Week 4 review

A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which prescription from the health care provider should the nurse verify before implementing? 1. Administer metoprolol 5 mg via intravenous (IV) push. 2. Titrate dobutamine to keep systolic blood pressure higher than 100 mm Hg. 3. Prepare for a pulmonary artery catheter insertion. 4. Call for urine output less than 30 mL per hour for 2 consecutive hours.

1. Administer metoprolol 5 mg via intravenous (IV) push.

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? 1. Continue to monitor the client as ordered. 2. Re-zero the equipment and take another reading. 3. Call the health care provider and obtain an order for a diuretic. 4. Call the health care provider and obtain an order for a fluid bolus.

1. Continue to monitor the client as ordered

The nurse is asked to assess a client prior to having an arterial blood gas (ABG) sample drawn to determine if the client can safely undergo this test. What assessment should the nurse conduct? 1. Perform an Allen's test. 2. Review the client's baseline ABG results. 3. Gather a full set of vital signs. 4. Palpate the radial artery for strength and rhythm.

1. Perform an Allen's test.

A client reports dyspnea, chills, headache, and flank pain while receiving a blood transfusion. Place the nurse's actions in order from highest to lowest priority? Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1. Monitor the client's vital signs 2. Keep the I.V. line open with 0.9% sodium chloride 3. Document the transfusion-related occurrence 4. Stop the transfusion 5. Inform the primary care provider and blood bank 6. Return blood products to the blood bank

1. Stop the transfusion 2. Keep the I.V. line open with 0.9% sodium chloride 3. Inform the primary care provider and blood bank 4. Monitor the client's vital signs 5. Return blood products to the blood bank 6. Document the transfusion-related occurrence

A client is receiving 2 units of packed red blood cells (PRBCs). Which safety measure(s) should the nurse implement? Select all that apply. 1. Stop the transfusion if a reaction occurs, but keep the line open. 2. Inspect the blood bag for leaks, abnormal color, and clots. 3. Infuse a unit of PRBCs in less than 4 hours. 4. Use a 22-gauge catheter for optimal flow of a blood transfusion. 5. Verify that the ABO and Rh of the 2 units are the same. 6. Take vital signs every 15 minutes while the unit is transfusing.

1. Stop the transfusion if a reaction occurs, but keep the line open 2. Inspect the blood bag for leaks, abnormal color, and clots. 3. Infuse a unit of PRBCs in less than 4 hours.

The nurse receives shift hand-off on an assigned client who had a surgical procedure. What objective assessment suggests that the client may be developing sepsis and is at risk for septic shock? Select all that apply. 1. Temperature increase 2. Blood pressure decrease 3. Pulse rate of 32 beats per minute 4. Tachypnea 5. 32 mL of urine in 2 hours

1. Temperature increase 2. Blood pressure decrease 4. Tachypnea 5. 32 mL of urine in 2 hours

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? 1. "generally caused by decreased blood volume" 2. "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" 3. "a decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" 4. "severe hypersensitivity reaction resulting in massive systemic vasodilation."

2. "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume"

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider suspects the client is experiencing a dissecting aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm? 1. Stroke 2. Cardiac tamponade 3. Pulmonary edema 4. Myocardial infarction

2. Cardiac tamponade

A client is receiving fluid replacement with lactated Ringer's solution after 40% of the body was burned 10 hours ago. The assessment reveals a temperature of 97.1°F (36.2°C), heart rate of 122 bpm, blood pressure of 84/42 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 25 mL for the last 2 hours. The intravenous (IV) rate is currently at 375 mL per hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse should request which prescription from the health care provider? 1. Furosemide 2. IV rate increase 3. Fresh frozen plasma 4. Dextrose 5%

2. IV rate increase

The nurse is assessing a client who sustained blunt chest trauma from a motor vehicle collision. There are no obvious signs of bleeding. The provider diagnoses the client with cardiac tamponade. What assessment data would the nurse anticipate? Select all that apply. 1. Peaked t-waves 2. Jugular vein distention 3. Apical pulse of 156 4. Blood pressure of 62/48 5. Muffled heart sounds

2. Jugular vein distention 3. Apical pulse of 156 4. Blood pressure of 62/48 5. Muffled heart sounds

A client in the intensive care unit has an arterial line that reads 58/30 mm Hg on the monitor. What is the nurse's first action? 1. Place the client in the Trendelenburg position. 2. Obtain a manual blood pressure. 3. Flush the catheter. 4. Recalibrate the arterial line.

2. Obtain a manual blood pressure.

A client has back pain 10 minutes after a unit of packed red blood cells (RBCs) was started. The client's pulse, blood pressure, and respirations are stable and similar to vital signs obtained before infusing the RBCs. What should the nurse do? Select all that apply. 1. Flush the Y-tubing with normal saline to clear the line. 2. Prepare for cardiopulmonary resuscitation. 3. Send the remaining blood to the lab. 4. Turn off the infusion of the packed RBCs. 5. Obtain a urine specimen to send to the laboratory.

2. Prepare for cardiopulmonary resuscitation. 3. Send the remaining blood to the lab. 4. Turn off the infusion of the packed RBCs. 5. Obtain a urine specimen to send to the laboratory

The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)? 1. Congestive heart failure 2. Pulmonary embolism 3. Renal calculi 4. Septic shock

2. Pulmonary embolism

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because 1. The client is in the early stage of right-sided heart failure. 2. The client is going into cardiogenic shock. 3. The client shows signs of aneurysm rupture. 4. The client is experiencing heart failure

2. The client is going into cardiogenic shock.

When assessing a client for early septic shock, the nurse should assess the client for which finding? 1. Hemorrhage 2. Warm, flushed skin 3. Increased blood pressure 4. Cool, clammy skin

2. Warm, flushed skin Rationale: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

The transducer system of an arterial line was disconnected from the monitoring cable. What is the best action by the nurse after reconnecting the transducer system to the monitoring cable? 1. Change the tubing. 2. Zero the transducer system. 3. Perform a square wave test. 4. Perform a dynamic response test.

2. Zero the transducer system.

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute kidney failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is: 1. A blood clot that formed in the kidneys." 2. Structural damage to the kidney." 3. A decrease in the blood flow through the kidneys." 4. An obstruction of urine flow from the kidneys."

3. A decrease in the blood flow through the kidneys."

The nurse is assessing a client with septic shock. Which finding is an indication of a complication of septic shock? 1. Chronic obstructive pulmonary disease (COPD) 2. Mitral valve prolapse 3. Acute respiratory distress syndrome (ARDS) 4. Anaphylaxis

3. Acute respiratory distress syndrome (ARDS)

The nurse is caring for a client in the intensive care unit who has an arterial line in the right radial artery. Which assessment finding is the greatest concern to the nurse? 1. Palpable ulnar pulse 2. Systolic pressure of 138 mm Hg 3. Capillary refill time of 4 seconds in right fingers 4. Arterial waveform with a sharp upstroke

3. Capillary refill time of 4 seconds in right fingers

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? 1. Cardiogenic 2. Neurogenic 3. Hypovolemic 4. Anaphylactic

3. Hypovolemic

A client who suffered blunt chest trauma in a motor vehicle accident reports of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The health care provider confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume? 1. Semi-Fowler's 2. Supine 3. Leaning forward while sitting 4. Prone

3. Leaning forward while sitting

A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, the nurse correctly identifies which ECG changes associated with an evolving MI? Select all that apply. 1. Notched T-wave 2. Presence of a U-wave 3. T-wave inversion 4. Prolonged PR-interval 5. ST-segment elevation

3. T-wave inversion 5. ST-segment elevation

Which statement indicates that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? 1. "This device helps stop life-threatening heart rhythms." 2. "This device increases how hard the heart has to work." 3. "This device decreases the blood flow in the heart." 4. "This device decreases the heart's need for oxygen.

4. "This device decreases the heart's need for oxygen. Rationale:An intra-aortic balloon pump increases coronary perfusion and cardiac output, and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock. A defibrillator is commonly used for termination of life-threatening ventricular rhythms.

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? 1. A white blood cell count of 19,000/mm3 2. Vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60 3. A Sa02 reading of 92% 4. A urinary output of 50 mL in the past 3 hours

4. A urinary output of 50 mL in the past 3 hours

A client is admitted with a spinal cord injury at level C3. The nurse notes a heart rate of 50 beat/minute and a blood pressure of 90/60 mmHg. What is the nurse's priority action? 1. Administer intravenous corticosteroid STAT. 2. Stabilize the spinal cord in a neutral position. 3. Sit the client upright, and remove restrictive clothing from the client. 4. Administer rapid infusion of intravenous fluids.

4. Administer rapid infusion of intravenous fluids.

The nurse is explaining to a client's spouse why an arterial line is needed to monitor the blood pressure for the hemodynamically unstable client. The nurse determines that the client's spouse understands the information when the spouse makes which statement? Select all that apply. 1. Arterial lines provide assessment of pulmonary artery pressure 2. Arterial lines provide monitoring of central venous pressure 3. Arterial lines are equivalence to manual blood pressure measurements 4. Arterial lines provide real-time blood pressure monitoring 5. Arterials lines provide continuous beat-to-beat monitoring of arterial pressure

4. Arterial lines provide real-time blood pressure monitoring 5. Arterials lines provide continuous beat-to-beat monitoring of arterial pressure

What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? 1. Cardiac pacemaker 2. Hypothermia-hyperthermia machine 3. Defibrillator 4. Intra-aortic balloon pump

4. Intra-aortic balloon pump

A health care provider admits a client with a history of I.V. substance use disorder to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has 1. A scratchy pericardial friction rub. 2. Pulsus paradoxus. 3. Retrosternal pain that worsens during supine positioning. 4. Osler's nodes and splinter hemorrhages.

4. Osler's nodes and splinter hemorrhages. Rationale: Infective endocarditis occurs when an infectious agent enters the bloodstream, such as from I.V. substance use disorder or during an invasive procedure or dental work. Typical assessment findings in clients with this disease include Osler's nodes (red, painful nodules on the fingers and toes), splinter hemorrhages, fever, diaphoresis, joint pain, weakness, abdominal pain, a new or altered heart murmur, and Janeway's lesions (small, hemorrhagic areas on the fingers, toes, ears, and nose). Retrosternal pain that worsens when the client is supine, pulsus paradoxus, and pericardial friction rub are common findings in clients with pericarditis, not infective endocarditis