Circulation/Oxygenation Practice Quiz for N3

A client states, "I feel like my heart is jumping out of my chest, and it is skipping beats." The client passes a thallium stress test; however, the healthcare provider identifies one premature ventricular complex (PVC) and several premature atrial complexes (PACs) on the 24-hour follow-up Holter monitor. Which question is most important for the nurse to ask the client? "Do you eat foods high in vitamins?" "Do you have small children at home?" "How much caffeine do you consume each day?" "How many glasses of water do you drink per day?"

"How much caffeine do you consume each day?"

A nurse obtains arterial blood gas (ABG) results of a client with pneumonia. Which value is the best indicator of poor alveolar ventilation? A paO2 of 80. An O2 saturation of 90%. A pH of 7.25. A paCO2 of 65.

A paCO2 of 65.

A client who had cardiac surgery 24 hours ago has a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. Based on these findings, the nurse would anticipate that the client is at risk for which of the following? Hypovolemia Acute renal failure Glomerulonephritis Urinary tract infection

Acute renal failure

The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. Which is the nurse's priority intervention? Anticipate administering an intermittent positive-pressure breathing treatment. Notify the health care provider and document the symptoms. Anticipate administering oxygen and prepare for chest tube insertion. Prepare the patient for intubation and ventilation.

Anticipate administering oxygen and prepare for chest tube insertion.

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? Aspirating gastric contents Getting an opioid overdose Experiencing an anaphylactic reaction Receiving multiple blood transfusions

Aspirating gastric contents

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Tracheal ischemia Aspiration pneumonia Pressure necrosis Tracheal bleeding

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis

A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin? Headache Bradycardia Hypertension Junctional tachycardia

Bradycardia Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate.

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor and concludes that these complexes are a sign of: Atrial fibrillation Cardiac irritability Impending heart block Ventricular tachycardia

Cardiac irritability Cardiac irritability is the cardinal reason for PVCs. Atrial fibrillation is a type of dysrhythmia, not the cause of PVCs

The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? Check cuff inflation on the endotracheal tube. Call the health care provider. Auscultate the lungs. Listen carefully to the client.

Check cuff inflation on the endotracheal tube. A cuff leak is suspected when the patient can talk or makes sounds. A leak should be corrected and not allowed to continue due to dislodgement and oxygenation.

What client response must the nurse monitor to determine the effectiveness of amiodarone? Absence of ischemic chest pain. Decrease in cardiac dysrhythmias. Improvement in fasting lipid profile. Maintenance of blood pressure control.

Decrease in cardiac dysrhythmias.

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? Rupture of the pericardium Infection of the subpleural lining Decreased filling of the right side of the heart Increased volume of the unaffected lung

Decreased filling of the right side of the heart

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? Position the client face-down on a soft mattress. Defer pain medication the first day after injury. Encourage coughing and deep breathing. Apply a thoracic binder for support.

Encourage coughing and deep breathing.

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? Encourage range of motion to the client's arm on the affected side Administer the prescribed cough suppressant at the prescribed times Empty and measure the drainage in the collection chamber each shift Apply clamps below the insertion site when getting the client out of bed

Encourage range of motion to the client's arm on the affected side

A client with chest trauma is admitted in the emergency department. Which intervention takes priority? Ensure patent airway. Monitor the cardiac rhythm. Release dressing in tension pneumothorax. Anticipate intubation for respiratory distress.

Ensure patent airway.

The nurse understands that in a first degree atrioventricular (AV) block: Every P wave is conducted to the ventricles. Some P waves are conducted to the ventricles. None of the P waves are conducted to the ventricles. There are no P waves visible on the rhythm strip.

Every P wave is conducted to the ventricles.

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the healthcare provider, which action should the nurse take? Place the client on the unaffected side Administer 60% oxygen via a Venturi mask Give oxygen at 2 L per minute via nasal cannula Prepare for intravenous (IV) administration of electrolytes

Give oxygen at 2 L per minute via nasal cannula

When a client develops ventricular fibrillation in a coronary care unit, what is the responsibility of the first person reaching the client? Administer oxygen. Initiate defibrillation. Initiate cardiopulmonary resuscitation (CPR). Administer sodium bicarbonate intravenously.

Initiate defibrillation.

The client is admitted with paroxysmal supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and the client is asymptomatic except for a "fluttering feeling" in the chest. Which treatments should the nurse be prepared to administer? Select all that apply. Intravenous adenosine. Intravenous beta blockers. Intravenous amiodarone. Synchronized cardioversion. Intravenous calcium channel blockers.

Intravenous adenosine. Intravenous beta blockers. Intravenous amiodarone. Intravenous calcium channel blockers.

A client experiences crushing chest pain and is brought to the emergency department. When assessing the ECG tracing, the nurse concludes that the client is experiencing premature ventricular complexes (PVCs). Which abnormalities of the electrocardiogram support this conclusion? Irregular rhythm, abnormal shaped P wave, and normal QRS Irregular rhythm, absence of a P wave, wide, and distorted QRS Regular rhythm, more than 100 beats per minute, normal P wave, and normal QRS Regular rhythm, 100 to 250 beats per minute, absent P wave, and wide, distorted QRS.

Irregular rhythm, absence of a P wave, wide, and distorted QRS

Which landmark is correct for a nurse to use when auscultating the mitral valve?

Left fifth intercostal space, midclavicular line

After a crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. For which complication, associated with this injury, should the nurse assess for in this client? Pericardial tamponade. Mediastinal shift. Open pneumothorax. Tracheal laceration.

Mediastinal shift. Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.

Which auscultatory area is found at the left midclavicular line at the level of the fifth intercostal space (ICS)? Aortic area Mitral area Tricuspid area Pulmonic area

Mitral area

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. The nurse should: Prepare for blood transfusions Administer the prescribed sedative Give the client nothing by mouth (NPO) Notify the surgeon immediately

Notify the surgeon immediately

While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure? Child client Pregnant client Older adult client Young adult client

Older adult client The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter.

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by: Adding pressure to lung tissue, which improves gas exchange. Providing more oxygen to lung tissue. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue. Opening collapsed alveoli and keeping them open.

Opening collapsed alveoli and keeping them open.

An 80-year-old client with a history of coronary artery disease is admitted to the hospital for observation after a fall. During the night the client has an episode of paroxysmal nocturnal dyspnea. In what position should the nurse place the client to best decrease preload? Contour Orthopneic Recumbent Trendelenburg

Orthopneic

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? Chest tube insertion Aggressive diuretic therapy Administration of beta-blockers Positive end-expiratory pressure (PEEP

Positive end-expiratory pressure (PEEP)

The nurse observes the following pattern on a client's ECG strip. What dysrhythmia does the nurse identify? Asystole Atrial flutter Ventricular fibrillation Premature ventricular contraction

Premature ventricular contraction

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. Which finding requires immediate attention? Puffiness of the skin around the chest tube insertion site and a crackling feeling. Dullness to percussion on the affected side. Pain at the chest tube insertion site. Fluctuation in the water seal chamber with breathing.

Puffiness of the skin around the chest tube insertion site and a crackling feeling. This is indicated of subcutaneous emphysema.

A nurse is caring for a client with pericarditis. Which signs will cause the nurse to suspect client is developing cardiac tamponade? Select all that apply. Hypertension. Pulsus paradoxus. Jugular vein distention. Muffled heart sounds. Increased urine output.

Pulsus paradoxus. Jugular vein distention. Muffled heart sounds.

When interpreting an ECG rhythm strip, the nurse identifies that ventricular contraction is displayed as the: P wave T wave PR interval QRS interval

QRS interval The QRS interval represents time taken for depolarization of both ventricles.

Which assessment best indicates to the nurse that a chest tube was effective for a client with emphysema? Temperature is less than 100F. Respiration are unlabored. White blood cell count is normal. Absence of blood in chest drainage.

Respiration are unlabored.

A client is admitted to the emergency department with multiple injuries including fractured ribs. Because of the client's fractured ribs, the nurse should assess for signs of: Pneumonitis Hematemesis Pulmonary edema Respiratory acidosis

Respiratory acidosis Fractured ribs cause extreme pain, especially on inhalation; this induces shallow breathing, which results in carbon dioxide retention.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? Lessens the client's chest discomfort Restores negative pressure in the pleural space Drains accumulated fluid from the pleural cavity Prevents subcutaneous emphysema in the chest wall

Restores negative pressure in the pleural space

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? Lessens the client's chest discomfort. Restores negative pressure in the pleural space. Prevents subcutaneous emphysema in the chest wall. Drains accumulated fluid from the pleural cavity.

Restores negative pressure in the pleural space.

Which electrolyte imbalance has the potential to precipitate dysrhythmias and cardiac arrest in a client? Serum sodium of 139 mEq/L (139 mmol/L) Serum chloride of 100 mEq/L (100 mmol/L) Serum calcium of 10.2 mg/dL (2.55 mmol/L) Serum potassium of 7.2 mEq/L (7.2 mmol/L)

Serum potassium of 7.2 mEq/L (7.2 mmol/L) Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L).

A client is admitted to the coronary care unit with atrial fibrillation with rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to avoid the potential danger of inducing ventricular fibrillation during cardioversion? Energy level is set at its maximum level. Synchronizer switch is in the "on" position. Skin electrodes are applied after the T wave. Alarm system of the cardiac monitor is functioning simultaneously.

Synchronizer switch is in the "on" position.

A client is admitted to the coronary care unit with symptomatic junctional tachycardia with no response to medication. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion? Energy level is set at its maximum level. Synchronizer switch is in the "on" position. Skin electrodes are applied after the T wave. Alarm system of the cardiac monitor is functioning simultaneously.

Synchronizer switch is in the "on" position.

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? Syncope Headache Tachycardia Hemiparesis

Syncope

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle? P wave T wave P-R interval QRS complex

T wave

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Pulmonary contusion Flail chest Cardiac tamponade Tension pneumothorax

Tension pneumothorax

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis? The fat-forming ketoacids were broken down. The irregular heartbeat produced oxygen deficit. The decreased tissue perfusion caused lactic acid production. The client received too much sodium bicarbonate during resuscitation efforts.

The decreased tissue perfusion caused lactic acid production.

A patient develops symptomatic third-degree heart block. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? "The device uses overdrive pacing to slow the heart to a normal" "The device delivers a current through your skin that will be uncomfortable." "The device converts your heart rate and rhythm back to normal." "The device fires only if your heart rate falls below 60 beats/min."

The device delivers a current through your skin that will be uncomfortable."

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? The signs and symptoms of pericarditis The possible need for prophylactic antibiotic therapy before dental work That cardiac surgery will have to be done eventually for the other valves That pregnancy and childbirth are too stressful when one has this problem

The possible need for prophylactic antibiotic therapy before dental work

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Absence of bloody drainage in the anterior/upper tube Bloody drainage is observed in the collection chamber. The tissues give a crackling sensation when palpated. Skin around tube is pink.

The tissues give a crackling sensation when palpated. Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings

The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding? Multifocal Unifocal Bigeminal Couplet

Unifocal

The nurse is analyzing the client's rhythm when she notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. This indicates that the PVCs are: Multifocal Unifocal. Bigeminal A pair.

Unifocal. A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs.

The nurse is preparing to administer digoxin to a patient with heart failure (HF). In preparation, lab results are reviewed with the following findings: sodium 139 mmol/L, potassium 3.0 mmol/L, chloride 103 mmol/L, and glucose 5.8 mmol/dL. The nurse should do which of the following at this time? Withhold the daily dose until the following day. Withhold the dose and report the potassium level. Give the digoxin with a salty snack, such as crackers. Give the digoxin with extra fluids to dilute the sodium level.

Withhold the dose and report the potassium level.

The nurse would recognize that indications for the use of dopamine (Intropin) in the care of a patient with heart failure include: acute anxiety. hypotension and tachycardia. peripheral edema and weight gain. paroxysmal nocturnal dyspnea (PND).

hypotension and tachycardia.

The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of Acute Respiratory Distress Syndrome (ARDS) for three days. Aside from assessing oxygenation, which is the nurse's priority action? Assess hemoglobin Administer ferrous sulfate. Assess nutritional requirements. Assess muscle strength.

Assess nutritional requirements.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered.

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A client with dyspnea is becoming very anxious and stressed. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene? Assist with relaxation techniques. Administer an anti-anxiety medication. Increase the oxygen. Administer a bronchodilator.

Assist with relaxation techniques.

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? Take the client's vital signs. Inform the healthcare provider. Turn the client to the unaffected side. Check the tube to ensure that it is not kinked

Check the tube to ensure that it is not kinked

A nurse on the disaster management team is caring for survivors of a bomb explosion. The nurse understands that some survivors may have chest trauma and may need a needle decompression to relieve the air or fluid trapped in the chest. Following the initial assessment, which client would the nurse treat first? Client A with muffled, distant heart sounds, neck vein distention. Client B with paradoxic movement of chest wall, respiratory distress. Client C with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side. Client D with hyperresonance to percussion, diminished or absent breath sounds on the affected side.

Client C with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side.

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? Collect drainage Ensure adequate suction Maintain negative pressure Sustain a continuance of the water seal

Collect drainage The chamber closest to the client in a three-chamber system [1] [2] is the first chamber; it collects drainage. Chamber 2 is the water seal that ensures that air does not enter the pleural space. Chamber 3 is the suction control chamber of the system.

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? Crackling Wheezing Decreased sounds Adventitious sounds

Decreased sounds Because the affected lung will not expand, aeration of the lung is not complete, and breath sounds are diminished.

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? Question the client about the confusion. Change the method of oxygen delivery. Percuss and vibrate the client's chest wall. Discontinue or decrease the oxygen flow rate.

Discontinue or decrease the oxygen flow rate. With emphysema, it is believed that the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe [1] [2] but rather to lowered oxygen levels; therefore, the oxygen being delivered must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe.

A nurse in the cardiovascular clinic reviews a client's ECG as shown below. What should the nurse next course of action? Recommend the Valsalva maneuver. Document that the rhythm is normal. Prepare to defibrillate the client at 200 joules Advise the client to reduce the intake of caffeine.

Document that the rhythm is normal.

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? Chronic pain Risk for injury Electrolyte imbalance Inadequate gas exchange

Electrolyte imbalance The stomach produces about 3 L of secretions per day. Fluid lost through vomiting can produce inadequate fluid volume and electrolyte imbalance, which can lead to dysrhythmias and death.

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? Flail chest Pneumothorax Tension pneumothorax ARDS

Flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs.

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? PO2 value is 80 mm Hg. PCO2 value is 60 mm Hg. HCO3 value is 50 mEq/L (50 mmol/L). Serum potassium value is 4 mEq/L (4 mmol/L).

HCO3 value is 50 mEq/L (50 mmol/L).

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do? Hyperoxygenate with 100% oxygen before and after suctioning. Suction two or three times in quick succession to remove secretions. Use the technique of short, pushing movements when applying suction. Apply suction for no more than 10 seconds while inserting the catheter.

Hyperoxygenate with 100% oxygen before and after suctioning.

A registered nurse is educating a client who has just undergone thoracentesis on the manifestations of pneumothorax. Which statements made by the client indicate effective learning? Select all that apply "I'll report any instance of blue skin right away." "I'll report any feeling of air hunger immediately." "I'll report any decrease in heart rate immediately." "I'll call you right away if my nagging cough disappears." "I'll call you right away if my shallow breathing goes awayy.

I'll report any instance of blue skin right away." "I'll report any feeling of air hunger immediately.

A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority? Elective cardioversion Immediate defibrillation An intramuscular (IM) injection of digoxin An intravenous (IV) line for emergency medications

Immediate defibrillation When ventricular fibrillation is verified, the first intervention is defibrillation; it is the only measure that will terminate this lethal dysrhythmia.

A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority? Elective cardioversion. Immediate defibrillation. An intramuscular (IM) injection of digoxin. An intravenous (IV) line for emergency medications.

Immediate defibrillation. When ventricular fibrillation is verified, the first intervention is defibrillation; it is the only measure that will terminate this lethal dysrhythmia.

A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concerns? Select all that apply. Impaired gas exchange Ineffective airway clearance Disturbed body image Risk for infection Knowledge deficit

Impaired gas exchange Ineffective airway clearance

When obtaining a health history, the nurse is informed that a client has been taking digoxin (Lanoxin). What therapeutic effect of digoxin does the nurse expect? Decreased cardiac output Decreased stroke volume of the heart Increased contractile force of the myocardium Increased electrical conduction through the atrioventricular (AV) node

Increased contractile force of the myocardium Digoxin produces a positive inotropic effect that increases the strength of myocardial contractions and thus cardiac output

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is most important for the nurse to take? Encourage the client to slow the breathing rate. Auscultate the client's lungs and suction if indicated. Advise the healthcare provider that the client needs supplemental oxygen. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.

Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure. A lower than expected PCO2 actually will benefit the client because it reduces intracranial pressure by preventing cerebral vasodilation; the results should be reported, and monitoring for signs and symptoms of increased intracranial pressure should continue

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Increase oxygen administration. Intubate the client and control breathing with mechanical ventilation. Schedule the client for pulmonary surgery. Administer a large dose of furosemide (Lasix) IVP stat.

Intubate the client and control breathing with mechanical ventilation.

The nurse is admitting a patient diagnosed with valvular heart disease who is scheduled to undergo a cardiac catheterization. Which of the following allergies is most important for the nurse to assess before this procedure? Iron Iodine Aspirin Penicillin

Iodine

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? Strip the chest tube periodically. Administer the prescribed cough suppressant at the scheduled times. Empty and measure the drainage in the collection chamber each shift. Keep the drainage system lower than the level of the client's chest

Keep the drainage system lower than the level of the client's chest

Endotracheal intubation and positive-pressure ventilation are instituted because of a client's deteriorating respiratory status. What is the priority nursing intervention at this time? Prepare the client for emergency surgery. Maintain sterility of the ventilation system. Assess the client's response to the mechanical ventilation. Facilitate verbal communication.

Maintain sterility of the ventilation system.

A client who is admitted with emphysema shows progressive respiratory failure and has a Paco2 of 60. To address the problems, the nurse expects to receive a prescription for: Mucolytics Bronchodilators Mechanical ventilation Intermittent positive-pressure breathing (IPPB)

Mechanical ventilation Mechanical ventilation indicates progressive respiratory failure; ventilatory support is needed when the Paco2 is more than 50.

A client who is admitted with emphysema shows progressive respiratory failure and has a Paco2 of 60. To address the problems, the nurse expects to receive an order for: Mucolytics Bronchodilators Mechanical ventilation Intermittent positive-pressure breathing (IPPB)

Mechanical ventilation Mechanical ventilation indicates progressive respiratory failure; ventilatory support is needed when the Paco2 is more than 50.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first? Cyanosis Bradycardia Mental confusion Distended neck veins

Mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess

The nurse considers that when a client has a tracheostomy tube with a high-volume, low-pressure cuff, it is used primarily to prevent: Leakage of air Lung infection Mucosal necrosis Tracheal secretion

Mucosal necrosis

A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures should be initiated in this client? High-protein oral diet Occupational therapy Psychological counseling Nutritional support

Nutritional support

The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? Older adult who has aspirated his tube feeding. Older adult who smokes two cigars a day. Young adult with a broken leg from a motorcycle accident. Middle-aged client receiving a blood transfusion.

Older adult who has aspirated his tube feeding.

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what? Providing more oxygen to lung tissue. Forcing pressure into lung tissue, which improves gas exchange. Opening collapsed alveoli and keeping them open. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue.

Opening collapsed alveoli and keeping them open The primary mechanism of PEEP is to deliver positive pressure to the lung at the end of expiration. This helps open collapsed alveoli and keeps them open

A client with a chest injury is suspected of developing Acute Respiratory Distress Syndrome (ARDS). Arterial blood gas (ABG) results on 6 L of oxygen per nasal cannula are as follows: pH = 7.50, pCO2 = 30, paO2 = 50, O2Sat = 70%, and HCO3 = 24. Which nursing intervention will do the most to improve the client's ABG's at this time? Encouraging pursed lip breathing. Oxygen via a non-rebreather mask. Elevating the head of the bed. Oro-tracheal suctioning.

Oxygen via a non-rebreather mask.

A client admitted for difficulty breathing becomes worse. Which assessment finding(s) indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply). PaO2 50. Increased dyspnea. Anxiety. Chest pain. Clubbing of fingertips.

PaO2 50. Increased dyspnea. Anxiety. Chest pain.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? Clamp the chest tubes when suctioning. Palpate the surrounding area for crepitus. Change the dressing daily using aseptic technique. Empty the drainage chamber at the end of the shift

Palpate the surrounding area for crepitus.

A client develops subcutaneous emphysema after a chest injury with a suspected pneumothorax. What assessment by the nurse is the best method for assessing this complication? Percussing the neck and chest Palpating the neck or face Auscultating for abnormal breath sounds Observing for asymmetry of chest movement

Palpating the neck or face

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? Aspiration Pneumothorax Cardiac ischemia Acute bronchitis

Pneumothorax If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs.

client who has emphysema for many years develops an enlarged liver. The nurse concludes that this results from: Liver hypoxia Hepatic acidosis Esophageal varices Portal hypertension

Portal hypertension The enlarged liver is caused by long-term respiratory acidosis with increased pulmonary pressure that eventually causes right ventricular enlargement and failure (cor pulmonale); the elevated pressure causes backup pressure in the hepatic circulation.

A patient admitted with heart failure (HF) appears anxious and complains of shortness of breath. Which of the following nursing actions would be appropriate to alleviate this patient's anxiety? (Select all that apply.) Position patient in a semi-Fowler's position. Administer ordered morphine sulphate. Position patient on left side with head of bed flat. Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient.

Position patient in a semi-Fowler's position. Administer ordered morphine sulphate. Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient.

A nurse is preparing dietary recommendations for a client with a lung empyema. Which statement would be included in the plan of care? "You must consume a diet low in fat by limiting dairy products and concentrated sweets." "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." "You must consume a diet rich in protein, such as chicken, fish, and beans."

"You must consume a diet rich in protein, such as chicken, fish, and beans."

A client is being discharged with a tracheostomy and voices concern about his appearance. Which discharge teaching will assist the client with maintaining a positive body image? "Tell people how sick you were when they ask about the tracheostomy." "You can put a bandage over your tracheostomy so no one will see it." "Your clothing can help hide the tracheostomy so it is not as noticeable." "You have to ignore comments that people make about your appearance."

"Your clothing can help hide the tracheostomy so it is not as noticeable."

A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water? Promotes pleural drainage via gravity Measures the pressures in the chest wall Prevents reflux of air back into the chest Ensures bubbling in the water-seal chamber

Prevents reflux of air back into the chest

A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? Obtain a new sterile drainage system. Use two clamps to close the drainage tube. Place the client in the high-Fowler position. Reconnect the client's tube to the drainage system

Reconnect the client's tube to the drainage system. To prevent further possibility of pneumothorax, the nurse should reconnect the tube immediately

A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? Remain with the client to assess responses. Allow family members to participate in the process. Permit the client more extended times alone for independence. Observe monitoring devices at the control panel of the ventilator

Remain with the client to assess responses. This is a critical time; the client's response to reduction of ventilator support must be observed closely and evaluated for signs of respiratory distress

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Permit the development of positive pressure between the layers of the pleura Provide access for the instillation of medication into the pleural space

Remove the air that is present in the intrapleural space

A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? Tetany Hypercapnia Metabolic acidosis Respiratory alkalosis

Respiratory alkalosis Increased rate and depth of breathing result in excessive elimination of CO2, and respiratory alkalosis can result

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? Productive coughing Return of breath sounds Increased pleural drainage in the chamber Constant bubbling in the water-seal chamber

Return of breath sounds

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on what likely cause of the spontaneous pneumothorax? Incorrect 1 Pleural friction rub Tracheoesophageal fistula Rupture of a subpleural bleb Puncture wound of the chest wall

Rupture of a subpleural bleb

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if the wall suction unit has malfunctioned. See if a kink has developed in the tubing. See if the chest tube is clogged. See if there are leaks in the system.

See if there are leaks in the system. Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks

A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? An irreversible phenomenon. Generally caused by decreased blood volume. Usually a fleeting reaction to tissue injury. A failure of the circulatory pump.

A failure of the circulatory pump. In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart.

To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? A change in the respiratory rate A tingling sensation in the hands Periodic changes in the fetal heart rate A pulse oximetry reading of less than 98%

A tingling sensation in the hands The presence of a tingling sensation in the hands indicates respiratory alkalosis due to a decrease in carbon dioxide

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Lung cancer Bronchitis Tracheobronchitis Acute respiratory distress syndrome

Acute respiratory distress syndrome

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? Acute respiratory distress syndrome Respiratory acidosis Atelectasis Metabolic alkalosis

Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances;

You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? Airway patency Level of consciousness Psychologic status Pain level

Airway patency

A client with pulmonary edema is currently receiving 3 L/min of oxygen per nasal cannula. The nasogastric tube is on low intermittent suction with a full container. The most recent arterial blood gas (ABG) results indicate the following: pH=7.50, pCO2=40 mmHg, pO2=88 mmHg, HCO3=30. The nurse anticipates that the health care provider will order which of the following? Add one ampule of sodium bicarbonate to the client's current intravenous fluids. Stop the nasogastric suctioning. Administer a diuretic intravenously. Change nasal cannula to face mask at 6L/min of oxygen.

Stop the nasogastric suctioning. From the nurses assessment of the full nasogastric tube container, there is an imbalance and the suctioning must be turned off to stop the removal of the gastric contents.

A client at 28 weeks' gestation with previously diagnosed mitral valve stenosis is being evaluated in the clinic. Which sign or symptom indicates that the client is experiencing cardiac difficulties? Systolic murmur Heart palpitations Syncope on exertion Displaced apical pulse

Syncope on exertion Syncope on exertion is a definitive sign of cardiac decompensation; cardiac output is not meeting cellular oxygen needs.

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle? P wave T wave P-R interval QRS complex

T wave The T wave is the period of repolarization of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation.

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply. Tachycardia Restlessness Warm, moist skin Decreased urinary output Bradypnea

Tachycardia Restlessness Decreased urinary output

Which nursing action should be included in the plan of care for a client who has a permanent pacemaker inserted? Instruct the client that it is better to sleep on two pillows Encourage the client to reduce activity from former levels Teach the client to keep daily accurate records of the pulse Inform the client that the pacemaker functions when the heart rate drops below a preset rate.

Teach the client to keep daily accurate records of the pulse

It is determined that a client with complete heart block will require implantation of a permanent pacemaker to assist heart function. The client expresses concern about having an increased risk of accidental electrocution. How should the nurse respond? "No one has been electrocuted yet by a pacemaker." "New technology prevents electrocution from occurring." "The pacemaker is pretested for safety before it is inserted." "The voltage emitted is not strong enough to electrocute."

The voltage emitted is not strong enough to electrocute.

A patient with a recent diagnosis of heart failure (HF) has been prescribed furosemide (Lasix) in an effort to: reduce preload. decrease afterload. increase contractility. promote vasodilation.

reduce preload.

Auscultation of a patient's heart reveals the presence of a murmur. This assessment finding is a result of: increased viscosity of the patient's blood. turbulent blood flow across a heart valve. friction between the heart and the myocardium. a deficit in heart conductivity that impairs normal contractility.

turbulent blood flow across a heart valve. turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? Increases the cardiac workload. Interferes with usual respirations. Produces an elevation in temperature. Decreases the amount of oxygen used.

Increases the cardiac workload. Irritability and restlessness associated with anxiety increase the metabolic rate, heart rate, and blood pressure; these complicate heart failure.

Which is the priority nursing action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation? Treating pain. Assessing respirations. Initiating defibrillation. Monitoring blood pressure.

Initiating defibrillation.

A nurse is providing discharge instructions about digoxin (Lanoxin). Which response should a nurse include as a reason for a client to withhold the digoxin? Chest pain Blurred vision Persistent hiccups Increased urinary output

Blurred vision

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis? Slow, bounding pulse Cold, clammy skin Increased blood pressure Hyperactive bowel sounds

Cold, clammy skin

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider?

Collect drainage

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. Crackles Atelectasis Hypoxemia Severe dyspnea Increased pulmonary wedge pressure

Crackles Atelectasis Hypoxemia Severe dyspnea

he nurse is providing care to a client who presents in the emergency department (ED) in cardiac arrest. Which are the priority nursing actions when providing care to this client? Select all that apply. Documenting care. Notifying family members. Determining the need for rapid defibrillation. Administering pain medication. Performing adequate chest compressions.

Determining the need for rapid defibrillation. Performing adequate chest compressions.

The nurse is caring for a client who is on a ventilator going through the weaning process. The client is on the continuous positive airway pressure (CPAP) mode. Which intervention is most appropriate for this client? Administering antianxiety medications PRN. Assessing that the breaths are spontaneous. Telling the client to relax and let the ventilator do the work. Administering a medication to help the client sleep.

Assessing that the breaths are spontaneous. In CPAP mode, the patient is doing all the work and must be awake and nothing must interfere with spontaneous breathing

The nurse is caring for a patient who is 24 hours post pacemaker insertion. Which of the following nursing interventions is most appropriate at this time? Reinforcing the pressure dressing as needed Encouraging range-of-motion exercises of the involved arm Assessing the incision for any redness, swelling, or discharge Applying wet-to-dry dressings every four hours to the insertion site

Assessing the incision for any redness, swelling, or discharge

While a pacemaker catheter is being inserted , the client's heart rate drops to 38 beats/min. What medication should the nurse expect the healthcare provider to prescribe? Digoxin Lidocaine Amiodarone Atropine sulfate

Atropine sulfate Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate.

A client has a mitral valve replacement, and the nurse provides health teaching to promote optimum health. Which client statement supports the nurse's conclusion that the client needs further teaching? "I should wear a Medic Alert bracelet." "I will start a vigorous aerobic exercise program." "I will take antibiotics when I have my teeth repaired." "I should go to the doctor when I get a respiratory infection."

"I will start a vigorous aerobic exercise program." Strenuous physical exercise should be avoided because the valve may be unable to accommodate the associated increase in cardiac output.

Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply. Edema Vertigo Polyuria Ascites Palpitations

Edema Ascites

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? Fibrotic Exudative Reparative Proliferative

Exudative

A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data? Loss of battery power Failure to stimulate the heart Ignoring the client's heartbeat Functioning as expected

Failure to stimulate the heart

A client with a history of heart failure reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? Fluid retention. Urinary retention. Renal insufficiency. Abdominal distention.

Fluid retention.

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary, and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. --Assess client's vital signs and lung sounds. --Rotate the catheter while suction is applied. --Activate the ventilator suction hyperoxygenation setting. --Insert the catheter without applying suction.

1- Assess client's vital signs and lung sounds. 2- Activate the ventilator suction hyperoxygenation setting. 3- Insert the catheter without applying suction. 4- Rotate the catheter while suction is applied.

A nurse is assessing a group of clients. Which client is considered at the highest risk for a dissecting aneurysm? 70-year-old male with peripheral vascular disease. 65-year-old male with uncontrolled hypertension. 40-year-old female with controlled hypertension. 42-year-old female with peripheral vascular disease.

65-year-old male with uncontrolled hypertension. The highest incidence of dissecting aneurysm is in people in their sixth and seventh decades of life; it is seen 2 to 5 times more frequently in men than in women.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? Dull sound on percussion Vocal fremitus on palpation Rales with rhonchi on auscultation Absence of breath sounds on auscultation

Absence of breath sounds on auscultation

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? Distended neck veins Paradoxical respirations Increasing amounts of purulent sputum Absence of breath sounds over the affected area

Absence of breath sounds over the affected area When the lung is collapsed, air is not moving into and out of the area, and therefore breath sounds are absent

The nurse in the intensive care unit is monitoring a client who had an aortic valve replacement. What can a slowing pulse rate during the early postoperative period after open heart surgery indicate? Shock Hypoxia Heart block Cardiac failure

Heart block During open heart surgery, the conductive system of the heart can be damaged because of trauma.

A client with paroxysmal supraventricular tachycardia (SVT) has a heart rate of 170 beats per minute. Following treatment with diltiazem hydrochloride, what assessment indicates to the nurse that the diltiazem hydrochloride is effective? Increased urine output Blood pressure of 90/60 mm Hg Heart rate of 110 beats per minute No longer complaining of heart palpations

Heart rate of 110 beats per minute Diltiazem hydrochloride's purpose is to slow down the heart rate.

A client who develops heart failure has a serum potassium level of 3.1 mEq/L. Digoxin (Lanoxin) and potassium chloride are prescribed. What action should the nurse take? Double the dose of potassium chloride and administer it with the prescribed digoxin. Give the digoxin and potassium chloride as prescribed and report the laboratory results to the health care provider. Hold the dose of digoxin, administer the potassium chloride, and call the health care provider immediately. Administer the prescribed digoxin and potassium chloride with a glass of orange juice and continue to monitor the client.

Hold the dose of digoxin, administer the potassium chloride, and call the health care provider immediately.

After a spontaneous pneumothorax, the client becomes extremely drowsy, and the pulse and respirations increase. What do these client responses indicate to the nurse? Hypercapnia Hypokalemia Increased PO2 Respiratory alkalosis

Hypercapnia

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hypercapnia, hypoventilation, and hypoxemia Hypotension, hyperoxemia, and hypercapnia Hyperoxemia, hypocapnia, and hyperventilation

Hypercapnia, hypoventilation, and hypoxemia

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority? Potential for Infection Ineffective Airway Clearance Acute Pain Impaired Gas Exchange

Impaired Gas Exchange The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity.

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client? Air will move from the lung into the pleural space. The heart and great vessels shift toward the affected side. There is greater negative pressure within the chest cavity. Collapse of the other lung will occur if not treated immediately

Air will move from the lung into the pleural space.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? Hypertension Tenacious sputum Altered mental status Slowed rate of breathing

Altered mental status

A nurse is providing tracheostomy care. Which action is priority? Place the client in the semi-Fowler position Maintain sterile technique during the procedure Monitor body temperature after the procedure is completed Clean the inner cannula with sterile water when it is removed

Maintain sterile technique during the procedure The tracheostomy site is a portal of entry for microorganisms. Sterile technique must be used.

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow, which action should the nurse take? Clear the ear of draining fluid. Discontinue anticonvulsant therapy. Elevate the head of the bed 30 degrees. Monitor serum carbon dioxide levels routinely.

Monitor serum carbon dioxide levels routinely.

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, what type of pressure will be reestablished? Neutral pressure in the pleural space Negative pressure in the pleural space Atmospheric pressure in the thoracic cavity Intrapulmonic pressure in the thoracic cavit

Negative pressure in the pleural space

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? Prepare for blood transfusions. Notify the surgeon immediately. Make the client nothing by mouth (NPO). Administer the prescribed preoperative sedative.

Notify the surgeon immediately.

A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do?

Palpate the area around the tubes for crepitus

The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which action by the nurse takes priority? Order supplies for tracheostomy care for 24 hours. Review orders for postoperative pain medications. Obtain report from the post-anesthesia care unit. Place a extra tracheostomy tube and obturator at the bedside.

Place a extra tracheostomy tube and obturator at the bedside.

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? Heart failure Pulmonary embolism Pneumothorax Myocardial infarction (MI)

Pneumothorax

A client receiving oxygen via a simple mask has the following ABG results: pH: 7.25, pCO2: 40 mmHg, PaO2: 90, O2Sat: 100%, and HCO3: 20. Which is the most appropriate nursing action for this client at this time? Encourage client to breath into a plastic bag. Activate the Rapid Response Team now. Change to a non-rebreather mask immediately. Prepare to administer sodium bicarbonate as ordered.

Prepare to administer sodium bicarbonate as ordered. These ABG results show metabolic acidosis. Administration of the sodium bicarbonate (NaHCO3) will correct this

A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? Assess a 24-hour calorie count. Elimination pattern during the last 30 days. Complete gynecological and sexual history. Presence of a cough and pulmonary secretions.

Presence of a cough and pulmonary secretions.

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? Sudden loss of lung function with history of normal lung function Progressive loss of lung function associated with chronic disease Progressive loss of lung function with history of normal lung function Sudden loss of lung function associated with chronic disease

Progressive loss of lung function associated with chronic disease

Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)? Pulse oximetry Arterial blood gas analysis Sputum studies Pulmonary function testing

Pulse oximetry

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Rapid onset of severe dyspnea Bilateral wheezing Cyanosis Inspiratory crackles

Rapid onset of severe dyspnea

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Rapid pulse. Deep respirations. Warm, flushed skin. Decreased urinary output Increased blood pressure.

Rapid pulse. Decreased urinary output The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys.

Which would indicate to the nurse that Acute Respiratory Distress Syndrome (ARDS) is developing in a client with a chest trauma? Coarse crackles and using three pillows at night to sleep. Refractory hypoxemia and a ground glass appearance on chest x-ray. Restlessness and uncompensated metabolic acidosis. Peripheral cyanosis and respiratory acidosis.

Refractory hypoxemia and a ground glass appearance on chest x-ray. Hallmarks of this disease are the refractory hypoxemia and the ground glass appearance on the chest x-ray.

A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? Removing excess air and fluid Providing positive intrathoracic pressure Monitoring pleural fluid osmolarit Maintaining positive chest-wall pressure

Removing excess air and fluid

A nurse is reviewing their understanding of acute respiratory failure. The nurse can expect which finding(s)? (Select all that apply). SaO2 <90%. HCO3 25. pH <7.30. PaCO2 >50 mmHg. PaO2 <60 mmHg.

SaO2 <90%. pH <7.30. PaCO2 >50 mmHg. PaO2 <60 mmHg.

The initial arterial blood gases (ABG's) of a recently admitted client with pulmonary edema reveals: pH = 7.30, pCO2 = 55, HCO3 = 32, pO2 = 50, and O2Sat = 65%. Which problem should the nurse address first? Severe hypoxemia. Respiratory acidosis. Metabolic alkalosis. Elevated HCO3.

Severe hypoxemia. The low pO2 & O2Sat indicate severe hypoxemia and this should be addressed first. Respiratory acidosis is a concern, but the hypoxemia is the greatest concern.

When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? Substernal chest pain Episodes of palpitation Severe shortness of breath Dizziness when standing up

Severe shortness of breath

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply. Hematemesis Shortness of breath Unilateral chest pain Increased thoracic motion Mediastinal shift toward the involved side

Shortness of breath Unilateral chest pain

Which complication would the nurse suspect if the client with Chronic Obstructive Pulmonary Disease (COPD) has absent breath sounds over the upper left lobe? Cor Pulmonale. Spontaneous pneumothorax. Pulmonary tamponade. Development of blebs/bullae.

Spontaneous pneumothorax. Many patients with COPD develop blebs/bullae on the surface of the lungs and if one of these blebs rupture, a spontaneous pneumothorax will result.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? Administer sedatives around the clock Turn client every four hours Increase ventilator settings as needed Suction as needed

Suction as needed

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Insidious onset of lung impairment in a client who had normal lung function. Sudden onset of lung impairment in a client who had normal lung function. Insidious onset of lung impairment in a client who had compromised lung function. Sudden onset of lung impairment in a client who had compromised lung function.

Sudden onset of lung impairment in a client who had normal lung function.

A mediastinal shift occurs in which type of chest disorder? Traumatic pneumothorax Cardiac tamponade Simple pneumothorax Tension pneumothorax

Tension pneumothorax A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift).

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? To assist with mechanical ventilation. To drain copious sputum secretions. To monitor bleeding around the lungs To remove air from the pleural space.

To remove air from the pleural space.

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which of the following medications? Vitamin K Protamine sulfate Vitamin B12 Heparin sodium

Vitamin K

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg

pH 7.28, PaO2 50 mm Hg

A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse? "These pacing wires can be attached to a temporary pacemaker to shock the heart if it starts beating too fast." "This type of pacemaker will automatically defibrillate the heart if the heart forgets to beat." "The pacemaker will maintain a constant cardiac rhythm." "In case of too slow heart rate, the epicardial leads are attached to a pacemaker to maintain a normal rate."

"In case of too slow heart rate, the epicardial leads are attached to a pacemaker to maintain a normal rate." Epicardial pacing involves attaching an atrial and ventricular pacing lead to the epicardium during heart surgery. The leads are passed through the chest wall and attached to the external power source.

hich signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply. Muffled heart sounds Hypertension Increased central venous pressure (CVP) Increased urine output Jugular vein distention

Muffled heart sounds Increased central venous pressure (CVP) Jugular vein distention

For what client response must the nurse monitor to determine the effectiveness of amiodarone (Cordarone)? Results of fasting lipid profile Presence of cardiac dysrhythmias Degree of blood pressure control Incidence of ischemic chest pain

Presence of cardiac dysrhythmias

A nurse in the pediatric clinic receives a call from the mother of an infant who has been prescribed digoxin (Lanoxin). The mother reports that she forgot whether she gave the morning dose of digoxin. How should the nurse respond? "Give the next dose immediately." "Wait 2 hours before giving the medication." "Skip this dose and give it at the next prescribed time." "Take the baby's pulse and give the medication if it's more than 90 beats/min."

"Skip this dose and give it at the next prescribed time." An additional dose may cause overdosage, leading to toxicity; it is better to skip the dose.

The healthcare provider prescribes permanent pacemaker implantation for a client with a heart block. Which explanation about the procedure should the nurse reinforce with this client? It stimulates a normal heart rate. It shocks the atrioventricular node. It slows the heart to a normal rate. It synchronizes heart valve action.

It stimulates a normal heart rate.

Which client is considered at the highest risk for a dissecting aneurysm? 50-year-old white male with moderate hypertension 42-year-old black female with peripheral vascular disease 55-year-old black male with uncontrolled hypertension 40-year-old white female with uncontrolled hypertension

55-year-old black male with uncontrolled hypertension The highest incidence of dissecting aneurysm is in people 40 to 70 years of age; it is seen four times more frequently in men than women, with a higher incidence in black men. It occurs most often in older clients with hypertension. Unless the 40-year-old female is pregnant or in labor, she is not at as great a risk as a black male. The 50-year-old white male with moderate hypertension and the 42-year-old black female with peripheral vascular disease are not at as high a risk as a black male.

A client's cardiac monitor indicates multiple premature ventricular complexes (PVCs). The nurse expects that the treatment plan will include a prescription for which medication? Amiodarone (Cordarone) Methyldopa (Aldomet) Epinephrine (Adrenalin) Hydrochlorothiazide (HCTZ)

Amiodarone (Cordarone)

A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. An appropriate treatment plan includes: Amiodarone bolus Intracardiac epinephrine Insertion of a pacemaker Cardiopulmonary resuscitation

Amiodarone bolus

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply. Weight loss Extreme fatigue Coughing at night Difficulty breathing Excessive urination

Extreme fatigue Coughing at night Difficulty breathing Fatigue is caused by a lack of adequate oxygenation of body cells caused by a decreased cardiac output. As the cardiac output decreases, pulmonary congestion increases, resulting in pulmonary edema; coughing, especially when lying down, and blood-tinged sputum occur.

How can the nurse best describe heart failure to a client? A cardiac condition caused by inadequate circulating 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 90 mm Hg.

An inability of the heart to pump blood in proportion to metabolic needs. As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume.

The nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. Which prophylactic medication does the nurse anticipate administering during the intrapartum period? Diuretic Anticoagulant Antibiotic Cardiotonic

Antibiotic

The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? Defibrillate. Assess the client's pulse. Initiate advanced cardiac life support. Check another lead to confirm asystole.

Assess the client's pulse. Pulse should be immediately assessed because a lead or electrode coming off may mimic this dysrhythmia Asystole is characterized by complete cessation of electrical activity. A flat baseline is seen, without any evidence of P, QRS, or T waveforms. A pulse is absent, and there is no cardiac output; cardiac arrest has occurred. Once confirmed, Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) protocols are initiated for asystole

While a pacemaker catheter is being inserted, the client's heart rate drops to 38 beats/min. What medication should the nurse expect the health care provider to prescribe? Digoxin (Lanoxin) Lidocaine (Xylocaine) Amiodarone (Cordarone) Atropine sulfate (Atropine)

Atropine sulfate (Atropine) Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate.

A client is admitted to an emergency room with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows: at 11 am, pulse (P), 92 beats/min, respiratory rate (RR), 24 breaths/min, blood pressure (BP), 140/88 mm Hg; 11:15 am, P, 96 beats/min, RR, 26 breaths/min, BP, 128/82 mm Hg; 11:30 am, P, 104 beats/min, RR, 28 breaths/min, BP, 104/68 mm Hg; 11:45 am, P, 118 beats/min, RR, 32 breaths/min, BP, 88/58 mm Hg. The nurse should alert the physician because these changes are most consistent with which of the following complications? Cardiogenic shock Cardiac tamponade Pulmonary embolism Dissecting thoracic aortic aneurysm

Cardiogenic shock Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? Check for a pulse. Start cardiac compressions. Administer oxygen via an ambu bag. Prepare to defibrillate the client.

Check for a pulse.

Which of the following findings supports the nursing diagnosis of deficient fluid volume R/T diuretic therapy on patient with HF? Polyuria Decreased pulse Difficulty breathing General restlessness

General restlessness During dehydration, water is osmotically pulled from cells into the extracellular space. To compensate, cells can generate osmotically active particles that pull water back into the cell and maintain cellular fluid volume. Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring

The nurse cares for a patient in the intensive care unit suffering from cardiogenic shock. When selecting between dopamine and dobutamine, the nurse notes the difference as: Dobutamine has no beta-receptor stimulation. Dopamine has alpha-receptor vasoconstrictive properties. Dobutamine has a greater alpha than beta stimulation. Dopamine has no effect on renal perfusion.

Dopamine has alpha-receptor vasoconstrictive properties.

The nurse is caring for a client who is experiencing cardiogenic shock. Which clinical findings support this diagnosis? Select all that apply. Polyuria Dyspnea Diaphoresis Tachycardia Hypertension

Dyspnea Diaphoresis Tachycardia

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling lightheaded. The client is pale and has a rapid pulse. The nurse concludes that the client is: Hyperventilating. Going into shock. Experiencing anxiety. Developing an infection.

Going into shock. Shock ensues rapidly after a ruptured aortic aneurysm because of profound hemorrhage.

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth? Graft leakage Bowel puncture Abdominal infection Postoperative flatulence

Graft leakage

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth. Graft leakage. Bowel puncture. Abdominal infection. Postoperative flatulence,

Graft leakage. During the first 24 hours after surgery, a sudden increase in abdominal girth most likely is graft related and needs to be investigated. Bowel puncture is a remote possibility but will present with classic signs (e.g., boardlike abdomen, abdominal pain) other than increasing abdominal girth.

A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the primary healthcare provider probably will insert a pacemaker? Angina Chest pain Heart block Tachycardia

Heart block Heart block is the primary indication for a pacemaker because there is an interference with the electrical conduction of impulses from the atria to the ventricles of the heart.

A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock is this client at risk for developing? Vasogenic Neurogenic Cardiogenic Hypovolemic

Hypovolemic

The nurse understands that shock associated with a ruptured abdominal aneurysm is called: Vasogenic shock Neurogenic shock Cardiogenic shock Hypovolemic shock

Hypovolemic shock

A client with a history of cirrhosis of the liver develops heart failure. When ventricular bigeminy develops, the provider orders lidocaine. What alterations in lidocaine dosages does the nurse anticipate? Higher to compensate for the impaired liver function. Lower because the drug is metabolized at a diminished rate. Reduced because other organs will compensate for the sluggish liver. Equal to that needed for other clients to provide a loading dose for the myocardium.

Lower because the drug is metabolized at a diminished rate.

An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I'm sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do? Suppress fears Deny the illness Maintain independence Reassure the adult child

Maintain independence

The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively? Administering supplemental oxygen Maintaining a reduced blood pressure Keeping the client in a supine position Monitoring the peripheral vascular status

Maintaining a reduced blood pressure

A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? Maintaining potassium levels. Preventing increased sodium levels. Limiting the drugs' synergistic effects. Correcting the associated dehydration.

Maintaining potassium levels. Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia.

Which if the following are important nursing measures after an abdominal aortic aneurysm repair? Elevate the legs. Assess cranial nerves and mental status. Administer IV heparin and monitor aPTT. Monitor urine output and creatinine.

Monitor urine output and creatinine. Patients undergoing AAA repair is on extreme risk for volume deficit. Monitoring of renal function is important.

Which drug used in the management of Heart Failure will decrease both preload and afterload and provide relief of anxiety? Morphine Amiodarone Dobutamine Aminophylline

Morphine Morphine has largely been used to treat patients with acute heart failure (AHF) with the most severe forms of dyspnea, and especially in those presenting with acute pulmonary edema. Morphine reduces patient anxiety and decreases the work of breathing.

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply. Pallor Nausea Tachycardia Narrow pulse pressure Decreased respirations

Pallor Tachycardia Narrow pulse pressure

During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client? Severe radiating abdominal pain Pattern of visible peristaltic waves Palpable pulsating abdominal mass Cyanosis with other symptoms of shock

Palpable pulsating abdominal mass

The nurse cares for a patient with hx mitral valve replacement. The patient is now developing deep vein thrombosis on his R calf and receives subcutaneous heparin therapy. Which laboratory value will the nurse follow to ensure effective therapy? Platelet count Partial Thromboplastin Time (PTT) International Normalized Ratio (INR) Prothrombin Time (PT)

Partial Thromboplastin Time (PTT) Activated PTT is used to monitor heparin therapy.

A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? Remove telemetry equipment. Provide the client with a walker. Premedicate the client with an analgesic. Encourage the client to cough and deep breathe

Premedicate the client with an analgesic. The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

A client is in third degree heart block with a heart rate of 40 beats/min, complains of dizziness, and has a blood pressure of 82/60 mmHg. Which of the following should the nurse anticipate will be prescribed? Defibrillate the client. Administer digoxin (Lanoxin). Continue to monitor the client. Prepare for transcutaneous pacing.

Prepare for transcutaneous pacing. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client.

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, what is the most accurate measurement of the client's left ventricular pressure? Right atrial pressure. Cardiac output by thermodilution. Pulmonary artery diastolic pressure. Pulmonary capillary wedge pressure.

Pulmonary capillary wedge pressure. Pulmonary capillary wedge pressure is an indirect measure of left ventricular end-diastolic pressure, an indication of ventricular contractility.

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment? Signs of shock Pulsating abdominal mass Visible peristaltic waves Radiating abdominal pain

Pulsating abdominal mass

he nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Rapid pulse Deep respirations Warm, flushed skin Increased blood pressure Decreased urinary output

Rapid pulse Decreased urinary output

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which of the following findings is (or are) significant? Respiratory rate of 18 and heart rate of 90. Regurgitant murmur at the apex. Heart rate of 90 and capillary refill time of two seconds. Point of maximal impulse palpable in fourth intercostal space.

Regurgitant murmur at the apex.

A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first? Remove all jewelry. Wash the chest area. Use a grounded electrical source. Remove medication patches on the chest.

Remove medication patches on the chest.

A client arrives in the emergency department in cardiac arrest. Which priority action indicates that the nurse is acting as a leader? Trying to find the reason for the disease Asking for the history of any other diseases Waiting for the primary health care provider Resuscitating the client using clinical protocol

Resuscitating the client using clinical protocol

The nurse is caring for a postpartum client with a history of rheumatic carditis. The nurse plans care for this client with what knowledge regarding this client? She should increase her oral fluid intake. She should maintain bed rest for a minimum of 4 days. She is out of immediate danger, because the stress associated with pregnancy is over. She requires monitoring during the first 48 hours because of the stress on the cardiopulmonary system.

She requires monitoring during the first 48 hours because of the stress on the cardiopulmonary system.

A client with heart failure is to receive digoxin (Lanoxin) and asks the nurse why the medication is necessary. The nurse explains that digoxin Increases ventricular contractions Reduces edema in extracellular spaces Slows and strengthens cardiac contractions Increases cardiac impulses through the conduction system of the heart

Slows and strengthens cardiac contractions

The nurse understands that in a second degree Mobitz II atrioventricular (AV) block: Select all that apply. A pacemaker is the only viable treatment. Some P waves are conducted to the ventricles. None of the P waves are conducted to the ventricles. Treatment consists of atropine or a pacemaker.

Some P waves are conducted to the ventricles. Treatment consists of atropine or a pacemaker.

A nurse is developing a health teaching plan for clients with pacemakers. Which activity should the nurse teach these clients to avoid? Having a computed tomography (CT) scan. Standing near a microwave. Swimming in saltwater. Touring a power plant.

Touring a power plant. Large electrical fields can change pacemaker settings and should be avoided

While assessing the cardiovascular status of a patient, the nurse performs auscultation. Which of the following practices should the nurse implement into the assessment during auscultation? Position the patient supine. Ask the patient to hold his or her breath. Palpate the radial pulse while auscultating the apical pulse. Use the bell of the stethoscope when auscultating S1 and S2.

Use the bell of the stethoscope when auscultating S1 and S2.

A client is receiving continuous ECG monitoring while intravenous medication is being administered for premature ventricular complexes (PVC). Which dysrhythmia does the nurse conclude that the client is experiencing when the following rhythm appears on the ECG monitor? Atrial flutter Atrial fibrillation Ventricular fibrillation Ventricular tachycardia

Ventricular tachycardia Ventricular tachycardia has a rate of 140 to 200 or even 250 beats per min; the rhythm is usually regular but may vary.

A nurse is reviewing medication instructions with the parents of an infant who is receiving digoxin (Lanoxin) and spironolactone (Aldactone). What parental response concerning their infant's care indicates that the instructions have been understood? Activity should be restricted. Orange juice must be offered daily. Vomiting should be reported to the health care provider. Anti-inflammatory drugs will not be given with spironolactone.

Vomiting should be reported to the health care provider.

A patient with a diagnosis of heart failure (HF) has been started on a nitroglycerin patch by his primary care provider. This patient should be advised to avoid: high-potassium foods. drugs to treat erectile dysfunction. over-the-counter H2-receptor blockers. nonsteroidal anti-inflammatory drugs (NSAIDs).

drugs to treat erectile dysfunction.