Nursing Concepts Wk 1 & 3
After teaching about ways to decrease risk factors for CAD, the nurse recognized that additional instruction is needed when the patient states: a- "I would like to add weight lifting to my exercise program." b- "I can only keep my BP normal with medication." c- "I can change my diet to decrease my intake of saturated fats." d- "I will change my lifestyle to reduce activites that increase my stress."
a- "I would like to add weight lifting to my exercise program."
A charge RN is anticipating the admission of four patients and planning their room assignments. Which of the patients should be closest to the nurses' station? a- A patient who sustained a head injury and is having periods of confusion b- A patient who reports a severe migraine HA c- A patient who has a suspected diagnosis of TB d- A patient who has a hx of A-fib and is on continuous ECG monitoring
a- A patient who sustained a head injury and is having periods of confusion
A patient is admitted to the ICU w/a dx of UA. Which of drug(s) would the nurse expect the patient to receive (Select all that apply.) a- ACE inhibitor b- Antiplatelet therapy c- Thrombolytic therapy d- Prophylacatic antibodies e- IV nitro
a- ACE inhibitor b- Antiplatelet therapy e- IV nitro
A RN is caring for a patient who has sustained a TBI. The RN should monitor the patient for which of the following manifestations of increased ICP? a- Decreased LOC b- Tachypnea c- Bilat weakness of extremities d- Hypotension
a- Decreased LOC
A RN is prepping to administer phenytoin IV to a patient who has a seizure disorder. What action should the RN plan to take? a- Administer the medication at 100 mg/min b- Administer a saline solution after injection c- Hold the injection if seizure activity is present d- Dilute the medication with dextrose 5% in water.
b- Administer a saline solution after injection
A RN is caring for a patient who has an ICP reading of 40 mm Hg. Which of the following findings should the RN identify as a late sign of ICP? (Select all that apply.) a- Confusion b- Bradycardia c- Hypotension d- Nonreactive dilated pupils e- Slurred speech
b- Bradycardia and d- Nonreactive dilated pupils
Patients with a heart transplantation are at risk for which complications in the first year after transplantation? (Select all that apply.) a- Cancer b- Infection c- Rejection d- Vasculopathy e- Sudden cardiac death
b- Infection c- Rejection e- Sudden cardiac death
The nurse is caring for a patient who is 2 days post MI. The patient reports that she is experiencing CP. She states "It hurts when I take a deep breath." Which action would be a priority? a- Notify the physician STAT and obtain a 12-lead ECG b- Obtain vital signs and auscultate for a pericardial friction rub. c- Apply high-flow O2 by face mask and auscultate breath sounds. d- Medicate the patient with PRN analgesic and reevaluate in 30 mins.
b- Obtain vital signs and auscultate for a pericardial friction rub.
A RN is caring for a child who is having a tonic-clonic seizure (grand mal) and vomiting. What action is the nurse's priority? a- Place a pillow under the child's head b- Position the child side-lying c- Loosen restrictive clothing d- Clear the area of hazards
b- Position the child side-lying
Which patient teaching points should the nurse include when providing d/c instructions to a patient with a new permanent pacemaker and the caregiver? (Select all that apply.) a- Avoid or limit air travel b- Take and record a daily pulse rate c- Obtain and wear a Medic Alert ID device at all times d- Avoid lifting arm on the side of the pacemaker above the shoulder e- Avoid microwave ovens because they interfere with pacemaker function.
b- Take and record a daily pulse rate c- Obtain and wear a Medic Alert ID device at all times d- Avoid lifting arm on the side of the pacemaker above the shoulder
A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is a- ventricular dilation b- ventricular hypertrophy c- neurohormonal response d- sympathetic nervous system activation
c- neurohormonal response
In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include: (Select all that apply.) a- diffuse involvement of plaque formation in coronary veins. b- abnormal levels of cholesterol, especially LDL. c- accumulation of lipid and fibrous tissue w/i the coronary arteries d- development of angina due to a decreased bloody supply to the heart muscle. e- chronic vasoconstriction of coronary arteries leading to permanent vasospasm.
b- abnormal levels of cholesterol, especially LDL. c- accumulation of lipid and fibrous tissue w/i the coronary arteries d- development of angina due to a decreased bloody supply to the heart muscle.
A hospitalized patient with a hx of chronic stable angina tells the nurse that she is having CP. The nurse bases his actions on the knowledge that ischemia: a- will always progress to MI b- will be relieved by rest, nitro, or both c- indicates that irreversible myocardial damage is occurring d- is frequently associated with vomiting and extreme fatigue.
b- will be relieved by rest, nitro, or both
To prevent autonomic hyperreflexia, what nursing action will the HH RN include in the plan of care for a patient who has paraplegia at the T4 level? a- Support selection of a high-protein diet. b- Discuss options for sexuality and fertility. c- Assist in planning a prescribed bowel program. d- Use quad coughing to strengthen cough efforts.
c- Assist in planning a prescribed bowel program.
A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a- Refrain from sexual activity for a minimum of 3 weeks b- Plan a diet program that aims for a 1- to 2- pound weight loss per week. c- Begin an exercise program that aims for at least five 30-min sessions per week d- Consider the use of ED agents and prophylactic NTG before engaging in sexual activity
c- Begin an exercise program that aims for at least five 30-min sessions per week
A nurse is caring for a client who had an evacuation of a subdural hematoma. What actions should the nurse take first? a- Observe for CSF leaks from the evacuation site. b- Assess for an increase in temp c- Check oximeter d- Monitor for manifestations for increased ICP
c- Check the oximeter
A patient admitted with ACS has continuous ECG monitoring. An examination of the rhythm strip reveals the following characteristics: atrial rate 74 bpm and regular, ventricular rate 62 bpm and irregular, P wave normal shape, PR interval lengthens progressively until a P wave is not conducted, QRS normal shape. What should the priority nursing intervention be? a- perform synchronized cardioversion b- administer epinephrine 1 mg IV push. c- observe for symptoms of hypotension or angina d- apply transcutaneous pacemaker pads on the patient.
c- observe for symptoms of hypotension or angina
Important teaching for the patient scheduled for a radiofrequency catheter ablation procedure includes explaining that: a- ventricular bradycardia may be induced and treated during the procedure. b- a catheter will be placed in both femorl arteries to allow double-catheter use. c- the procedure will destroy areas of the conduction system that are causing rapid heart rhythms. d- a general anesthetic will be given to prevent the awareness of any "sudden cardiac death" experiences.
c- the procedure will destroy areas of the conduction system that are causing rapid heart rhythms.
A RN is performing d/c teaching for a patient who has seizures and a new Rx for phenytoin. What statement by the patient indicates a need for further teaching? a- "I will notify my doctor before taking any other medications." b- "I have made an appointment to see my dentist next week." c- "I know that I cannot switch brands of this medication." d- "I'll be glad when I can stop taking this medicine."
d- "I'll be glad when I can stop taking this medicine."
A RN is caring for a patient who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. What therapeutic outcome should the RN expect to see? a- Delay in disease progression b- Improved bladder function c- Relief of depression d- Decreased tremors
d- Decreased tremors
A RN is caring for a patient who has a tramatic head injury and is exhibiting signs of increasing ICP. What medication should the RN plan to administer? a- Albumin 25% b- Dextran 70 c- Hydroxyethyl glucose d- Mannitol 25%
d- Mannitol 25%
A RN is caring for a patient who is experiencing Cushing's Triad following a subdural hematoma. What medication should the RN plan to administer? a- Albumin 25% b- Dextran 70 c- Hydroxyethyl glucose d- Mannitol 25%
d- Mannitol 25%
A RN is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. What position should the RN place the child? a-Trendelenburg b- Sem-Fowler's c- Prone d- On the unoperated side
d- On the unoperated side
A RN is receiving a transfer report for a patient who has a head injury. The patient has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. What is an appropriate conclusion based on this information? a- The patient can follow simple motor commands b- The patient is unable to make vocal sound c- The patient is unconscious d- The patient opens his eyes when spoken to.
d- The patient opens his eyes when spoken to.
The ECG monitor of a patient in the cardiac care unit after an MI indicates ventricular bigeminy with a rate of 50 bpm. The nurse would anticipate: a- performing defibrillation b- treating with IV amiodarone c- inserting a temporary transvenous pacemaker d- assessing the patient's response to the dysrhythmia
d- assessing the patient's response to the dysrhythmia
The nurse prepares a patient for synchronized cardioversion knowing that cardioversion differs from defibrillation in that: a- defibrillation requires a lower dose of electrical energy b- cardioversion is indicated to treat atrial bradydysrhythmias c- defibrillation is synchronized to deliver a shock during the QRS complex d- patients should be sedated if cardioversion is done on a nonemergency basis.
d- patients should be sedated if cardioversion is done on a nonemergency basis.
A RN at a rehab center is planning care for a patient who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. What goals should the RN include in the patient's rehab program? a- Establish the ability to communicate effectively b- Compensate for loss of depth perception c- Learn to control impulsive behavior d- Improve left-side motor function
a- Establish the ability to communicate effectively
A RN is performing a neurological assessment for a patient that has had head trauma. What assessment will give the RN information about the fx of cranial nerve III? a- Instruct the patient to look up and down without moving his head. b- Observe the patient's ability to smile and frown. c- Have the patient stand with eyes closed and have him touch his nose. d- Ask the patient to shrug his shoulders against passive resistance.
a- Instruct the patient to look up and down without moving his head.
A patient with chronic HF and a-fib is treated with a digitalis glycodise and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do? (Select all that apply.) a- Monitor serum K+ levels b- Teach the patient how to take a pulse rate c- Keep an accurate measure of I&Os d- Teach the patient about dietary restriction of K+ e- Withhold digitalis and notify HCP if pulse is irregular.
a- Monitor serum K+ levels b- Teach the patient how to take a pulse rate
A RN is caring for a 2-yo child who has seizures and is receiving phenytoin in suspension form. What action should the RN take before administering each dose? a- Shake the container vigorously b- Be sure the child has not eaten w/i the hour. c- Perform mouth care. d- Check the child's BP.
a- Shake the container vigorously
A RN is assessing a patient who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the patient's right nostril. What action should the RN take first? a- Test the drainage for glucose b- Suction the nostril c- Notify the physician d- Ask the client to blow his nose
a- Test the drainage for glucose
The nurse recognizes that primary manifestation of systolic failure include: a- decrease ejection fraction (EF) and increased pulmonary arterial wedge pressure (PAWP). b- decreased PAWP and increased EF c- decreased pulmonary hypertension associated w/ normal EF d- decreased afterload and decreased left ventricular end-diastolic pressure.
a- decrease ejection fraction (EF) and increased pulmonary arterial wedge pressure (PAWP).
A patient has an incomplete left spinal cord lesion at the T7 level, resulting in Brown-Sequard syndrome. What nursing action should be including in the plan of care? a- Assessment of the patient for right arm weakness b- Assessment of the patient for increased right leg pain c- Positioning the patient's left leg when turning the patient d- Teaching the patient to look at the right leg to verify its position
c- Positioning the patient's left leg when turning the patient
The nurse is monitoring the ECG of a patient admitted with ACS. Which ECG characteristics would be most suggestive of MI? a- Sinus rhythm with a pathological Q wave b- Sinus rhythm with an elevated ST segment c- Sinus rhythm with a depressed ST segment d- Sinus rhythm with premature atrial contractions
c- Sinus rhythm with a depressed ST segment
You are caring for a patient with acute decompensated heart failure (ADHF) who is receiving IV dobutamine (Dobutrex). You know the this drug is ordered because it (Select all that apply.): a- increased systemic vascular restriction (SVR) b- produces diuresis c- improves contractility d- dilates renal blood vessels e- works on the beta 1 receptors in the heart
c- improves contractility e- works on the beta 1 receptors in the heart
The most common finding in individuals at risk for sudden cardiac death is: a- aortic valve disease b- mitral valve disease c- left ventricular dysfunction d- atherosclerotic heart disease
c- left ventricular dysfunction
