Exam2 Part 1
40.3
A 4-year-old child is receiving vancomycin 220 mg q6 h, IV via syringe pump. The child weighs 48 lb. Recommended dosage is 40 to 60 mg/kg/24h. Calculate the milligrams per kilogram per 24 hours the child is receiving? Do not round your answer. Enter numeric value only.
post op pt w/ bypass graft sitting w/ leg dependent post op bypass graft to the lower extremity should avoid prolonged sitting with the leg dependent because it can cause pain and edema and increase the risk of venous thrombosis.
The licensed vocational nurse (LPN) is assigned to a client who is 2 days postoperative femoral popliteal bypass graft to the right leg. The registered nurse (RN) should intervene if the LPN does which of the following?
Continue assessment This client is asymptomatic with a heart rate of 40. The nurse should continue to finish the assessment to assist in finding the cause for the bradycardia.
The nurse at the local health clinic is performing a pre-employment physical assessment for a 25-year-old male client who denies any physical problems or discomforts. The client's 12 lead electrocardiogram (ECG) shows a narrow complex rhythm with normal P, Q, R, S, T wave progression and a heart rate of 40. Which of the following actions should the nurse take? Continue assessment Notify provider right away Consult w/ specialist
ICD that fired twice and has a dose of amiodarone due ICD that fired twice and has a dose of amiodarone due. The client should receive the medication asap because the reason the ICD is firing is because it is detecting a lethal dysrhythmia
The nurse has received change-of-shift report about the following clients. Which client should the nurse see first? The client with the temporary pacemaker The client with A-fib The client with second-degree atrioventricular (AV) block, type 1 The client with ICD that fired twice and has a dose of amiodarone due
Calcium Channel Blockers Digoxin Beta Blockers CCB- decreases how hard heart works Dig - can be used as a anti-dysrhythmia BB- helps decrease HR
The nurse has taught a client about anti-dysrhythmia medications. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. Class iii Calcium Channel Blockers Digoxin Beta Blockers
About Buergers disease - smoking disease It is not an autoimmune disease. There is no laboratory or diagnostic test for Buerger's disease it is diagnosed based on age of onset, history, clinical symptoms, involvement of distal vessels, presence of ischemic ulcerations and exclusion of autoimmune disease, diabetes, thrombophilia and other sources of emboli. Signs and symptoms include color and temperature changes of the limbs, paresthesia superficial vein thrombosis and cold sensitivity. The client should try to avoid trauma to the extremities, quit smoking, assess for ulcers, take analgesic for pain.
The nurse has taught a client newly diagnosed with Buerger's disease. Which of the following statements by the client would indicate the need for further teaching?
MI Segment elevation in leads I, avL, V5, and V6 looks at the lateral wall and could indicate an MI
The nurse in the emergency department (ED) is caring for client who reports having chest pressure. The nurse performs a 12 lead electrocardiograph (ECG) and notes ST segment elevation in leads I, avL, V5 and V6. Which of the following should the nurse suspect the client may be experiencing?
Chest compressions and defibrillation when available
The nurse in the emergency room is caring for a client who reports having chest pain and nausea. The cardiac monitor begins to show irregular waveforms of varying shapes and amplitude on the cardiac monitor. Which of the following actions would be a priority for the nurse to take?
injury to the SA node
The nurse is caring for a client who had a myocardial infarction (MI) 12 hours ago and is being monitored via remote telemetry. While reviewing the client's telemetry strip, the nurse notes the absence of P waves in the rhythm. The nurse should suspect injury to which of the following?
Prepare Transcutaneous pacing Prepare the client for transcutaneous pacing, to improve cardiac output
The nurse is caring for a client who had an inferior wall myocardial infarction (MI) 4 days ago. The client reports feeling "dizzy and chest discomfort" and has a blood pressure of 96/48 mm Hg and is in a second-degree AV block Type II with a heart rate of 52 beat/min. The nurse should prepare the client for which of the following interventions? Administering prescribed metoprolol Prepare Transcutaneous pacing Synchronized cardioversion Admin Adenosine
Sinus Bradycardia The nurse should expect to see a telemetry strip indicating sinus bradycardia before administering atropine
The nurse is caring for a client who has a prescription to receive atropine IV now. Which of the following telemetry strips should the nurse expect to see for this client? Artifact V-tach Sinus Brady A-fib
14.25
The nurse is caring for a client who is in heart failure and weighs 209 pounds. The client is to receive prescribed dobutamine 10 mcg/kg/min. The supply available is 1,000 mg in 250 mL of 0.9% normal saline. How many mL per hour should the nurse administer to the client? Round your answer to the nearest tenth. Enter numeric value only.
Defibrilate pt The client is experiencing unstable ventricular tachycardia and the first action would be to prepare to defibrillate the client
The nurse is caring for a client who suddenly develops a wide QRS complex. The client's blood pressure is 82/40 mm Hg; respiratory rate is 22 breaths/min; the client is not arousable and the nurse cannot palpate a pulse. Which of the following actions would be most appropriate for the nurse to take? fluid bolus betapace cardio inversion defibrilate
The nurse should immediately call the health care provider and obtain a prescription for IV heparin. The client may need surgery as well but the heparin is a priority to prevent thrombus growth and inhibit further embolization
The nurse is caring for a client who was admitted with atrial fibrillation and suddenly reports experiencing pain, tingling and numbness to the left lower extremity. The nurse notes the extremity is pale, cool to touch and absent of pulse. Which of the following actions would be a priority for the nurse to take? Notify provider and order IV Heparin Use doppler Check v/s Send pt to surgery
Assess the clients pulses Picture is ventricular tachycardia so Assess the clients pulses as the treatment for this rhythm is dependent on the presence or absence of pulses.
The nurse is caring for a client with a cardiac monitor who suddenly experiences the rhythm shown in the strip below. The client's blood pressure (BP) is "90/35 mm/Hg". Which of the following actions should be a priority for the nurse to take? *LOOK AT PICTURE* DEFIB CHECK PULSE GIVE OXYGEN ADMIN B/P MED
7.5
The nurse is caring for a client with heart failure (HF) that is to receive prescribed Dopamine 2mcg/kg/min. The client's weight is 110 pounds. The supply available is 200 mg/250 mL. How many mL/hr should the nurse administer to the client? Round answer to the nearest tenth. Enter numeric value only.
Vagal stimulation The client is experiencing PSVT so the nurse should first try vagal stimulation to convert the PSVT to a normal sinus rhythm
The nurse is caring for a client with telemetry monitoring who is showing a heart rate of 200 beats/min with a regular rhythm, abnormal P wave shape and a normal PR interval and QRS complex. The client reports dyspnea and is hypotensive. Which of the following actions would be a priority for the nurse to take? Vagal Stimulation Cardioversion Admin Atropine Admin Adenosine
I will take this Holter off when showering DO NOT TAKE THIS OFF The client can go about normal daily activities but should keep a diary of symptoms and the activities the client did throughout the day. An event monitor requires the client to push a button if symptoms are felt and also can use an app with a smart phone to record activity
The nurse is educating a client who is being discharged with a Holter monitor. Which of the following statements by the client would indicate the need for more teaching? Select all that apply.
Atropine Atropine is given to a client who is experiencing type 1, second-degree AV block and is symptomatic
The nurse is evaluating a client who received prescribed atropine IV for symptomatic type 1, second-degree atrioventricular (AV) block. Which of the following findings would indicate that the medication was effective? Digoxin Adenosine Atropine Lasix
Instruct pt to lie down or sit down when taking the first dose. Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. The client should lie down or sit down when taking the first dose to prevent orthostatic hypotension. This medication should be taken one hour before or two hours after meals with a full glass of water for faster absorption
The nurse is providing discharge teaching for a client with angina who has newly prescribed nitroglycerin tablets. The nurse informs the client that immediately after administration, the client may experience a throbbing headache or dizziness. Which of the following information should the nurse give the client? Initiate that the pt may be bleeding Instruct pt to lie down or sit down when taking the first dose. Teach pt the medication should be taking at night
The nurse should first REASSESS the client's jugular vein at a 45 degree angle to see if the vein is still distended
The nurse notes that a client who was admitted with heart failure has jugular venous distention (JVD) when lying flat in bed. Which of the following actions should the nurse take next?
Pt with angina complaining of chest pain The client with angina should be asymptomatic; when the client is reporting chest pain, this is abnormal data. Therefore, this client should be assessed first.
The nurse received shift report for a group of assigned clients. The nurse should first assess the client diagnosed with? Pt w/ CHF who had 4+ pitting edema Pt diagnosed with endocarditis is experiencing a fever Pt with angina complaining of chest pain The client diagnosed with aortic valve stenosis has the classic triad of syncope, angina, and exertional dyspne
