NURS 225 Exam 3
How fast do you transfuse platelets? A. 15-30 min B. 2-4hrs
A
Which population is especially vulnerable to crisis development? A. Those with severe and chronic mental illness B. Politicians C. Pet owners D. Married people
A
A client loses all possessions in a house fire experiences which of the following crisis? A. Maturational B. Situational C. Medical D. Adventitious
B
The universal blood recipient is A. O- B. AB+
B
Before initiating the blood transfusion, you obtain the patient's baseline vital signs, which are: heart rate 100, blood pressure 115/72, respiratory rate 18, and temperature 100.8'F. Your next action is to: A. Administer the blood transfusion as ordered. B. Hold the blood transfusion and reassess vital signs in 1 hour. C. Notify the physician before starting the transfusion. D. Administer 200 mL of the blood and then reassess the patient's vital signs.
C
In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms
C
What are factors common to all crises? A. They are experienced suddenly B. Early intervention is most effective C. The focus is on immediate problem solving D. All of the above
D
What blood type is known as the "universal donor"? A. Type A B. Type B C. Type AB D. Type O
D
24-36 hours after a myocardial infarction _________ congregate at the site during the inflammation phase. A. Neutrophils B. Eosinophils C. Platelets D. Macrophages
A
A family member, who is caring for a 2-year-old with Tetralogy of Fallot, asks you why the child will periodically squat when playing with other children. Your response is: A. "Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." B. "Squatting helps to decrease systemic vascular resistance, which will decrease the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels." C. "Squatting helps to decrease systemic vascular resistance, which will increase the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." D. "Squatting helps to normalize systemic vascular resistance, which will increase the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels."
A
A nurse is admitting a client who has a suspected MI and a history of angina. Which of the following findings will help the nurse distinguish stable angina from an MI? A. Stable angina can be relieved with rest and nitroglycerin B. The pain of an MI resolves in less than 15 min C. The type of activity that causes an MI can be identified D. Stable angina can occur for longer than 30 min
A
A nurse is caring for a client who asks why the provider prescribed a daily aspirin. Which of the following responses should the nurse make? A. "Aspirin reduces the formation of blood clots that could cause a heart attack" B. "Aspirin relieves pain due to myocardial ischemia" C. "Aspirin dissolves clots that are forming in your coronary arteries" D. "Aspirin relieves headaches that are caused by other medications"
A
A nurse is providing discharge teaching for a client who has HF and is on a fluid restriction of 2000mL/day. The client asks the nurse how to determine the appropriate amount of fluids they are allowed. Which of the following statements is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2L bottle to keep track of how much you drink" B. "Each glass contains 8oz. There are 30 mL per oz, so you can have a total of 8 glasses per day" C. "This is the same as 2 quarts, or about the same as 2 pots of coffee" D. "Take sips of water or ice chips so you will not take in too much fluid"
A
A patient is admitted with chest pain to the ER. The patient has been in the ER for 5 hours and is being admitted to your unit for overnight observation. From the options below, what is the most IMPORTANT information to know about this patient at this time? A. Troponin result and when the next troponin level is due to be collected B. Diet status C. Oxygen saturation D. CK result and when the next CK level is due to be collected
A
A patient started receiving their first unit of blood at 1000. It is now 1010 and the patient is reporting itching, chills, and a headache. In addition, the patient's temperature is now 99.8'F from 98'F. Your next nursing action is: A. Stop the transfusion B. Notify the physician C. Decrease the rate of the transfusion D. Reassure the patient that this is normal and will resolve in 30 minutes.
A
A patient's morning lab work shows a potassium level of 6.3. The patient's potassium level yesterday was 4.0 The patient was recently started on new medications for treatment of myocardial infarction. What medication below can cause an increased potassium level? A. Losartan B. Norvasc C. Aspirin D. Cardizem
A
After speaking with the mother of the infant in the previous question, who may have a ventricular septal defect, you auscultate heart sounds. If a ventricular septal defect was present, you may hear a harsh murmur that is _______________________. A. Located at the lower left sternal border and starts at S1 and extends into S2. B. Located at the upper left sternal border and is continuous during systole. C. Located at the lower left sternal border and is continuous machine-like. D. Located at the upper left sternal border and is only heard during diastole.
A
As the nurse you know that some patients who have coarctation of the aorta will develop collateral circulation of the arteries due to the abnormality on the aorta. Which option below indicates a patient is experiencing collateral circulation? A. Chest x-ray that demonstrates notching on the ribs B. A harsh diastolic murmur on inspiration at the 2nd intercostal border C. Ejection fraction of 12% on an echocardiogram D. Chest x-ray that demonstrates cardiomegaly
A
As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which patient below it is at most RISK for a febrile (non-hemolytic) transfusion reaction? A. A 38 year old male who has received multiple blood transfusions in the past year. B. A 42 year old female who is immunocompromised. C. A 78 year old male who is B+ that just received AB+ blood during a transfusion. D. A 25 year old female who is AB+ and just received B+ blood.
A
In regards to the patient in the previous question, after administering the first dose of Nitroglycerin sublingual the patient's blood pressure is now 68/48. The patient is still having chest pain and T-wave inversion on the cardiac monitor. What is your next nursing intervention? A. Hold further doses of Nitroglycerin and notify the doctor immediately for further orders. B. Administer Morphine IV and place the patient in reverse Trendelenburg position. C. Administer Nitroglycerin and monitor the patient's blood pressure. D. All the options are incorrect.
A
TRUE or FALSE: A small muscular ventricular septal defect has a high probability of self-closure, and these types of VSDs are found in the lower portion of the ventricular septum. A. True B. False
A
The goal in primary care in crisis management is which of the following? A. Decrease the incidence of crisis B. Lessen the severity of acute trauma C. Provide support for families of trauma victims D. Ensure the client seeks appropriate follow up
A
The most effective way of planning crisis resolution is which of the following? A. In collaboration with the client B. Plan standardized interventions C. Focus on long term problem D. Organize follow up first
A
The patient has B+ blood. What type of blood can they accept? A. B- B. A+
A
The patient has type O- blood. What type of blood can they accept for transfusion? A. O- B. A-
A
True or False: In a normal heart without any type of congenital heart defect, the pulmonary vein carries oxygenated blood away from the lungs to the left side of the heart. A. True B. False
A
True or False: Pulmonary and systemic vascular resistance both play a role with influencing cardiac afterload. A. True B. False
A
What is a complication that can happen if the blood is run too quickly on some patients? A. Fluid volume overload B. They will turn red
A
What is a complication that can happen when the cells are damaged during transfusion? A. Hyperkalemia B. Hypokalemia
A
What is a self care technique a nurse could use when working with clients in crisis? A. Be aware of personal feelings and healthy coping skills B. Become cold and hardened C. Stop working with that population D. Leave the profession
A
What solution or solutions below are compatible with red blood cells? A. Normal Saline B. Dextrose Solutions C. Any medications with normal saline D. No solutions are compatible with blood
A
What type of fluid can be run with blood? A. NS B. LR
A
When giving blood what type of tubing do you need to use? A. Filtered B. No special tubing needed
A
Which of the following is true of a crisis? A. It can lead to personal growth B. It is precipitated by unhealthy coping skills C. It is a leading cause of mental illness D. It is always caused by a sudden stress
A
You're providing an in-service to a group of new nurses who will be caring for patients who have Tetralogy of Fallot. Which statement below is INCORRECT concerning how the blood normally flows through the heart? A. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium. B. The pulmonic valve receives blood from the right ventricle and allows blood to flow to the lungs via the pulmonary artery. C. The left atrium allows blood to flow down through the bicuspid valve (mitral) into the left ventricle. D. Oxygenated blood leaves the left ventricle and flows up through the aortic valve and aorta to be pumped to the rest of the body.
A
Before a blood transfusion you educate the patient to immediately report which of the following signs and symptoms during the blood transfusion that could represent a transfusion reaction: A. Sweating B. Chills C. Hives D. Poikilothermia E. Tinnitus F. Headache G. Back pain H. Pruritus I. Paresthesia J. Shortness of Breath K. Nausea
A, B, C, F, G, H, J, K
As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply: A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." C. "Tetralogy of Fallot is treated with only palliative surgery." D. "Many patients with this condition will experience clubbing of the nails."
A, B, D
What conditions below can result in an increased cardiac afterload? Select all that apply: A. Vasoconstriction B. Aortic stenosis C. Vasodilation D. Dehydration E. Pulmonary Hypertension
A, B, E
A newborn has severe coarctation of the aorta. What signs and symptoms would you expect to find in this patient? Select all that apply: A. Very strong bounding pulses in the upper extremities B. Cool legs and feet C. Machine-like murmur only on systole D. Tet spells with activity E. Severe cyanosis F. Absent/diminished femoral pulses
A, B, F
What two factors are used to calculate cardiac output? Select all that apply: A. Heart rate B. Blood pressure C. Stroke volume D. Mean arterial pressure
A, C
A patient needs 2 units of packed red blood cells. The patient is typed and crossmatched. The patient has B+ blood. As the nurse you know the patient can receive what type of blood? Select all that apply: A. B- B. A+ C. O- D. B+ E. O+ F. A- G. AB+ H. AB-
A, C, D, E
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? (Select all that apply) A. Stop the transfusion B. Monitor for hypertension C. Maintain an IV infusion with 0.9% sodium chloride D. Position the client in an upright position with the feet lower than the heart E. Administer diphenhydramine
A, C, E
A 4-month-old is scheduled to take Digoxin for treatment of a ventricular septal defect. The patient's apical pulse is 89 beats per minute. As the nurse you will? Select all that apply: A. Hold the dose B. Recheck the pulse via the brachial artery C. Administer the dose as scheduled D. Notify the physician
A, D
Select all the true statements about the aorta: A. "The ascending aorta branches off to supply the coronary arteries of the heart." B. "It's the third largest artery in the body." C. "The aorta comes off the right ventricle and supplies oxygenated blood to the body." D. "The aortic arch branches off to supply the head, neck, and upper extremities."
A, D
A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce T-wave inversion. You obtain the patient's vital signs and find the following: Blood pressure 190/98, HR 110, oxygen saturation 96% on room air, and respiratory rate 20. Select-all-that-apply in regards to the MOST IMPORTANT nursing interventions you will provide based on the patient's current status: A. Obtain a 12-lead EKG B. Place the patient in supine position C. Assess urinary output D. Administer Nitroglycerin sublingual as ordered per protocol E. Collect cardiac enzymes as ordered per protocol F. Encourage patient to cough and deep breath G. Administer Morphine IV as ordered per protocol H. Place patient on oxygen via nasal cannula I. No interventions are needed at this time
A, D, E, G, H
A nurse is teaching a client who has heart failure and new prescriptions for furosemide and digoxin. Which of the following info should the nurse include? (Select all that apply) A. Weigh daily, first thing each morning B. Decrease intake of potassium C. Expect muscle weakness while taking digoxin D. Hold digoxin if HR is less than 70 beats/min E. Decrease sodium intake
A, E
A crisis is defined as which of the following? A. Pathological stress reaction B. Acute time limited state of disequilibrium C. Panic attack D. A time for deep reflection
B
A newborn baby, who is diagnosed with transposition of the great arteries, is ordered by the physician to be started on an infusion of prostaglandin E (alprostadil). The purpose of this medication is to: A. Prevent the closure of the foramen ovale. B. Allow a continued connection between the aorta and pulmonary artery via the ductus arteriosus. C. Prevent the closure of the ductus venosus. D. Increase the blood flow to the pulmonary vein, which will increase oxygen levels.
B
A nurse is caring for a client who has heart failure and reports increased SOB. Which of the following actions should the nurse take first? A. Obtain the client's weight B. Assist the client into high-fowler's position C. Auscultate lung sounds D. Check oxygen saturation with pulse oximetry
B
A nurse is preparing to administer packed red blood cells to a client who has a Hgb of 8g/dL. Which of the following actions should the nurse take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion B. Assess for an acute hemolytic reaction C. Explain the transfusion procedure to the client D. Obtain blood culture specimens to send to the lab
B
A patient has a blood pressure of 220/140. The physician prescribes a vasodilator. This medication will? A. Decrease the patient's blood pressure and increase cardiac afterload B. Decrease the patient's blood pressure and decrease cardiac afterload C. Decrease the patient's blood pressure and increase cardiac preload D. Increase the patient's blood pressure but decrease cardiac output.
B
A patient is complaining of a nagging cough that is continuous. Which medication below can cause this side effect? A. Losartan B. Lisinopril C. Cardizem D. Lipitor
B
A patient is ordered to receive 2 units of packed red blood cells. The first unit was started at 1400 and ended at 1800. You send for the other bag of red blood cells. As the nurse you know it is priority to: A. obtain signed informed consent for the second unit of blood from the patient B. obtain a new y-tubing set for this unit of blood C. type and crossmatch the patient D. hang a new bag of dextrose to transfuse with the blood
B
A patient with hypovolemic shock is given IV fluids. IV fluids will help _________ cardiac output by: A. decrease; decreasing preload B. increase, increasing preload C. increase, decreasing afterload D. decrease, increasing contractility
B
A person with mature coping skills will never experience a crisis A. True B. False
B
According to the American Association of Blood Banks, what is the recommended hemoglobin level for a blood transfusion? A. 5-7 g/dL B. 7-8 g/dL C. 4-7 g/dL D. 9-10 g/dL
B
Before starting a blood transfusion the nurse will perform a verification process with __________. This will include? A. any available personnel; physician's order, patient's identification, blood bank's information, expiration date of blood B. licensed personnel only (another RN); physician's order, patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, assess the bag of blood for damage or abnormal substances C. blood bank; patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, bag of blood for damage or abnormal substances D. licensed personnel only (another RN); blood compatibility, physician order, expiration date
B
How fast do you infuse fresh frozen plasma? A. 15-30 min B. 30-60 min
B
How long should you stay with the patient to monitor for blood transfusion reactions? 10 min 15 min 30 min
B
Red blood cells are very vital for survival. Which statement below is NOT correct about red blood cells? A. "Red blood cells help carry oxygen throughout the body with the help of the protein hemoglobin." B. "Extreme loss of red blood cells can lead to a suppressed immune system and clotting problems." C. "Red blood cells help remove carbon dioxide from the body." D. "Red blood cells are suspended in the blood's plasma."
B
TRUE or FALSE: The signs and symptoms of a ventricular septal defect are most commonly detected in a baby following birth. A. True B. False
B
The patient has A- blood. What blood transfusion can they accept? A. A+ B. O-
B
What is an autologous blood transfusion? A. One that is done automatically B. When a patient donates their own blood to be transfused
B
What is the first line medication for reducing after load for HF patients? A. Heparin B. Lisinopril C. Plavix D. Aspirin
B
Which statement below best describes the term cardiac preload? A. The pressure the ventricles stretch at the end of systole. B. The amount the ventricles stretch at the end of diastole. C. The pressure the ventricles must work against to pump blood out of the heart. D. The strength of the myocardial cells to shorten with each beat.
B
You are assessing the heart sounds of a patient with a severe case of Tetralogy of Fallot. You would expect to hear a __________ murmur at the _______ of the sternal border? A. diastolic; right B. systolic; left C. diastolic; left D. systolic; right
B
You note in the patient's chart that the patient recently had a myocardial infarction due to a blockage in the left coronary artery. You know that which of the following is true about this type of blockage? A. A blockage in the left coronary artery causes the least amount of damage to the heart muscle. B. Left coronary artery blockages can cause anterior wall death which affects the left ventricle. C. Left coronary artery blockage can cause posterior wall death which affects the right ventricle. D. The left anterior descending artery is least likely to be affected by coronary artery disease.
B
You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is: A. No stroke symptoms B. Severe stroke symptoms C. Mild stroke symptoms D. Moderate stroke symptoms
B
You're caring for a child with coarctation of the aorta and educating the parents about the child's condition. Which statement by the parents demonstrates they understood the pathophysiology of this defect? A. "This condition can lead to right-sided heart failure." B. "The narrowing of the aorta leads to a high blood pressure in the arteries that are found before the site of narrowing in the aorta." C. "The dilation of the aorta leads to a decrease blood pressure in the arteries that are found after the site of dilation." D. "The upper and lower extremities will experience a decrease in blood flow due to the defect in the aorta."
B
You're educating a patient about the causes of a myocardial infarction. Which statement by the patient indicates they misunderstood your teaching and requires you to re-educate them? A. Coronary artery dissection can happen spontaneously and occurs more in women. B. The most common cause of a myocardial infarction is a coronary spasm from illicit drug use or hypertension. C. Patients who have coronary artery disease are at high risk for developing a myocardial infarction. D. Both A and B are incorrect.
B
You're performing a head-to-toe- assessment on a newborn with severe coarctation of the aorta. You note a systolic heart murmur. Where is this heart murmur best auscultated in a patient with this condition? A. at the 4th intercostal space left to the sternal border B. at the left interscapular area C. at the 2nd intercostal space right to the sternal border D. at the mid-subclavicular line right of the sternal border
B
our patient is having a transfusion reaction. You immediately stop the transfusion. Next you will: A. Notify the physician. B. Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%. C. Collect urine sample. D. Send the blood tubing and bag to the blood bank.
B
After the birth of a newborn with severe coarctation of the aorta, the physician orders a prostaglandin infusion. As the nurse you know that this medication will have what type of therapeutic effects? Select all that apply: A. Prevent the foramen ovale from closing B. Allow a connection between the aorta and pulmonary artery C. Decrease the workload on the left ventricle D. Increase blood flow to the lower extremities
B, C, D
Stroke volume plays an important part in cardiac output. Select all the factors below that influence stroke volume: A. Heart rate B. Preload C. Contractility D. Afterload E. Blood pressure
B, C, D
Which of the following EKG changes are abnormal findings that may indicate ischemia or injury to the cardiac muscle found on a 12-lead EKG? SELECT-ALL-THAT-APPLY: A. Lengthening p-waves B. ST-segment elevation C. T-wave inversion D. Tall t-waves E. QT interval narrowing F. ST-segment depression
B, C, D, F
Select all the signs and symptoms of how a newborn with transposition of the great arteries may present after birth: A. Machinery-like heart murmur B. Cyanosis C. Low oxygen levels D. Bounding pulses in the upper extremities E. Increased respiratory rate F. Increased heart rate G. Knee-to-chest position
B, C, E, F
A newborn baby with transposition of the great arteries has an echocardiogram performed to detect if any other defects are present in the heart. As the nurse, you know that what other defects can most commonly occur with TGA? Select all that apply: A. Complete atrioventricular canal defect B. Ventricular septal defect C. Patent ductus arteriosus D. Tricuspid atresia E. Tetralogy of fallot F. Atrial septal defect
B, C, F
Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? (Select all that apply) A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.
B, D
You're providing discharge education to the parents of a child who just had surgery to repair coarctation of the aorta. What should the nurse include in the teaching about issues that can arise after surgery that must be closely monitored by a cardiologist? Select all that apply: A. Dilation of the aorta B. Restenosis of the aorta C. Hyperglycemia D. Hypertension
B, D
A concerned mother brings her 3-month-old to the clinic. The mother states the infant seems to be small for its age. In addition, she states the infant fatigues very easily while feeding and rarely finishes a feeding. While collecting a thorough health history, what other signs and symptoms described by the mother may indicate the child has a congenital heart defect, such as a ventricular septal defect? Select all that apply: A. Diarrhea B. Frequent treatment for lung infections C. Excessive wet diapers D. Diaphoresis when nursing E. Swelling in the hands and feet
B, D, E
A 4-month-old is diagnosed with Tetralogy of Fallot. You're providing an illustration to the parent to help him understand the pathophysiology of this condition. What defects must be present in the illustration to help the parent understand their child's condition? Select all that apply: A. Aortic stenosis B. Ventricular septal defect C. Coarctation of aorta D. Right ventricular hypertrophy E. Displacement of the aorta F. Pulmonic stenosis G. Patent ductus arteriosus
B, D, E, F
A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and MI. Which of the following changes should the nurse recommend be made first? A. Diet modification B. Relaxation exercises C. Smoking cessation D. Taking omega-3 capsules
C
A nurse is providing preop teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to surgery" B. "If you need an autologous transfusion, the blood your brother donates can be used" C. "You can donate blood each week if your hemoglobin is stable" D. "Any unused blood that is donated can be used for other clients"
C
A nurse is talking with a client who has class I heart failure and asks about obtaining a ventricular assistive device (VAD). Which of the following statement should the nurse make? A. "VADs are only implanted during heart transplantation" B. "A VAD helps to pace the heart" C. "VADs are used when heart failure is not responsive to meds" D. "A VAD is useful for clients who also have chronic lung issues"
C
A nurse on a cardiac unit is reviewing lab findings of a client who has a diagnosis of MI and reports that his dyspnea began two weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A. CK-MB B. Troponin I C. Tropinin T D. Myoglobin
C
A patient is being discharged home after receiving treatment for a myocardial infarction. The patient will be taking Coreg. What statement by the patient demonstrates they understood your education material about this drug? A. "I will take this medication at night." B. "I will take this medication as needed." C. "I will monitor my heart rate and blood pressure while taking this medication." D. "I will take this medication in the morning with grapefruit juice."
C
A patient with O+ blood received A+ blood. The patient is at risk for? A. Febrile transfusion reaction B. None: O+ and A+ are compatible blood types C. Hemolytic transfusion reaction D. Allergic transfusion reaction
C
A two-month-old is showing signs and symptoms of heart failure. An echocardiogram is ordered. The test shows the infant has a ventricular septal defect (VSD). Which statement below best describes the blood flow in the heart due to this congenital heart defect? A. "The blood in the heart is shunting from the right ventricle to the left ventricle, which is increasing pulmonary blood flow." B. "The blood in the heart is shunting from the left ventricle to the right ventricle, which is decreasing pulmonary blood flow." C. "The blood in the heart is shunting from the left ventricle to the right ventricle, which is increasing pulmonary blood flow." D. "The blood in the heart is bypassing the left ventricle and is being shunted to the right ventricle, which is decreasing lung blood flow."
C
An initial assessment in crisis intervention is which of the following? A. Perception of precipitating event B. Adherence to follow up plan C. Client's risk of harm D. Coping skills
C
The long term goal of crisis intervention is which of the following? A. Address long term stressors and behaviors B. Prevent lasting effects C. Return to pre-crisis level of function D. Get the client into psychotherapy
C
What blood type is known as the "universal recipient"? A. Type A B. Type B C. Type AB D. Type O
C
Which patient below is at most risk for a hemorrhagic stroke? A. A 65 year old male patient with carotid stenosis. B. A 89 year old female with atherosclerosis. C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55 year old female with atrial flutter.
C
While feeding a 3-month-old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to? A. Continue feeding the infant and place the infant on oxygen. B. Stop feeding the infant and provide suction. C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. D. Assess the infant's heart rate and rhythm.
C
You're educating the parents of a patient with transposition of the great arteries about the treatment options. Which treatment option below provides a permanent solution and is performed within the first few weeks of life? A. Prostaglandin E infusion B. Balloon atrial septostomy C. Arterial switch procedure D. Complete repair with a patch
C
You're providing care to a 36 year old male. The patient experienced abdominal trauma and recently received 2 units of packed red blood cells. You're assessing the patient's morning lab results. Which lab result below demonstrates that the blood transfusion was successful? A. Hemoglobin level 7 g/dL B. Platelets 300,000 µl C. Hemoglobin level 15 g/dL D. Prothrombin Time 12.5 seconds
C
Your patient needs 1 unit of packed red blood cells. You've completed all the prep and the blood bank notifies you the patient's unit of blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know that you must start transfusing the blood within _________. A. 5 minutes B. 15 minutes C. 30 minutes D. 1 hour
C
As the registered nurse you are developing a plan of care for a patient with Tetralogy of Fallot. Select all the appropriate nursing diagnoses below that would be specific to this patient: A. Risk for deficient fluid volume B. Ineffective airway clearance C. Activity Intolerance D. Failure to thrive E. Risk for impaired liver function
C, D
Which treatments below would decrease cardiac preload? Select all that apply: A. IV fluid bolus B. Norepinephrine C. Nitroglycerin D. Furosemide
C, D
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of febrile transfusion reaction? (Select all that apply) A. Temp change from 37 degrees celsius (98.6 deg F) pretransfusion to 37.2 degrees celsius (99.0 degrees F) B. Current BP 178/90 mm Hg C. HR change from 88/min pretransfusion to 120/min D. Client report of itching E. Client appears flushed
C, E
A client who had a serious injury in a car accident 3 months ago is now depressed and withdrawn. Phase of crisis? A. First B. Second C. Third D. Fourth
D
A doctor has ordered cardiac enzymes on a patient being admitted with chest pain. You know that _________ levels elevate 2-4 hours after injury to the heart and is the most regarded marker by providers. A. Myoglobin B. CK-MB C. CK D. Troponin
D
A donor has AB- blood. Which patient or patients below can receive this type of blood safely? A. A patient with O- blood. B. A patient with A- blood. C. A patient with B- blood. D. A patient with AB- blood.
D
A newborn baby is born with transposition of the great arteries (TGA). You're explaining the condition to the parents. Which statement by the father demonstrates he understood the education provided about this condition? A. "The pulmonary vein and artery are switched, which causes the pulmonary vein to deliver unoxygenated blood to the systemic circulation while the pulmonary artery delivers oxygenated blood back to the lungs." B. "The aorta and pulmonary vein are switched, which causes the aorta to arise from the right ventricle and the pulmonary vein to arise from the left ventricle." C. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the left ventricle and the pulmonary artery to arise from the right ventricle." D. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the right ventricle and the pulmonary artery to arise from the left ventricle."
D
A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? A. "I should place the tablet under my tongue" B. "I should have clotting time checked weekly" C. "I will report ringing in my ears" D. "I will call my doctor if my pulse rate is less than 60"
D
A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18-gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with assistive personnel C. Administers Dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtains VS every 15 min throughout the procedure
D
A patient is 36 hours status post a myocardial infarction. The patient is starting to complain of chest pain when they lay flat or cough. You note on auscultation of the heart a grating, harsh sound. What complication is this patient mostly likely suffering from? A. Cardiac dissection B. Ventricular septum rupture C. Mitral valve prolapse D. Pericarditis
D
A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will: A. Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood transfusion. B. Administer the IV antibiotic via secondary tubing into the blood transfusion's y-tubing. C. Hold the antibiotic until the blood transfusion is done. D. Administer the IV antibiotic as scheduled in a second IV access site.
D
A patient who needs a unit of packed red blood cells is ordered by the physician to be premedicated with oral diphenhydramine and acetaminophen. You will administer these medications? A. 15 minutes before starting the transfusion B. Immediately after starting the transfusion C. Right before starting the transfusion D. 30 minutes before starting the transfusion
D
According to Roberts (2005), crisis resolution occurs after which of the following? A. An action plan is developed B. Rapport with the client is established C. Major problems are identified D. Follow up plan is established
D
An infant has a large ventricular septal defect (VSD). The defect is located in the upper section of the ventricular septum and is near the tricuspid and aortic valve. Based on this description, what type of ventricular septal defect is this? A. Outlet (conal or subarterial) B. Muscular C. Inlet (atrioventricular) D. Membranous
D
How do you know your client teaching was effective about nitrates? A. "I will stand up quickly after taking this med" B. "I will not have a headache" C. "I will take even after I took my viagra" D. "I will call 911 if my pain isn't any better after 5 min"
D
Nursing interventions of the client in crisis include which of the following? A. Engage in problem solving B. Assist in identification/ development of coping skills C. Assist client to identify personal strengths D. All of the above
D
Select the statement below that best describes cardiac afterload: A. It's the volume amount that fills the ventricles at the end of diastole. B. It's the volume the ventricles must work against to pump blood out of the body. C. It's the amount of blood the left ventricle pumps per beat. D. It's the pressure the ventricles must work against to open the semilunar valves so blood can be pumped out of the heart.
D
What will you tell your client is the reason for giving them a plavix loading dose before the cath lab? A. To put you to sleep B. To help with your breathing C. To lower your HR D. To prevent platelets from sticking together and clotting the stent
D
You're caring for a newborn who has Tetralogy of Fallot with severe cyanosis. You anticipate the newborn will be started on ___________? A: Indomethacin B. Diclofenac C. Celecoxib D. Alprostadil
D
You're gathering supplies to start a blood transfusion. You will gather? A. PVC free tubing and dextrose B. Polyethylene-line tubing and 0.9% Normal Saline C. Y-tubing with in-line filter and dextrose D. Y-tubing with in-line and 0.9% Normal Saline
D
You've started the first unit of packed red blood cells on a patient. You stay with the patient during the first 15 minutes and: A. run the blood at 100 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. B. run the blood at 20 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. C. run the blood at 200 mL/min and then decrease the rate after 15 minutes, if tolerated by the patient. D. run the blood at 2 mL/min and then increase the rate after 15 minutes, if tolerated by the patient.
D
___________ is the amount of blood pumped by the left ventricle with each beat. A. Cardiac output B. Preload C. Afterload D. Stroke volume
D
