-a-boo. b. Ask father to place the infant on the examination table. c. Undress the infant while he is still sitting on his father's lap. d. Talk softly to the infant while taking him from his father.

A

The order is for the patient to receive 500 mL over 4 hours. The nurse has an electronic infusion device (EID) in place that provides for the regulation of hourly infusion. The IV tubing available is 10 gtt/mL. What is the setting for the infusion device? a. 125 mL/hr b. 500 mL/hr c. 21 gtt/min d. 32 gtt/min

A

The peripheral parenteral nutrition bag that has been infusing into the patient is empty, and the nurse realizes that the next bag is not ready. The nurse should immediately hang which of these intravenous solutions until the new bag arrives? a. 10% dextrose in water b. 20% dextrose in water c. 0.9% sodium chloride d. Lactated Ringer's solution

A

When administering digoxin immune Fab (Digibind) to a patient with severe digoxin toxicity, the nurse knows that each vial can bind with how much digoxin? a. 0.5 mg b. 5 mg c. 5.5 mg d. 15 mg

A

When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? a. "Rotate application sites with each dose." b. "Use only the chest area for application sites." c. "Temporarily remove the patch if you go swimming." d. "Apply the patch to the same site each time."

A

When counseling a male patient about the possible adverse effects of antihypertensive drugs, the nurse will discuss which potential problem? a. Impotence b. Bradycardia c. Increased libido d. Weight gain

A

When monitoring a patient who is taking hydrochlorothiazide (HydroDIURIL), the nurse notes that which drug is most likely to cause a severe interaction with the diuretic? a. Digitalis b. Penicillin c. Potassium supplements d. Aspirin

A

When using an automated external defibrillator, it is important for the nurse to ensure that no one is touching the patient: a. after connecting the cable to the machine. b. when the machine is plugged in. c. while the pads are applied. d. while the machine analyzes the rhythm.

A

Which approach would be best to use to ensure a positive response from a toddler? a. Assume an eye-level position and talk quietly. b. Call the toddler's name while picking him or her up. c. Call the toddler's name and say, "I'm your nurse." d. Stand by the toddler, addressing him or her by name.

A

Which of the following is the appropriate technique for a nurse to implement when inserting an oral airway? a. Insert the airway with the curved end up, then rotate it 180 degrees at the back of the throat. b. Insert the airway with the curved end down along the curve of the tongue. c. Use a tongue blade to insert and push the airway into position. d. Insert the airway sideways, then rotate it with the curved end up.

A

Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater? a. Axillary sensor b. Tympanic membrane sensor c. Rectal mercury glass thermometer d. Rectal electronic thermometer

A

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

A

While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? A. Grade 3 phlebitis at IV site B. Infection at IV site C. Thrombosed area at IV site D. Infiltration at IV site

A

While measuring an oral airway for proper fit, the nurse places the airway so that the flange is held parallel to the front teeth with the airway against the patients cheek. Where is the end of the curve? a. At the angle of the jaw b. Above the ear c. To the level of the nose d. Upside down

A

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

A,B,D

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

A,B,C

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

A,B,C

The nurse walks into her patients room to find him unresponsive. She begins CPR, knowing that during a code situation, chest compressions should be interrupted for which of the following situations? (Select all that apply.) a. Ventilation b. Pulse checks c. Intubation d. Defibrillation

A,B,C,D

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

A,B,C,E

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer

A,B,D

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

A,B,D

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients safety prior to discharging home? (Select all that apply.) a. Are your bedroom and bathroom on the first floor? b. What social support do you have at home? c. Will you be able to afford your oxygen therapy? d. What spiritual beliefs may impact your recovery? e. Are you able to accurately weigh yourself at home?

A,B,D

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

A,B,D,E

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night

A,B,E

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.) a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder for 8 weeks.

A,B,E

A patient will be taking dabigatran (Pradaxa) as part of treatment for chronic atrial fibrillation. Which statements about dabigatran are true? (Select all that apply.) a. The dose of dabigatran is reduced in patients with decreased renal function. b. Bleeding is the most common adverse effect. c. Potassium chloride is given as an antidote in cases of overdose. d. Dabigatran levels are monitored by measuring prothrombin time/international normalized ratio (PT/INR) results. e. This drug is a prodrug and becomes activated in the liver.

A,B,E

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

A,B,E,F

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) a. Reposition the client every 2 hours. b. Teach the client to perform deep-breathing exercises .c. Accurately record intake and output. d. Use the same scale to weigh the client each morning. e. Place the client on oxygen if the client becomes short of breath.

A,C,D

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

A,C,E

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse.e. Take and record a full set of vital signs per hospital protocol.

A,C,E

A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

A,C,E

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine outputf. Increase in urine output

A,D,E

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. Ill read the nutritional labels on food items for salt content. b. I will drink at least 3 liters of water each day. c. Using salt in moderation will reduce the workload of my heart. d. I will eat oatmeal for breakfast instead of ham and eggs. e. Substituting fresh vegetables for canned ones will lower my salt intake.

A,D,E

A patient's blood pressure reading is 150/92 mm Hg. This would be considered a. hypotension. b. stage 1 hypertension. c. normotension. d. stage 2 hypertension.

B

A risk factor for coronary heart disease that cannot be controlled is a. obesity. b. family history. c. lack of exercise. d. smoking.

B

During therapy with the hematopoietic drug epoetin alfa (Epogen), the nurse instructs the patient about adverse effects that may occur, such as: a. anxiety. b. drowsiness. c. hypertension. d. constipation.

C

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

D

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

D

A cancer patient is receiving drug therapy with epoetin alfa (Epogen). The nurse knows that the medication must be stopped if which laboratory result is noted? a. White blood cell count of 550 cells/mm3 b. Hemoglobin level of 12 g/dL c. Potassium level of 4.2 mEq/L d. Glucose level of 78 mg/dL

B

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? a. Both you and the father are equally responsible for passing it on. b. I can see you are upset. I can stay here with you a while if you like. c. Its not your fault; there is no way to know who will have this disease. d. There are many good treatments for sickle cell disease these days.

B

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

B

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the clients leg. d. Provide an ice pack.

B

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? a. Encourage high-protein foods. b. Perform a Hemoccult test on the clients stools. c. Offer frequent oral care. d. Prepare to administer cobalamin (vitamin B12).

B

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. Do you have trouble affording your medications? b. Most people with hypertension do not have symptoms. c. You are lucky; most people get severe morning headaches. d. You need to take your medicine or you will get kidney failure.

B

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowlers position.

B

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the clients support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life d. Inquire about delegating some of the clients obligations.

B

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

B

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

B

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the clients chart. d. Notify the surgeon immediately.

B

A client is having a bone marrow biopsy today. What action by the nurse takes priority? a. Administer pain medication first. b. Ensure valid consent is on the chart. c. Have the client shower in the morning. d. Premedicate the client with sedatives.

B

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

B

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the clients neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

B

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline.

B

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best?a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

B

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Documenting the events in the clients medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies

B

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. Fish oil is contraindicated with most drugs for CAD. b. The best source is fish, but pills have benefits too. c. There is no evidence to support fish oil use with CAD. d. You can reverse CAD totally with diet and supplements.

B

A food that should be limited by patients with heart failure is a. shredded wheat cereal b. salted potato chips c. tofu d. angel food cake

B

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RNJanuary 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? a. Notify the health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route.

B

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

B

A localized area of dying or dead tissue is called a(n) a. atheroma. b. infarct. c. thrombus. d. lesion.

B

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night. b. My shoes fit really tight lately. c. I wake up coughing every night. d. I have trouble catching my breath.

B

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients heart failure? a. Do you have trouble breathing or chest pain? b. Are you able to walk upstairs without fatigue? c. Do you awake with breathlessness during the night? d. Do you have new-onset heaviness in your legs?

B

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

B

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

B

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond? a. The prosthetic valve places you at greater risk for a heart attack. b. Blood clots form more easily in artificial replacement valves. c. The vein taken from your leg reduces circulation in the leg. d. The surgery left a lot of small clots in your heart and lungs.

B

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.

B

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

B

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

B

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

B

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe

B

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

B

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? A. Begin the prescribed infusion via the new access. B. Ensure an x-ray is completed to confirm placement. C. Check medication calculations with a second RN. D. Make sure the solution is appropriate for a central line.

B

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? A. Administer a sublingual nitroglycerin tablet. B. Prepare to assist with chest tube insertion. C. Place a sterile dressing over the IV site. D. Re-position the client into the Trendelenburg position.

B

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1 F (37.8 C) d. Pain rating of 8 on a scale of 0 to 10

B

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

B

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? A. Administer topical lidocaine to the site. B. Place warm compresses on the site. C. Administer prescribed oral pain medication. D. Massage the site with scented oils.

B

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

B

A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

B

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

B

A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiers b. Ensuring informed consent is obtained if required c. Hanging the blood product with Ringers lactate d. Staying with the client for the entire transfusion

B

A patient has been placed on a milrinone (Primacor) infusion as part of the therapy for end-stage heart failure. What adverse effect of this drug will the nurse watch for when assessing this patient during the infusion? a. Hypertension b. Hyperkalemia c. Nausea and vomiting d. Cardiac dysrhythmias

D

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. I wake up to go to the bathroom at night. b. My shoes fit tighter by the end of the day. c. I seem to be feeling more anxious lately. d. I drink at least eight glasses of water a day.

B

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients discharge teaching? a. Use a soft-bristled toothbrush and avoid flossing. b. Avoid large crowds and people who are sick. c. Change positions slowly to avoid hypotension. d. Check your heart rate before taking the medication.

B

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. The best way to lose weight is a high-protein, low-carbohydrate diet. b. You should balance weight loss with consuming necessary nutrients. c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you wont need to change your diet.

B

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching? a. Walk until you become short of breath, and then walk back home. b. Gather everything you need for a chore before you begin. c. Pull rather than push or carry items heavier than 5 pounds. d. Take a walk after dinner every day to build up your strength.

B

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an Ask the nurse booth at the pet store.

B

A patient has a digoxin level of 1.1 ng/mL. Which interpretation by the nurse is correct? a. It is below the therapeutic level. b. It is within the therapeutic range. c. It is above the therapeutic level. d. It is at a toxic level.

B

A patient has been taking iron supplements for anemia for 2 months. During a follow-up assessment, the nurse will observe for which therapeutic response? a. Decreased weight b. Increased activity tolerance c. Decreased palpitations d. Increased appetite

B

A patient has had recent mechanical heart valve surgery and is receiving anticoagulant therapy. While monitoring the patient's laboratory work, the nurse interprets that the patient's international normalized ratio (INR) level of 3 indicates that: a. the patient is not receiving enough warfarin to have a therapeutic effect. b. the patient's warfarin dose is at therapeutic levels. c. the patient's intravenous heparin dose is dangerously high. d. the patient's intravenous heparin dose is at therapeutic levels.

B

A patient in the neurologic intensive care unit is being treated for cerebral edema. Which class of diuretic is used to reduce intracranial pressure? a. Loop diuretics b. Osmotic diuretics c. Thiazide diuretics d. Vasodilators

B

A patient is being discharged on anticoagulant therapy. The nurse will include in the patient-education conversation that it is important to avoid herbal products that contain which substance? a. Valerian b. Ginkgo c. Soy d. Saw palmetto

B

A patient is concerned about the adverse effects of the fibric acid derivative she is taking to lower her cholesterol level. Which is an adverse effect of this class of medication? a. Constipation b. Diarrhea c. Joint pain d. Dry mouth

B

A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug's effectiveness? a. Bleeding times b. Activated partial thromboplastin time (aPTT) c. Prothrombin time/international normalized ratio (PT/INR) d. Vitamin K levels

B

A patient tells the nurse that he likes to eat large amounts of garlic "to help lower his cholesterol levels naturally." The nurse reviews his medication history and notes that which drug has a potential interaction with the garlic? a. Acetaminophen (Tylenol) b. Warfarin (Coumadin) c. Digoxin (Lanoxin) d. Phenytoin (Dilantin)

B

A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride

B

A patient who has been taking antihypertensive drugs for a few months complains of having a persistent dry cough. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs? a. Beta blockers b. Angiotensin-converting enzyme (ACE) inhibitors c. Angiotensin II receptor blockers (ARBs) d. Calcium channel blockers

B

A patient who has recently started therapy on a statin drug asks the nurse how long it will take until he sees an effect on his serum cholesterol. Which statement would be the nurse's best response? a. "Blood levels return to normal within a week of beginning therapy." b. "It takes 6 to 8 weeks to see a change in cholesterol levels." c. "It takes at least 6 months to see a change in cholesterol levels." d. "You will need to take this medication for almost a year to see significant results."

B

A patient will be discharged on quinidine sulfate (Quinidex) extended-release tablets for the treatment of ventricular ectopy. The nurse will include which information in the teaching plan? a. The medication should be stopped once the cardiac symptoms subside. b. Signs of cinchonism, such as tinnitus, loss of hearing, or slight blurring of vision, may occur. c. It is important to use sunscreen products when outside because of increased photosensitivity. d. If any tablet or capsule is visible in the stool, contact the prescriber immediately.

B

A patient with type 2 diabetes mellitus has been found to have trace proteinuria. The prescriber writes an order for an angiotensin-converting enzyme (ACE) inhibitor. What is the main reason for prescribing this class of drug for this patient? a. Cardioprotective effects b. Renal protective effects c. Reduces blood pressure d. Promotes fluid output

B

A woman has been receiving both radiation and chemotherapy for her cancer. Lately, she has developed anorexia caused by the treatments, so she needs short-term nutrition supplementation. The nurse anticipates that the physician will initiate which therapy? a. Central total parenteral nutrition b. Peripheral parenteral nutrition c. Oral nutritional supplements with meals d. Nasogastric enteral supplementation

B

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

B

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. I should wear a snug-fitting shirt over the ICD. b. I will avoid sources of strong electromagnetic fields. c. I should participate in a strenuous exercise program. d. Now I can discontinue my antidysrhythmic medication.

B

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching? a. Ill be able to carry heavy loads after 6 months of rest. b. I will have my teeth cleaned by my dentist in 2 weeks. c. I must avoid eating foods high in vitamin K, like spinach. d. I must use an electric razor instead of a straight razor to shave.

B

An example of a food that is a good source of calcium is a. olive oil. b. skim milk. c. oatmeal. d. lemonade.

B

An example of a food that is recommended with the DASH eating plan is a. lemonade. b. a fresh orange. c. a bread roll. d. bottled water.

B

An oral iron supplement is prescribed for a patient. The nurse would question this order if the patient's medical history includes which condition? a. Decreased hemoglobin b. Hemolytic anemia c. Weakness d. Concurrent therapy with erythropoietics

B

Dietary guidelines from the American Heart Association for foods to limit or consume in moderation include a. avoid all foods that contain cholesterol and animal fats. b. cut back on foods that contain partially hydrogenated vegetable oils. c. aim to eat less than 100 mg of cholesterol each day. d. do not consume foods with dairy fat.

B

Of the following, an appropriate seasoning choice to use for a sodium-restricted diet would be a. celery salt. b. lemon juice. c. soy sauce. d. BBQ sauce.

B

The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Delegate taking a set of vital signs. d. Look at todays laboratory results.

B

The nurse is administering intravenous iron dextran for the first time to a patient with anemia. After giving a test dose, how long will the nurse wait before administering the remaining portion of the dose? a. 30 minutes b. 1 hour c. 6 hours d. 24 hours

B

The nurse is administering liquid oral iron supplements. Which intervention is appropriate when administering this medication? a. Have the patient take the liquid iron with milk. b. Instruct the patient to take the medication through a plastic straw. c. Have the patient sip the medication slowly. d. Have the patient drink the medication, undiluted, from the unit-dose cup.

B

The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately how many pounds? a. 10 b. 15 c. 20 d. 25

B

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

B

The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse discovers that the intravenous site is red, edematous, and painful. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events? a. Occlusion b. Extravasation c. Phlebitis d. Thrombophlebitis

B

The nurse is creating a plan of care for a patient with a new diagnosis of hypertension. Which is a potential nursing diagnosis for the patient taking antihypertensive medications? a. Diarrhea b. Sexual dysfunction c. Urge urinary incontinence d. Impaired memory

B

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

B

The nurse is preparing to administer medications to a patient who is receiving a feeding via a gastric tube. When reviewing the patient's medication list, the nurse notes a potential concern about a food-drug interaction if which medication is listed? a. Multivitamin solution b. Phenytoin (Dilantin) c. Metoclopramide (Reglan) d. Warfarin (Coumadin)

B

The nurse is reviewing the classes of antidysrhythmic drugs. Amiodarone (Cordarone) is classified on the Vaughan Williams classification as a class III drug, which means it works by which mechanism of action? a. Blocking slow calcium channels b. Prolonging action potential duration c. Blocking sodium channels and affecting phase 0 d. Decreasing spontaneous depolarization and affecting phase 4

B

The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined? a. Ask for detailed listing of symptoms. b. Ask adolescent, "Why did you come here today?" c. Use what adolescent says to determine, in correct medical terminology, what the problem is. d. Interview parent away from adolescent to determine chief complaint.

B

The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? a. Ask her, "Are you sexually active?" b. Ask her, "Are you having sex with anyone?" c. Ask her, "Are you having sex with a boyfriend?" d. Ask both the girl and her parent whether she is sexually active.

B

The nurse needs to specifically prevent air emboli that may result from IV therapy. What should the nurse make sure to do to prevent air emboli? a. Use a needleless system. b. Prime the tubing completely. c. Check for medication compatibility. d. Select a larger-gauge needle or catheter.

B

The nurse notes in a patient's medical record that nesiritide (Natrecor) has been ordered. Based on this order, the nurse interprets that the patient has which disorder? a. Atrial fibrillation b. Acutely decompensated heart failure with dyspnea at rest c. Systolic heart failure d. Chronic, stable heart failure

B

The nurse notes in the patient's medication orders that the patient will be taking ibutilide (Corvert). Based on this finding, the nurse interprets that the patient has which disorder? a. Ventricular ectopy b. Atrial fibrillation c. Supraventricular tachycardia d. Bradycardia

B

The nurse sees on the cardiorespiratory monitor that the patients cardiac rhythm has changed from normal sinus rhythm to ventricular fibrillation. The nurse knows that the most effective means of converting this rhythm is: a. CPR. b. defibrillation. c. oxygen. d. precordial thump.

B

The nurse will monitor for myopathy (muscle pain) when a patient is taking which class of antilipemic drugs? a. Niacin b. HMG-CoA reductase inhibitors c. Fibric acid derivatives d. Bile acid sequestrants

B

The nurse would call the code team for which of the following patients? a. A patient with blood pressure of 60/28 b. A patient experiencing severe dyspnea secondary to asthma c. A patient in atrial fibrillation d. An unconscious patient in ventricular tachycardia

B

The patient has an IV ordered to infuse at 1000 mL over 10 hours. The infusion set has a calibration of 15 gtt/mL. At which rate does the nurse regulate the infusion? a. 20 gtt/min b. 25 gtt/min c. 30 gtt/min d. 32 gtt/min

B

The patient is brought to the emergency department after a motor vehicle accident. The patient has head and neck trauma and has stopped breathing. What should the nurse do? a. Open the airway using the head tiltchin lift method. b. Open the airway using the jaw-thrust method. c. Give two breaths using mouth-to-mouth and a barrier device. d. Give two breaths using a bag-mask device.

B

The underlying pathologic process in coronary heart disease is known as a. angina. b. atherosclerosis. c. hypertension. d. myocardial infarction.

B

What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral IV site? a. Wear sterile gloves to remove the old dressing. b. Keep one finger over the IV catheter until the tape is replaced. c. Cleanse with an antiseptic solution in a circular manner toward the site. d. Tape the connection between the IV catheter port and the tubing.

B

What is an important consideration for the nurse who is communicating with a very young child? a. Speak loudly, clearly, and directly. b. Use transition objects, such as a doll. c. Disguise own feelings, attitudes, and anxiety. d. Initiate contact with child when parent is not present.

B

What is the earliest age at which a satisfactory radial pulse can be taken in children? a. 1 year b. 2 years c. 3 years d. 6 years

B

What should be the next action by the nurse, once an over-the-needle catheter (ONC) has been inserted through the skin and into the vein? a. Loosen the stylet for removal b. Check for blood return in the flashback chamber c. Stabilize the catheter and release the tourniquet d. Advance the catheter until the hub rests at the insertion site

B

What should the nurse do upon noting bleeding around a dressing at an IV insertion site? a. Discontinue the IV. b. Assess the insertion site. c. Leave the dressing intact, but reinforce it. d. Elevate and apply warm compresses to the extremity.

B

When applying an automated external defibrillator, the nurse would: a. connect the cable to the machine, apply the pads, and turn on the power. b. turn on the power, apply the pads, and connect the cable. c. turn on the power, connect the cable, and apply the pads. d. connect the cable, turn on the power, and apply the pads.

B

When monitoring a patient who has been receiving peripheral parenteral nutrition for more than 3 weeks, the nurse will watch for which potential complication? a. Diarrhea b. Phlebitis c. Hypernatremia d. Hypoglycemia

B

When monitoring a patient who has diabetes and is receiving a carbonic anhydrase inhibitor for edema, the nurse will monitor for which possible adverse effect? a. Metabolic alkalosis b. Elevated blood glucose c. Hyperkalemia d. Mental alertness

B

When teaching a patient who is beginning antilipemic therapy about possible drug-food interactions, the nurse will discuss which food? a. Oatmeal b. Grapefruit juice c. Licorice d. Dairy products

B

When the nurse interviews an adolescent, which is especially important? a. Focus the discussion on the peer group. b. Allow an opportunity to express feelings. c. Emphasize that confidentiality will always be maintained. d. Use the same type of language as the adolescent.

B

Which communication technique should the nurse avoid when interviewing children and their families? a. Using silence b. Using clichés c. Directing the focus d. Defining the problem

B

Which is most important to document about immunizations in the child's health history? a. Dosage of immunizations received b. Occurrence of any reaction after an immunization c. The exact date the immunizations were received d. Practitioner who administered the immunizations

B

Which nursing diagnosis is appropriate for a patient receiving antidysrhythmics? a. Risk for infection b. Deficient knowledge c. Deficient fluid volume d. Urinary retention

B

Which of the following patients would the nurse anticipate requiring the placement of a central venous catheter? a. A patient in same-day surgery who might require blood transfusions b. A patient in the intensive care unit requiring multiple simultaneous intravenous medications c. A patient in the cardiac care unit diagnosed with possible myocardial infarction d. A patient on the surgical unit recovering from hernia repair

B

Which tool measures body fat most accurately? a. Stadiometer b. Calipers c. Cloth tape measure d. Paper or metal tape measure

B

While assessing a patient who is receiving intravenous digitalis, the nurse recognizes that the drug has a negative chronotropic effect. How would this drug effect be evident in the patient? a. Decreased blood pressure b. Decreased heart rate c. Decreased conduction d. Decreased ectopic beats

B

While assessing the patient, the nurse recognizes that special caution should be taken with the IV infusion because of fluid volume excess when the nurse notes the presence of which condition? a. Poor skin turgor b. Crackles in the lungs c. Decreased blood pressure d. Dry skin and mucous membranes

B

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98 F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2 F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored .Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine.Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline d. Ask the client to cough and deep breathe.

B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the clients heart rate.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status.

B The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The clients code status should already be known by the nurse prior to this event.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

B,C,D,E

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) a. Weight gain b. Night sweats c. Cardiac murmur d. Abdominal bloating e. Oslers nodes

B,C,E

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

B,C,E

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing

B,D,E

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

B,D,E

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the clients prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

B,D,E

The nurse is monitoring for adverse effects in a patient who is receiving an amiodarone (Cordarone) infusion. Which are adverse effects for amiodarone? (Select all that apply.) a. Tachycardia b. Constipation c. Chest pain d. QT prolongation e. Headache f. Hypotension g. Blue-gray coloring of the skin on the face, arms, and neck

B,D,F,G

A patient with a history of angina will be started on ranolazine (Ranexa). The nurse is reviewing the patient's history and will note potential contraindications to this drug therapy if which condition is present? (Select all that apply.) a. Type 2 diabetes mellitus b. Prolonged QT interval on the electrocardiogram c. Heart failure d. Closed-angle glaucoma e. Decreased liver function

B,E

1. A nurse is assessing a 12-month-old infant. Which statement best describes the infant's physical development a nurse should expect to find? a. Anterior fontanel closes by age 6 to 10 months. b. Binocularity is well established by age 8 months. c. Birth weight doubles by age 5 months and triples by age 1 year. d. Maternal iron stores persist during the first 12 months of life.

C

4. What is the single most important factor to consider when communicating with children? a. The child's physical condition b. Presence or absence of the child's parent c. The child's developmental level d. The child's nonverbal behaviors

C

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

C

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the clients legs. b. Elevate the clients legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the clients legs.

C

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the clients sheets. c. Put on a pair of gloves. d. Assess blood pressure.

C

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug? a. Enoxaparin (Lovenox) b. Salicylates (aspirin) c. Unfractionated heparin d. Warfarin (Coumadin)

C

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?a. I brush and use dental floss every day. b. I chew hard candy for my dry mouth. c. I usually put ice on bumps or bruises. d. Nonslip socks are best when I walk.

C

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

C

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the clients pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

C

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

C

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

C

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.

C

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure? a. I have been drinking more water than usual. b. I am awakened by the need to urinate at night. c. I must stop halfway up the stairs to catch my breath. d. I have experienced blurred vision on several occasions.

C

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

C

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine

C

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

C

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

C

A patient has been found with no pulse or respirations. The cardiopulmonary arrest team has been called. What should the nurse do while awaiting the teams arrival? a. Gather the patients medical record and medication administration record. b. Obtain the crash cart. c. Notify the patients primary care provider. d. Perform CPR.

D

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?

C

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

C

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

C

A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? a. Toddler b. Preschooler c. School-age child d. Adolescent

C

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? a. Arrange a visitation schedule among friends and family. b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.

C

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? a. Genetic testing b. Infection prevention c. Sperm banking d. Treatment options

C

A nurse is caring for four clients. After reviewing todays laboratory results, which client should the nurse see first? a. Client with an international normalized ratio of 2.8 b. Client with a platelet count of 128,000/mm3 c. Client with a prothrombin time (PT) of 28 seconds d. Client with a red blood cell count of 5.1 million/L

C

A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being overweight? a. 10th percentile b. 9th percentile c. 85th percentile d. 95th percentile

C

A nurse is giving instructions to a patient who will be receiving oral iron supplements. Which instructions will be included in the teaching plan? a. Take the iron tablets with milk or antacids. b. Crush the pills as needed to help with swallowing. c. Take the iron tablets with meals if gastrointestinal distress occurs. d. If black tarry stools occur, report it to the doctor immediately.

C

A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child? a. Always proceed in a head-to-toe direction. b. Perform traumatic procedures first. c. Use minimal physical contact initially. d. Demonstrate use of equipment.

C

A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age? a. 1 month b. 6 to 9 months c. 1 to 2 years d. to 3 years

C

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery? c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?

C

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? A. You will need to wear a sling on your arm while the device is in place. B. There is no risk of infection because sterile technique will be used during insertion. C. Ask all providers to vigorously clean the connections prior to accessing the device. D. You will not be able to take a bath with this vascular access device.

C

A patient calls the clinic office saying that the cholestyramine (Questran) powder he started yesterday clumps and sticks to the glass when he tries to mix it. The nurse will suggest what method for mixing this medication for administration? a. Mix the powder in a carbonated soda drink to dissolve it faster. b. Add the powder to any liquid, and stir vigorously to dissolve it quickly. c. Mix the powder with food or fruit, or at least 4 to 6 ounces of fluid. d. Sprinkle the powder into a spoon and take it dry, followed by a glass of water.

C

A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? a. Take up to 5 doses at 15-minute intervals for an angina attack. b. If the tablet does not dissolve quickly, chew the tablet for maximal effect. c. If the chest pain is not relieved after one tablet, call 911 immediately. d. Wait 1 minute between doses of sublingual tablets, up to 3 doses.

C

A patient has been instructed to take one enteric-coated low-dose aspirin a day as part of therapy to prevent strokes. The nurse will provide which instruction when providing patient teaching about this medication? a. Aspirin needs to be taken on an empty stomach to ensure maximal absorption. b. Low-dose aspirin therapy rarely causes problems with bleeding. c. Take the medication with 6 to 8 ounces of water and with food. d. Coated tablets may be crushed if necessary for easier swallowing.

C

A patient has received an overdose of intravenous heparin, and is showing signs of excessive bleeding. Which substance is the antidote for heparin overdose? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride

C

For which of the following patients would the nurse request the rapid response teams immediate intervention? a. A patient complaining of severe postoperative incisional pain b. A patient with no pulse who is not breathing c. A patient complaining of chest pain, hypotension, and shortness of breath d. A patient with blood pressure of 164/96

C

A patient is in the intensive care unit and receiving an infusion of milrinone (Primacor) for severe heart failure. The prescriber has written an order for an intravenous dose of furosemide (Lasix). How will the nurse give this drug? a. Infuse the drug into the same intravenous line as the milrinone. b. Stop the milrinone, flush the line, and then administer the furosemide. c. Administer the furosemide in a separate intravenous line. d. Notify the prescriber that the furosemide cannot be given at this time.

C

A patient is in the intensive care unit because of an acute myocardial infarction. He is experiencing severe ventricular dysrhythmias. The nurse will prepare to give which drug of choice for this dysrhythmia? a. Diltiazem (Cardizem) b. Verapamil (Calan) c. Amiodarone (Cordarone) d. Adenosine (Adenocard)

C

A patient is started on a diuretic for antihypertensive therapy. The nurse expects that a drug in which class is likely to be used initially? a. Loop diuretics b. Osmotic diuretics c. Thiazide diuretics d. Potassium-sparing diuretics

C

A patient is to receive iron dextran injections. Which technique is appropriate when the nurse is administering this medication? a. Intravenous administration mixed with 5% dextrose b. Intramuscular injection in the upper arm c. Intramuscular injection using the Z-track method d. Subcutaneous injection into the abdomen

C

A patient reports having adverse effects with nicotinic acid (niacin). The nurse can suggest performing which action to minimize these undesirable effects? a. Take the drug on an empty stomach. b. Take the medication every other day until the effects subside. c. Take an aspirin tablet 30 minutes before taking the drug. d. Take the drug with large amounts of fiber.

C

A patient will be receiving a thrombolytic drug as part of the treatment for acute myocardial infarction. The nurse explains to the patient that this drug is used for which purpose? a. To relieve chest pain b. To prevent further clot formation c. To dissolve the clot in the coronary artery d. To control bleeding in the coronary vessels

C

A patient with end-stage renal failure has been admitted to the hospital for severe anemia. She is refusing blood transfusions. The nurse anticipates drug therapy with which drug to stimulate the production of red blood cells? a. Folic acid b. Cyanocobalamin (vitamin B12) c. Epoetin alfa (Epogen) d. Filgrastim (Neupogen)

C

A patient with type 2 diabetes will be receiving a nasogastric tube feeding for a few days. The nurse expects which type of formula to be used? a. Jevity b. Ensure Plus c. Glucerna d. Polycose

C

A pediatric patient has an IV with a microdrip. The order is for 40 mL/hr to infuse. At what rate does the nurse set the microdrip? a. 10 gtt/min b. 20 gtt/min c. 40 gtt/min d. 80 gtt/min

C

A student nurse asks what essential hypertension is. What response by the registered nurse is best? a. It means it is caused by another disease. b. It means it is essential that it be treated. c. It is hypertension with no specific cause. d. It refers to severe and life-threatening hypertension

C

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

C

According to Piaget, the 6-month-old infant should be in which developmental stage? a. Use of reflexes b. Primary circular reactions c. Secondary circular reactions d. Coordination of secondary schemata

C

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, Why is this important? How should the nurse respond? a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures. b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness. c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes. d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke

C

An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action? a. Ask her why she wants to know. b. Determine why she is so anxious. c. Explain in simple terms how it works. d. Tell her she will see how it works as it is used.

C

An infarct in a major artery supplying the brain results in a. a myocardial infarction. b. a coma. c. a cerebrovascular accident. d. hypertension.

C

Appropriate food choices for a breakfast while following the DASH diet may include a. fried egg, biscuit and gravy. b. hash brown casserole and sausage. c. whole grain toast with a banana. d. chipped beef and a croissant with butter.

C

Appropriate snacks for a patient with hypertension would include a. corn chips and salsa. b. pretzel rings and cheese dip. c. orange juice with whole wheat toast. d. french fries with apple slices.

C

At what age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 10 months

C

By which age should the nurse expect an infant to be able to pull to a standing position? a. 6 months b. 8 months c. 11 to 12 months d. 14 to 15 months

C

Dietary modifications during the first 24 to 48 hours after myocardial infarction include a. increasing fiber intake. b. avoiding cholesterol. c. reducing energy intake. d. reducing fluid intake.

C

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action? a. Teach parents appropriate exercises. b. Recheck head control at next visit. c. Refer child for further evaluation. d. Refer child for further evaluation if anterior fontanel is still open.

C

During the secondary survey of the code event, the nurse realizes that the patient is not breathing on his own. What should the nurse do next? a. Immediately intubate the patient. b. Have a laryngoscope handle and curved blades available. c. Ensure that the light source on the laryngoscope is functional. d. Have a laryngoscope handle and straight blades available.

C

The nurse finds a patient lying on the bathroom floor. The patient is unresponsive and has a pulse but is not breathing. What is the nurses first action? a. Give two breaths using mouth-to-mouth without a barrier device. b. Give two breaths using mouth-to-mouth without a barrier device and watch for chest movement. c. Give two breaths using a bag-mask device. d. Start chest compressions until an AED is available.

C

The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurses first action should be to: a. notify the primary care provider. b. assess the patient. c. reduce the infusion rate. d. notify the charge nurse.

C

The nurse is performing cardiac compressions on a 4-year-old child with the assistance of another nurse. The nurses would deliver breaths and compressions at a ratio of _____ compressions for _____ breaths. a. 30; 2 b. 5; 1 c. 15; 2 d. 5; 2

C

The nurse is preparing to administer adenosine (Adenocard) to a patient who is experiencing an acute episode of paroxysmal supraventricular tachycardia. When giving this medication, which is important to remember? a. The onset of action occurs in 5 minutes. b. The medication must be given as a slow intravenous (IV) push. c. Asystole may occur for a few seconds after administration. d. The medication has a long half-life, and therefore duration of action is very long.

C

The nurse is preparing to insert an oral airway in a patient who is exhibiting signs of potential respiratory distress. The nurse knows that candidates for oral airway placement are those: a. with oral trauma. b. with loose teeth. c. who are unconscious. d. who have had recent oral surgery.

C

The nurse is providing an educational seminar to a group of nursing students on the advantages of using an automated external defibrillator (AED). She knows that her teaching has been effective when the students reply: a. Health care providers do not need to learn CPR to use the AED. b. The health care provider is given a printout of the rhythm change. c. The health care provider can safely use both CPR skills and AED skills. d. The health care provider can adjust the level of shock administered.

C

The nurse is reviewing drug therapy for hypertension. According to the JNC-8 guidelines, antihypertensive drug therapy for a newly diagnosed hypertensive African-American patient would most likely include which drug or drug classes? a. Vasodilators alone b. ACE inhibitors alone c. Calcium channel blockers with thiazide diuretics d. Beta blockers with thiazide diuretics

C

The nurse is reviewing the orders for a patient and notes a new order for an angiotensin-converting enzyme (ACE) inhibitor. The nurse checks the current medication orders, knowing that this drug class may have a serious interaction with what other drug class? a. Calcium channel blockers b. Diuretics c. Nonsteroidal anti-inflammatory drugs d. Nitrates

C

The nurse is working in the emergency department when an 8-year-old patient is brought in with respiratory distress. The nurse is preparing to insert an oral airway. Which of the following is the appropriate size for this patient? a. Size 1 b. Size 2 c. Size 3 d. Size 7

C

The nurse notes in the patient's medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy? a. Stabilizing an existing thrombus b. Dissolving an existing thrombus c. Preventing thrombus formation d. Dilating the vessel around a clot

C

The nurse observes a person collapse and stop breathing. The nurse would establish an airway by: a. inserting an endotracheal tube. b. inserting a finger to pull the tongue forward. c. using the head tiltchin lift maneuver. d. using a modified jaw-thrust maneuver.

C

The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings? a. Normal b. Erythema c. Jaundice d. Ecchymosis

C

The nurse will teach a patient who is receiving oral iron supplements to watch for which expected adverse effects? a. Palpitations b. Drowsiness and dizziness c. Black, tarry stools d. Orange-red discoloration of the urine

C

The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process. Which of the following would be the best choice for venous access in this patient? a. Peripherally inserted central catheter (PICC) b. Nontunneled percutaneous central venous catheter c. Subcutaneous implanted port d. Peripheral IV

C

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. It constricts vessels, improving blood flow b. It dilates vessels, which lessens the work of the heart. c. It increases the force of the hearts contractions. d. It slows the heart rate down for better filling.

C

The underlying pathologic process in coronary heart disease appears to be a. atrophy of the heart muscle. b. weakened coronary vessels. c. fibrous plaques in coronary vessels. d. inadequate nutrition to the heart muscle.

C

What should the nurse do once she recognizes that the patient has phlebitis at his IV site? a. Reduce the IV flow rate. b. Elevate the affected extremity. c. Place a moist warm compress over the site. d. Adjust the additive in the current IV.

C

What should the nurse do to decrease the potential for infection related to IV therapy? a. Use the clean technique for dressing changes. b. Change the IV tubing every 12 hours. c. Palpate the insertion site daily through the intact dressing. d. After cleansing the skin, dab it dry with a sterile gauze pad.

C

When a patient is receiving diuretic therapy, which of these assessment measures would best reflect the patient's fluid volume status? a. Blood pressure and pulse b. Serum potassium and sodium levels c. Intake, output, and daily weight d. Measurements of abdominal girth and calf circumference

C

When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet? a. Indicates they live in poverty b. Is lacking in protein c. May provide sufficient amino acids d. Should be enriched with meat and milk

C

When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. How should this question be considered? a. Unnecessary information because child is age 3 years b. An important part of the family history c. An important part of the child's past history d. An important part of the child's review of systems

C

When reviewing the mechanisms of action of diuretics, the nurse knows that which statement is true about loop diuretics? a. They work by inhibiting aldosterone. b. They are very potent, having a diuretic effect that lasts at least 6 hours. c. They have a rapid onset of action and cause rapid diuresis. d. They are not effective when the creatinine clearance decreases below 25 mL/min.

C

When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? a. To prevent low blood pressure b. To relieve shortness of breath c. To prevent the occurrence of angina d. To keep the heart rate from rising too high during exercise

C

When the nurse is administering topical nitroglycerin ointment, which technique is correct? a. Apply the ointment on the skin on the forearm. b. Apply the ointment only in the case of a mild angina episode. c. Remove the old ointment before new ointment is applied. d. Massage the ointment gently into the skin, and then cover the area with plastic wrap.

C

Where in the health history should the nurse describe all details related to the chief complaint? a. Past history b. Chief complaint c. Present illness d. Review of systems

C

Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face b. Buttocks c. Oral mucosa d. Palms and soles

C

Which is most likely to encourage parents to talk about their feelings related to their child's illness? a. Be sympathetic. b. Use direct questions. c. Use open-ended questions

C

Which of the following steps is necessary when a patient is prepared for IV insertion? a. Shaving the hair from the site b. Selecting a proximal site in an extremity c. Applying a tourniquet 4 to 6 inches above the selected site d. Vigorously taping and massaging the selected vein

C

Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)? a. An older adult who is having cataracts removed b. A perinatal patient who is having prolonged labor c. A neonate requiring blood therapy d. An adolescent who is having surgery for reduction of a fracture

C

While assessing a patient who is taking a beta blocker for angina, the nurse knows to monitor for which adverse effect? a. Nervousness b. Hypertension c. Bradycardia d. Dry cough

C

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the clients current medications first.

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? A. The catheter has been in place for 20 hours. B. The client has poor vascular access in the upper extremities. C. The catheter is placed in the proximal tibia. D. The clients left lower extremity is cool to the touch.

D

.A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

D

.A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? A. Provide a bed bath instead of letting the client take a shower. B. Use sterile technique when changing the dressing. C. Disconnect the intravenous fluid tubing prior to the clients bath. D. Use a plastic bag to cover the extremity with the device.

D

A 79-year-old patient is taking a diuretic for treatment of hypertension. This patient is very independent and wants to continue to live at home. The nurse will know that which teaching point is important for this patient? a. He should take the diuretic with his evening meal. b. He should skip the diuretic dose if he plans to leave the house. c. If he feels dizzy while on this medication, he needs to stop taking it and take potassium supplements instead. d. He needs to take extra precautions when standing up because of possible orthostatic hypotension and resulting injury from falls.

D

A calcium channel blocker (CCB) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. Which instruction is correct? a. Chew the tablet for faster release of the medication. b. To increase the effect of the drug, take it with grapefruit juice. c. If the adverse effects of chest pain, fainting, or dyspnea occur, discontinue the medication immediately. d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur.

D

A client is having a radioisotopic imaging scan. What action by the nurse is most important? a. Assess the client for shellfish allergies. b. Place the client on radiation precautions. c. Sedate the client before the scan. d. Teach the client about the procedure.

D

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the clients stress levels. d. Tell the client that anxiety is common and that you can help.

D

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

D

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?a. Preparing to administer a blood transfusion b. Reinforcing the dressing and documenting findings c. Removing the dressing and assessing the surgical site d. Taking a set of vital signs and notifying the surgeon

D

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?a. Bortezomib (Velcade) b. Dexamethasone (Decadron) c. Thalidomide (Thalomid) d. Zoledronic acid (Zometa)

D

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately? a. Hematocrit: 25% b. Hemoglobin: 9.2 mg/dL c. Potassium: 3.2 mEq/L d. White blood cell count: 38,000/mm3

D

A food that can be used freely on a sodium-restricted diet is a. canned salmon. b. a peanut butter sandwich. c. a biscuit. d. a fresh apple.

D

A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best? a. Encourage high-protein foods. b. Institute neutropenic precautions. c. Limit visitors to healthy adults. d. Place the client on safety precautions.

D

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

D

A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

D

A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? A. Apply cold compresses to the IV site. B. Elevate the extremity on a pillow. C. Flush the catheter with normal saline. D. Stop the infusion of intravenous fluids.

D

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.

D

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. How should the nurse respond? a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you. c. Do you want to come off the transplant list? d. Would you like information about advance directives?

D

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? A. The initial site dressing is 3 days old. B. The PICC was inserted 4 weeks ago. C. A securement device is absent. D. Upper extremity swelling is noted.

D

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a. Apply an ice pack to the clients chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

D

A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusion b. Placing the client on NPO status c. Placing the client in isolation d. Putting on a pair of gloves

D

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

D

A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure? A. Lower the extremity below the level of the heart. B. Apply warm compresses to the extremity. C. Tap the skin lightly and avoid slapping. D. Place a washcloth between the skin and tourniquet.

D

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching? a. Avoid drinking more than 3 quarts of liquids each day. b. Eat six small meals daily instead of three larger meals. c. When you feel short of breath, take an additional diuretic. d. Weigh yourself daily while wearing the same amount of clothing.

D

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching? a. Avoid taking aspirin or aspirin-containing products. b. Increase your intake of foods that are high in potassium. c. Hold this medication if your pulse rate is below 80 beats/min. d. Do not take this medication within 1 hour of taking an antacid.

D

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

D

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present. b. The client is in a blast crisis and has too many WBCs. c. There must be a mistake; the WBCs should be very low. d. Those WBCs are abnormal and dont provide protection.

D

A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best? a. Because of immunosuppression, the donor cells take over. b. Its like a transfusion reaction because no perfect matches exist. c. The clients cells are fighting donor cells for dominance. d. The donors cells are actually attacking the clients cells.

D

A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best? a. It is due to side effects of medications for bronchodilation. b. It is from overactive bone marrow in response to chronic disease. c. It combats the anemia caused by an increased metabolic rate. d. It compensates for tissue hypoxia caused by lung disease.

D

A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next? a. Administer the dose. b. Administer the dose, and notify the prescriber. c. Check the radial pulse for 1 full minute. d. Withhold the dose, and notify the prescriber.

D

A patient has a new order for the adrenergic drug doxazosin (Cardura). When providing education about this drug, the nurse will include which instructions? a. "Weigh yourself daily, and report any weight loss to your prescriber." b. "Increase your potassium intake by eating more bananas and apricots." c. "The impaired taste associated with this medication usually goes away in 2 to 3 weeks." d. "Be sure to lie down after taking the first dose, because first-dose hypotension may make you dizzy."

D

A patient has been prescribed warfarin (Coumadin) in addition to a heparin infusion. The patient asks the nurse why he has to be on two medications. The nurse's response is based on which rationale? a. The oral and injection forms work synergistically. b. The combination of heparin and an oral anticoagulant results in fewer adverse effects than heparin used alone. c. Oral anticoagulants are used to reach an adequate level of anticoagulation when heparin alone is unable to do so. d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels.

D

A patient has been receiving epoetin alfa (Epogen) for severe iron-deficiency anemia. Today, the provider changed the order to darbepoetin (Aranesp). The patient questions the nurse, "What is the difference in these drugs?" Which response by the nurse is correct? a. "There is no difference in these two drugs." b. "Aranesp works faster than Epogen to raise your red blood cell count." c. "Aranesp is given by mouth, so you will not need to have injections." d. "Aranesp is a longer-acting form, so you will receive fewer injections."

D

A patient has been receiving total parenteral nutrition. Upon assessment, the nurse notes these assessment findings: blood pressure 150/92 mm Hg (elevated from previous readings); pulse rate 110 beats/min and weak; pitting edema on both ankles; and new-onset confusion. The nurse suspects that the patient is experiencing which condition? a. Infection b. Hypoglycemia c. Hyperglycemia d. Fluid overload

D

A patient has been started on therapy of a continuous infusion of lidocaine after receiving a loading dose of the drug. The nurse will monitor the patient for which adverse effect? a. Drowsiness b. Nystagmus c. Dry mouth d. Convulsions

D

A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? a. "Watch for unusual weight loss." b. "Monitor your pulse for increased heart rate." c. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."

D

A patient has been taking digoxin at home but took an accidental overdose and has developed toxicity. The patient has been admitted to the telemetry unit, where the physician has ordered digoxin immune Fab (Digifab). The patient asks the nurse why the medication is ordered. What is the nurse's best response? a. "It will increase your heart rate." b. "This drug helps to lower your potassium levels." c. "It helps to convert the irregular heart rhythm to a more normal rhythm." d. "This drug is an antidote to digoxin and will help to lower the blood levels."

D

A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy? a. Dysrhythmias b. Nausea and vomiting c. Anaphylactic reactions d. Internal and superficial bleeding

D

A patient on diuretic therapy calls the clinic because he's had the flu, with "terrible vomiting and diarrhea," and he has not kept anything down for 2 days. He feels weak and extremely tired. Which statement by the nurse is correct? a. "It's important to try to stay on your prescribed medication. Try to take it with sips of water." b. "Stop taking the diuretic for a few days, and then restart it when you feel better." c. "You will need an increased dosage of the diuretic because of your illness. Let me speak to the physician." d. "Please come into the clinic for an evaluation to make sure there are no complications."

D

A patient with coronary artery disease asks the nurse about the "good cholesterol" laboratory values. The nurse knows that "good cholesterol" refers to which lipids? a. Triglycerides b. Low-density lipoproteins (LDLs) c. Very-low-density lipoproteins (VLDLs) d. High-density lipoproteins (HDLs)

D

A patient with primary hypertension is prescribed drug therapy for the first time. The patient asks how long drug therapy will be needed. Which answer by the nurse is the correct response? a. "This therapy will take about 3 months." b. "This therapy will take about a year." c. "This therapy will go on until your symptoms disappear." d. "Therapy for high blood pressure is usually lifelong."

D

A patient with severe liver disease is receiving the angiotensin-converting enzyme (ACE) inhibitor, captopril (Capoten). The nurse is aware that the advantage of this drug for this patient is which characteristic? a. Captopril rarely causes first-dose hypotensive effects. b. Captopril has little effect on electrolyte levels. c. Captopril is a prodrug and is metabolized by the liver before becoming active. d. Captopril is not a prodrug and does not need to be metabolized by the liver before becoming active.

D

A pregnant woman is experiencing hypertension. The nurse knows that which drug is commonly used for a pregnant patient who is experiencing hypertension? a. Mannitol (Osmitrol) b. Enalapril (Vasotec) c. Hydrochlorothiazide (HydroDIURIL) d. Methyldopa (Aldomet)

D

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

D

A woman who is planning to become pregnant should ensure that she receives adequate levels of which supplement to reduce the risk for fetal neural tube defects? a. Vitamin B12 b. Vitamin D c. Iron d. Folic acid

D

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

D

An example of a low-sodium food is a. canned salmon. b. a peanut butter sandwich. c. a biscuit. d. shredded wheat cereal.

D

An older adult patient will be taking a vasodilator for hypertension. Which adverse effect is of most concern for the older adult patient taking this class of drug? a. Dry mouth b. Restlessness c. Constipation d. Hypotension

D

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. I nearly always wear comfy sweatpants and house shoes. b. Im glad I get energy assistance so my house isnt so cold. c. My daughter makes sure I have plenty of lotion for my feet. d. My hands shake when I try to do things requiring coordination.

D

During a follow-up visit, the health care provider examines the fundus of the patient's eye. Afterward, the patient asks the nurse, "Why is he looking at my eyes when I have high blood pressure? It does not make sense to me!" What is the best response by the nurse? a. "We need to monitor for drug toxicity." b. "We must watch for increased intraocular pressure." c. "The provider is assessing for visual changes that may occur with drug therapy." d. "The provider is making sure the treatment is effective over the long term."

D

During the night shift, a patient's total parenteral nutrition (TPN) infusion ran out, and the nurse discovered that there was no TPN solution on hand to continue the infusion. The pharmacy is closed and will not reopen for 5 hours. The nurse will have to implement measures to prevent which consequence of abruptly discontinuing TPN infusions? a. Dehydration b. Hyperglycemia c. Dumping syndrome d. Rebound hypoglycemia

D

Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce IV fluid contamination and prevent catheter site complications. a. 24 b. 48 c. 72 d. 96

D

Examples of foods high in soluble dietary fiber are a. whole-wheat bread and crackers. b. pureed fruits and vegetables. c. potatoes and yams. d. oat bran and legumes.

D

Furosemide (Lasix) is prescribed for a patient who is about to be discharged, and the nurse provides instructions to the patient about the medication. Which statement by the nurse is correct? a. "Take this medication in the evening." b. "Avoid foods high in potassium, such as bananas, oranges, fresh vegetables, and dates." c. "If you experience weight gain, such as 5 pounds or more per week, be sure to tell your physician during your next routine visit." d. "Be sure to change positions slowly and rise slowly after sitting or lying so as to prevent dizziness and possible fainting because of blood pressure changes."

D

Pulses can be graded according to certain criteria. Which is a description of a normal pulse? a. 0 b. +1 c. +2 d. +3

D

The best way to control coronary heart disease is a. by early diagnosis. b. to meet regularly with a dietitian. c. to eliminate fat from the diet. d. to develop a heart-healthy lifestyle during childhood.

D

The cause of essential hypertension is a. coronary heart disease. b. stress. c. hormone imbalance. d. unknown.

D

The nurse assesses a clients oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

D

The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with? a. Changing empty IV solution containers b. Confirming the correct IV drip rate c. Assessing the patient for response to IV therapy d. Informing the nurse if they notice anything abnormal

D

The nurse enters her patients room to find him unresponsive. She begins CPR according to protocol. How deep should the nurse do chest compressions in this pulseless adult? a. 1 to inches in depth b. to 3 inches in depth c. to 1 inch in depth d. to 2 inches in depth

D

The nurse is administering folic acid to a patient with a new diagnosis of anemia. Which statement about treatment with folic acid is true? a. Folic acid is used to treat any type of anemia. b. Folic acid is used to treat iron-deficiency anemia. c. Folic acid is used to treat pernicious anemia. d. The specific cause of the anemia needs to be determined before treatment.

D

The nurse is caring for a patient diagnosed with pneumonia who receives IV antibiotics every 8 hours. How often should the nurse change the primary intermittent IV sets? a. No more often than every 72 hours b. At least every 72 hours c. With each IV bag change d. Every 24 hours

D

The nurse is caring for a patient receiving intravenous therapy. The nurse should report which of the following to the primary care provider? a. Completion of each liter of fluid b. Initiation of IV fluids c. Small infiltration d. Extravasation

D

The nurse is conducting a class about antilipemic drugs. The antilipemic drug ezetimibe (Zetia) works by which mechanism? a. Inhibiting HMG-CoA reductase b. Preventing resorption of bile acids from the small intestines c. Activating lipase, which breaks down cholesterol d. Inhibiting cholesterol absorption in the small intestine

D

The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? a. The solution will be slightly colored green or blue. b. The intravenous form is given by bolus injection. c. It can be given in infusions with other medications. d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.

D

The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

D

The nurse is preparing to draw blood from a central venous access device for blood cultures. Which of the following steps is part of that process? a. Apply sterile gloves. b. Flush the port with 5 to 10 mL of 0.9% sodium chloride. c. Slowly aspirate 5 mL of blood and discard the syringe. d. Use the distal lumen to draw blood.

D

The nurse is reviewing discharge teaching for a patient who will be taking digoxin (Lanoxin) therapy. The nurse will teach the patient to avoid which foods when taking the digoxin? a. Leafy green vegetables b. Dairy products c. Grapefruit juice d. Bran muffins

D

The nurse is reviewing new medication orders for a patient who has an epidural catheter for pain relief. One of the orders is for enoxaparin (Lovenox), a low-molecular-weight heparin (LMWH). What is the nurse's priority action? a. Give the LMWH as ordered. b. Double-check the LMWH order with another nurse, and then administer as ordered. c. Stop the epidural pain medication, and then administer the LMWH. d. Contact the prescriber because the LMWH cannot be given if the patient has an epidural catheter.

D

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

D

The nurse is reviewing the medical record of a patient before giving a new order for iron sucrose (Venofer). Which statement regarding the administration of iron sucrose is correct? a. The medication is given with food to reduce gastric distress. b. Iron sucrose is contraindicated if the patient has renal disease. c. A test dose will be administered before the full dose is given. d. The nurse will monitor the patient for hypotension during the infusion.

D

The nurse is teaching a patient with iron-deficiency anemia about foods to increase iron intake. Which food may enhance the absorption of oral iron forms? a. Milk b. Yogurt c. Antacids d. Orange juice

D

The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. What knowledge should the nurse's response should be based? a. Unacceptable because of the risk of sudden infant death syndrome (SIDS) b. Unacceptable because it does not encourage achievement of developmental milestones c. Acceptable to encourage fine motor development d. Acceptable to encourage head control and turning over

D

The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant's stools. The nurse's explanation of this is based on which statement? a. Child should not be given fibrous foods until digestive tract matures at age 4 years. b. Child should not be given any solid foods until this digestive problem is resolved. c. This is abnormal and requires further investigation. d. This is normal because of the immaturity of digestive processes at this age.

D

What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? a. Omit a dose once a week. b. Leave the patch on for 2 days at a time. c. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.

D

When administering heparin subcutaneously, the nurse will follow which procedure? a. Aspirating the syringe before injecting the medication b. Massaging the site after injection c. Applying heat to the injection site d. Using a - to -inch 25- to 28-gauge needle

D

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this? a. Some form of cancer b. Local scalp infection common in children c. Infection or inflammation distal to the site d. Infection or inflammation close to the site

D

When starting a patient on antidysrhythmic therapy, the nurse will remember that which problem is a potential adverse effect of any antidysrhythmic drug? a. Deficiency of fat-soluble vitamins b. Hyperkalemia c. Heart failure d. Dysrhythmias

D

Which following parameters correlates best with measurements of the body's total protein stores? a. Height b. Weight c. Skinfold thickness d. Upper arm circumference

D

Which sign or symptom of airway compromise may require insertion of an oral airway? a. Ability of the patient to speak b. Ability of the patient to cough forcefully c. Presence of wheezing between coughs d. Presence of gurgling with the respiratory cycle

D

While a patient is receiving antilipemic therapy, the nurse knows to monitor the patient closely for the development of which problem? a. Neutropenia b. Pulmonary problems c. Vitamin C deficiency d. Liver dysfunction

D

While assessing the patients IV infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first? a. Discontinue the IV. b. Increase the rate of infusion. c. Observe for fluid overload. d. Check the position of the IV fluid and extremity.

D

A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

The nurse is providing CPR to an unresponsive patient according to the 2010 American Heart Association (AHA) resuscitation guidelines. The nurse is performing chest compressions correctly when she performs them at which rate? a. 60 to 80 per minute b. 120 per minute c. 100 per minute d. 40 to 60 per minute

c