Exam 2 Practice Questions - adult health 2
. A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest X-ray, an ECG, and two (2) mg of morphine given intravenously. The nurse should first: A. Administer the morphine. B. Obtain a 12-lead ECG. C. Obtain the lab work. D. Order the chest x-ray.
A
A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted two (2) days ago. The nurse would plan to do which of the following next? A. Review the intake and output records for the last two (2) days. B. Change the time of diuretic administration from morning to evening. C. Request a sodium restriction of one (1) g/day from the physician. D. Order daily weight starting the following morning.
A
Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include a demonstration of the proper use of: A. A manual toothbrush B. An electric toothbrush C. An irrigation device D. Dental floss
A
. What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. A. The RR intervals are relatively consistent. B. One P wave precedes each QRS complex. C. Four to eight complexes occur in a 6-second strip. D. The ST segment is higher than the PR interval. E. The QRS complex ranges from 0.12 to 0.2 seconds.
A, B
A nurse is concerned because the client's cardiac output is low. The nurse would implement interventions affecting which parameters? Select all that apply. a. Heart rate b. BMI c. Preload d. Afterload e. Contractility
A, C, D, E
Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. B. Activity intolerance related to increased cardiac output. C. Decreased cardiac output related to structural and functional changes. D. Impaired gas exchange related to decreased sympathetic nervous system activity. E. Acute pain related to inability to meet the oxygen demands.
A, C, E
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Check the client's status. 3. Call the health care provider. 4. Document the lack of complexes.
Answer: 2 Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.
A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The complication the nurse will constantly observe for is: A. Presence of heart murmur B. Systemic emboli C. Fever D. Congestive heart failure
B
A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse's next action would be to: A. Call for the doctor. B. Start an intravenous line. C. Obtain a portable chest radiograph. D. Draw blood for laboratory studies.
B
The cardiac nurse is assessing their patient after emergent admission to the CCU. The patient is complaining of chest pain and just reported a large frank red, bloody stool to the RN. The nurse knows that further investigation is needed as anemia can cause: a. Poor perfusion to the right ventricle b. Lack of oxygen carrying capacity d/t decreased circulating RBC's c. Infarction to primary vasculature d. Decreased cardiac output
B
When ventricular fibrillation occurs in a CCU, the first person reaching the client should: A. Administer oxygen. B. Defibrillate the client. C. Initiate CPR. D. Administer sodium bicarbonate intravenously.
B
Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet? A. Apples B. Tomato juice C. Whole wheat bread D. Beef tenderloin
B
While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: A. Increase the IV infusion rate. B. Notify the physician promptly. C. Increase the oxygen concentration. D. Administer a prescribed analgesic.
B
A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? A. Monitoring vital signs. B. Completing a physical assessment. C. Maintaining cardiac monitoring. D. Maintaining at least one IV access site
C
A client is experiencing tachycardia. The nurse's understanding of the physiological basis for this symptom is explained by which of the following statements? A. The demand for oxygen is decreased because of pleural involvement. B. The inflammatory process causes the body to demand more oxygen to meet its needs. C. The heart has to pump faster to meet the demand for oxygen when there is lowered arterial oxygen tension. D. Respirations are labored.
C
A PA catheter has just been inserted. What is the nurse's primary intervention? a. Place a bulky dressing over the catheter site. b. Draw 30 mL of blood back through the catheter to check patency. c. Flush the catheter with heparinized solution. d. for a chest x-ray.
D
A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? A. Intake and output B. Baseline peripheral pulse rates C. Height and weight D. Allergy to iodine or shellfish
D
What is the primary nursing intervention indicated for a symptomatic client with a PAWP of 3 mm Hg? a. Decrease afterload. b. Restrict the client's fluids. c. Administer diuretics to decrease preload. d. Begin volume replacement.
D
When assessing an ECG, the nurse knows that the P-R interval represents the time it takes for the: A. Impulse to begin atrial contraction. B. Impulse to transverse the atria to the AV node. C. SA node to discharge the impulse to begin atrial depolarization. D. Impulse to travel to the ventricles.
D
A client enters the ER complaining of chest pressure and severe epigastric distress. His VS are 158/90, 94, 24, and 99*F. The doctor orders cardiac enzymes. If the client were diagnosed with an MI, the nurse would expect which cardiac enzyme to rise within the next 3 to 8 hours? A. Creatine kinase (CK or CPK) B. Lactic dehydrogenase (LDH) C. LDH-1 D. LDH-2
A
A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. A nurse assesses the client for: A. Hypotension and dizziness B. Nausea and vomiting C. Hypertension and headache D. Flat neck veins
A
A client is having frequent premature ventricular contractions. A nurse would place a priority on the assessment of which of the following items? A. Blood pressure and peripheral perfusion. B. Sensation of palpitations. C. Causative factors such as caffeine. D. Precipitating factors such as infection.
A
A client's electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is: A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia D. Sinus dysrhythmia
A
A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: A. Normal because of the increased blood flow through the leg. B. Slightly deteriorating and should be monitored for another hour. C. Moderately impaired, and the surgeon should be called. D. Adequate from the arterial approach, but venous complications are arising.
A
Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn't understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is: A. "Cardiac rehabilitation is not a cure but can help restore you to many of your former activities." B. "Here we teach you to gradually change your lifestyle to accommodate your heart disease." C. "You are probably right but we can gradually increase your activities so that you can live a more active life." D. "Do you feel that you will have to make some changes in your life now?"
A
The physician orders continuous intravenous nitroglycerin infusion for the client with MI. Essential nursing actions include which of the following? A. Obtaining an infusion pump for the medication. B. Monitoring BP q4h. C. Monitoring urine output hourly. D. Obtaining serum potassium levels daily.
A
The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2. Nonarousable, sinus rhythm, BP 88/60 mm Hg 3. Arousable, marked bradycardia, BP 86/54 mm Hg 4. Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg
Answer: 1 Rationale: After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.
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 interpret the client's heart rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia
Answer: 1 Rationale: Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.
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. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication. Refer to chart. (increasing HR, RR, and decreasing BP) 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm
Answer: 1 Rationale: 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. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.
A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for: A. Thrombocytopenia and weight gain B. Anorexia, nausea, and visual disturbances C. Diarrhea and hypotension D. Fatigue and muscle twitching
B
A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to an aneurysm? A. Pulsatile abdominal mass. B. Hyperactive bowel sounds in that area. C. Systolic bruit over the area of the mass. D. Subjective sensation of "heart beating" in the abdomen.
B
A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? A. Breathe deeply, regularly, and easily. B. Inhale deeply and cough forcefully every 1 to 3 seconds. C. Lie down flat in bed. D. Remove any metal jewelry.
B
A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead, there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial fibrillation D. Asystole
B
A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary artery pressure monitoring, including pulmonary capillary wedge pressures. The purpose of this is to help assess the: A. Degree of coronary artery stenosis. B. Peripheral arterial pressure. C. Pressure from fluid within the left ventricle.
C
After cardiac surgery, a client's blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following? A. 46 mm Hg B. 80 mm Hg C. 95 mm Hg D. 90 mm Hg
C
As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug's principal effects are produced by: A. Antispasmodic effect on the pericardium. B. Causing an increased myocardial oxygen demand. C. Vasodilation of peripheral vasculature. D. Improved conductivity in the myocardium.
C
A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? A. "Have you ever had this pain before?" B. "Can you describe the pain to me?" C. "Does the pain get worse when you breathe in?" D. "Can you rate the pain on a scale of 1-10, with ten (10) being the worst?"
C
Patient Rogers is admitted to the emergency department with evidence of a STEMI. The nurse recognizes that the patient is developing signs and symptoms of cardiogenic shock and low CO. The nurse recognizes the patient's need for what type of cardiac assist device? a. Aortic valve replacement b. Coronary bypass graft procedure c. Impella; Left ventricular support system d. ECMO
C
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. How should the nurse interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status shows adequate arterial flow, but venous complications are arising.
Answer: 1 Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per 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 interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm
Answer: 1 Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output with cerebral and myocardial ischemia.
Answer: 1 Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. Clients frequently experience a feeling of impending doom. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness).
The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should assess the client for which associated signs and/or symptoms? Select all that apply. 1. Syncope 2. Dizziness 3. Palpitations 4. Hypertension 5. Flat neck veins
Answer: 1, 2, 3 Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats per minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Hypertension and flat neck veins are not associated with the loss of cardiac output.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position
Answer: 1, 2, 3, 4Rationale: Extreme dyspnea, tachycardia, and lung crackles in a client with heart failure indicate pulmonary edema, a life-threatening event. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.
A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? 1. Pulsus paradoxus 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure
Answer: 2 Rationale: Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Pulsus paradoxus is a finding associated with cardiac tamponade.
A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin
Answer: 2 Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld before and after cardiac catheterization.
The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Airway patency 3. Oxygen flow rate 4. Level of consciousness
Answer: 2 Rationale: Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
A client with myocardial infarction suddenly becomes tachycardic, 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? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds
Answer: 2 Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.
A client who had cardiac surgery 24 hours ago has had 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 anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection
Answer: 2 Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to20 mg/dL (3.6 to 7.1 mmol/L), and creatinine 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) for males and 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) for females. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? 1. Anxiety level of the client and family 2. Activation status and settings of the device 3. Presence of a MedicAlert card for the client to carry 4. Knowledge of restrictions on postdischarge physical activity
Answer: 2 Rationale: The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.
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? 1. Muffled heart sounds 2. Client reports dyspnea 3. A rise in blood pressure 4. Jugular venous distention
Answer: 3 Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.
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 measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Monitor for any rhythm change. 4. Notify the primary health care provider.
Answer: 3 Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the primary health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Causative factors, such as caffeine 2. Sensation of fluttering or palpitations 3. Blood pressure and oxygen saturation 4. Precipitating factors, such as infection
Answer: 3 Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.
The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse interpret this rhythm? 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia
Answer: 3 Rationale: Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions
Answer: 3 Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses per minute. The rhythm is regular.
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/hr, 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 most recent). The client's blood urea nitrogen level 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? 1. Check the serum albumin level. 2. Check the urine specific gravity. 3. Continue monitoring urine output. 4. Call the primary health care provider (PHCP).
Answer: 4 Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) for males and 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) for females. Continuing to monitor urine output or checking other parameters can wait. Urine output lower than 30 mL/hr is reported to the PHCP for urgent treatment
A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? 1. Administer digoxin. 2. Defibrillate the client. 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing
Answer: 4 Rationale: Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. 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. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.
A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1. 50 J 2. 120 J 3. 200 J 4. 360 J
Answer: 4 Rationale: The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads on the client's chest and before discharging the device, which intervention is a priority? 1. Ensure that the client has been intubated. 2. Set the defibrillator to the "synchronize" mode. 3. Administer an amiodarone bolus intravenously. 4. Confirm that the rhythm is ventricular fibrillation.
Answer: 4 Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize.
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I should notify my cardiologist if my feet or legs start to swell." 2. "I am supposed to report to my cardiologist if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."
Answer: 4 Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the primary health care provider or cardiologist. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with her or his spouse.
The nurse is caring for a newly admitted patient who presents with crushing chest pain, diaphoresis, and jaw discomfort. The patient's symptoms are not relieved by active vasodilating measures and are progressively worsening. A 12-lead EKG shows ST-elevation in leads II, III, AVF. The nurse knows to prepare for what priority intervention? a. Transcutaneous pacing and supplemental oxygen b. Surgical bathing for CABG c. Cardiac Catherization with possible PCI d. Morphine Sulfate administration
C
