N430 HESI Exam 2

Which of these clients in the emergency department would the nurse see FIRST?

A client with ventricular fibrillation

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery?

Assist client to use the incentive spirometer

When performing a focused respiratory assessment, which action would the nurse take FIRST?

Check for any evidence of respiratory distress

Which action would the nurse take FIRST in a client with an abdominal aortic aneurysm who is suddenly pale and report feeling light-headed and having abdominal pain?

Check the blood pressure for hypotension

Which clinical indicator would the nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? SATA

Crackles Atelectasis Hypoxemia Severe dyspnea

The nurse would monitor postoperative clients for which clinical manifestation of a pulmonary embolus? SATA

Dyspnea Hemoptysis Feeling of impending doom

Which laboratory result will the nurse expect when caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI)?

Elevated serum troponins I and T

Which response would the nurse give when a client is admitted with chest pain and a family member asks about the purpose of the prescribed 12-lead electrocardiogram (ECG)?

Indicates whether a heart attack is occurring

While in the post anesthesia care unit, a client reports shortness of breath and chest pain. Which is the MOST appropriate initial response by the nurse?

Initiate oxygen via a nasal cannula

Which nursing intervention would be the priority action for a patient experiencing cardiac arrest from ventricular fibrillation?

Initiating defibrillation

The nurse is caring for a client with the following arterial blood gas (ABG) vales: PO2 89 mmHg, PCO2 35 mmHg, and pH of 7.37. These findings indicate that the client is experiencing which condition?

Normal acid-base balance

Which prescribed action has the HIGHEST PRIORITY when a client comes to the emergency department with moderate substernal chest pain that is unrelieved by rest and nitroglycerin?

Obtain a 12-lead electrocardiogram (ECG)

Which manifestation would the nurse expect to find upon assessment of a client with a 10-year history of emphysema hospitalized for acute respiratory distress?

Prolonged expiration with use of accessory muscles

Which part of the electrocardiogram (ECG) represents depolarization of the ventricles?

QRS interval

The nurse is providing postoperative care to a client who is being weaned from mechanical ventilation. Which is a PRIORITY nursing action?

Remaining with the client to evaluate for respiratory distress

Which common response would the nurse monitor for in a client who has recently been extubated in the post anesthesia care unit after surgery?

Restlessness

Which finding in a client seen in the emergency department with chest pain is MOST important to communicate to the health care provider?

ST segment elevation on electrocardiogram

When completing an assessment, which response would the nurse expect a client experiencing severe acute respiratory distress to exhibit?

Tachycardia

Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation?

Take pulse apically for a full minute

Which rhythm would the nurse document when observing the following dysrhythmia on a client's cardiac monitor? (ventricular fibrillation)

Ventricular fibrillation