FINAL 2

1,2,4,5 (1, a 2lb weight gain indicates retain fluid and should contact HCP, 2 Keeping HOB elevated will help breathing, 4, Na retains water 5, isotonic exercise such as walking, swimming helps tone the muscles. WRONG: #3 loop should be taken in morning)

40 The cardiac nurse is teaching the client diagnosed with CHF. Which teaching interventions should the nurse discuss with the client. SATA 1. Notify the HCP if the client gains more than 2 lbs in one day 2. keep the HOB elevated when sleeping 3. Take the loop diuretic once a day before sleep 4 Teach the client which foods high in Na should be avoided 5 Perform isotonic exercises at least once a day

1,3,4 (1 The HCP must order insertion of a Sengstaken-Blakemore tube, so this is collaborative 3. This is a collab intervention the nurse should implement needs HCP orders 4. Obtaining lab data requires HCP orders)

53 The nurse is caring for a client who is hemorrhaging from a duodenal ulcer. Which collaborative interventions should the nurse implement? SATA 1. Prepare to admin a SEngstaken-Blakemore tube 2. Assess the VS 3. Admin PPI IV 4.. Obtain a type and crossmatch for 4 units of blood 5. Monitor the I&O's

a (Rationale: The symptoms and age of the client lead the nurse to conclude that the client may be experiencing a myocardial infarction or, since the client has had surgery, a pulmonary embolus. The chest x-ray is done to detect the embolus, and an ECG is done to rule out a myocardial infarction. An MRI is not done for either condition and, in any case, would take about 2 hours to complete; this client's symptoms indicate an emergency. Electrolyte panels and a complete blood count will not diagnose a pulmonary embolus or myocardial infarction.)

A 65-year-old client begins to have chest pain, decreasing oxygen saturation, and dyspnea after surgery. The nurse expects the physician to order which diagnostic test for a definitive diagnosis of pulmonary embolism? a Chest x-ray and ECG b Electrolyte panel c MRI d Complete blood count

4 (sinus tach means the SA node is the pacemaker, but the rate is greater than 100 because of pain or fever. The nurse should determine the cause and tx appropriately.)

A client 1 day post op CAB surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement first? 1. Assess the apical HR for 1 full min 2. Notify the cardiac surgeon 3. Prepare for synchronized cardioversion 4. determine if the client is having pain

a (Explanation: ECG changes associated with hypokalemia are peaked P waves, flat T waves, depressed ST segments, and prominent U waves. Answers B, C, and D are not associated with low potassium levels, so they are incorrect.)

A client admitted with gastroenteritis and a potassium level of 2.9mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client's potassium results? a A depressed ST segment b An elevated T wave c An absent P wave d A flattened QRS

2 (Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine)

A client experiences initial indications of dizziness after having an IV infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having: 1. palpitations 2, tinnitus 3, urinary frequency 4. lethargy

a (Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.)

A client is having frequent premature ventricular contractions. A nurse would place priority on 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

2 (cardiac cath is done in clients with angina primarily to assess the extent and the severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization result Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac cath can be used to assess the functional adequacy of the valves, and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage)

A client with unstable angina is scheduled to have a cardiac catheterization The nurse explains to the client that this procedure is being used to : 1. open and dilate blocked coronary arteries 2 assess the extent of arterial blockage 3. bypass obstructed vessels 4. assess the functional adequacy of the valves and heart muscle

2 (advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the HCP, obtaining a portable chest radiograph, and drawing blood for the lab are important but secondary to starting the IV line)

A middle aged client being admitted to the hospital has a history of hypertension and informs the nurse that his father died from a heart attack at the age of 60. The client reports having indigestion. The nurse connects the client to a cardiac monitor which reveals eight premature ventricular contractions per minute. The nurse should next: 1. call the HCP 2. start an IV line 3. obtain a portable chest radiograph 4 draw blood for lab studies

1,2,4 (RR <12, urine output < 30 mL/hr, Decreased LOC are signs of mag toxicity. The ABSENCE of DTR's is a sign of mag toxicity. Flushing and sweating are adverse effects, but not signs of toxicity)

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? select all 1. respirations less than 12 2. urinary output less than 30 ml/hr 3. hyperreflexic deep tendon reflexes 4. decreased LOC 5. flushing and sweating

a,c,e (CORRECT: A; Hx of congenital malformations is a risk factor. C; HTN risk factor. E; a murmur indicates turbulent blood flow, which is often from valvular heart disease. WRONG: B; Strep or Rheumatic fever is a risk factor. D. A SUDDEN wt gain could indicate fluid collected related to L sided valvular heart disease)

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? SATA a. surgical repair of an atrial septal defect at age 2 b. measles in childhood c. HTN for 5 years d. weight gain of 10 lb in past year e. diastolic murmur present

2 (RDS is a developmental condition that primarily affects preterm infants before 35 weeks gestation because of inadequate lung development from deficient surfactant production. Placenta previa has little correlation with development of RDS. The neonates sluggish respiratory activity postpartum in not likely the cause of but may be a sign the infant has the condition)

A viable male neonate born to a 28 year old multiparous client by cesarean section because of placenta previa is diagnosed with RDS (hyaline membrane disease) AKA respiratory distress syndrome. Which factor would the nurse explain as the factor placing theneonate at the greatest risk for this syndrome? 1. mothers development of placenta previa 2. neonates born preterm 3. mother receiving analgesia 4 hrs before birth 4. neonate with sluggish respiratory efforts after birth

5 2 4 1 3 (5: victim placed on back 2: just look quickly 4: get an AED or 911. The faster defib the better outcomes 1: Initiate compressions immed. Breathing not initiated without barrier device 3: Compression rate is 30:1)

According to the 2010 AHA guidelines which steps of CPR for an adult suffering from cardiac arrest should the nurse teach individuals in the community? RANK IN ORDER OF PERFORMANCE 1. Place the hands over the lower half of the sternum 2. Look for obvious signs of breathing 3. Begin compressions at a ratio of 30:2 4. Call for an AED immed 5. Position the victim on the back

c (Explanation: Theo-Dur(theophylline) is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D are not necessary)

Before administering Theo-Dur (theophylline), the nurse should check the patient's: a Urinary output b Blood pressure c Pulse d Temperature

2 1 3 4 (To decrease myocardial workload and promote timely intervention, the client should be assisted to the bed. Assessing the VS provides the data needed to determine client tolerance. Early initiation of an IV access will enable timely medication administration if it is emergently needed. While a 12 lead ECG is needed it can be obtained after the IV is initiated)

Cardiac telemetry shows that a client who is up to the bathroom has converted from normal sinus rhythm with a rate of 72 to atrial fibrillation with a ventricular response rate of 100 bpm. In what order from first to last should the nurse perform these interventions? Use all and no commas 1. assess the VS 2 assist the client to bed 3. initiate IV access 4. obtain a 12 lead electrocardiogram stat

1 (Airways assessed first. RR, rhythm, and depth. )

The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1. Assess the breath sounds 2. Apply o2 via nc 3. Take the BP 4. Monitor the O2 sat

1,2,4,5,6 (The nurse must have assessment data and verify VS if necessary in order to determine the action required. If there is a significant change in the clients condition, the charge nurse should be notified in order to help the nurse with both this client and the nurses other assigned clients if necessary. Most acute care facilities have a rapid response team that can also help assess and intervene with basic standing orders if necessary. Positioning the client semi fowlers is a nursing action that may assist the client with breathing and relieve SOB. It is important that the nurse reassure the client and stay calm remaining with the client. The nurse must notify the HCP of the change in condition.)

The UAP reports to the nurse that the client is "feeling short of breath" The clients BP was 124/78, 2 hours ago with a HR of 82bpm. the UAP reports that BP is now 84/44 with a HR of 54 bpm. and the client stated "I just do not feel good". What actions should the nurse take? SATA 1. confirm the clients VS and complete a quick assessment 2. inform the charge nurse of the change in condition, and initiate the hospitals rapid emergency response team 3. make a quick check on other assigned clients before spending the amount of time required to take care of this client 4. position the client semi fowlers 5. stay with the client and reassure the client 6. call the HCP and report using SBAR

d (In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result there is decreased cerebral circulation, causing syncope.)

The adaptations of a client with complete heart block would most likely include: A Nausea and vertigo B Flushing and slurred speech C Cephalalgia and blurred vision D Syncope and slow ventricular rate

2 4 3 1 5 (2: the nurse should check the clients H&H . Most facilities have a procedure to only admin PRBCs only when the H/H are less than 8 and 24. 4: The client must consent to receiving the blood 3: The nurse must assess the clients px status prior to picking up the blood in case there is a situation that requires consult with the HCP 1: if ordered a diuretic is usually administered between units to prevent FVE 5: Return the bags after infusion)

The client dx with CHF and iron def anemia is prescribed a unit of PRBCs. Rank the interventions in order of performance: 1. Admin furosemide (Lasix) a loop diuretic between units 2. Check the clients hgb and hct 3. Assess the lung sounds and periphery 4. Have the client sign a permit to receive blood 5. Return the empty bags to the lab

3 (promote Oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock)

The client has recently experienced a MI Which action by the nurse helps prevent cardiogenic shock? 1. Monitor the clients telemetry 2. Turn the client q2h 3. Admin O2 via NC 4. Place the client in Trendelenburg

1 (These are expected ABGS which would not be expected in client with ARDS. WRONG: #2 The O2 level below 80-100 so may be developing ARDS. #3 is respiratory acidosis which expected with ARDS. #4 These are expected ABGS of client with ARDS. There is a low O2 level despite high O2 admin)

The client is admitted to the ICU with rule out ARDS. The client is receiving 10 mL O2 via nc. Which arterial blood gases indicate the client does not have ARDS? 1. PH 7.38 PaO2 82, PaCO2 45, HCO 26 2. PH 7.35, PaO2 74, PaCO2 43 HCO 24 3. PH 7.45, PaO2 60, PaCO2 45 HCO 28 4. PH 7.32 PaO2 50, PaCO@ 55 HCO 28

d ( Feedback Rationale: A platelet transfusion replaces platelets used in the abnormal clotting process of DIC. Platelets do not replace clotting factors or increase the oxygen carrying ability of the blood. Promotion of intravascular clotting is not a desired effect.)

The nurse administering platelets to a client with disseminated intravascular coagulation (DIC) understands that the intended effect of this treatment is to: a restore tissue oxygenation. b replace specific clotting factors. c promote intravascular clotting. d replace depleted platelets.

2,3,4 (The nurse should maintain ICP by elevating the HOB 15-20 degrees and monitoring neuro status. An ICP >15 with 20-25 upper limits of normal indicates increased ICP and the HCP should be notified. Coughing and ROM will increase ICP ad should be avoided post op)

The nurse established a goal to maintain ICP within the normal range for a client who had a crainiotomy 12 hrs ago What should the nurse do? SATA 1 Encourage the client to cough to expel secretions 2. elevate the HOB 15-20 degrees 3. Contact the HCP if the ICP is >15 mmHg 4. Monitor the neuro status using the Glasglow Coma Scale 5. Stimulate the client with active ROM exercises

4 3 2 1 5 (4: multifocal PVC is LIFE THREAT 3: Myasthenia gravis must have med as close to specific time as possible. It allows skeletal muscle to function, if delayed the client may experience resp distress 2: Pain is a priority, and should be attended after the life threatening issues attended 1: This client is symptomatic, and diuretic should help with dyspnea 5: IV antibiotics are priority but the client has received several doses of the med or there would not be a trough level so this can wait unit the others are covered)

The nurse has received report and has the following medications due or being requested In which order should the nurse administer the medications? LIST IN ORDER OF PRIORITY 1. Furosemide, IVP daily to client dx with HF who is dyspneic on exertion 2. Morphine, IVP prn to a client dx with lower back pain who is complaining of pain "10" on 0-10 scale 3. Admin neostigmine (prostigmine) PO to a client dx with myasthenia gravis 4. Admin lidocaine and antidysrhythmic IVP prn to a client in normal sinus rhythm with multifocal PVCs 5. Admin vancomycin, to a client dx with a staph infection who has a trough level of 14

4 (cultures are the priority because the antibiotics should not be administered until the cultures have been drawn)

The nurse is admitting a client with the results listed below.. WBC 25.3 RBC 4.8 Hgb 10 Hct 30% Plt 250 Which priority intervention should the nurse implement first? 1. Admin prescribed antibiotic IVPB 2. Start IV line in the client LFA 3. Perform admission assessment 4. Have the lab draw cultures blood stat

4 (Sinus tachycardia is characterized by normal conduction and a regular rhythm. but with a rate exceeding 100 bpm A P wave precedes each QRS, and the QRS is normal)

The nurse is assessing a client who has had a MI. The nurse notes the cardiac rhythm shown on the ECG strip. The nurse interprets this rhythm as: 1. atrial fibrillation 2. ventricular tachycardia 3. premature ventricular contractions 4. sinus tachycardia

1,2,3,5 (HF can be a result of severe CV conditions, which will affect the hearts ability to pump effectively. The body attempts to compensate thru several neurohormonal mechanisms Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the HR and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys, decreased renal perfusion (due to low cardiac output and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of ADH. This causes fluid retention in an attempt to increase the BP and therefore, cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary distress)

The nurse is assessing the client with chronic HF who is demonstrating neurohormonal compensatory mechanisms. which are expected findings on assessment? SATA 1 decreased cardiac output 2. increased HR 3. vasoconstriction on skin, Gi tract and kidneys 4. decreased pulmonary perfusion 5. fluid overload

b,d,e

The nurse is assessing the client with metabolic alkalosis. Which findings would likely be observed in this client? Select all that apply. a Kussmaul's respirations b Numbness of the extremities c Vomiting and nausea d Warm flushed skin e Circumoral paresthesia f Hypertonic muscle contractions

1 (The nurse should first obtain VS as changes in VS will reflect the severit of the sudden drop in Cardiac Output; decrease in BP, increase in HR, and increase in RR. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the L atrium, which is heard at the 5th intercostal space, midclavicular line The murmur worsens during expiration and in the supine or left side position and can best be heard when the client is in thses positions, not with the client leaning forward A 12 lead ECG views the electrical activity of the heart; an echocardiogram views valve function)

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur of the apex. The nurse should first: 1 assess for changes in VS 2. draw an ABG 3. evaluate heart sounds with the client leaning forward 4. obtain a 12 lead ECG

1 2 4 3 (When a client returns from having a transluminal balloon angioplasty with femoral access, the nurse should first obtain baseline VS and O2 sat to determine evidence of bleeding or decreased tissue perfusion. The nurse should next assess the pedal pulses to determine if the client has adequate peripheral tissue perfusion Next the nurse should inspect the cath site and then determine color and sensation in the affected leg)

The nurse is caring for a client who has just returned from having a percutaneous transluminal balloon angioplasty with femoral artery access. In which order, from first to last, should then nurse obtain information about the client? use all options, do not separate with commas 1. VS and O2 sat 2. pedal pulses 3. color and sensation of extremity 4. cath site

b (Rationale: Diminished reflexes signify magnesium toxicity. Slurred speech, decreased appetite, and awkward movements indicate a therapeutic magnesium level.)

The nurse is caring for a client with severe pregnancy-induced hypertension who is in the hospital on a magnesium sulfate drip. The nurse monitors the client for which sign of magnesium toxicity? a Slurring of speech b Diminished reflexes c Awkward movements d Decreased appetite

c (​Rationale: Patients with chronic DIC may receive continuous heparin infusion by pump for​ long-term treatment. The administration of fresh frozen​ plasma, platelets, and oxygen are used for acute DIC.)

The nurse is caring for a patient with chronic DIC. Which order from the healthcare provider would the nurse​ expect? a Administer platelet infusion. b Administer fresh frozen plasma. c Administer heparin via continuous infusion pump. d Administer oxygen.

a,c,e (Rationale: Clinical manifestations of torsades de pointes include​ tachycardia, seizures, and hypotension. Epistaxis and bradypnea are not assessment findings that support this​ client's diagnosis.)

The nurse is caring for an adolescent client who is brought to the emergency department​ (ED) experiencing torsades de pointes. Which clinical manifestations found during the nursing assessment support this​ diagnosis? ​(Select all that​ apply.) a Seizures b Bradypnea c Tachycardia d Epistaxis e Hypotension

1 (complication of immobility DVT. Assess for DVT)

The nurse is caring for clients on the surgical floor. Which client should be assessed first? 1. The client 4 days postop abd surgery and is complaining of L leg pain when ambulating 2. The client who is 1 day postop hernia repair who has just been able to void 550 mL clear amber urine 3. The client who is 5 days post op open cholecystectomy who has a T tube and is being discharged 4. The client 16h post abd hysterectomy and is complaining of abd pain and expelling flatus

a,b,c,e ( Rationale ​Pregnancy, fracture of long bones​ (especially the​ femur), reproductive​ surgery, and MI are all factors that increase the risk of the development of DVT or PE. Asthma alone is not a risk factor for these conditions.)

The nurse is caring for four clients on the​ medical-surgical unit. Which clients will the nurse recognize as having the greatest risk of deep vein thrombosis​ (DVT) or pulmonary embolism​ (PE)? ​(Select all that​ apply.) ​a 24-year-old male in traction device after femur fracture ​b 65-year-old male recovering from an MI ​c 19-year-old pregnant female with gestational diabetes ​d 32-year-old female with an asthma exacerbation. ​e 55-year-old female scheduled for a hysterectomy

c (Explanation: Complications of TPN therapy are osmotic diuresis and hypovolemia. Answer A is incorrect because the intake and output would not reflect metabolic rate. Answer B is incorrect because the client is most likely receiving no oral fluids. Answer D is incorrect because the complication of TPN therapy is hypovolemia, not hypervolemia.)

The nurse is infusing total parenteral nutrition (TPN). The primary purpose for closely monitoring the client's intake and output is: a To determine how quickly the client is metabolizing the solution b To determine whether the client's oral intake is sufficient c To detect the development of hypovolemia d To decrease the risk of fluid overload

1

The nurse is told the client has aortic stenosis. Which anatomical position should the nurse assess the murmur? 1 2nd intercostal space R sternal notch 2. ERbs point 3. 2nd intercostal space L sternal notch 4. 4th intercostal space L sternal border

1,4 (The nurse must monitor the systolic and diastolic pressure to obtain the mean arterial pressure (MAP) which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP) which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations and pain, however the crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP there is no CPP.)

The nurse monitoring a client with ICP What indicators are most critical for the nurse to monitor? SATA 1. systolic BP 2. urine output 3. breath sounds 4. cerebral perfusion pressure 5. level of pain

1,3,5,6 (Dyspnea, crackles, oliguria and decreased o2 sat are s/s related to pulmonary congestion and inadequate tissue perfusion associated with Left Sided Heart Failure. JVD and RUQ pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in Right Sided Heart Failure)

The nurse should assess the client with Left sided heart failure for which findings? SATA 1. dyspnea 2 JVD (jugular vein distension) 3. crackles 4. RUQ pain 5. oliguria 6. decreased O2 sat levels

c (Explanation: When given within eight hours of the injury, Solu-Medrol has proven effective in reducing cord swelling, thereby improving motor and sensory function. Answer A is incorrect because Solu-Medrol does not prevent spasticity. Answer B is incorrect because Solu-Medrol does not decrease the need for mechanical ventilation. Answer D is incorrect because Solu-Medrol is used to reduce inflammation, not used to treat infections.)

The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in: aPreventing spasticity associated with cord injury b Decreasing the need for mechanical ventilation c Improving motor and sensory functioning d Treating post injury urinary tract infections

a,c,d (Rationale: PDA, ASD, and AV canal all cause increased pulmonary blood flow. Pulmonic stenosis decreases pulmonary blood flow because the pulmonary valve is stenosed. Coarctation of the aorta obstructs systemic blood flow to the lower extremities and does not directly affect pulmonary blood flow.)

There are a number of infants in the cardiac unit with congenital defects. The nurse realizes that the congenital defects that can cause increased pulmonary blood flow are which of the following? (Select all that apply.) a Patent ductus arteriosus (PDA) b Pulmonic stenosis c Atrial septal defect (ASD) d Atrioventricular canal defect (AV canal) e Coarctation of the aorta

1,2,4 (Complications assoc with admin of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air occlusive dressing and all connections of the system must be secure. Ambulation and ADLs are encouraged and not limited during the admin of TPN)

To prevent complications associated with TPN admin through a central line, the nurse should: SATA 1 use strict aseptic technique for all dressing changes 2. secure all connections of the system 3. encourage bed rest 4. cover the insertion site with a moisture proof dressing

4

Which lab data confirms the dx of CHF? 1. Chest x ray 2. liver fx tests 3. BUN 4. BNP

2 (PVC's are usually a precursor of life threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVC's occur at a rate greater than 5 or 6 per minute in the post-MI client, the HCP should be notified immediately. More than 6 PVC's per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion would not decrease the number of PVC's. Increasing the oxygen concentration should not be the nurses first course of action rather the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.)

While caring for a client who has sustained a MI, the nurse notes eight premature ventricular contractions (PVC's) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2L/min. The nurse should first: 1. increase the IV infusion to 150 mL/h 2 notify the HCP 3. increase the oxygen concentration to 4L/min 4. administer prescribed analgesic

a,b,c (CORRECT: A; The use of cardiopulm bypass reduces the demand for O2, which reduces risk of inadeq oxygenation of vital organs. B; motion of the heart ceases during the procedure to allow placement of graft near affected coronary artery. C; the core body temp is lowered for the procedure, rewarming occurs through heat exchanges in the cardiopulmonary bypass machine. WRONG: D; the use of cardiopulmonary bypass decreases the rate of metabolism. E; The flow to the heart is maintained by the action of the bypass machine)

nurse educator is reviewing the use cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? SATA a The clients demand for O2 is lowered b Motion of the heart ceases c. rewarming of the client takes place d. the clients metabolic rate is increased e. blood flow to the heart is stopped

a,c (RIGHT;A; A client with ttl chol level greater than 200 is at increased risk heart disease. C; A client who has LDL greater than 130 is at increased risk for heart disease. WRONG ANSWERS: B; HDL greater than 55 for female or greater than 45 for male decreases clients risk for HD. D; A triglyceride between 35-135 female or 40-160 male is in range. E; Troponin I level is monitored to detect cardiac injury a Troponin I less than 0.03 is wnl)

A nurse at HCP office reviewing lab test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? SATA a. Cholesterol (total) 245 mg/dL b. HDL 90 mg/dL c LDL 140 mg/dL d. Triglycerides 125 mg/dL e. Troponin I 0.02 ng/mL

1,3,4 (The client has atrial fibrillation and will have an irregularly irregular pulse and will commonly be tachycardic, with rapid ventricular responses (HR) typically in the 110 to 140 range, but rarely over 150-170. The goal of treatment is the restoration of sinus rhythm. With a heart rate >150 and symptoms of sob, dizziness and syncope, and chest pain, synchronized cardioversion will most likely be the treatment of choice. With more controlled HR and more minor S/S, chemical conversion with drugs such as diltiazem and digoxin prior to other interventions such as synchronized cardioversion with appropriate anticoagulation may be attempted. Because of the decreased cardiac output, monitoring is essential. Obtaining consent for cardioversion requires a prescription from the HCP, but with the current HR having cardioversion is a very strong possibility for this client. Defib is used for ventricular fibrillation, not atrial fibrillation. Teaching the client about warfarin will be a possibility, but not an immediate intervention. Clients in continued atrial fib usually require some form of anticoagulation. Drawing labs for CBC's to detect anemia or infection, and thyroid function studies (to determine thyrotoxicosis a rare but not to be missed cause, especially in older adults) serum electrolytes and BUN/creatinine (looking for electrolyte disturbances or renal failure) are commonly drawn for determining the cause of the atrial fibrillation, they are not an immediate action)

An 85 year old client is admitted to the ER at 2000 hrs with syncope, shortness of breath, and reported palpitations. (see notes below) At 2015 the nurse places the client on the ECG monitor and identifies the following rhythm (see picture) What should the nurse do? SATA Admitted: 2000 hours HR 150 BP 90/62 O2 sat 92% room air RR 22 client is sob states "heart is jumping out of my chest and hurts some, I am having trouble catching my breath, I dont want to faint again" 1. apply oxygen 2.. prepare to defibrillate 3. monitor VS 4. have the client sign the consent for cardioversion as prescribed 5. teach the client about warfarin treatment and the need for frequent blood testing 6. draw a CBC count and thyroid function study

1 ("HAS DEVELOPED" indicates a new condition. The nurse should notify the HCP which indicate developing HF The other actions done treat, and the furosemide has to be ordered by the provider)

The client dx with ST elevation MI (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in the lower lung fields. Which should the nurse implement first? 1. notify the HCP 2. Assess what the client ate at the last meal 3. request a stat 12 lead ECG 4. Admin furosemide IVP

4,5 (Signs of pulmonary edema are identical to those of acute heart failure. S/s are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachycardia. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated depending on the severity of the edema Jugular vein distention, dependent edema, and anorexia are symptoms of right sided heart failure)

Which are indications that a client with a history of Left Sided heart failure is developing pulmonary edema? SATA 1. distended jugular veins 2. dependent edema 3. anorexia 4. coarse crackles 5. tachycardia

b (Increased voiding at night is a symptom of right-sided heart failure. Answers A, C, and D are incorrect because they are symptoms of left-sided heart failure.)

Which of the following findings is associated with right-sided heart failure? aShortness of breath bNocturnal polyuria c Daytime oliguria d Crackles in the lungs

3 (norm ICP is 15 or less. for 15-30 sec or longer. Hyperventilation causes vasoconstriction. which reduces cerebrospinal fluid and blood volume, two important factors for reducing sustained ICP of 20 mm Hg. A cooling blanket is used to control the temp eleavation because fever increases metabolic rate, which in turn increases ICP. High doses of barbituates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure > 80 mm Hg)

A client has ICP of 20 mm Hg. The nurse should: 1.. give the client a warming blanket 2. admin low dose barbituates 3. encourage the client to take deep breaths to hyperventilate 4. restrict fluids

5 4 1 2 4 2 4 2 4 3 ( The client should be placed on telemetry upon admission to the unit. When the client experiences chest pain, vital signs should be checked immediately, followed by the ECG. Nitroglycerin is usually tried before morphine to relieve the chest pain. Hypotension is a side effect of nitroglycerin. Blood pressure and heart rate are monitored whenever nitroglycerin is administered. When nitroglycerin fails to relieve chest pain, IV morphine is the next action, and the health care provider should be notified. Focus: Prioritization)

4. The health care provider's orders for Ms. J, who is currently experiencing chest pain, are as follows. List the orders in the sequence in which they should be completed. (Answers may be used more than once.) 1. Obtain a 12-lead electrocardiogram (ECG) when the client experiences chest pain. 2. Administer nitroglycerin (Nitrostat) 0.6 mg sublingually every 5 minutes as needed for chest pain. 3. Administer morphine 2 mg IV push as needed for chest pain. 4. Monitor blood pressure and heart rate. 5. Place on a telemetry monitor. _______, _______, _______, _______, _______, _______, _______, _______, _______, _______ Answer

1 3 4 2 (Because atrial fibrillation causes a decrease in cardiac output, the HR increases in response to this drop. As a result of an increased HR the O2 demands of the heart increase. It is important O2 is administered first to compensate for the increased workload and o2 demand. Placing the client on a cardiac monitor will help confirm a diagnosis of atrial fibrillation. Performing VS will determine the client response to the abnormal rhythm and responses to treatment. If the rhythm is determined to be atrial fibrillation it will be necessary for an IV to be inserted so medication can be administered)

A client has atrial fibrillation and a HR of 165 bpm. In which order from first to last should the nurse implement these prescriptions? Use all options, no commas 1. admin o2 via nasal cannula 2.. gather supplies for IV insertion 3. place the client on ECG monitor 4. obtain VS including BP, HR, RR, T and O2 sat

4 3 2 1 (The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short sentences when explaining care given. The nurse should assure the client safety by protecting the client from injury. Maintain a quiet and calm environment by removing extra noises to prevent overstimulation. Pharm intervention is used only when other plans for care are not effective. when the underlying problems related to the head injury are resolved, the delirium likely will improve)

A client has delirium following a head injury, The client is disoriented and agitated. In which order from first to last should the nurse initiate care for this client? All options should be used, no commas 1. request a prescription for haloperidol 2. maintain a quiet environment 3. assure the clients safety 4. approach the client using short sentences

3 (A complication of balloon valvuloplasty is emboli resulting in a stroke. The clients increased drowsiness should be evaluated Some degree of mitral regurgitation is common after the procedure. The O2 status and urine output should be monitored closely but do not warrant concern)

A client has returned from the cardiac catheterization lab after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action? 1. There is a low grade 1 intensity mitral regurgitation murmur 2 SpO2 is 94% on 2 L of O2 via nasal cannula 3. Client has become more somnolent 4 Urine output decreased from 60 mL/h to 40 mL/hr over the last hour

2,3,4 (For clients scheduled for a cardiac catheterization, it is important to assess for iodine allergy, verify written consent, and instruct the client NPO for 6-18 hours before the procedure. ORal medications are withheld unless specifically prescribed. A urinary drainage cath is rarely prescribed for this procedure.)

A client is scheduled for a cardiac catheterization. The nurse should do which pre-procedure tasks? SATA 1. Administer all prescribed medications 2. check for iodine sensitivity 3.. verify that written consent has been obtained 4. withhold food and oral fluids before the procedure 5. insert a urinary drainage catheter

c (Rationale: All cardiomyopathies have similar symptoms, but only dilated cardiomyopathy presents with orthopnea, nocturnal dyspnea, peripheral edema, and ascites. Hypertrophic and restrictive cardiomyopathy usually present with dyspnea on exertion. Hypotrophic cardiomyopathy is not a cardiomyopathy classification. )

A client presents to the emergency department with symptoms of orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, and ascites. The physician suspects cardiomyopathy. The nurse suspects the client is experiencing which type of myopathy? a Restrictive cardiomyopathy b Hypertrophic cardiomyopathy c Dilated cardiomyopathy d Hypotrophic cardiomyopathy

a (Explanation: If the nurse suspects a leaking or a ruptured abdominal aortic aneurysm, the first action is to improve blood flow to the brain and elevate the blood pressure. This can be accomplished quickly with the change in position. Answers B and C would be appropriate, but not before answer A. Answer D would not be required at this time.)

A client was transferred to the hospital unit as a direct admit. While the nurse is obtaining part of the admission history information, the client suddenly becomes semiconscious. Assessment reveals a systolic BP of 70, heart rate of 130, and respiratory rate of 24. What is the nurse's best initial action? a Lower the head of the client's bed. b Initiate an IV with a large bore needle. c Notify the physician of the assessment results. d Call for the cardiopulmonary resuscitation team

2,4,5 (This ECG strip indicates the client has atrial fibrillation. There is no P wave and PR interval. these are replaced with fine wavy lines. In atrial fibrillation, the ventricular rate may be normal, slow, or fast. Clients with atrial fibrillation may have palpitations secondary to a fast and irregular atrial rhythm. Because atrial fibrillation also may result in a sudden decrease in cardiac output, the client may also experience light headedness and SOB. A carotid bruit, nausea and a systolic murmur are not manifestations of new onset atrial fib)

A client with a normal sinus rhythm converts to the pictured rhythm on the cardiac monitor. For which symptoms should the nurse assess the client? 1. carotid bruit 2.. light-headedness 3. nausea 4 palpitations 5.. shortness of breath 6. systolic murmur

d (Explanation: The normal CVP is 3-8cm of water. An elevation in CVP indicates a fluid volume excess. Answers A, B, and C indicate that the reading is normal or low, so they are incorrect.)

A client with burns is admitted and fluid resuscitation has begun. The client's CVP reading is 14cm/H2O. Which evaluation by the nurse would be most accurate? a The client has received enough fluid. b The client's fluid status is unaltered. c The client has inadequate fluids. d The client has a volume excess

2 (The TPN is usually a HYPERtonic dextrose solution. The greater the concentration of dextrose in the solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the bodies calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution; ie; 5% dextrose in water or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloid are plasma expanders, and blood products are not used in TPN)

A client with inflammatory bowel disease is receiving TPN The basic component of the clients TPN solution is most likely to be: 1. an isotonic dextrose solution 2. a hypertonic dextrose solution 3. hypotonic dextrose solution 4. a colloid dextrose solution

a (Correct: A; long term NSAIDS can lower platelets. the finding is out of normal range. WRONG: b; glucose not affected, C; kidney function which is monitored by creatinine is affected but this result is wnl. D: liver function which is monitored by ALT is affected, but this is wnl)

A nurse in a clinic is caring for a pt who has been on long term NSAIDS to treat myocarditis. Which of the following lab finding should the nurse report? a Plt 100,000 b Serum glucose 110 c. Creatinine 0.7 d ALT 30

B,C,E (b; The nurse should expect the pt to have bilateral crackles for an increased CVP and PAWP C; The nurse would expect the client to have JVD with elevated CVP &PAWP. E: The nurse should expect the client to have hepatomegaly with elevated CVP and PAWP. WRONG ANSWERS: a; clients CVP and PAWP are above the expected reference range poor skin turgor for decreased CVP, d; dry mucous membranes are sign of decreased CVP PAWP)

A nurse is assessing a client who is undergoing hemodynamic monitoring The client has a CVP of 7 mmHg, and a PAWP of 17 mmHg Which of the following findings should the nurse expect? (SATA) a. poor skin turgor b. bilateral lung crackles c. JVD d dry mucous membranes e. hepatomegaly

a,e (Rationale During Stage I cardiogenic​ shock, the body alters capillary hydrostatic pressures in order to maintain fluid volume and preserve cardiac output. Decreases in MAP decrease capillary hydrostatic pressures.​ Also, when these pressures are​ decreased, fluid shifts from the interstitial space into the capillaries. The other answer choices are incorrect.)

A nurse is caring for a client in Stage I cardiogenic shock. The nurse understands that capillary hydrostatic pressures may be altered during this stage of shock. What is true regarding capillary hydrostatic pressures in Stage I​ shock? ​(Select all that​ apply.) a Decreases as mean arterial pressure​ (MAP) decreases b Increases as mean arterial pressure​ (MAP) decreases c When​ increased, causes fluid shifts from interstitial space into the capillaries d When​ decreased, causes fluid shifts from capillaries into the interstitial space e When​ decreased, causes fluid shifts from interstitial space into the capillaries

a,d,e (Rationale A pulmonary angiography involves an IV injection of contrast​ dye, which is injected into the pulmonary arteries and is illuminated on​ x-ray. The ventilation part of the​ ventilation-perfusion (V/Q) lung scan involves the inhalation of a​ radio-tagged gas that measures ventilation.)

A nurse is caring for a client suspected of having a pulmonary embolism. The​ client's health care provider has ordered the client to have a pulmonary angiogram. Which statements will the nurse include in teaching the client about this​ procedure? ​(Select all that​ apply.) ​a "Part of this procedure involves the placement of an​ IV." ​b "Part of this procedure involves inhaling a gas that measures​ ventilation." ​c "Part of this procedure uses radioisotopes to help diagnose pulmonary​ embolism." ​d "Part of this procedure involves the use of​ x-ray." ​e "Part of this procedure involves contrast injected into the pulmonary​ arteries."

a (Rationale This client is likely in Stage I shock. During this​ stage, the sympathetic nervous system​ (SNS) is stimulated as a compensatory mechanism. The result is tachycardia and hypertension. Early shock often shows no symptoms. Stage II shock occurs with prolonged​ vasoconstriction, eventually leading to decreased BP. Stage III is irreversible​ shock, which is identified with a complete lack of cardiac output​ (CO), despite treatment. Tachycardia and hypertension do not occur during this stage.)

A nurse is caring for a client with hypovolemic shock secondary to a gunshot wound to the abdomen. The nurse notes the client​'s heart rate is 120 and blood pressure is​ 150/90. Which stage of shock does the nurse determine this client is​ experiencing? a Stage I b Stage II c Stage III d Early

a,c,d (Rationale Current​ medications, history of​ DVT, and recent surgical history are factors assessed during the health history portion of the nursing assessment. The degree of edema and apical pulse quality are assessed during the physical exam portion of the nursing assessment.)

A nurse is performing a nursing assessment on a client with a pulmonary embolism​ (PE). Which assessments will the nurse anticipate during the health history portion of the nursing​ assessment? ​(Select all that​ apply.) a Current medications b Quality of apical pulse c Recent surgeries d History of DVT e Degree of edema

b (Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.)

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: A Premature ventricular contractions B Ventricular tachycardia C Ventricular fibrillation D Sinus tachycardia

1,2,5

A nurse is working with a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? SATA 1. follow up ECG 2. Energy setting s used 3. IV fluid intake 4. Urinary output 5. Skin condition under electrodes

a (Rationale: In hypertrophic cardiomyopathy, symptoms may not develop until the demand for oxygen increases as with exercising. This type of cardiomyopathy is not a problem with filling the heart, but rather an obstruction of blood being ejected from the heart to meet the body's oxygen demand. It is not likely that the child had symptoms. The ventricle does not rupture due to scarring. )

A young athlete collapsed and died due to hypertrophic cardiomyopathy. The parents ask the nurse how it is possible that their child had no symptoms of this disorder before experiencing sudden cardiac death. What is the most appropriate response made by the nurse? a "Exercise causes the heart to contract more forcefully and can lead to changes in the heart's rhythm or outflow of blood." b "It is likely that your child had symptoms of the disorder but may not have thought them important." c "During exercise, the heart may not be able to meet the body's demands for blood and oxygen." d "Cardiomyopathy results in destruction and scarring of cardiac muscle cells. As a result, the ventricle may rupture, causing sudden death."

2 (Fluid retention/weight gain)

The client dx with end stage CHF is being cared for by the HH nurse. Which intervention should the nurse teach the caregiver? 1. Report any time the client starts having difficulty breathin 2. Notify the HCP if the client gains more than 3lb in a week 3. Teach how to take the clients apical puse for 1 full min 4. Encourage the client to participate in 10 mins exercise a day

5 4 3 2 1 (5: The nurse first must obtain informed consent prior to blood admin 4: The nurse needs to complete the pre transfusion assessment including assess for any signs of allergic reaction PRIOR to administering unit of blood 3: The blood must be hung with Y-tubing and NS, and an 18 gauge angiocath is preferred 2: The nurse must check the unit of blood from the lab with another nurse and with the clients blood band 1: During the first 15 mins the blood transfusion must be administered slowly to determine if the client is going to have an allergic reaction)

Don't know 9. The cardiac RN is preparing to admin 1 unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority. 1. Infuse the unit of blood at 20 gtt/min the first 15 min 2 Check the unit of blood and the clients blood band with another nurse 3. Initiate the Y-tubing with NS via an 18 guage angiocatheter 4 Assess the clients VS and lung sounds and assess for a rash 5. Obtain informed consent for the unit of blood from the client

b (Explanation: The client is hypotensive, so the necessary intervention at this time is to increase the rate of the IV infusion. Answers A, C, and D are not initial interventions to take, so they are incorrect.)

The nurse is caring for a postoperative client when the client becomes nonresponsive and pale, with a BP of 90/40. The nurse recognizes that the necessary intervention at this time is to: a Place the client in Trendelenburg position b Increase the IV infusion rate c Administer atropine intravenously d Move the emergency cart to the bedside

2 (Client being discharged most stable. Wrong #1: this client requires teaching of the preprocedure interventions for diagnostic testing, needs more experienced nurse. #3 SVT is not life threatening but this client requires IV meds and close monitoring... give to more experienced RN. #4 A client with atrial fibrillation is usually taking warfarin, and the therapeutic INR is 2-3. An INR of 5 is high and the client is at risk for bleeding)

The charge nurse is making shift assignments. Which client would be most appropriate to assign to a new grad who just completed orientation on the medical floor? 1. The client admitted for Dx tests to rule out valvular heart disease 2. The client 3 days post MI being discharged tomorrow 3. The client experiencing SVT on telemetry 4. The client Dx with atrial fibrillation who has an INR of 5

1 4 5 2 3 (1 Assess to determine if client is hypovolemic or in shock the stem does not provide info to state client is hypovolemic. 4 Start IV to replace fluid volume 5 While the nurse starts IV a sample can be sent for match 2 A NG tube should be inserted to direct iced saline to cause constriction which will decrease the bleed 3 The iced lavage will decrease bleeding)

The client is admitted to the ED complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement? LIST IN ORDER OF PRIORITY 1. Assess the clients VS 2. Insert a NG tube 3. Begin iced saline Lavage 4. Start and IV with an 18 gauge needle 5. Type and crossmatch for blood transfusion

1 (increasing ICP causes unequal pupils as a result of pressure on 3rd cranial nerve. Increasing ICP increases the systolic pressure which reflects additional pressure on the vagus nerve which produces bradycardia, and it causes an increase in body temp from the hypothalmic damage)

The client is at risk for ICP. Which finding is the priority for the nurse to monitor? 1. Unequal pupil size 2. decreasing systolic BP 3. Tachycardia 4, decreasing body temp

3 (TReat the PATIENT! The nurse must assess the apical pulse and BP to determine if the client is in cardiac arrest and then treat as V-fib. If the clients heart is beating, the nurse would then admin lidocaine. WRONG: #1 Amiodarone is the drug of choice for V-tach, but not the first intervention. #2 defib with V-fib, but not first intervention. #4 CPR is performed on client not breathing and no pulse. Must know if there is a pulse FIRST)

The client is exhibiting V-tach. Which intervention should the nurse implement first? 1. Admin amiodarone, and antidysrhythmic IVP 2. Prepare to defibrillate the client 3. Assess the clients apical pulse and BP 4. Start basic CPR

1,3,4,5 (Vfib indicates no heartbeat. Start CPR. You will need the crash cart and defib ready. Amiodarone is used in ventricular dysrhythmias, WRONG #2 Adenosine is for SVT)

The client is in V-fib. Which interventions should the nurse implement? SATA 1. Start CPR 2. Prepare to admin adenosine (the antidysrhythmic) IVP 3. Prepare to defibrillate the client 4. Bring the crash cart to bedside 5. Prepare to admin amiodarone (the antidysrhythmic) IVP

a,b,c (Explanation: Prior to the Cardiac Computer Tomography Angiography, the nurse should check renal function by reviewing the creatinine levels, question the client regarding allergies to shellfish and iodine, and obtain a permit for the procedure. Answer D is incorrect since a cardiac CTA does not affect hearing. Answer E is incorrect since drinking increased amounts of fluid should be done after the exam. There is no need to force fluids prior to the exam.)

The client is scheduled for a cardiac CTA. Prior to the cardiac CTA, the nurse should do which of the following? Select all that apply. a Check the client's creatinine. b Question the client regarding allergies to shellfish. c Obtain a consent from the client or responsible person. d Question the client regarding difficulty hearing. e Instruct the client to drink 8 glasses of water the day prior to the exam.

1,2,3,4 (You dont defib a client with a heart beat And this drug can cause hepatomegaly so watch liver too)

The client is showing ventricular ectopy and the HCP orders amiodarone (Cordarone) IV. Which interventions should the nurse implement? SATA 1. Monitor telemetry continuously 2. Assess the clients respiratory status 3. evaluate liver fx studies 4. Confirm orig order with another nurse 5. Prepare to defib the client at 200 Joules

2 (dyspnea at night while in recumbent position indicates the cardiac muscle is not able to compensate for extra fluid returning to the heart during sleep. WRONG #4 The client is at risk for HF as result of MI, but does not happen with all clients and does not support the dx)

The nurse identifies concept of perfusion for client dx with CHF. Which assessment data supports this concept? 1. the client has a large abdomen and positive tympanic wave 2. The client has paroxysmal nocturnal dyspnea 3. The client has 2+ glucose in urine 4. The client has comorbid condition of MI

c,d (Rationale: The client's edema is unlikely to be due to fluid retention if daily weights have been stable, so the nurse's interventions are aimed at promoting venous return to the heart by having the client elevate the legs and applying antiembolism stockings. While reviewing the diet and lab values is appropriate, it is unlikely the client is experiencing fluid retention if daily weights are not increasing. There is no need to increase the client's diuretic dosage. )

The nurse in a long-term care facility is talking with the family of a client diagnosed with heart failure, diabetes, hypertension, and chronic renal failure. The nurse notes mild edema of the ankles while the client is sitting in the chair. Breath sounds are clear, equal, and with good chest excursion, and the client denies any feeling of shortness of breath. The nurse reviews the medical record and sees no significant change in the client's daily weights over the last week. What are the nurse's priority interventions for this client? (Select all that apply.) a Call the doctor for an order to increase the client's diuretic. b Review the client's BUN and creatinine. c Apply antiembolism stockings. d Encourage the client to elevate feet when sitting. e Review the client's diet to determine sodium intake

c (Explanation: Readings of pH 7.35, PO2 85, PCO2 55, and HCO3 27 represent compensated respiratory acidosis with increased PCO2 (normal 35-45), low pH of less than 7.4 (normal 7.35-7.45), and high HCO3 with compensation (normal 22-26). Answers A, B, and D are not reflected in the blood gas results listed in the stem.)

The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. What do these values indicate? a Uncompensated respiratory acidosis b Uncompensated metabolic acidosis c Compensated respiratory acidosis d Compensated metabolic acidosis Answer

a (Rationale: The motor pathways of the nervous system cross at the medulla and spinal cord, so that damage to a cerebral vessel on one side will manifest neurologic deficits in the opposite, or contralateral, side. This client will exhibit deficits on the right side. )

The nurse is assigned to care for a client who has had an acute ischemic stroke of a left cerebral vessel. The chart reveals that the client has contralateral deficits. The nurse explains to the family that this means: a The client will have neurological deficits on the right side. b The client will have neurological deficits on the left side. c Both sides of the client's body are involved. d Deficits will be present below the level of the stroke

b,d,e (Rationale Medical conditions associated with atrial fibrillation include​ long-standing hypertension, mitral​ regurgitation, mitral​ stenosis, acute myocardial​ infarction, and heart failure. Mitral valve prolapse is associated with development of premature atrial contractions. Cor pulmonale is associated with development of premature atrial contractions and atrial flutter.)

The nurse is caring for a client being evaluated for atrial fibrillation. Which medical conditions should the nurse inquire about during the health history interview with the​ client? ​(Select all that​ apply.) a Cor pulmonale ​b Long-standing hypertension c Mitral valve prolapse d Heart failure e Mitral regurgitation

a,b,d (Rationale Incidence of torsades de pointes is common in individuals who are on liquid protein​ diets, experiencing​ starvation, or taking prescribed diuretics. The incidence of asystole is associated with massive cardiac muscle damage. The incidence of pulseless electrical activity is associated with overdose of cardiac medication.)

The nurse is caring for a client diagnosed with torsades de pointes. Which information might the nurse anticipate finding in the​ client's admission​ history? ​(Select all that​ apply.) a Experiencing starvation b Currently on liquid protein diet c Overdose of cardiac medication d Taking prescribed diuretics e Massive cardiac muscle damage

2 (The rapid response team should be called immed to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. IF the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided)

The nurse is caring for a client who has become unresponsive, the BP is 80/40 and SpO2 is 90% on 50% face mask. The nurse should: 1 begin chest compressions 2. call the rapid response team 3. remove the family from the room 4 ventilate the client with a bag mask device

a (ationale: The endotoxins released by bacteria stimulate the release of vasoactive proteins causing peripheral vasodilation and decreased peripheral resistance. Cardiogenic, hypovolemic, and obstructive shock are not characterized by these symptoms. )

The nurse is caring for a client who is diagnosed with shock. Which type of shock will the nurse provide an intervention if the client presents with widespread vasodilation and decreased peripheral resistance? a Septic shock b Hypovolemic shock c Cardiogenic shock d Obstructive shock

2,3,5 (Type 2 HIT is an immune mediated disorder that typically occurs after exposure to heparin for 4-10 days and has life threatening and limb threatening thrombotic complication. The client clots rather than bleeds. Spontaneous bleeding is not associated with HIT. Clots would indicated HIT either DVT or PE, sometimes arterially which can cause an MI. Hit IS a decrease in baseline plateelet count by 50%. It may manifest as lesions at the site of heparin injection or chills fever, dyspnea or chest pain)

The nurse is caring for a client who is receiving heparin therapy IV. Which assessment data would indicate to the nurse the client is developing Heparin induced thrombocytopenia (HIT) SATA 1. The client has spontaneous bleeding from around the IV site 2. The client complains of chest pain on inspiration and becomes restless 3 The clients platelet count on admission was 420 and now is 200 4. The client complains that the gums bleed when brushing the teeth 5. The client has developed skin lesions at the IV site

2,3,5 (Type 2 HIT is an immune mediated disorder that typically occurs after exposure to heparin for 4-10 days and has life threatening and limb threatening thrombotic complication. The client clots rather than bleeds. Spontaneous bleeding is not associated with HIT. Clots would indicated HIT either DVT or PE, sometimes arterially which can cause an MI. Hit IS a decrease in baseline plateelet count by 50%. It may manifest as lesions at the site of heparin injection or chills fever, dyspnea or chest pain)

The nurse is caring for a client who is receiving heparin therapy IV. Which assessment data would indicate to the nurse the client is developing Heparin induced thrombocytopenia (HIT) SATA 1. The client has spontaneous bleeding from around the IV site 2. The client complains of chest pain on inspiration and becomes restless 3 The clients platelet count on admission was 420 and now is 200 4. The client complains that the gums bleed when brushing the teeth 5. The client has developed skin lesions at the IV site

c (Rationale Cough is the most common manifestation of PE.​ Syncope, cyanosis, and hemoptysis may​ occur; however, these are less common.)

The nurse is caring for a client who is suspected of having a pulmonary embolism​ (PE). Which is the most common manifestation of PE that the nurse will recognize upon​ assessment? a Syncope b Cyanosis c Cough d Hemoptysis

d,e (Rationale Morphine​ sulfate, used to decrease​ pain, also decreases the​ client's anxiety and dilates the coronary​ arteries, improving perfusion to the myocardium. This medication does not improve gas exchange or myocardial contractility.)

The nurse is caring for a client with cardiogenic shock who appears anxious and short of breath. The healthcare provider orders morphine sulfate for the treatment of the​ client's symptoms. What is the​ nurse's best understanding about the reason for this​ order? ​(Select all that​ apply.) a This medication improves gas exchange. b This medication improves myocardial contractility. c This medication constricts the coronary arteries. d This medication increases perfusion to the myocardium. e This medication decreases anxiety.

c (EARLYExplanation: EARLY****symptoms of hypocalcemia include numbness and tingling of the toes and extremities as well as around the mouth. Answers A, B, and D are later symptoms; therefore, they are incorrect.)

The nurse is caring for a patient following a thyroidectomy. Which of the following is an early symptom of hypocalcemia? a Positive Chvostek's sign b 3+ deep tendon reflexes c Numbness or tingling of the toes and extremities d Prolonged ST and QT intervals Answer

a,c (Rationale: The left lateral position reduces pressure on the vena cava, thereby increasing venous return. Hyperreflexia indicates central nervous involvement and is a sign of progression toward eclampsia. Blood pressure is assessed every 1-4 hours. Urine output is decreased in preeclampsia; the client is weighed daily for fluid status)

The nurse is caring for a pregnant woman who is admitted with preeclampsia. The nurse plans care based on the nursing diagnosis of deficient fluid volume related to fluid shifts from vasospasms. Which nursing intervention is a priority for this client? (Select all that apply.) a Assess deep tendon reflexes. b Assess blood pressure every 8 hours. c Place client in the left lateral recumbent position. d Monitor for increased urine output. e Weigh client weekly.

a (Rationale: The woman experiencing eclampsia is at great risk for seizures, and the highest priority of care is a patent airway. Checking blood pressure, fetal heart tones, and administering magnesium sulfate and oxygen are all components of care but are of lower priority than maintaining a patent airway. )

The nurse is caring for a woman who has been admitted with early pregnancy-induced hypertension (PIH) that has progressed to eclampsia. The priority intervention by the nurse is to: a maintain a patent airway. b prepare to administer magnesium sulfate. c administer oxygen. d check the blood pressure and fetal heart tones.

a (Explanation: The phlebostatic axis is located at the fifth intercostal space mid-axillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostal space mid-clavicular line, so answer B is incorrect. Erb's point is the location at which you can auscultate the valves closing simultaneously, making Answer C incorrect. The tail of Spence (the upper outer quadrant of the breast) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, Answer D is incorrect.)

The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the: a Phlebostatic axis b Point of maximal impulse c Erb's point d Tail of Spence

1,2,3,4,5

The nurse is demonstrating the use of a blood pressure monitor to a client newly diagnosed with HTN. WHich should the nurse teach the client? SATA 1. Tell the client to make sure the cuff is over the artery 2. Teach the client to notify the HCP if the BP is >160/100 3. Instruct the client about orthostatic hypotension 4. Encourage the client to keep a record of the BP readings 5. Explain that even when the BP is wnl the meds should still be taken

a,b,e (Rationale: Laboratory findings that support a diagnosis of DIC include the presence of​ schistocytes, a decreased platelet​ count, and an increase in fibrin degradation products or fibrin split products. The client with DIC would not have an elevated hemoglobin or shortened prothrombin​ time, thromboplastin​ time, and thrombin time.)

The nurse is evaluating the lab results for a client suspected of having DIC. Which laboratory findings would support the​ diagnosis? ​(Select all that​ apply.) a Decreased platelet count b Increased fibrin degradation products or fibrin split products c Shortened prothrombin​ time, thromboplastin​ time, and thrombin time d Elevated hemoglobin e The presence of fragmented red blood cells called schistocytes

a,c,e (Rationale Presence of​ trauma, burns, and recent surgical history are factors assessed during the health portion of the nursing assessment. The recent vital signs and CVP are assessed during the physical exam portion of the nursing assessment.)

The nurse is performing an assessment on a client with hypovolemic shock. Which assessments will the nurse anticipate during the health history portion of the nursing​ assessment? ​(Select all that​ apply.) a Presence of burns b Recent vital signs c Presence of trauma d Recent CVP measurement e Recent surgeries

a,c (Rationale: Any type of cardiomyopathy has a very poor prognosis, so the client and family will likely experience anticipatory grieving of the loss of a loved one. The client will likely experience fear in confronting death. Risk for bleeding, decisional conflict, and risk for electrolyte imbalance are not priorities for this client. )

The nurse is planning care for a client with cardiomyopathy. Which nursing diagnoses are appropriate for the client? (Select all that apply.) a Fear b Decisional Conflict c Anticipatory Grieving d Risk for Electrolyte Imbalance e Risk for Bleeding

b (Rationale Countershock delivers a direct current charge that depolarizes all cardiac cells at the same time. This may stop a tachydysrhythmia and allow the SA node to regain control of impulse formation. A pacemaker is a pulse generator that provides electrical stimulus to the heart when it does not provide its own stimulus sufficient to maintain cardiac output. An ECG is a diagnostic test that measures the electrical activity of the​ heart, not a therapy. Medical teams use cardiac mapping and cardiac ablation to locate and destroy an ectopic focus.)

The nurse is providing care for a client who demonstrates a tachydysrhythmia. Which treatment option does the nurse anticipate for this​ client? a Cardiac ablation b Countershock c Pacemaker d ECG

d (Explanation: Troponin, T or I, is a protein found in the myocardium. Testing for protein is frequently used to identify an acute myocardial infarction. Answers A, B, and C return to normal in less than four days, which makes them incorrect.)

The nurse is reviewing the laboratory values of a client with a myocardial infarction. Which laboratory test is used to identify injury to the myocardium and can remain elevated for up to three weeks? a Total CK b CK-MB c Myoglobulin d Troponin T or I

3 (INR is used to assess effectiveness of the warfarin therapy INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the WHO was used for the plasma test It is now the recommended method to monitor effectiveness of warfarin. Generally, the INR for clients administered warfarin should range from 2 to 3. In the past prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5-2.5 times the control value Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin anticoagulant effect, whereas, protamine sulfate reverses the effects of heparin. Warfarin will help prevent blood clots.)

The nurse should teach the client who is receiving warfarin sodium that 1. partial thromboplastin time values determine the dosage of warfarin 2. protamine sulfate is used to reverse the effects of warfarin 3. international normalized ratio (INR) is used to assess effectiveness 4. warfarin will facilitate clotting of the blood

a (Rationale Chronic use of digoxin is a risk factor for developing a​ second-degree heart block.Chronic use of​ amiodarone, beta-blockers, and​ calcium-channel blockers is a risk factor for developing a​ third-degree heart​ block, not a​ second-degree heart block.)

The nursing team is caring for a client diagnosed with a​ second-degree heart block. Which prescribed medication found in the​ client's medical record may have caused this​ diagnosis? a Digoxin b A calcium channel blocker c A​ beta-blocker d Amiodarone

3 (transcutaneous pads should be placed on the client with third-degree heart block. For a client who is symptomatic, transutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is performed for ventricular fibrillation or ventricular tachycardia with no pulse.)

Upon assessment of third degree heart block on the monitor, what should the nurse do first? 1. call a code 2. begin CPR 3. Place transcutaneous pacing pads on the client 4. prepare for defibrillation

a,b,d,e (Explanation: A, B, D, and E can all be performed by the licensed practical nurse. Removing a peripherally inserted central line should be performed by the RN or the doctor.)

Which task should be delegated to the licensed practical nurse? Select all that apply. a Administering heparin subcutaneously b Feeding the client with a percutaneous endoscopy gastrostomy tube c Removing a peripherally inserted central line d Monitoring chest tube drainage e Performing tracheostomy care

1,2,4,5 (#3 is wrong: Salt should be RESTRICTED in the diet of a client with HTN not CAD)

Which teaching should the nurse implement fro the client dx with CAD? SATA 1. encourage low fat low cholesterol diet 2. Instruct the client to walk 30 min a day 3. decrease salt intake to 2g a day 4. refer to a counselor for stress reduction techniques 5. teach the client to increase fiber in the diet