Perfusion EAQ
For clients experiencing an anaphylactic attack, which medication would the nurse initiate immediately? Isoproterenol diphenhydramine HCI Hydrocortisone sodium succinate Methylprednisolone sodium succinate
Isoproternol Rationale - Isoproterenol is a beta-adrenergic, sympathomimetic medication that is considered to be a first-line of medication for management of anaphylaxis.
When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin Vitamin K Vitamin D Vitamin B 1 Vitamin B 12
Vitamin K Rationale - Warfarin causes inhibition of
Which range of heart rate is acceptable for a preschooler? 60 to 100 80 to 110 75 to 100 90 to 140
80 to 110 Rationale - The acceptable range for a heart rate in preschoolers is 80 to 110 beats per minute. Adults have a range of 60 to 100 beats per minute. In school-age children, the heart rate is from 75 to 100 beats per minute. The acceptable range of heart beats per minute in toddler is 90 to 140 beats per minute.
To be universal recipient, a person much have which blood type? a b o ab
AB Rationale - Type AB blood has both A dn B antigens on its red blod cells (RBCs) and no antibodies against either antigen in their plasma. Clients with type AB blood can receive packed RBCs and any ABO blood type. Blood types A,B, and O are not universal recipients because each has antibodies against another blood type. People with type O blood are called Universal Donors
which electrical activity of the cardiac conduction system is reflected in the P wave? Atrial Depolarization Atrial Repolarization Ventricular Depolarization Ventricular Repolarization
Atrial Depolarization Rationale - The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but becuzse of the larger muscle mass of the ventricles, the QRS complex obscures visualization of atrial repolarization. The T wave represents ventricular repolarization.
What client response indicates to the nurse that a vasodilator medication is effective? Pulse rate decreases from 110 to 752. Absence of adventitious breath sounds Increase in the daily amount of urine produced Blood pressure changes from 154/90 to 126/72
Blood pressure changes from 154/90 to 126/72 Rationale - Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time.
A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? Metabolic Acidosis Cardiac arrest Seizure activity Respiratory depression
Cardiac Arrest - Rationale Too rapid an administration can cause hyperkalemia, which contributes to a long refractory period in the cardiac cycle, resulting in cardiac dysrhythmias and arrest. Although acidosis can cause hyperkalemia, hyerkalemia will not lead to acidosis. Hyperkalemia causes muscle flaccidity and weakness, not seizures. Respiratory depression can occur with to rapid intravenous (IV) magnesium administration, not potassium administration.
Which action would the nurse take to prevent venous thrombus formation after abdominal surgery? Keep the client in a gatch bed to elevate the knees Have the client dangle the legs off the side of the bed Help the client use an incentive spirometer every hour Encourage the client to ambulate multiple times daily
Encourage the client to ambulate multiple times daily Rationale - Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client in a gatch bed to elevate the knees of having the client dangle the legs off the side of the bed cause increased popliteal pressure and impair venous return, which will increase risk for venous thrombosis in teh legs. Having the client us incentive spirometer every hour helps prevent atelectasis, not thrombi
Enoxaparin 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given for what purpose? To control postoperative fever To provide a constant source of mild analgesia to limit the postsurgical inflamatory response To provide prophylaxis against postoperative thrombus formation
To provide prophylaxis against postoperative thrombus formation Rationale - Enoxaparin, a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and of prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III. Enoxaparin is not an antipyretic. Enoxaparin is not analgesic. Enoxaparin is not an anti-inflammatory medication.
which color of cerebrospinal fluid (CSF) my indicate subarachnoid hemorrhage in the client ? Hazy Yellow Brown Colorless
Yellow Rationale - The Yellow color of CSF can be attributed to the hemolysis of the red blood cells, which leads to increased production of bilirubin. Other causes include subarachnoid hemorrhage, jaundice, increased CSF protein, hypercarotenemia, or hemoglobinemia. Hazy or unclear CSF is indicative of an elevated white blood cell count as a result of infection If the CSF has a brown color, it is indicative of te presence of methemoglobin, indicating a previous meningeal hemorrhage. Colorless CSF indicates a normal finding.
For the client taking clopidogrel, the nurse will monitor for which adverse effect? Nausea Epistaxis Chest Pain Elevated temperature.
Epistaxis Rationale - Clopidogrel is a platelet aggregation inhibitor; therefore bleeding can occur as an adverse effect. The high vascularity of the nose, combined with it's susceptibility to trauma (sneezing, nose blowing), makes it a frequent site of hemorrhage. Nausea, chest pain, and elevated temperature are not associated with anticoagulant therapy .
when a child is newly diagnosed with hemophilia A, the nurse will teach family members that hemophilia A is linked to a deficiency in which clotting factor? Factor 2 Factor 12 Factor 9 Factor 8
Factor 9 Rationale - Hemophilia type A, the most common type of hemophilia, is from a deficiency of Factor V111. Factors 11 and X11 are part of the clotting cascade, but they are not associated with hemophilia. Factor 1X is associated with hemophilia type B.
Which oxytocic medication may help control uterine bleeding postdelivery and promote milk ejection? Oxytocin Mifepristone Dinoprostone Ergot Alkaloids
Oxytocin Rationale - Oxytocin is used to induce labor, control uterine bleeding after delivery, and promote milk ejection during lactation. Mifepristone is generally used to induce abortion. Dinoprostone induces labor but has no effect on milk ejection or uterine bleeding. although ergot alkaloids control uterine bleeding after delivery, they do not cause milk ejection during lactation.
the nurse described a clients abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rub. whcih breath sounds did the nurse hear? Vesicular Bronchial Adventitious Bronchovesicular
Adventitious Rationale - Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheeze, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pictched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.
how can the nurse describe heart failure to a client? A cardiac condition caused by inadequate circulation blood volume An acute state in which the pulmonary circulation pressure decreases An inability of the heart to pump blood in proportion to metabolic needs A chronic state in which the systolic blood pressure drops below 99 mm Hg.
An inability of the heart to pump blood in proportion to metabolic needs Rationale - As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients, and it will result in the heart's inability to pump blood in proportion to metabolic needs. heart failure is related to an increases, no decreased or inadequate, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure may be decrease with heart failure, but a systolic blood pressure below 90 mm Hg can occur in healthy clients or be caused by many other diagnoses.
After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? I have abnormal platelets I have abnormal hemoglobin i have abnormal hematocrit i Have abnormal white blood cells
I have abnormal hemoglobin Rationale - The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. Although it can affect heatocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.
Which physiological alteration would be expteced with a higher-than-normal red blood cell (RBC) count?
Increased blood pH Decreased hematocrit Increased blood viscosity Decreased immune response - increased blood viscosity Rationale - Viscosity, a measure of fluid's internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. the number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity
Which autoimmune disease can result in damage to the heart ? Uveitis Rheumatic fever Myasthenia gravis Graves disease
Rheumatic fever Rationale - Rheumatic fever is an example of an autoimmune disease that can potentially result in permanent damage to the heart, including damage to valves and heart failure. Uveitis is an eye disorder that is an example of an autoimmune disease. Myasthenia gravis is a muscular disorder that is an example of an autoimmune disease. Graves disease is an ednocrine disorder that is an example of an autoimmune disease. Other than rheumatic fever, these autoimmune disease are not linked to cardiac damage.
Which dietary restriction will the nurse expect to be included n the plan for a client with left ventricular failure? Sodium calcium Potassium Magnesium
Sodium Rationale - restriction of sodium reduces the amount of water retention, thus reducing cardiac workload. Calcium is restricted in individuals who develop renal calculi. Potassium is not restricted, especially if a diuretic is prescribed, because diuresis facilitates the loss of potassium in the urine. Magnesium is not restricted.
The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products? Stay with client during first 15 minutes of infusion Flush packed red blood cells with 5% dextrose and 0.45 % NS remove the intravenous catheter if a blood transfusion reaction occurs. Administer the red blood cells through a percutaneously inserted central catheter line with a 20 gauge needle.
Stay with client during first 15 minutes of infusion Rationale - the nurse would remain with the client for the first 15 to 30 minutes. Any severe reaction usually occurs with the infusion of the first 50 ml of blood. Blood components are viscous, requiring a large needle to be used for venous access. A 20 gauge needle is not used to access a central catheter line. NS is the solution to administer with blood productions. LR and dextrose in water are not used for infusion because of hemolysis.
which pulse site is used to perform Allen test? Ulnar Brachial Femoral Dorsalis pedis
Ulnar Rationale - the ulnar pulse site is used to perform Allen test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the statues of circulation in the foot.
Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. Which is the best response by the nurse. "It's a type of x-ray that shows us the size of the baby's heart ""Electrical activity in the baby's heart is recorded, then printed on graph paper. ""It's an ultrasound procedure that produces images of the structures in the baby's heart. ""Contrast material is injected into the baby's vein to visualize the flow of blood through the heart."
"Electrical activity in the baby's heart is recorded, then printed on graph paper." Rationale - An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy. The x-ray procedure that shows the size of a baby's heart is a chest x-ray. The ultrasound procedure that would be used to produce images f the structures in a baby's heart is the electrocardiogram. The intravenous injection of contrast material to visualize the flow of blood through the heart is an angiogram.
Several minutes after the start of the infusion, the client reports itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next? Administer an antihistamine flush the red blood cells with 5% dextrose slow the rate of infusion Stop the transfusion
Stop the transfusion Rationale - The client is experiencing and allergic reaction to the transfusion. The nurse would stop the transfusion immediately. the health care provider then should be notified. An antihistamine may be indicated but must be prescribed. Flushing red blood cells with dextrose will cause heolysis and will not be effective in stopping the reaction. Slowing down the rate but continuing the infusion will make the situation worse.