Exam 1

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? a. Troponin I b. Lipase c. BNP d. AST

A) Troponin I

A Nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the clients EKG should the Nurse interpret as a sign of Hypokalemia? A) abnormally prominent U wave B) elevated ST segment C) Wide QRS D) Inverted P wave

A) abnormally prominent U wave

A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." B. "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." C. "Exercise is good for you and good for your heart." D. "Your doctor is the expert here, and I'm sure he would only recommend what is best for you.

A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? A. "Place the tablet under your tongue, and then take a small sip of water. "B. "The medication can take up to 15 minutes to take effect." C. "Avoid taking the medication prior to exercising." D. "Stop taking the medication and notify your provider if you develop a headache."

A. "Place the tablet under your tongue, and then take a small sip of water.

A nurse is making a home visit to a client who receives diuretics daily for heart failure. Which of the following signs would the client manifest with hypokalemia? A) Pitting edema B) Fatigue C) Dyspnea D) Oliguria

B) Fatigue

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription forgabapentin. Which of the following statements should the nurse include in the teaching? A. "Take this medication with an antacid to reduce gastric irritation." B. "You may experience drowsiness while taking this medication. C. "You should take this medication with meals." D. "You may continue to breastfeed while taking this medication.

B. "You may experience drowsiness while taking this medication.

A Nurse is performing cardiopulmonary Resuscitation (CPR) for an adult who is unresponsive. The Nurse should evaluate the client circulation by palpating which of the following pulses? A. Attach defibrillator pads to the client. B. Check for a carotid pulse. C. Begin chest compressions. D. Deliver two breaths.

B. Check for a carotid pulse.

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? A. Increased pulse B. Increased urine output C. Decreased blood pressure D. Decreased blood glucose level

B. Increased urine output

A Nurse is caring for a client who has Hypovolemia shock. Which of the following should the Nurse recognize as an expected finding? A. Hypotension B. Oliguria C. Narrowing pulse pressure/Increased respiratory rate D. Decreased level of consciousness

B. Oliguria

A client who has a history of myocardial infarction is prescribed Aspirin 325mg. The Nurse recognizes that the Aspirin is given due to which of the following actions of the medication. A) analegesic B) anti-inflammatory C) antiplatelet aggregate D) antipyretic

C) antiplatelet aggregate

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? A. Low body temperature B. Jugular vein distention C. Skin tenting present D. Blood pressure 178/90 mm Hg

C. Skin tenting present

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a lipid whose levels reflect the risk for coronary artery disease. C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.

C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A nurse is caring for a client who has chemotherapy-induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? A) Hot flashes throughout body B) Nausea C) Need to urinate D) Tingling feeling in the extremities E) Metallic taste in mouth

D) Tingling feeling in the extremities.

A Nurse in the emergency room is caring for a client who presents with manifestation that indicates a myocardial infarction. Which of the following prescriptions should the Nurse take first? A: Attach the leads for a 12 lead EKG B: Obtain a blood sample C: Initiate Oxygen Therapy D: Insert the IV Catheter

A: Attach the leads for a 12 lead EKG

A Nurse is caring for a 73yrs old client in the emergency department (incomplete)

Administer broad spectrum antibiotics B. Obtain urine specimen Obtain blood cultures

A nurse is preparing to perform a 12 lead electrocardiogram which of the following instructions should the nurse provide to the client? A) Hold your breath for this procedure B) I will lower the head of your bed so you can lie flat C) Do not hold your breath for this procedure D) I will sit you up so you can be up-right

B) I will lower the head of your bed so you can lie flat

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching? A. "I will not smoke prior to my test. B. "I'll take my heart medicatons the morning of my test." C. "I'll get 8 hours of sleep the night before the test." D. "I'll skip my cofee the morning of my test."

B) I will take my heart medications the morning of my test.

A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test? A. It might cause slight discomfort in the chest area B. It takes about 5 or 10 min C. It requires lying quietly on one side D. It is best to have no food or beverages on the day of the test

C. It requires lying quietly on one side

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension B. Oliguria C. Narrowing pulse pressure/Increased respiratory rate D. Decreased level of consciousness

C. Narrowing pulse pressure/Increased respiratory rate

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? a. "Cardiac enzymes will identify the location of the MI "b. "These tests help determine the degree of damage to the heart tissues. "c. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." d. "These tests will enable the provider to determine the heart structure and mobility of the heart valves."

"b. "These tests help determine the degree of damage to the heart tissues.

A Nurse is caring for a client who has pericarditis and reports feeling of new onset of palpation and shortness of breath. Which of the following assessment should indicate to the nurse that the client may have developed atrial fibrillation? A) Different apical and radial pulses B) Asymmetrical chest C) Dyspnea D) Unilateral apical and radial pulses

A) Different apical and radial pulses

A Nurse is interpreting the ECG Strip of a client who has Bradycardia. Which of the following Cardiac components should the Nurse identify as the role of the pwave? A) Atrial Depolarization B) Atrial Repolarization C) Ventricle Depolarization D) Ventricle Repolarization

A) Atrial Depolarization

A nurse in a clinic is caring for a client who has recently begun taking Warfarin. The nurse is reviewing potential drug and food interaction risk and should instruct the client to avoid which of the following? a. Cabbage b. Cantaloupe c. Green beans d. White beans

A) Cabbage Cabbage should be limited in the diet when taking warfarin, because it is rich in vitamin K.

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A) Confusion B) Blood pressure C) Anuria D) Petechiae

A) Confusion Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

A Nurse is caring for a client who has hypertension and has a potassium level 6.8 Meq which of the following should the Nurse take? A) Obtain a lead 12-Led ECG B) Administer antithrombotic medication C) Report to the provider D) Administer calcium channel blocker

A) Obtain a lead 12-Led ECG

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitoring strip? A) Pacemaker spikes before each QRS complex B) Pacemaker spikes before each P wave complex C) T wave appears at a rate between 0.10 - 0.20 seconds D) U wave does not appear

A) Pacemaker spikes before each QRS complex

A nurse is caring for a client who has a serum potassium level of 5.5mEq/L. The providerprescribes polystyrene sulfate. If this medication is effective, the nurse should expect which of the following changes on the clients ECG?A.Reduction of T wave amplitude B.Shortening of P wave duration C.Widening of the QRS complex D.Restoration of QRS complex amplitude

A. Reduction of T wave amplitude

A nurse at a provider's office receives a phone call from a client who reports unrelieved chest pain after taking a nitroglycerin (Nitrostat) tablet 5 minutes ago. Which of the following is an appropriate response by the nurse? A) Tell the client to take an aspirin. B) Instruct the client to call 911. C) Have the client take another nitroglycerin tablet in 15 min. D) Advise the client to come to office.

B) Instruct the client to call 911

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A) Serum cardiac enzyme levels B) MRI of the chest C) Physical therapy D) low-sodium diet

B) MRI of the chest

The Nurse is evaluating a client who has a cardiac cauterization with a left antecubital insertion size. Which of the following pulses should the Nurse palpate? A) Distal pulse in left arm B) Redial pulse in left arm C) Distal pulse in right arm D) Redial pulse in right arm

B) Redial pulse in left arm

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following info should the nurse include? A. The client cannot travel by air due to security screenings. B. The client should hold their cellphone on the side opposite the ICD C. The client should avoid the use of small electric devices D. The client can carry their ICD in a small pocket

B. The client should hold their cell phone the side opposite the ICD. Close proximity could interfere w/ the ICD's function

A nurse in the emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following lab tests are used to diagnose MI? Select all that apply A. LDL B. Troponin C. Creatinine D. Myoglobin E. CK-MB

B. Troponin D. Myoglobin E. CK-MB

A Nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the Nurse expect? A) Hypokalemia B) Heart Rate 160/Min C) Blood Pressure 115-68mmHG D) Mottled skin

C) Blood pressure 115/68 mmHg The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A) ECG tracing shows irregularly irregular heart rate without P waves. B) aPTT result of 70 seconds C) Client experiences sudden weakness of one arm and leg followed by slurred speech D) Urine output is cloudy and odorous

C) Client experiences sudden weakness of one arm and leg followed by slurred speech

A nurse is providing teaching to a client about interventions to reduce risk of developing cardiovascular disease. what statement would show the need for further teaching? A) Limiting alcohol use B) Reducing my intake of sodium C) Increasing my intake of foods containing trans fatty acids can lower my risks. D) Increasing more vegetables and fruits in my diet

C) Increasing my intake of foods containing trans fatty acids can lower my risks.

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.) A) Orthopnea B) Headache C) Nausea D) Tachycardia E) Diaphoresis

C) Nausea D) Tachycardia E) Diaphoresis

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider required clarification? A. Morphine sulfate 2mg IV bolus every 2hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% Normal saline IV at 50ml/hr continuous D. Bumetanide 1mg IV bolus every 12 hr

C. 0.9% Normal saline IV at 50ml/hr continuous Rationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift need in this client to reduce circulatory overload. This prescription requires clarification

A Nurse is caring for a client 48hrs following a cardiac cauterization. Which of the following anchors should the Nurse take? A) Place the patient in high-fowler position B) Place the patient on the side C) Have the client sit up straight D) Have the client lie-down flat in bed

D) Have the client lie-down flat in bed

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A) T wave is slower than QRS wave B) P-R interval has a constant duration between 0.08 and 0.20 seconds. C) QRS has a constant duration between 0.02 and 0.10 seconds D) P wave falls before QRS complex

D) P wave falls before QRS complex

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A) Cryoprecipitates B) Platelets C) Albumin D) Packed RBCs

D) Packed RBCs

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? A) Dyspnea B) Constipation C) Oliguria D) Shallow respiration

D) Shallow respiration

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? a. Increased heart rate b. Widening pulse pulse pressure c. Increased deep tendon reflexes d. Pulse oximetry 96%

a. Increased heart rate

A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? a. QT interval b. ST segment c. PR interval d. QRS complex

a. QT interval

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? a. First-degree AV block b. Atrial fibrillation c. Sinus bradycardia d. Sinus tachycardia

b. Atrial fibrillation

A Nurse is collecting a medication listing from a client who is scheduled to have a cardiac cauterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury? a. Atorvastatin b. Metformin c. Nitroglycerin d. Carvedilol

b. Metformin

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider? a. Sodium 136 mEq/L b. Potassium 2.3 mEq/L c. Chloride 99 mEq/L d. Calcium 10mg/dL

b. Potassium 2.3 mEq/L

Nurse is performing ECG on client who is experiencing chest pain. Which of the following statements should nurse make? a."Test will be complete in 30-60 minutes" b."I will need to apply electrodes to chest & extremities" c."Radioactivity from dye lasts only a few hours" d."You might feel slight tingling while test is being done"

b."I will need to apply electrodes to chest & extremities"

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations? a. Increased blood pressure b. Increased heart rate c. Fatigued. d. sneezing

c. Fatigued.

Nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the Nurse expect? a. Slow b. Not palpable c. Irregular d. Bounding

c. Irregular

A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker which client statement should the nurse recognize as an understanding of the teaching? a. MRI is compatible with a pacemaker b. Hiccups are okay with a pacemaker c. The pacemaker can be checked from home by using the telephone d. I will take my pulse before bedtime before going to sleep

c. The pacemaker can be checked from home by using the telephone