Adult Health 4 Midterm Questions
ECG readings "Sinus rhythm with unifocal premature ventricular contractions"
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs.
ECG reading "Sinus rhythm with multifocal premature ventricular contractions"
Sinus rhythm with multifocal premature ventricular contractions
The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which medication that has a short half-life and is recommended to treat symptomatic SVT? a. Adenosine b. Amiodarone c. Diltiazem d. Procainamide
a. Adenosine
The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? a. Arterial lactate level of 1.0 mEq/L b. Cardiac output of 2.5 L/min c. Mixed venous (SvO2) of 40% d. Cardiac index of 1.5 L/min/m2
a. Arterial lactate level of 1.0 mEq/L
The nurse is reading the cardiac monitor and notes that the patient's heart rhythm is extremely irregular and there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patient is demonstrating what rhythm? a. Atrial fibrillation b. Atrial flutter c. Atrial flutter with rapid ventricular response d. Junctional escape rhythm
a. Atrial fibrillation
The patient's monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature ventricular contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which drug? a. Atropine 0.5 to 1 mg intravenous push b. Dopamine drip—continuous infusion c. Lidocaine 1 mg/kg intravenous push d. Transcutaneous pacemaker
a. Atropine 0.5 to 1 mg intravenous push
Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? a. Check the inflation volume of the flush system pressure bag. b. Disconnect the flush system from the arterial line catheter. c. Zero reference the transducer system at the phlebostatic axis. d. Reduce the number of stopcocks in the flush system tubing.
a. Check the inflation volume of the flush system pressure bag.
The patient diagnosed with acute respiratory distress syndrome (ARDS) would exhibit which symptom? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation
a. Decreasing PaO2 levels despite increased FiO2 administration
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. Diminished breath sounds over left lung field b. Localized pain at catheter insertion site c. Measured central venous pressure of 5 mm Hg d. Slight bloody drainage around insertion site
a. Diminished breath sounds over left lung field
Benefits of having the family present during resuscitation include which of the following? (Select all that apply.) a. Facilitates the grief process b. Letting family sees that everything is being done c. Sustaining patient-family relationships d. Allows the staff easy access to ask for organ transplant e. Provides a sense of closure
a. Facilitates the grief process b. Letting family sees that everything is being done c. Sustaining patient-family relationships e. Provides a sense of closure
The patient's heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The heart rate is 54 beats per minute. The nurse recognizes the rhythm as a junctional escape rhythm, and understands that the rhythm is due to what cause? a. Loss of sinus node activity b. Increased rate of the AV node c. Increased rate of the SA node d. Decreased rate of the AV node
a. Loss of sinus node activity
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous
a. Mannitol 1 g intravenous
The patient is having premature ventricular contractions (PVCs). What is the nurse's greatest concern? a. The proximity of the R wave of the PVC to the T wave of a normal beat. b. The fact that PVCs are occurring, because they are so rare. c. If the number of PVCs are decreasing d. If the PVCs are wider than 0.12 seconds.
a. The proximity of the R wave of the PVC to the T wave of a normal beat.
The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this patient is which of the following? (Select all that apply.) a. Transcutaneous pacemaker b. Atropine IV c. Temporary transvenous pacemaker d. Permanent pacemaker e. Amiodarone IV
a. Transcutaneous pacemaker c. Temporary transvenous pacemaker d. Permanent pacemaker
The primary health care provider writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's invasive line, what is the priority nursing action? a. Apply an air occlusion dressing to insertion site. b. Apply pressure to the insertion site for 5 minutes. c. Elevate the affected limb on pillows for 24 hours. d. Keep the patient's wrist in a neutral position.
b. Apply pressure to the insertion site for 5 minutes.
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the physician of the patient's blood pressure.
b. Assess for a kinked urinary catheter and assess for bowel impaction.
A 74-year-old patient is admitted to the coronary care unit with an inferior wall myocardial infarction and develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The nurse knows to prepare to administer which drug? a. Amiodarone b. Atropine c. Lidocaine d. Magnesium
b. Atropine
The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should take what action immediately? a. Treat with intravenous amiodarone or lidocaine. b. Begin cardiopulmonary resuscitation and advanced life support. c. Provide electrical cardioversion. d. Ignore the rhythm since it is benign.
b. Begin cardiopulmonary resuscitation and advanced life support.
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. During the nurse's 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How does the nurse interpret the following blood gas levels?
b. Hypoxemia and uncompensated respiratory acidosis
What is an early signs of the effect of hypoxemia on the nervous system? a. Cyanosis b. Restlessness c. Tachycardia d. Tachypnea
b. Restlessness
The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? a. The mechanical ventilator is malfunctioning. b. The patient may require fluid resuscitation. c. The arterial line may need to be replaced. d. The left limb may have reduced perfusion.
b. The patient may require fluid resuscitation.
The patient is admitted with a fever and rapid heart rate and a temperature of 103° F (39.4°C). The nurse places the patient on a cardiac monitor and finds the patient's atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. What should be the nurse's initial focus? a. Medications to lower heart rate b. Treatment to lower temperature c. Treatment to lower cardiac output d. Treatment to reduce heart rate
b. Treatment to lower temperature
The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is most important for the nurse to complete? a. Document a pulmonary artery catheter occlusion pressure. b. Zero reference the transducer system at the phlebostatic axis. c. Inflate the pulmonary artery catheter balloon with 1 mL air. d. Inject 10 mL of 0.9% normal saline into the proximal port.
b. Zero reference the transducer system at the phlebostatic axis.
The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which order should the nurse institute first? a. Blood cultures (2 specimens) for temperature > 101° F b. Acetaminophen 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours
c. 500 mL albumin infusion intravenously
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg
c. 90 mm Hg CPP = MAP - ICP. In this case, CPP = 108 mmHg - 18 mm Hg = 90 mm Hg
The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? a. Activate the rapid response system. b. Place the patient in Trendelenburg position. c. Assess the cuff for proper arm size. d. Administer 0.9% normal saline bolus.
c. Assess the cuff for proper arm size.
The QT interval is the total time taken for ventricular depolarization and repolarization. Prolongation of the QT interval will result in what outcome? a. Decreased risk of lethal dysrhythmias b. Increase in heart rate c. Increase in the risk of lethal dysrhythmias. d. Will only be measured with irregular rhythms.
c. Increase in the risk of lethal dysrhythmias.
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)
c. Increased cerebral blood volume due to vessel dilation
A patient's status deteriorates and mechanical ventilation is now required. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is referred to by what term? a. Assist/control ventilation b. Controlled ventilation c. Intermittent mandatory ventilation d. Positive end-expiratory pressure
c. Intermittent mandatory ventilation
The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? a. Do not document hemodynamic values until the patient can be placed in the supine position. b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.
c. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values.
The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the following? a. Obtain a 12-lead electrocardiogram (ECG). b. Call for a pacemaker interrogation. c. Palpate the pulse. d. Run a 2-minute monitor strip for analysis.
c. Palpate the pulse.
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.
c. Place a nasal drip pad under the nose.
A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through what action by the endotracheal tube? a. Continuous positive airway pressure b. Positive end-expiratory pressure c. Pressure support ventilation d. T-piece adapter
c. Pressure support ventilation
The nurse notes that the patient's arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. what is the nurse's first intervention to relieve hypoxemia? a. Call the physician for an emergency intubation procedure. b. Obtain an order for bilevel positive airway pressure (BiPAP). c. Provide for oxygen administration. d. Suction secretions from the oropharynx.
c. Provide for oxygen administration.
The patient has pulseless electrical activity (PEA). The primary care provider decides that the cause of the PEA is pericardial tamponade. What is the most appropriate treatment for pericardial tamponade? a. Atropine b. Chest tube placement c. Resternotomy d. Transcutaneous pacemaker
c. Resternotomy
A patient is brought to the critical care unit after a motor vehicle crash. On admission, the patient is reporting dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left side and a tracheal shift. What would be the most likely diagnosis? a. Pericardial tamponade b. Symptomatic bradycardia c. Tension pneumothorax d. Unstable tachycardia
c. Tension pneumothorax
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse? a. The catheter is not positioned correctly and should be removed. b. The catheter position increases the risk of ventricular dysrhythmias. c. The distal tip of the catheter is in the appropriate position. d. The physician should be called to advance the catheter into the pulmonary artery.
c. The distal tip of the catheter is in the appropriate position.
The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F
The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.
d. Apply a small nasal drip pad.
The nurse working on the night shift when notices sinus bradycardia on the patient's cardiac monitor. What initial action should the nurse take? a. Give atropine to increase heart rate. b. Begin transcutaneous pacing of the patient. c. Start a dopamine infusion to stimulate heart function. d. Assess for hemodynamic instability.
d. Assess for hemodynamic instability.
The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg
d. CVP of 2 mm Hg Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output A CVP of 2 mm Hg indicates hypovolemia
The nurse is caring for a patient with a left radial arterial line, and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? a. Document all waveform values. b. Limit the pressure tubing length. c. Zero reference the system daily. d. Ensure alarm limits are turned on.
d. Ensure alarm limits are turned on.
The nurse caring for a mechanically ventilated patient notes the high pressure alarm sounding but cannot quickly identify the cause of the alarm. The nurse notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse's priority action? a. Ask the respiratory therapist to get a new ventilator b. Call the rapid response team to assess the patient c. Continue to find the cause of the alarm and fix it d. Manually ventilate the patient while calling for a respiratory therapist
d. Manually ventilate the patient while calling for a respiratory therapist
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the primary care provider immediately.
d. Notify the primary care provider immediately.
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What is the nurse's interpretation of these values? pH 7.4 PaCO2 40 mm Hg Bicarbonate 24 mEq/L PaO2 95 mm Hg O2 saturation 97% Respirations 20 breaths per minute a. Compensated metabolic acidosis b. Metabolic alkalosis c. Normal ABG values d. Respiratory acidosis
d. Respiratory acidosis
ECG strip: shows VT The patient is alert and talking when the nurse notices the following rhythm. The patient's blood pressure is 90/44 mm Hg. The nurse should take what action? a. Defibrillate immediately. b. Begin basic life support. c. Begin advanced life support. d. Treat with intravenous amiodarone or lidocaine.
d. Treat with intravenous amiodarone or lidocaine.
1. After coronary artery bypass graft surgery a patient is transported to the hypoxemia intensive care unit at noon and placed on mechanical ventilation. How should the nurse interpret the patient's initial arterial blood gas levels? pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm Hg O2 saturation 99% a. Normal arterial blood gas levels with a high oxygen level b. Partly compensated respiratory acidosis, normal oxygen c. Uncompensated metabolic acidosis with high oxygen levels d. Uncompensated respiratory acidosis; hyperoxygenated
d. Uncompensated respiratory acidosis; hyperoxygenated
Which of the following are common causes of sinus tachycardia? (Select all that apply.) a. Hyperthyroidism b. Hypovolemia c. Hypothyroidism d. Heart Failure e. Sleep
a. Hyperthyroidism b. Hypovolemia d. Heart Failure
The nurse is educating a patient's family member about a pulmonary artery catheter (PAC).Which statement by the family member best indicates understanding of the purpose of the PAC? a. "The catheter will provide multiple sites to give intravenous fluid." b. "The catheter will allow the primary health care provider to better manage fluid therapy." c. "The catheter tip comes to rest inside my brother's pulmonary artery." d. "The catheter will be in position until the heart has a chance to heal."
b. "The catheter will allow the primary health care provider to better manage fluid therapy."
The patient's heart rate is 70 beats per minute with the P waves coming after the QRS complex. The nurse correctly determines that the patient is demonstrating what heart rhythm? a. A normal junctional rhythm b. An accelerated junctional rhythm c. A junctional tachycardia d. Atrial fibrillation
b. An accelerated junctional rhythm
What factors may predispose a patient to respiratory acidosis? a. Anxiety and fear b. Central nervous system depression c. Diabetic ketoacidosis d. Nasogastric suctioning e. Overdose of sedatives
b. Central nervous system depression e. Overdose of sedatives
When assessing the patient for hypoxemia, the nurse recognizes what as an early sign of the effect of hypoxemia on the cardiovascular system? a. Heart block b. Restlessness c. Tachycardia d. Tachypnea
c. Tachycardia
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. Spontaneous respirations are 12 breaths/min. The patient receives a dose of morphine sulfate, and now respirations decrease to 4 breaths/min. What adjustments may need to be made to the patient's ventilator settings? a. Add positive end-expiratory pressure (PEEP). b. Add pressure support. c. Change to assist/control ventilation at a rate of 4 breaths/min. d. Increase the synchronized intermittent mandatory ventilation respiratory rate
d. Increase the synchronized intermittent mandatory ventilation respiratory rate
What does pulse oximetry measure? a. Arterial blood gases b. Hemoglobin values c. Oxygen consumption d. Oxygen saturation
d. Oxygen saturation
The normal width of the QRS complex is which of the following? (Select all that apply.) a. 0.06 to 0.10 seconds. b. 0.12 to 0.20 seconds. c. 1.5 to 2.5 small boxes. d. 3.0 to 5.0 small boxes. e. 0.04 seconds or greater
a. 0.06 to 0.10 seconds. c. 1.5 to 2.5 small boxes.
The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min b. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg c. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg d. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min
Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg
a. A patient with a complete spinal injury at the C5 dermatome level
A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent premature ventricular contractions. Upon assessment, you note that she is lethargic and has complained of dizziness for the past 12 hours. Which of the following are acceptable treatments for symptomatic bradycardia? (Select all that apply.) a. Atropine b. Epinephrine c. Lidocaine d. Transcutaneous pacemaker e. Magnesium sulfate infusion
a. Atropine b. Epinephrine d. Transcutaneous pacemaker
Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting? a. Automatic external defibrillator b. Carbon dioxide detector c. Pocket mask d. Transcutaneous pacemaker
a. Automatic external defibrillator
Sinus bradycardia is a symptom of which of the following? (Select all that apply.) a. Calcium channel blocker medication b. Beta-blocker medication c. Athletic conditioning d. Hypothermia e. Hyperthyroidism
a. Calcium channel blocker medication b. Beta-blocker medication c. Athletic conditioning d. Hypothermia
Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening d. Restraining all four extremities with soft limb restraints e. Ensuring all junctions are tightly connected
a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening
The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a. Coughing or attempting to talk b. Disconnection from the ventilator c. Kinks in the ventilator tubing d. Need for suctioning e. Spontaneous breathing
a. Coughing or attempting to talk c. Kinks in the ventilator tubing d. Need for suctioning
A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from.60 to.70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity
a. Decrease in cardiac output
The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse will take what action first? a. Identify the markers on the ECG paper that indicate a 6-second strip. b. Count the number of large boxes between two consecutive P waves. c. Count the number of small boxes between two consecutive QRS complexes. d. Divide the number of complexes in a 6-second strip by 10.
a. Identify the markers on the ECG paper that indicate a 6-second strip.
The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports prior to use. d. Dispose of all bloody dressings in biohazard bags.
a. Implement droplet precautions upon admission.
Why is the sinus node identified as the pacemaker of the heart? a. It contains the fastest pacemaker cell in the heart. b. It has the only pacemaker cell in the heart. c. It contains the only cell that does not affect the cardiac cycle. d. It is located in the left side of the heart.
a. It contains the fastest pacemaker cell in the heart.
Because of the location of the AV node, the possible P waveforms that are associated with junctional rhythms include which of the following? (Select all that apply.) a. No P wave b. Inverted P wave c. Shortened PR interval d. P wave after the QRS complex e. Normal P wave and PR interval
a. No P wave b. Inverted P wave c. Shortened PR interval d. P wave after the QRS complex
The nurse is caring for a patient diagnosed with atrial fibrillation. Sequelae that place the patient at greater risk for mortality/morbidity include which of the following? (Select all that apply.) a. Stroke b. Ashman beats c. Pulmonary emboli d. Prolonged PR interval e. Decreased cardiac output
a. Stroke c. Pulmonary emboli e. Decreased cardiac output
When it is noted that a patient's endotracheal tube is not secured tightened, he respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient's lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects is the cause of this finding? a. The endotracheal tube is in the right mainstem bronchus. b. The patient has a left pneumothorax. c. The patient has aspirated secretions during the procedure. d. The stethoscope earpiece is clogged with wax.
a. The endotracheal tube is in the right mainstem bronchus.
Which statement is true about a patient diagnosed with sinus arrhythmia? a. The heart rate varies, dependent on vagal tone and respiratory pattern. b. Immediate treatment is essential to prevent death. c. Sinus arrhythmia is not well tolerated by most patients. d. PR and QRS interval measurements are prolonged.
a. The heart rate varies, dependent on vagal tone and respiratory pattern
A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs) and is placed on a T-piece for ventilatory weaning. During the nurse's 7 PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In communicating with the physician, which statement indicate
b. "My assessment indicates potential fluid overload."
The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam. c. Obtain stat portable chest x-ray. d. Administer phenytoin.
b. Administer lorazepam.
The monitor technician notifies the nurse "stat" that the patient has a rapid, chaotic rhythm that looks like ventricular tachycardia. What is the nurse's first action? a. Call a code overhead. b. Check the patient immediately. c. Go to the nurse's station and look at the rhythm strip. d. Take the crash cart to the room.
b. Check the patient immediately.
The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? a. Apply a pressure dressing to the insertion site. b. Ensure all tubing connections are tightened. c. Obtain a portable x-ray to confirm placement. d. Restrain the affected extremity for 24 hours.
b. Ensure all tubing connections are tightened.
The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices e. Fogging of the endotracheal tube
b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices
The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or QRS complexes following the spikes. The nurse realizes this as what? a. Normal pacemaker function b. Failure to capture c. Failure to pace d. Failure to sense
b. Failure to capture
A PaCO2 of 48 mm Hg is associated with what outcome? a. Hyperventilation b. Hypoventilation c. Increased absorption of O2 d. Increased excretion of HCO3
b. Hypoventilation
Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock e. Fever
b. Hypovolemia c. Myocardial infarction d. Shock
A 65-year-old patient admitted to the progressive care unit with a diagnosis of community-acquired pneumonia, has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect what condition? a. Hypoxemia and compensated metabolic alkalosis. b. Hypoxemia and compensated respiratory acidosis. c. Normal oxygenation and partly compensated metabolic alkalosis. d. Normal oxygenation and uncompensated respiratory acidosis.
b. Hypoxemia and compensated respiratory acidosis.
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.
b. Maintain proper head and neck alignment.
The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.
b. Monitor blood pressure.
The nurse is examining the patient's cardiac rhythm strip in lead II and notices that all of the P waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably a result of what? a. Originating from the SA node since all P waves come from the SA node. b. Originating from some area in the atria other than the SA node. c. Ventricular depolarization. d. Normal firing even though it is inverted in lead II.
b. Originating from some area in the atria other than the SA node.
What does oxygen saturation (SaO2) represent? a. Alveolar oxygen tension. b. Oxygen that is chemically combined with hemoglobin. c. Oxygen that is physically dissolved in plasma. d. Total oxygen consumption.
b. Oxygen that is chemically combined with hemoglobin.
It is determined that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be inserted. What is the most appropriate nursing intervention? a. Apply conductive gel to the skin. b. Provide adequate sedation and analgesia. c. Recheck leads to make sure that the rhythm is asystole. d. Set the milliamperes to 2 mA below the capture level.
b. Provide adequate sedation and analgesia.
ECG strip: shows VF The nurse notes the following rhythm on the heart monitor. The patient is unresponsive and not breathing. The nurse should be prepared to implement what action? a. Treat with intravenous amiodarone or lidocaine. b. Provide emergent basic and advanced life support. c. Provide electrical cardioversion. d. Ignore the rhythm because it is benign.
b. Provide emergent basic and advanced life support.
The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula
c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula
Which rhythm would be an emergency indication for the application of a transcutaneous pacemaker? a. Asystole b. Bradycardia (heart rate 40 beats/min) normotensive and alert c. Bradycardia (heart rate 50 beats/min) with hypotension and syncope d. Supraventricular tachycardia (heart rate 150 beats/min), hypotensive
c. Bradycardia (heart rate 50 beats/min) with hypotension and syncope
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mmHg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal d. ICP is high; CPP is low.
c. ICP is high; CPP is normal
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bed rest at all times.
c. Implement seizure precautions.
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. Spontaneous respirations are 12 breaths/min. After receiving a dose of morphine sulfate, respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
c. Respiratory acidosis
The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? a. Limit the patient's supine position to no more than 10 seconds. b. Administer anxiety medications while recording the pressure. c. Encourage the patient to take slow deep breaths while supine. d. Elevate the head of the bed 45 degrees while recording pressures.
d. Elevate the head of the bed 45 degrees while recording pressures.
The patient's heart rate is 165 beats per minute and the cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient's blood pressure has dropped from 124/62 to 78/30; skin is cold and diaphoretic and the patient is reporting nausea. The nurse prepares the patient for what intervention? a. Administration of beta-blockers b. Administration of atropine c. Transcutaneous pacemaker insertion d. Emergent cardioversion
d. Emergent cardioversion
A 90-year-old nursing home patient is admitted to the critical care unit with a severe case of pneumonia. No living will or designation of healthcare surrogate is noted on the chart. In the event this patient needs intubation and/or cardiopulmonary resuscitation, what should be the nurse's action? a. Activate the code team, but initiate a "slow" code. b. Call the nursing home to determine the patient's or family's wishes. c. Code the patient for 5 minutes and then cease efforts. d. Initiate intubation and/or cardiopulmonary resuscitation efforts.
d. Initiate intubation and/or cardiopulmonary resuscitation efforts.
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mmHg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient's head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions
d. Provide rest periods between nursing interventions
The nurse caring for a patient diagnosed with acute respiratory failure identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. What nursing intervention is relevant to this diagnosis? a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours.
d. Reposition patient every 2 hours.
The primary care provider orders the following mechanical ventilation settings for a patient who weighs 75 kg and whose spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
d. Respiratory alkalosis
The nurse is caring for a mechanically ventilated patient. The primary care providers are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a. Patient outcomes are better if the tracheostomy is done within a week of intubation. b. Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist. c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.
d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.
A patient presents to the emergency department demonstrating agitation and reporting numbness and tingling in the fingers. Arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. How should the nurse interprets these blood gas values? a. Compensated metabolic alkalosis b. Normal values c. Uncompensated respiratory acidosis d. Uncompensated respiratory alkalosis
d. Uncompensated respiratory alkalosis
While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? a. Increase supplemental oxygen and notify respiratory therapy. b. Notify the physician immediately of the assessment findings. c. Obtain a stat chest x-ray film to verify proper catheter placement. d. Zero reference and level the catheter at the phlebostatic axis.
d. Zero reference and level the catheter at the phlebostatic axis.
