Crisis 2 A
A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow-up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes
A, B, E
A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39 C (102.2 F) orally. Which of the following actions should the nurse take? A. Inform the surgeon of the elevated temperature B. Transfer the client to the preoperative unit C. Apply ice packs to the groin D. Encourage the client to increase intake of clear liquids
A. The nurse should immediately notify the surgeon of the elevated temperature to determine if canceling the surgery is necessary due to an underlying infection.
A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? A. Assess bowel sounds B. Administer antiemetic medication C. Restart prescribed IV fluids D. Insert a prescribed nasogastric tube
A. Using the nursing process, the first step is to assess the client. Assessing bowel sounds is the priority action by the nurse.
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia
C
A nurse is completing the admission physical assessment of client who has a history of mitral valve insufficiency. Which of the following findings should the nurse expect? A. S4 heart sound B. Petechiae C. Crackles in lung bases D. Splenomegaly
C. Crackles in the lung bases is an expected finding in a client who has pulmonary congestion due to mitral valve insufficiency.
A nurse administered midazolam IV bolus to a client before a procedure. His blood pressure is 86/40 Hg, and his pulse is 134/min. Which of the following IV medications should the nurse administer? A. Naloxone B. Morphine C. Flumazenil D. Atropine
C. Midazolam is a benzodiazepine. The nurse should administer flumezenil to reverse its effects.
A clients electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? A. Sinus tachycardia B. Sinus bradycardia C. Sinus dysrhythmia D. Normal sinus rhythm
A
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? A. The neurovascular status is normal because of increased blood flow through the leg. B. The neurovascular status is moderately impaired, and the surgeon should be called. C. The neurovascular status is slightly deteriorating and should be monitored for another hour. D. The neurovascular status is adequate from an arterial approach, but venous complications are arising.
A
The nurse should evaluate that defibrillation of a client was most successful if which observation was made? A. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg B. Nonarousable, sinus rhythm, BP 88/60 mm Hg C. Arousable, marked bradycardia, BP 86/54 mm Hg D. Nonarousable, supraventriculare tachycardia, BP 122/60 mm Hg
A
A nurse is reviewing the health records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (Select all that apply.) A. A client who has a WBC of 22,500/uL B. A client who uses and insulin pump C. A client who takes warfarin daily D. A client who has heart failure E. A client who has a BMI of 26
A, B, C, D An increased WBC indicates an underlying infection and places the client at risk for postoperative complications. An insulin pump indicates the client has type 1 diabetes mellitus and places the client at risk of postoperative complications, such as delayed wound healing. A client who takes warfarin daily is at risk for bleeding and postoperative complications, such as hemorrhage. A client who has heart failure is at risk for complications, such as fluid overload or dysrhythmias.
A nurse is caring for a female client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (Select all that apply.) A. Urine output less than 25 mL/hr B. Hematocrit 48% C. BUN 24 mg/dL D. Tenting of skin over the sternum E. Apical pulse rate 62/min
A, B, C, D Urine ouput less than 25 mL/hr is a manifestation of hypovolemia and requires intervention by IV fluid therapy. Hematocrit 48% indicates concentrated blood volume and is a manifestation of hypovolemia, requiring intervention by IV fluid therapy. BUN 24 mg/dL indicates decreased kidney function and can be a manifestation of hypovolemia, requiring intervention with IV fluid therapy. Tenting of skin indicates decreased or absent skin turgor due to dehydration, requiring intervention with IV fluid therapy.
A client who has had abdominal surgery complaints of feeling as though "something gave way" in the incision site. The nurse removes the dressing and notes the presence of a loop of bowel protruding though the incision. Which interventions should the nurse take? Select all that apply. A. Contact the surgeon B. Instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken E. Place a sterile saline dressing and ice packs over the wound F. Place the client in a supine position without a pillow under the head
A, B, C, D Wound dehiscence is the separation of the wound edges. Wound evisceration is the protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applies because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? A. Infuse iced IV fluids B. Provide 100% oxygen C. Place the client on a cooling blanket D. Treat the complication while continuing surgery E. Administer IV dantrolene
A, B, C, E Infusing iced IV fluids should help lower the client's rapidly rising temperature. Providing 100% oxygen will help prevent hypoxia due to muscle tremors and rigidity from increased lactic acid. Placing the client on a cooling blanket will help lower the rapidly rising temperature. Dantrolene IV is a muscle relaxant that treats malignant hyperthermia.
A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Encourage the use of the incentive spirometer every 2 hr B. Instruct the client to splint the incision when coughing and deep breathing C. Reposition the client every 2 hr D. Administer antibiotic therapy E. Assist with early ambulation
A, B, C, E Use of the incentive spirometer every 2 hr expands the lungs and prevents atelectasis. Incisional splinting with a pillow or blanket supports the incision during coughing and deep breathing, which prevents ateletasis. Repositioning the client every 2 hr will mobilize secretions and allow the client to deep breathe and expand the lungs to prevent atelectasis. Early ambulation expands the lungs through deep breathing and prevents atelectasis.
A nurse providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (Select all that apply.) A. "Take your heart medication with a sip of water before surgery" B. " Splint the abdominal incision with a pillow when coughing and deep breathing" C. "Bed rest is recommended for the first 48 hr" D. "Antiembolism stockings are applied before surgery" E. "You may eat solid foods up to 4 hr before surgery"
A, B, D The nurse should teach the client to take a certain cardiac and other medications as prescribed with a sip of water before surgery. The nurse should teach the client how to splint with a pillow to support the incision when coughing and deep breathing postoperatively. The nurse should inform the client of the application of antiembolism stockings to prevent deep-vein thrombosis.
A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a with a group of nurses. Which of the following findings should the nurse include in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema
A, B, E
A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestations are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea
A, B, E Tachypnea is an expected finding in a client who has pulmonary edema. A persistent cough with pink, frothy sputum is an expected finding in a client who has pulmonary edema. Orthopnea is an expected finding in a client who has pulmonary edema.
A nurse is caring for a client following the insertion of a temorary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following should the nurse report to the provider? (Select all that apply.) A. Cool and clammy foot with capillary refill of 5 seconds B. Observed pacing spike followed by a QRS complex C. Persistent hiccups D. Heart rate 84/min E. Blood pressure 104/62 mmHg
A, C A cool, clammy foot can be an indication of a femoral hematoma secondary to insertion of the lead wires and should be reported. Persistent hiccups can indicate lead wire perforation and stimulation of the diaphragm and should be reported.
A nurse is admitting a client to the client to the coronary care unit following placement of a temporary pacemaker. Which of the following nursing actions should the nurse use to promote client safety? (Select all that apply.) A. Wear gloves when handling pacemaker leads B. Ensure electronic equipment has three-pronged grounding plugs C. Minimize the client's shoulder movements D. Hold the lead wires taut when turning the client E. Keep extra pacemaker batteries at least 300 ft away from the client
A, C The nurse should wear gloves when handling pacemaker leads. The client should wear a sling to minimize shoulder movement and promote secure anchoring of the lead wires.
A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? (Select all that apply.) A. 1 slice cheddar cheese B. 1 medium beef hotdog C. 3 oz Atlantic salmon D. 3 oz roasted chicken breast E. 2 oz lean baked ham
A, C, D One slice cheddar cheese contains 180 mg sodium. Three ounces Atlantic salmon contains 37 mg sodium. Three ounces roasted chicken breast contains 62 mg sodium.
A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize the following data as risk factors for this condition? (Select all that apply.) A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for 5 years D. Weight gain of 10 lb in past year E. Diastolic murmur present
A, C, E A history of congenital malformations is a risk factor for valvular heart disease. Hypertension places a client a risk for valvular heart disease. A murmur indicates turbulent blood flow, which is often due to valvular heart disease.
A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery
A, D, E
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? A. "Use of an incentive spirometer will help prevent pneumonia" B. "Close monitoring of your oxygen saturation will detect hypoxemia" C. "Administration of intravenous fluids will prevent or treat fluid imbalance" D. "Early ambulation and administration of blood thinners will prevent pulmonary embolism"
A. Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly connected to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a defict; however, this is not related to coughing and deep-breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques.
The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway B. Check tubes or drains for patency C. Check the dressing to assess for bleeding D. Assess the vital signs to compare with preoperative measurements
A. The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and tubes or drains. The other nursing actions should be performed after a patent airway has been established.
A nurse is assisting an anesthesiologist in the delivery of nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A. Assess oxygen saturation B. Measure blood pressure C. Palpate pulse rate D. Check temperature
A. The greatest risk for the client is injury from hypoxia. Therefore, this is the priority finding.
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A. Urinary output of 20 mL/hour B. Temperature of 37.6 C (99.6 F) C. Blood pressure of 100/70 mm Hg D. Serous drainage on the surgical dressing
A. Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7 C (100 F) or lower than 36.1 C (97 F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review? A. "This means the pacemaker fires in an asynchronous pattern" B. "This means the pacemaker fires only when the heart rate is below a certain rate" C. "The pacemaker can automatically adjust to a client's increased activity" D. "The pacemaker activity is triggered by heart muscle activity"
A. Fixed rate mode is asynchronous, meaning the pacemaker fires without regard from electrical activity in the heart.
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats/minutes C. Blood pressure of 110/70 mm Hg D. Hypoactive bowel sounds in all 4 quadrants
A. Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.
A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following laboratory findings should the nurse report to the provider? A. Platelets 100,000/mm3 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase (ALT) 30 IU/L
A. Long-term NSAID therapy can lower platelets. This finding is outside the expected reference range and should be reported to the provider.
A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropritate amount of fluids he is allowed. Which of the followign statements is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink" B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day" C. "This is the same as 2 quarts or about the same as two pots of coffee" D. "Take sips or water or ice chips so you will no take in too much fluid"
A. Pouring the amount of fluid consumed into an empty 2 L bottle provides a visual guide for the client as to the amount consumed and how to plan daily intake.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? A. Hemoglobin, 8.0 g/dL (80 mmol/L) B. Sodium, 145 mEq/L (145 mmol/L C. Serum creatinine, 0.8 mg/dL (70.6 µm/L) D. Platelets, 210,000 cells/mm3 (210 x 10^3/ µL/210x10^9/L)
A. Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis
A. Splinter hemorrhages in nail beds and and a report of fever are findings associated with infective endocarditis.
A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? A. "I will notify the airport screeners about my pacemaker" B. "I will expect to have occasional hiccups" C. "I will have to disconnect my garage door opener" D. "I will take my pulse every 2 to 3 days"
A. The client should notify airport screening personnel about a pacemaker.
The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? A. Prednisone B. Ferrous Sulfate C. Cyclobenzaprine D. Conjugated estrogen
A. Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in post menopausal women. These last three medications may be withheld before surgery without undue effects on the client.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide D. Administering morphine sulfate intravenously E. Transporting the client to the coronary care unit F. Placing the client in a low Fowler's side-lying position
AC
A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monoplastic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? A. 50 J B. 120 J C. 200 J D. 300 J
B
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? A. Bradycardia B. Ventricular dysrhythmias C. Rising diastolic blood pressure D. Falling central venous pressure
B
A client with myocardial infarction suddenly becomes tachycardiac, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? A. Stridor B. Crackles C. Scattered rhonchi D. Diminished breath sounds
B
The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is the most recent). The client's blood urea nitrogen is 35 mg/dL (12.6 mmol/L) and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? A. Check the urine specific gravity B. Call the health care provider (HCP) C. Put the IV line on a pump so that the infusion rate is sure to stay stable D. Check to see if the client had a blood sample for a serum albumin level drawn.
B
The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? A. Blood pressure B. Status of airway C. Oxygen flow rate D. Level of consciousness
B
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A. Muffled heart sounds B. A rise in blood pressure C. Jugular vein distension D. Client expressions of dyspnea
B
A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine
B. A client who has bradycardia is a candidate for a pacemaker to increase his heart rate.
A nurse is completing discharge teaching with a client who has a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A. "I will be glad to get back to my exercise routine right away" B. "I will have my prothrombin time checked on a regular basis" C. "I will talk to my dentist about no longer needing to take antibiotics before dental exams" D. "I will continue to limit my intake of foods containing potassium"
B. Anticoagulant therapy with warfarin (Coumadin) is necessary for the client following placement of a mechanical heart valve; the client's prothrombin time will be checked on a regular basis.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, tender skin
B. Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warn, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight B. Assist the client into a high-Fowler's position C. Auscultate lung sounds D. Check oxygen saturation with a pulse oximeter
B. Using the airway, breathing, and circulation (ABC) priority approach to client care, the first action the nurse should take is to assist the client into high-Fowler's position. This will decrease venous return to the heart (preload) and help relieve lung congestion.
A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk of acquiring rheumatic endocarditis? A. Older adult who has chronic obstructive pulmonary disease B. Child who has streptococcal pharygitis C. Middle-age adult who has lupus erythematosus D. Young adult who recently received a body tattoo
B. A child who has streptococcal pharyngitis is at risk for developing rheumatic fever which could result in rheumatic endocarditis.
A nurse is completing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should hte nurse include as having the highest source of potassium? A. 1 medium apple B. 1 medium baked potato C. 1 slice toast with 1 tbsp peanut butter D. 1 scrambled egg
B. A medium baked potato is the best food source of potassium because it contains 926 mg potassium per serving.
A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A. Monitor serum creatinine levels B. Provide airway support C. Turn the client to the right side D. Administer 0.9% sodium chloride 500 mL IV bolus
B. A systemic toxic reaction results in CNS depression. In this event, it is important to support the client's airway with maintaining patency and administering supplemental oxygen.
A nurse is caring for a client 72-year-old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? A. "This will improve blood flow in your mother's coronary arteries" B. "This will permit your mother to resume her activities of daily living" C. "This will prolong your mother's life" D. "This will reverse the effects to damaged area"
B. Surgery is indicated for older adult clients when manifestations interfere with activities of daily living.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? A. Glipizide B. Metformin C. Repaglinide D. Regular Insulin
C
A client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. A nurse should assess the client for which associated signs and/or symptoms? A. Flat neck veins B. Nausea and vomiting C. Hypotension and dizziness D. Hypertension and headache
C
A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? A. Administer digoxin B. Defibrillate the client C. Continue to monitor the client D. Prepare for transcutaneous pacing
C
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? A. Sensation of palpitations B. Causative factors, such as caffeine C. Blood pressure and oxygen saturation D. Precipitating factors, such as infection
C
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse see no electrocardiographic complexes on he screen. Which is the priority nursing action? A. Call a code B. Call the health care provider C. Check the client's status and lead placement D. Press the recorder button on the elecrocardiogram console
C
A client who had cardiac surgery 24 hours ago has 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 (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticiate that the client is at risk for which problem? A. Hyopvolemia B. Acute kidney injury C. Glomerulonephritis D. Urinary tract infection
C
The nurse is watching the cardiac monitor and notices the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhytmia? A. Sinus tachycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions
C
A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (Select all that apply.) A. Explain to the client the purpose of having the procedure B. Inform the client of risks to having the procedure C. Ensure the client understands information about the procedure D. Witness the client signing the informed consent form E. Determine if the client is capable of understanding the reason for the procedure
C, D, E The nurse should ensure the client understands the information about the procedure. The nurse should witness the client sign the informed consent. The nurse should determine if the client is capable of understanding the reason for the procedure.
A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all that apply.) A. Potassium 3.9 mEq/L B. Sodium 145 mEq/L C. Creatinine 2.8 mg/dL D. Blood glucose 235 mg/dL E. WBC 17, 850/mm3
C, D, E The nurse should report an elevated creatinine level, which can indicate impaired renal function. The nurse should report an elevated blood glucose, which needs treatment prior to surgery. The nurse should report an elevated WBC count, which indicates a need for antibiotic therapy before surgery.
A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? A. Respiratory history (Dyspnea with exertion for 3 years) B. Vital signs (T 99F, BP 142/86 mmHG, HR 88/min, RR 20/min) C. Medication history (iron supplement, multivitamin, antilipemic, and nitroglycerin) D. Medications to be administered (Ferrous sulfate, Diazepam, Isosorbide)
C. A client who is to undergo cardioversion needs to be on anticoagulant therapy for 4 to 6 weeks prior to the procedure.
A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that... A. the cardioverter is being charged to the appropriate setting B. they should initiate CPR due to pulseless electrical activity C. they cannot be in contact with equipment connected to the client D. a time-out is being called to verify correct protocols
C. A safety concern for personnel performing cardioversion is to "stand clear" of the client and equipment connected to the client when a shock is delivered to prevent them from also receiving a shock.
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan on the day of surgery? A. Avoid oral hygiene and rinsing with mouthwash B. Verify that the client has not eaten for the last 24 hours C. Have the client void immediately before going into surgery D. Report immediately any slight increase in blood pressure or pulse
C. The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of foods and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? A. "Aspirin can cause bleeding after surgery" B. "Aspirin can cause my ability to clot blood to be abnormal" C. "I need to continue to take the aspirin until the day of surgery" D. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery"
C. Antiplatelets alter normal clotting factors an increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options A, B, and D are accurate client statements.
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? A. "If it's any help, everyone is nervous before surgery" B. "I will be happy to explain the entire surgical procedure to you" C. "Can you share with me what you've been told about your surgery" D. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"
C. Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option A does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option D avoid the client's anxiety and ins focused on postoperative care.
A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? A. Decrease the client's fluid intake B. Apply pressure to the puncture site C. Place the head of the head of the bed flat D. Instruct the client to lie prone
C. Placing the head of the bed flat will decrease the intensity of the headache.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? A. It can develop into ventricular fibrillation at any time B. It is almost impossible to convert to a normal rhythm C. It is uncomfortable for the client, giving a sense of impending doom D. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia
D
A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication? Changes over 45 minutes Pulse increase from 92 to 118 bpm Respiratory rate increase from 24 to 32 breaths/min Blood pressure decrease from 140/88 to 88/58 mm Hg A. Cardiogenic shock B. Cardiac tamponade C. Pulmonary embolism D. Dissecting thoracic aortic aneurysm
D
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? A. Ensure that the client has been intubated B. Set the defibrillator to the "synchronize" mode C. Administer an amiodarone bolus intravenously D. Confirm that the rhythm is actually ventricular fibrillation
D
The nurse is caring for a client who has just has implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? A. Anxiety level of the client and family B. Presence of MedicAlert card for the client to carry C. Knowledge of restrictions on postdischarge physical activity D. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
D
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes ,easure 0.06 seconds. The overal heart rate is 64 beats/minute. Which action should the nurse take? A. Check vital signs B. Check laboratory test results C. Notify the health care provider D. Continue to monitor for any rhythm change
D
A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. Compare and contrast the peripheral pulses B. Apply a warm blanket C. Assess dressings D. Place the client in a lateral position
D The greatest risk to the client who is unresponsive or unconscious is injury from aspiration
A client with gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? A. Obtain a court order for the surgery B. Have the charge nurse sign the informed consent immediately C. Send the client to surgery without the consent form being signed D. Obtain a telephone consent from a family member, following agency policy
D. Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but the data in question do not indicate an emergency. Options A, B, and C are not appropriate in this situation. Also agency policies regarding informed consent should always be followed.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible B. Keep a loose seal between the lips and the mouthpiece C. After maximum inspiration, hold the breath for 15 seconds and exhale D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees
D. For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.
A nurse is admitted a client who had complete heart block as demonstrated by ECG. The client's heart rate is 34/min and blood pressure is 83/49mmHG. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? A. Transport the client to the cardiovascular laboratory B. Prepare the client for insertion of a permanent pacemaker C. Obtain a signed informed consent form for a pacemaker D. Apply transcutaneous pacemaker pads
D. The greatest risk to this client is injury or death from inadequate tissue perfusion; therefore, the first action the nurse should take is to apply transcutaneous pacemaker can be placed.
A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub
D. A friction rub can be heard during auscultation of a client who has pericarditis
A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture
D. A throat culture can reveal the presence of of streptococcus, which is the leading cause of rheumatic endocarditis.
A preoperative nurse is caring for a client who is having colon resection. Which of the following actions should the nurse take? A. Encourage the client to void after preoperative medication administration B. Administer antibiotics 2 hr prior to surgical incision C. Remove hair using a manual razor D. Remove nail polish on fingers and toes
D. The nurse should ensure the nail beds are visible for color and circulation by removing nail polish before surgery.
