AMS

The nurse would instruct a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) to monitor for which indication of right-sided heart failure upon discharge?

weight gain

An ABG report indicates the clients pH is 7.25, PCO2 is 35mmHg and HCO3 is 20 mEq/L. Which disturbance would the nurse identify based on these results? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis

Which finding would the nurse expect when assessing a client who has right ventricular failure? Slowed pulse rate Pleural friction rub Neck vein distention Elevated temperature

Neck vein distention

Which assessment finding is a late sign of heart failure? Tachypnea Tachycardia Peripheral edema Periorbital edema

Peripheral edema

Which change in A8G would the nurse expect in Respiratory acidosis Respiratory alkalosis Respiratory compensation Respiratory decompensation

Respiratory alkalosis

The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rationale? A. Deeptendonreflexeshavebeenlost. B. Thereispartialtransectionofthecord. C. Thereisdamageabovethesixththoracicvertebra. D. Flaccidparalysisofthelowerextremitieshasoccurred

Thereisdamageabovethesixththoracicvertebra.

Which parameter would the nurse assess in a client with right-sided heart failure? a. Fluid volume b. Lung sounds c. Mental status d. Respiratory rate

a. Fluid volume

When providing care for a client receiving mechanical ventilation through an endotracheal tube, which collaborative action would the nurse anticipate when the client's partial pressure of end-tidal carbon dioxide (PETCO2) is 60 mm Hg? a. Increase respiratory rate setting b. Prepare for patient extubation c. increase FiO2 setting d. Administer sedative medication

a. Increase respiratory rate setting

Which respiratory test would be the most useful to differentiate between obstructive and restrictive pulmonary dysfunction? a. Pulmonary function test b. Chest radiographs (chest x-ray) c. spinal computed tomography (spinal CT) d. ABG

a. Pulmonary function test

Which assessment finding, in a laboring client, indicates alkalosis? a. A change in respiratory rate b. A tingling sensation in the hands c. Periodic chances in the fetal heart rate d. A pulse oximetry of less than 98%

b. A tingling sensation in the hands

Which finding would the nurse expect when assessing a client with left ventricular failure a. Crushing chest pain b. Dyspnea on exertion c. Jugular vein distention d. Extensive peripheral edema

b. Dyspnea on exertion

The patient with Ischemic Dilated Cardiomyopathy has signs and symptoms a.Diastolic heart failure b. Hyperglycemia c. Systolic Heart failure d. Thrombocytopenia

c. Systolic Heart failure

Which education would the nurse teach the parent of an infant with a cardiac defect about an early sign of heart failure?

increased heart rate

Which finding on an electrocardiogram for a client complaining of chest pain indicates possible acute myocardial infarction?

C) Elevated ST segments

Which type of medication will the nurse anticipate the need to administer to a client with cardiogenic shock who has an increased pulmonary artery wedge pressure reading of 30 mmHg?

LOOP DIURETIC

Which predisposing condition would the nurse anticipate in the client observed to have edema at the dorsum of the foot and ankle? Neurotrauma Hypothyroidism Hyperthyroidism Congestive heart failure

Congestive heart failure

A client is receiving mechanical ventilation. When condensation collects in the ventilator tubing, which action would the nurse take? a. Notify a respiratory therapist b. Drain the fluid from the tubing c. Decrease the humidity d. Record the amount of fluid removed from the tubing

b. Drain the fluid from the tubing

Which medication prescribed for a client with an acute episode of heart failure would the nurse question?

beta blocker

When providing care for a client experiencing cardiogenic shock, which clinical manifestation would the nurse anticipate? Select all that apply. One, some, or all responses may be correct.

A - Rapid pulse E - Decreased UO

Which early sign of respiratory acidosis would the nurse expect the client with restrictive airway disease to exhibit? Select all that apply. One, some, or all responses a. Headache b. Irritability c. Restlessness d. Hypertension c. Lightheadedness

A,B,C

When a client has supraventricular tachycardia that has persisted despite treatment with vagal maneuvers and medications, which collaborative intervention will the nurse anticipate to treat the dysrhythmia? A) Defibrillation B) Pacemaker placement C) Synchronized cardioversion D) Cardiac resynchronization therapy

C) Synchronized cardioversion

Which additional assessment finding will the nurse expect when the blood pressure for a client with possible ruptured spleen after a motor vehicle accident is 100/60 mm Hg?

D - Weakened peripheral pulses

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? A)Stroke volume B) Venous pressure C) Coronary artery patency D) Left ventricular functioning

D) Left ventricular functioning