exam 5

A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. Bronchospasm Pneumothorax Infection Air embolism Atelectasis

Pneumothorax Infection Air embolism

Which of the following is the most common site for a dissecting aneurysm? Lumbar area Thoracic area Sacral area Cervical area

Thoracic area

When hemodynamic monitoring is ordered for a client, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a client who has such a device in place, the nurse should check which of the following components? Select all that apply. A pressure bag A transducer A flush system A leveler An oscillator

A pressure bag A transducer A flush system

A client who has recently been diagnosed with chronic heart failure is being taught by the nurse how to live successfully with her chronic condition. Her ability to meet this goal will primarily depend on her ability to do which of the following? Adapt her lifestyle to accommodate her symptoms. Access community services to eventually cure her disease. Lower her expectations for quality of life and level of function. Establish good rapport with her primary care provider.

Adapt her lifestyle to accommodate her symptoms.

You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect? Coronary artery disease Aortic aneurysm Raynaud's disease Peripheral artery disease

Aortic aneurysm

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 15 ml/hour and 2+ hematuria Urine output of 150 ml/hour and heart rate of 45 beats/minute

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply. Carry nitroglycerin at all times. Stop smoking. Balance rest with activity. Follow a diet high in saturated fats. Avoid all physical activity.

Carry nitroglycerin at all times. Stop smoking. Balance rest with activity.

A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin? Nausea, vomiting, depression, fatigue, and impotence. Headache, hypotension, dizziness, and flushing. Sedation, nausea, vomiting, constipation, and respiratory depression. Flushing, dizziness, headache, and pedal edema.

Headache, hypotension, dizziness, and flushing.

The nurse is caring for a patient who is having chest pain associated with a myocardial infarction (MI). What medication should the nurse administer intravenously to reduce pain and anxiety? Meperidine hydrochloride Hydromorphone hydrochloride Morphine sulfate Codeine sulfate

Morphine sulfate

During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action? Notify the surgeon that the client took warfarin the day before surgery. No action is needed, because the client takes warfarin on a continuing basis. Tell the client to inform the circulating nurse before the anesthesia is administered. Put a note on the preoperative checklist before sending the client into surgery.

Notify the surgeon that the client took warfarin the day before surgery.

The critical care nurse is caring for a client who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the client's left ventricular function? Pulmonary artery pressure monitoring (PAPM) Systemic arterial pressure monitoring (SAPM) Central venous pressure (CVP) monitoring Arterial blood gases (ABGs)

Pulmonary artery pressure monitoring (PAPM)

A hospitalized client with heart failure puts on the call light and states, "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications? Pulmonary edema Decreased cardiac workload Decreased renal perfusion pressure Hepatomegaly

Pulmonary edema

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Increasing blood pressure and monitoring fluid intake and output Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility Stabilizing heart rate and blood pressure and easing anxiety

Stabilizing heart rate and blood pressure and easing anxiety

The nurse is discussing cardiac hemodynamics with a nursing student, who understands the following formula: CO = HR X SV (cardiac output equals heart rate times stroke volume). The student asks what determines stroke volume. The correct response by the nurse is which of the following? Stroke volume depends on three factors: P-R interval, preload, and contractility. Stroke volume depends on three factors: S-T elevation, catecholamines, and temperature. Stroke volume depends on three factors: preload, afterload, and contractility. Stroke volume depends on three factors: afterload, P-R interval, and preload.

Stroke volume depends on three factors: preload, afterload, and contractility.

The nurse is educating the patient about administering nitroglycerin prior to discharge from the hospital. What information should the nurse include in the instructions? Take 2 nitroglycerines every 10 minutes until a total of 6 pills are taken. If pain is not relieved, activate the emergency medical system. Take a nitroglycerin and if the pain is not relieved, drive to the nearest emergency department. Take 2 nitroglycerines and if the pain is not relieved, go to the emergency department. Take a nitroglycerin and repeat every 5 minutes if the pain is not relieved until a total of 3 are taken. If pain is not relieved, activate the emergency medical system.

Take a nitroglycerin and repeat every 5 minutes if the pain is not relieved until a total of 3 are taken. If pain is not relieved, activate the emergency medical system.

The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs? The client's oxygen saturation level drops below 96%. The client experiences a noticeable increase in heart rate during activity. The client's respiratory rate exceeds 30 breaths/min. The client experiences chest pain, palpitations, or dyspnea.

The client experiences chest pain, palpitations, or dyspnea.

When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information? The client's activities limitations and level of consciousness after the attacks The client's symptoms and the activities that precipitate attacks The client's coping strategies surrounding the attacks The client's understanding of the pathology of angina

The client's symptoms and the activities that precipitate attacks

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? The infusion rate should be titrated according the client's subjective sensation of adequate perfusion. The drug should be discontinued immediately after blood pressure increases. The drug dose should be tapered down once vital signs improve. The client should have arterial blood gases drawn every 10 minutes during treatment.

The drug dose should be tapered down once vital signs improve.

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse? Administer the medications and then notify the physician. Administer the medication and inform the charge nurse about the rate. Administer atropine to speed the heart rate and then administer the digoxin. Withhold the medication and notify the physician of the heart rate.

Withhold the medication and notify the physician of the heart rate.

The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition? hemorrhage catheter-related bloodstream infections pneumothorax air embolism

catheter-related bloodstream infections