Evolve module 3 quiz

Which description would the nurse expect the client to use to characterize the pain when admitted to the coronary care unit with a diagnosis of ST-segment elevation myocardial infarction? a) Severe, intense chest pain b) Burning sensation of short duration c) Sharp, stabbing chest pain with breathing d) Squeezing chest pain, relieved by nitroglycerin

a) Severe, intense chest pain Rationale: Classic pain with myocardial infarction is described as intense and severe. It is continuous because it is caused by ongoing myocardial ischemia and injury. Burning pain is more consistent with gastric reflux of acid. Pain with myocardial infarction is not usually stabbing pain associated with breathing, which would be more typical of pericarditis or pleurisy. Pain that is relieved by nitroglycerin indicates angina rather than myocardial infarction.

Which description would the nurse use to document the rhythm when a client's cardiac monitor shows a PQRST wave for each beat with a regular rhythm and a rate of 120 beats per minute? a) Atrial fibrillation b) Sinus tachycardia c) Ventricular fibrillation d) First-degree atrioventricular block

b) Sinus tachycardia Rationale: The presence of P wave before each QRS complex indicates a sinus rhythm; a heart rate greater than 100 regular beats per minute is referred to as tachycardia. Atrial fibrillation has no well-defined P waves, with an irregularly irregular pattern of ventricular beats. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a slow and regular rate with a prolonged PR interval.

The nurse caring for a client receiving magnesium sulfate observes respirations of 10 breaths/minute, heart rate of 68 beats/minute, and blood pressure of 88/55 mm Hg. After discontinuing the magnesium sulfate, which priority action would the nurse take? a) Administer oxygen b) Initiate rescue breathing c) Initiate a bolus of intravenous (IV) fluid d) Administer calcium gluconate

d) Administer calcium gluconate Rationale: The client is experiencing magnesium sulfate toxicity, which can be reversed with calcium gluconate. If left untreated, magnesium sulfate toxicity can result in respiratory or cardiac arrest. Oxygen, rescue breathing, and an IV fluid bolus will not reverse the effects of the magnesium sulfate.

Which manifestation would the nurse include when the parents of a child who has just been diagnosed with hemophilia A ask what symptoms of bleeding should they look for in the future? Select all that apply. One, some, or all responses may be correct. a) Nosebleeds b) Blood in the urine c) Painful and swollen joints d) Easy bruising e) Frequent fevers f) Fast clotting of injuries g) Dark-colored tarry stools

Answers: A,B,C,D,G Rationale: Epistaxis, also known as nosebleeds, is a common symptom of a lack of clotting factors. Hematuria (blood in the urine) may be grossly apparent. The child may experience joint pain and deformities from bleeding into joints. Excessive bruising will occur from bleeding into tissue with seemingly minor injuries. Dark-colored tarry consistency stools are indicative of gastrointestinal bleeding. Frequent fevers are not associated with hemophilia. Prolonged clotting times occur with this condition.

Which criteria indicates that a client on a cardiac monitor is in sinus rhythm? Select all that apply. One, some, or all responses may be correct. a) The RR intervals are relatively consistent b) One P wave precedes each QRS complex c) The ST segment is higher than the PR interval d) Four to eight complexes occur in a 6-second strip e) The QRS duration ranges from 0.12 to 0.2 seconds

Answers: A,B Rationale: The consistency of the RR intervals indicates a regular rhythm. A normal P wave before each complex indicates the impulse originated in the sinoatrial (SA) node. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100 beats per minute. Fewer than 6 complexes per 6 seconds equals a heart rate less than 60 beats per minute. The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 seconds.

Which assessments and interventions are necessary once an epidural catheter has been inserted? Select all that apply. One, some, or all responses may be correct. a) Maintain intravenous fluid administration b) Have oxygen available in case of hypotension c) Check the bladder for distention every 2 hours d) Position the client supine for ease of monitoring e) Monitor fetal heart rate and labor progress per hospital protocol f) Administer an oxytocin infusion to maintain the labor pattern

Answers: A,B,C,E Rationale: Hypotension is a common problem in the client receiving epidural analgesia. Intravenous fluids can help counter this problem and provide a vehicle for emergency medication administration. Oxygen should be available in case of hypotension as a result of the epidural block or as emergency care should the anesthetic agent migrate upward. Because sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor, possibly resulting in trauma to the bladder. Fetal heart rate and the progress of labor should be monitored. The client should be positioned on her side to prevent vena cava syndrome. labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.

Which action will the nurse take for a client with a suspected pulmonary embolus? Select all that apply. One, some, or all responses may be correct. a) Administer oxygen at high flow rates b) Notify the Rapid Response Team c) Lower the head of the client's bed d) Place the client on a cardiac monitor e) Anticipate rapid administration of warfarin

Answers: A,B,D Rationale: Administration of oxygen at high flow rates (typically through a nonrebreather mask) will optimize the client's oxygen saturation. The Rapid Response Team will be notified immediately because clients with pulmonary embolus may rapidly develop severe hypoxemia and hypotension. Cardiac monitoring is needed because the client is at risk for dysrhythmias. The head of the bed will be raised to allow fuller lung expansion and improve oxygenation. Warfarin is a slow-acting anticoagulant and would not be given initially to a client with pulmonary embolism. Rather, the nurse will anticipate the need to administer rapidly acting anticoagulants such as fractionated or unfractionated heparin.

A postpartum client is being treated with subcutaneous enoxaparin for deep vein thrombosis of the left calf. Which client cue is of most concern to the nurse? a) Dyspnea b) Pulse rate of 62 beats/min c) Blood pressure of 136/88 mm Hg d) Positive Homan sign in the left leg

a) Dyspnea Rationale: One complication of deep vein thrombosis is pulmonary embolism; dyspnea is a significant sign that should be reported immediately. A low pulse rate is common for several days after birth because of the cardiovascular changes that occur during the early postpartum period. A blood pressure of 136/88 mm Hg is not significant in a client with a deep vein thrombosis. Checking for the Homan sign is contraindicated because the clot could be dislodged.

Which is the initial nursing action when a multipara requests something for pain? a) Examining the client's cervix for dilation and effacement b) Determining the client's options by assessing the prescriptions in the chart c) Asking her whether she prefers an epidural or something in her intravenous line d) Evaluating the fetal monitoring strip to determine the frequency and duration of contractions

a) Examining the client's cervix for dilation and effacement Rationale: Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the initial step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor, information on the fetal monitoring strip regarding contractions will not add to the assessment data.

A client develops a deep vein thrombophlebitis in her leg 3 weeks after giving birth and is admitted for anticoagulant therapy. The nurse would anticipate developing a teaching plan for which anticoagulant? a) Heparin b) Warfarin c) Clopidogrel d) Enoxaparin

a) Heparin Rationale: Heparin is the medication of choice during the acute phase of a deep vein thrombosis; it prevents conversion of fibrinogen to fibrin and prothrombin to thrombin. Warfarin, a long-acting oral anticoagulant, is started after the acute stage has subsided; it is continued for 2-3 months. Clopidogrel is a platelet aggregate inhibitor and is used to reduce the risk of a brain attack. A low-molecular weight heparin (e.g. enoxaparin) is not administered during the acute stage, it may be administered later to prevent future deep vein thromboses.

Which pain relief medication would the nurse expect to find in the plan of care of a client with a myocardial infarction admitted to the cardiac intensive care unit? a) Morphine b) Diazepam c) Midazolam d) Oxycodone

a) Morphine Rationale: Morphine is the medication of choice for a myocardial infarction because it relieves pain quickly and reduces anxiety. It also decreases cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the severe pain associated with a myocardial infarction. Midazolam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the severe pain associated with a myocardial infarction. Oxycodone is an orally administered analgesic; an analgesic that is administered via the intravenous, not the oral, route provides more immediate pain relief.

Which action would the nurse take next after observing this rhythm in a client who came to the emergency department after experiencing "skipped heartbeats"? a) Obtain the client's blood pressure b) Ask the client about caffeine intake c) Review the client's home medications d) Question the client about alcohol use

a) Obtain the client's blood pressure Rationale: The cardiac monitor shows sinus rhythm with unifocal premature ventricular contractions (PVCs). The nurse's first action would be to determine whether the client is hemodynamically stable by assessing blood pressure. Stimulants such as caffeine can cause PVCs, and the nurse would ask about caffeine use after determining that the client is hemodynamically stable and does not need immediate treatment for the PVCs. The client's home medications may provide information about possible causes of the PVCs, but these will be reviewed by the nurse after assessing for hemodynamic effects of the PVCs. Alcohol use can cause PVCs, so the nurse will ask the client about alcohol use after assessing for hemodynamic stability.

Which precaution would the nurse implement for a client with a diagnosis of severe preeclampsia? a) Padding the side rails on the bed b) Having a vacuum extractor available at the time of birth c) Placing 2 units of packed red blood cells (PRBCs) on hold in the blood bank d) Assigning a nursing assistant to stay with the client

a) Padding the side rails on the bed Rationale: A client with severe preeclampsia is at risk for developing seizures. Padded side rails help prevent injury during the clonic-tonic phase of a seizure. The client must be protected from injury if there is a seizure. A vacuum extractor is not a precaution that is necessary for a client with severe pre-eclampsia. This client is at risk for seizures, placing blood products on hold for this client is inappropriate at this time. Assigning a staff member to stay with the client in anticipation of a seizure is impractical and unproductive.

A laboring client receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. Which would be the nurse's immediate action? a) Turning the client on her side b) Checking the vaginal area for bleeding c) Notifying the primary health care provider d) Checking the fetal heart rate every 3 minutes

a) Turning the client on her side Rationale: Maternal hypotension is a common complication of epidural anesthesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. Checking the vaginal area for bleeding is not an assessment specific to epidural anesthesia; it is part of the general nursing care during labor. If signs and symptoms do not abate after the client is turned on her side, the primary health care provider should be notified. Fetal heart rate monitoring is a continuous process, and the rate should be recorded every 15 minutes; if this monitoring is not being performed, the rate should be checked and recorded every 15 minutes

Which laboratory result will the nurse expect when caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI)? a) Decreased white blood cell count b) Elevated serum troponins 1 and T c) Decreased creatinine kinase-MB (CK-MB) d) Decreased B-type natriuretic peptide (BNP)

b) Elevated serum troponins 1 and T Rationale: Elevations of troponin 1 and T levels are indicative and specific for cardiac muscle damage as would occur with STEMI. White blood cell count would increase in the first days after myocardial infarction because of the inflammatory response associated with myocardial cell death. CK-MB is found in cardiac muscle and levels would increase with myocardial cell death. BNP levels are not directly reflective of myocardial infarction but might increase if the client develops heart failure as a complication of myocardial infarction

A postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an activated partial thromboplastin time (aPTT) of 128 seconds. Which action would the nurse take in response to this situation? a) Increase the IV rate of heparin b) Interrupt the infusion and notify the primary health care provider of the aPTT result c) Document the result on the medical record and recheck the aPTT in 4 hours d) Call the primary health care provider to obtain a prescription for a low-molecular-weight heparin

b) Interrupt the infusion and notify the primary health care provider of the aPTT result Rationale: The heparin should be withheld, because 128 seconds is almost 4 times the normal time it takes a fibrin clot to form (25-36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is 1 1/2 to 2 times the normal range. The primary health care provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.

Which action would be taken first when a staff nurse is instructed by the charge nurse to give the scheduled warfarin dose to a client whose current international normalized ratio (INR) is 6? a) Refuse to give the unsafe medication dose b) Remind the charge nurse of the INR result c) Ask the hospital pharmacist to talk with the nurse manager d) Ask the health care provider whether to give the medication

b) Remind the charge nurse of the INR result Rationale: Because the INR is at an unsafe level, warfarin would not be given. Professional communication would include first clarifying concerns with the charge nurse, by discussing the abnormal INR result and reasons for not administering another dose of warfarin. Although the nurse could refuse to give the medication as the first action, this is not likely to foster professional communication or workplace relationships. Direct communication with coworkers about concerns is more professional and fosters better relationships than having a third party (such as the pharmacist) address concerns. Because the INR is prolonged and the warfarin would be unsafe to give, the nurse does not need to ask the health care provider about giving the warfarin but would notify the provider about the INR result.

Which complication would the nurse be alert for in a client receiving an oxytocin infusion to induce labor? a) Intense pain b) Uterine tetany c) Hypoglycemia d) Umbilical cord prolapse

b) Uterine tetany Rationale: Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise. Intense pain can be associated with strong uterine contractions; this is not a complication. Hypoglycemia is unrelated to uterine contractions. Umbilical cord prolapse is not likely to occur when induction of labor is initiated.

Assessment of a primipara who has had a vaginal birth 2 hours earlier reveals a moderate to large amount of lochia rubra, a firm fundus that is at the umbilicus and deviated to the right, and pain that she rates as a 3 on a scale of 1 to 10. Which is an immediate goal of nursing care for this client? a) Relieve pain b) Prevent hypotension c) Facilitate client voiding d) Decrease the amount of lochia

c) Facilitate client voiding Rationale: A fundus that is deviated to the right during the fourth stage of labor commonly is caused by a distended bladder. If the bladder remains distended, involution will be inhibited, resulting in a boggy uterus that is prone to hemorrhage. Therefore client voiding is an immediate goal of nursing care. Because the client's pain is minimal, the immediate goal of care is emptying the bladder to prevent hemorrhage. Preventing hypotension is not an immediate goal of care because there is no indication that a risk for hypotension exists, as the fundus is firmly contracted. The amount of lochia is normal for 2 hours postpartum.

Which therapeutic effect of digoxin would the nurse expect? a) Decreased cardiac output b) Decreased stroke volume of the heart c) Increased contractile force of the myocardium d) Increased electrical conduction through the atrioventricular (AV) node

c) Increased contractile force of the myocardium Rationale: Digoxin produces a positive inotropic effect that increases the strength of myocardial contractions and thus cardiac output. The positive inotropic effect of digoxin increases, not decreases, cardiac output. Digoxin increases the strength of myocardial contractions (positive inotropic effect) and slows the heart rate (negative chronotropic effect); these effects increase the stroke volume of the heart. Digoxin decreases the refractory period of the AV node and decreases conduction through the sinoatrial (SA) and AV nodes.

Which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider? a) Severe right calf pain b) Right calf redness and swelling c) Oxygen saturation 89% d) Heart rate of 136 beats/minute

c) Oxygen saturation 89% Rationale: Low oxygen saturation in the setting of venous thrombosis may indicate pulmonary embolism, which will require rapid interventions, such as actions to improve oxygenation. Severe right calf pain is consistent with the client diagnosis of right calf venous thrombosis. Right calf redness and swelling are consistent with a diagnosis of right calf venous thrombosis. The elevated heart rate may be due to pulmonary embolism, and improvement of oxygen saturation would also decrease the heart rate.

Which diagnostic test is most important for the nurse to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome (ACS)? a) Chest radiograph b) Troponin T (cTnT) c) Creatine kinase MB (CK-MB) d) 12-lead electrocardiogram (ECG)

d) 12-lead electrocardiogram (ECG) Rationale: With acute coronary syndrome, ECG changes indicating myocardial injury and infarction occur within minutes. Because treatment for ACS usually involves actions to restore blood flow to the myocardium as rapidly as possible, it is essential that the ECG be done and evaluated immediately. The other tests are also appropriate but will be done after the ECG. Changes in the chest radiograph will occur if there is cardiac enlargement, pericardial effusion, or heart failure secondary to the myocardial infarction. Troponin T will increase in an average of 4-6 hours with myocardial infarction. CK-MB starts to increase at about 6 hours after myocardial infarction.

Which explanation would the nurse give to a client with a diagnosis of myocardial infarction who asks the nurse, "What is causing the pain I am having?" a) Compression of the heart muscle b) Release of myocardial isoenzymes c) Rapid vasodilation of the coronary arteries d) Inadequate oxygenation of the myocardium

d) Inadequate oxygenation of the myocardium Rationale: Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain.

Which rhythm is the client experiencing when the cardiac monitor shows sudden bursts of a regular heart rhythm with a rate of 220 beats/minute, normal QRS duration, and P waves that are difficult to see? a) Sinus tachycardia b) Atrial fibrillation c) Ventricular tachycardia (VT) d) Paroxysmal supraventricular tachycardia (PSVT)

d) Paroxysmal supraventricular tachycardia (PSVT) Rationale: PSVT occurs above the ventricles, and it has an abrupt onset and cessation. Sinus tachycardia results when the sinoatrial node fires faster than 100 beats/minute. Onset is gradual rather than abrupt. PR interval is 0.12 to 0.20 seconds. P and QRS waves are consistent in shape. Atrial fibrillation is irregular and does not start and stop suddenly. VT occurs at a rate greater than 100 beats/minute, but the rate is usually around 150 beats/minute and may be up to 250 beats/minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex.

For which purpose would enoxaparin 40 mg subcutaneously daily be prescribed for a client who had abdominal surgery? a) To control postoperative fever b) To provide a constant source of mild analgesia c) To limit the postsurgical inflammatory response d) To provide prophylaxis against postoperative thrombus formation

d) To provide prophylaxis against postoperative thrombus formation Rationale: Enoxaparin, a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and of prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III. Enoxaparin is not an antipyretic. Enoxaparin is not an analgesic. Enoxaparin is not an anti-inflammatory medication.

The nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. Which other parameter can the nurse use to estimate blood loss in a postpartum client? a) Odor of the lochia b) Color of the lochia c) Presence of small clots on the pad d) Weighing blood-stained pads and items

d) Weighing blood-stained pads and items Rationale: Knowing the time elapsed between pad changes will help the nurse quantify the blood loss. The most accurate estimate of blood loss involves quantifying blood loss through weight. The dry weight of the soaked item is subtracted from the blood-soaked item to produce a weight in grams. 1 gram=1 mL. Postpartum hemorrhage may occur after the third stage of labor or during the first 24 postpartum hours; hemorrhage is defined as a blood loss in excess of 500 mL. The best estimation of blood loss takes into consideration a combination of factors, including degree of saturation of perineal pads and frequency of pad changes. The nurse must also assess whether there is pooling of blood under the buttocks. Odor will reflect the possible complication of infection, not hemorrhage. The color of vaginal discharge at this time will not indicate hemorrhage. The color of lochia during the first postpartum day is expected to be red (rubra). The presence of clots is common and is not an indicator of the amount of blood loss.

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct. a) Providing oxygen b) Assessing vital signs c) Obtaining a 12-lead EKG d) Drawing blood for cardiac enzymes e) Auscultating heart sounds f) Administering nitroglycerin

All of the answers are correct Rationale: The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital signs, obtain a 12-lead EKG, and auscultate heart sounds to determine rhythm changes related to cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enzymes. Changes in the levels of these enzymes (including troponin, creatine kinase, and myoglobin) can indicate damage to heart tissue. Nitroglycerin is administered to promote coronary vasodilation.

Which action would the nurse implement to enhance safety for a laboring client and fetus with a prolapsed cord? Select all that apply. One, some, or all responses may be correct. a) Increasing the client's intravenous fluid drip rate b) Placing the client in the extreme Trendelenburg position c) Administering oxygen to the client via a nonrebreather mask d) Immediately notifying the client's primary health care provider e) Quickly gloving the examining hand and inserting two fingers into the vagina to the cervix

All of the answers are correct Rationale: To enhance safety for a laboring client and fetus experiencing cord prolapse, the nurse would immediately notify the health care provider, or ask a colleague to do so. The nurse would increase the client's existing intravenous drip rate; place the client in the extreme Trendelenburg position; and administer oxygen using a nonrebreather mask. Then, after gloving the examining hand, the nurse can insert two fingers into the vagina to the cervix to alleviate cord compression.

An amniotomy is performed in a laboring client at 42 weeks gestation. Place the nursing care actions in their order of priority. a) Inspecting the perineum for umbilical cord prolapse b) Checking the fetal heart rate tracings c) assessing the characteristics of the amniotic fluid d) Monitoring the client for signs of an infection

Order: B, A, C, D Rationale: An Amniotomy is when the provider ruptures the amniotic membranes. Fetal heart rate is monitored just before and immediately after the amniotomy and then they are compared. If there are any drastic changes between the two, then the next step would be to check for prolapse of the umbilical cord. After this step, the amniotic fluid needs to be assessed for amount, color, odor, and the presence of meconium or blood. Since there is now an opening for organisms to make their way into the uterus, the mother should then be monitored for a rise in temperature at least every 2 hours and vaginal exams should be minimal

Which diagnosis increases the risk for development of a pulmonary embolism? a) Atrial fibrillation b) Forearm laceration c) Migraine headache d) Respiratory infection

a) Atrial fibrillation Rationale: Inadequate atrial contraction that occurs during fibrillation leads to the pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headaches. Respiratory infections do not increase pulmonary embolism risk.