Exam 1 PrepU

The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour?

2.7 mL/hr The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration)

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

Which is a late sign of hypoxia?

Cyanosis Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.

A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess?

Pinpoint pupils Signs of an acute overdose of heroin, an opioid, include pinpoint pupils, marked respiratory depression, decreased blood pressure, stupor progressing to coma, seizures, and pulmonary edema. Flushed face typically reflects a barbiturate overdose.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

Reduced cardiac output PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter?

Sawtooth Sawtooth is the characteristic pattern of the atrial waves in atrial flutter.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

See if there are leaks in the system. Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse's pressing the discharge button?

Shouting "Clear!" Before pressing the discharge button, the nurse shouts "Clear!" or "All clear!" to ensure that no one is in contact with the client. The nurse may call this warning multiple times. The other options are also performed but not immediately before discharging the defibrillator.

The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. What order does the nurse describe?

Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers The correct sequence of conduction through the normal heart is the SA node, AV node, bundle of His, right and left bundle branches, and Purkinje fibers.

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

Tension pneumothorax Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.

A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.

70 58 kg X 2 = 116 mcg/min. 116 mcg X 60 minutes = 6,960 mcg per hour. 6,960 mcg/1000 = 6.96 mg, rounded to 7 mg/hour. (7 mg/50 mg) X 500 mL = 70 mL/hour.

When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?

A systolic blood pressure that is lower during inhalation

The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

Arterial blood gas (ABG) findings Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.

The nurse is caring for a client who has a suspected dysrhythmia. What most appropriate intervention should the nurse use to help detect dysrhythmias?

Monitor cardiac rhythm continuously The nurse should monitor cardiac rhythm continuously. Cardiac monitors display real-time heart rate and rhythm and alert the nurse to potentially life-threatening dysrhythmias. Monitoring blood pressure continuously and palpating the client's pulse do not help detect life-threatening dysrhythmias. Providing supplemental oxygen helps maintain adequate cardiac output and does not help detect life-threatening dysrhythmias.

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?

Call for a chest x-ray A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.

The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse?

Call for help and begin chest compressions.

A family member brings a client to the ED following an apparent oxycodone overdose. The client is experiencing severe respiratory depression. Which medication will the nurse administer?

Naloxone hydrochloride Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Flumazenil is a benzodiazepine antagonist. Diazepam is a benzodiazepine. N-acetylcysteine is used for acetaminophen toxicity.

A nurse enters a client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?

Immediate CPR Immediate CPR is used during pulseless ventricular tachycardia and ventricular fibrillation.

For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death?

Increased restlessness As the oxygen supply to the brain decreases, the client may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.

A novice hospice nurse is reviewing the orders of several clients. Which orders will the nurse most likely have to clarify? Select all that apply.

Infuse two units PRBC PRN for hemoglobin <7 g/dL Infuse TPN at 80 mL/hr via central line. Not all hospice service providers cover services such as intravenous blood administration and total parenteral nutrition (TPN), as these may be considered life-sustaining methods. The other orders are common to all hospice programs and would be appropriate orders.

A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for?

Removing excess air and fluid Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.

Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions?

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel."

It is important for a nurse to be aware of the normal hemodynamics of blood flow to recognize and understand pathology when it occurs. The nurse should know that incomplete closure of the tricuspid valve results in a backward flow of blood from the:

Right ventricle to the right atrium. The tricuspid valve is located between the right atrium and the right ventricle. Therefore, incomplete closure results in the backward flow of blood from the right ventricle to the right atrium.

It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur:

Right ventricular pressure must be higher than pulmonary arterial pressure. For the right ventricle to pump blood in need of oxygenation into the lungs via the pulmonary artery, right ventricular pressure must be higher than pulmonary arterial pressure.

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?

To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells.

The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client?

alerting the healthcare provider of the third-degree heart block The client may experience low cardiac output with third-degree AV block. The healthcare provider needs to intervene to preserve the client's cardiac output. Monitoring the blood pressure and heart rate are important, but not a priority. The identification of a code status during a heart block is not appropriate. IV fluids are not helpful if the heart is not perfusing.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient?

"Are you hearing anything that is disturbing you?" The Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale is used in the assessment of alcohol withdrawal. The patient's score on this scale helps determine the level of intervention that is required to support safe, withdrawal from alcohol. Assessing for auditory disturbances is one subsection on the scale. In order to effectively assess for this symptom, the nurse should ask the patient if they are hearing anything that is disturbing. By asking the patient if they are experiencing any numbness or burning would help to assess for tactile disturbances. By asking the patient if the light is bothering their eyes would support the assessment for visual disturbances. Asking the patient if it feels like there is a tight band around their head would help determine if the patient has a headache or fullness of the head. These are all symptom items that are measured by this scale.

Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?

"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers.

The client asks the nurse what urine output has to do with cardiac function. What is the best response by the nurse?

"Poor urine output may indicate inadequate blood flow to the kidneys." Urine output is an important indicator of cardiac function. Low urine output is caused by the inability of the heart to generate enough cardiac output, leading to reduced blood flow to the brain and other vital organs such as the kidneys. High urine output may indicate an endocrine problem.

A client has been placed on a ventilator, and the spouse begins to cry during the initial visit. What is the best therapeutic statement for the nurse to communicate?

"Tell me what you are feeling." The best option is to have the spouse verbalize feelings. The other statements are not therapeutic because teaching should not be done while the spouse is crying. People on a ventilator may experience pain. The best treatment statement minimizes what the spouse is experiencing and does not encourage communication.

A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?

Administer epinephrine PEA can be caused by hypovolemia, hypoxia, hypothermia, hyperkalemia, massive pulmonary embolism, myocardial infarction, and medication overdose (beta blockers, calcium channel blockers). PEA is treated with epinephrine according to advanced life support protocol. Applying oxygen or analyzing an arterial blood gas will not change the client's heart rhythm. PEA is treated until there is no change in the client's rhythm after treatments.

A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the client's cardiopulmonary status, the nurse should prepare to perform what intervention?

Administer naloxone hydrochloride (Narcan). Naloxone is an opioid antagonist that is given for the treatment of narcotic overdoses. There is no definitive need for a urinary catheter or for a bolus of lactated Ringer. The client's basic neurologic status should be ascertained during the rapid assessment, but a detailed examination is less important than administration of an antidote.

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem?

Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

Levophed The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this?

Maintaining a patent airway Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a client with an endotracheal or a tracheostomy tube. Airway management is not primarily conducted to reduce the need for suctioning, to maintain sterility or to increase compliance because none of these are important if the client's airway is not patent.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Measure blood glucose concentration every 4 to 6 hours Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?

Monitor vital signs and cardiac rhythm The nurse should monitor the client's vital signs and cardiac rhythm for effectiveness of the medication and for side effects and should always have emergency life support equipment available when caring for an acutely ill client. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria. It is not necessary to place a client flat during or after vasopressor administration. When administering cholinergic antagonists, documentation of the heart rate is necessary.

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication?

N-acetylcysteine Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

Acetaminophen overdose is treated with administration of which medication?

N-acetylcysteine Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

Which medication reverses severe respiratory depression and coma?

Naloxone hydrochloride Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Diazepam is a benzodiazepine. Flumazenil is a benzodiazepine antagonist. N-acetylcysteine is used for acetaminophen toxicity.

A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply.

P wave P-R interval T wave The EKG cardiac complex waves include the P wave, the QRS complex, the T wave, and possibly the U wave. The intervals and segments include the PR interval, the ST segment, and the QT interval.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?

Pulmonary edema The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action?

Report possible signs of aspiration pneumonia to the primary provider. The client should be assessed for further signs of aspiration pneumonia. It is unnecessary to remove the NG tube and chest physiotherapy is not indicated. A different feeding solution will not resolve this complication.

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize?

Risk for infection related to the presence of a subclavian catheter The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The client will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these.

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:

Wipes catheter ports from distal end to insertion site Proper cleansing of a CVAD includes cleaning the insertion site with a chlorhexidine solution in a circular motion from insertion site outward. The nurse will obtain another pair of sterile gloves to perform the procedure if contamination of gloves occurs. The nurse cleanses from insertion site outward to distal catheter ports.

The nurse is proving discharge instructions for a client with a new arrhythmia. Which statement should the nurse include?

Your family and friends may want to take a CPR class. Having friends and family learn to perform CPR will help the client manage the arrhythmia. Monitoring pulse rate at home also helps the client manage the condition. Antiarrhythmic medication should be taken on time. Lightheadedness and dizziness should be reported to the provider.

A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply.

dobutamine dopamine epinephrine Dobutamine (Dobutrex), dopamine (Intropin), and epinephrine (Adrenalin) are inotropic agents used to improve client's contractility. Nitroprusside (Nipride) and nitroglycerin (Tridil) are vasodilators used to reduce preload and afterload, reducing oxygen demand in the heart.

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?

friction rub During pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A murmur is created by the turbulent flow of blood. A cause of the turbulence may be a critically narrowed valve. An opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. An ejection click is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve.

What is the major clinical use of dobutamine?

increase cardiac output Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.

pH PaCO2 HCO3 Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.

Which set of arterial blood gas (ABG) results requires further investigation?

pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L The ABG results pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L indicate respiratory alkalosis. The pH level is increased, and the HCO3- and PaCO2 levels are decreased. Normal values are pH 7.35 to 7.45; PaCO2 35 to 45 mm Hg; HCO3- 22 to 26 mEq/L.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition?

reduced blood supply to the heart Ischemia is reduced blood supply to body organs. Cardiac ischemia is caused by reduced blood supply to the heart muscle. It may lead to a myocardial infarction. Chest pain is a symptom of ischemia.

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of arrhythmia would the cardiologist likely diagnose?

sinus tachycardia Sinus tachycardia is an arrhythmia that proceeds normally through the conduction pathway but at a faster than usual rate (100 to 150 beats/minute).

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as

sodium nitroprusside Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.

Which of the following responses is most helpful to the client when in an emergency situation?

A response by the sympathetic nervous system The most common pathway for the stress response is through the sympathetic nervous system, which uses norepinephrine to stimulate body systems, arousal, and anxiety in response to stress. This response overrides the control of the parasympathetic nervous system, which slows metabolic processes. The cardiovascular system and musculoskeletal system respond because of sympathetic stimulation.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing One event that could cause the ventilator's peak-airway-pressure alarm to sound is a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart?

All options are correct There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart, including fever, shock, and strenuous exercise.

The ECG of a new patient shows a P wave slightly different than normal. The nurse is considering the possibility of premature atrial contractions (PAC). The nurse will ask about which factors when taking this client's history?

All options are correct. There are a number of causes of premature atrial contractions (PAC), which is why it is so important to know and review a patient's complete history when examining for arrhythmias.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross?

Anger Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.

You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

Arterial blood gas (ABG) findings Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color A nonrebreather mask can deliver high concentrations of oxygen to the client in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy. There is no need for the nurse to post a "No smoking" sign over the client's bed. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the client is receiving oxygen from a nonrebreather mask. Oil-based lubricants can cause pneumonia by promoting bacteria growth. Equipment should be changed daily, but this is a lower priority than assessing respiratory status, orientation, and skin color.

Which medication is the drug of choice for sinus bradycardia?

Atropine Atropine is the medication of choice in treating symptomatic sinus bradycardia. Lidocaine treats ventricular dysrhythmias. Pronestyl treats and prevents atrial and ventricular dysrhythmias. Cardizem is a calcium channel blocker and treats atrial dysrhythmias.

A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Anemic hypoxia is an issue, but would not be most important factor before weaning ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

The nurse is administering metoprolol to a client. What type of medication should the nurse educate the client about?

Beta blocker Metoprolol is classified as a beta blocker. Beta blockers block beta adrenergic receptors of the sympathetic nervous system, causing vasodilation and decreased cardiac output and heart rate. Metoprolol is not classified as a diuretic, ACE inhibitor, or vasodilator.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?

Bilateral lower lobes Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)

Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP) An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning (Sole et al., 2013).

The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient?

Decreases the sinoatrial node automaticity Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect).

A 60-year-old client who has been fighting cancer for more than 20 years has just been diagnosed with metastases to the brain. The client finds it difficult to get out of bed in the morning, has no interest in eating, and no longer finds fulfillment in favorite hobbies. Within which emotional reaction is the client functioning?

Depression Depression is the fourth stage of the Kubler-Ross five emotional reactions of the dying client. As clients recognize the reality of their situation, they may mourn their potential losses, such as separation from their loved ones, the inability to fulfill their future goals, or loss of control. Denial is the first stage of the Kubler-Ross five emotional reactions of the dying. It is a psychological coping mechanism in which a person refuses to believe certain information. The third stage of the Kubler-Ross five emotional reactions of the dying, bargaining is an attempt to postpone death. Anger is the second stage of the Kubler-Ross five emotional reactions of the dying, during which clients ask "Why me," and may displace their anger onto others.

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding?

Document that the chest drainage system is operating as it is intended. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply.

Dopamine Dobutamine Nitroglycerin Vasopressin Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. It may be used with dobutamine and nitroglycerin to improve tissue perfusion. Dobutamine produces inotropic effects by stimulating myocardial beta-receptors, increasing the strength of myocardial activity and improving cardiac output. Myocardial alpha-adrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance. Intravenous nitroglycerin in low doses acts as a venous vasodilator and reduces preload. At higher doses, nitroglycerin causes arterial vasodilation and reduces afterload as well. These actions, in combination with dobutamine, increase cardiac output while minimizing cardiac workload. In addition, vasodilation enhances blood flow to the myocardium, improving oxygen delivery to the weakened heart muscle. In addition, vasopressin is another agent used to manage cardiogenic shock. Diphenhydramine is indicated in anaphylactic shock rather than cardiogenic shock, and can be given intravenously to reverse the effects of histamine.

The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade? Select all that apply.

Dyspnea Tachycardia Distant heart sounds Jugular vein distention Pericardial fluid may build up slowly without causing noticeable symptoms until a large amount (1 to 2 L) accumulates. However, a rapidly developing effusion can quickly stretch the pericardium to its maximum size and cause an acute problem. As pericardial fluid increases, pericardial pressure increases, reducing venous return to the heart and decreasing CO. This can result in cardiac tamponade, which causes low CO and obstructive shock. Symptoms of cardiac tamponade include dyspnea, tachycardia, distant heart rounds, and jugular vein distention. Anuria is not a symptom of cardiac tamponade.

A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis?

Echocardiography Echocardiography is useful in detecting the presence of pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.

The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?

Ensure no one is touching the client at the time shock is delivered In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads, or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the client's skin to prevent leaking. Second, ensure that no one is in contact with the client or with anything that is touching the client when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the client. Ventilation should be stopped during defibrillation.

A nurse is caring for a client who has premature ventricular contractions. What sign would the nurse assess in this client?

Fluttering/heart skipping Premature ventricular contractions usually cause a flip-flop sensation in the chest, sometimes described as "fluttering" or "skipping a beat." Associated signs and symptoms include pallor, nervousness, sweating, and faintness. Symptoms of premature ventricular contractions are not nausea, hypotension, and fever.

The pathophysiology of pericardial effusion is associated with all of the following except:

Increased venous return Venous return is decreased (not increased) with Pericardial effusion because there is an increase in the pericardial fluid, which raises the pressure within the pericardial sac and compresses the heart. Increased right and left ventricular end-diastolic pressures, inability of the ventricles to fill adequately, and atrial compression are all effects of pericardial effusion.

The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation?

Sit with the client's daughter privately and encourage her to express her feelings frankly. Failure to verbalize feelings, express emotions, and show tenderness for the dying person is often a source of regret for grieving relatives. Therefore, families must feel that they can express their feelings with nurses who are compassionate listeners. If nurses encourage family members and listen to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. Families must feel that they can express their feelings with nurses who are compassionate listeners. Reminding a family member that their loved one will die soon shows a lack of compassion in this situation. Although the client is the nurse's main priority, it is the nurse's role to encourage family members to identify strengths and express feelings as a method of coping with the death of their loved one. The response regarding making the father's final days happy ones shows a lack of caring on the part of the nurse.

The nurse assessing a patient with pericardial effusion at 0800 notes the apical pulse is 74 and the BP is 140/92. At 1000, the patient has neck vein distention, the apical pulse is 72, and the BP is 108/92. Which action would the nurse implement first?

Stay with the patient, use a calm voice, and ask for assistance via call light. The nurse stays with the patient and continues to assess and record signs and symptoms while intervening to decrease patient anxiety. The pulse pressure is narrowing, and the patient is experiencing neck vein distention, indicative of rising central venous pressure. After reaching assistance via the call light from the patient's beside, the nurse notifies the physician immediately and prepares to assist with diagnostic echocardiography and pericardiocentesis. A left lateral recumbent position is used when administering enemas. Morphine would be given to someone who may be experiencing a myocardial infarction, not cardiac tamponade.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.

A client needs additional information about a heart condition. The client asks the nurse, "What is considered the pacemaker of the heart?"

The SA node The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. Normally, it produces between 60 and 100 impulses per minute; the average is approximately 72 impulses per minute.

A client who is frightened of needles has been told that the client will have to have an intravenous (IV) line inserted. The client's blood pressure and pulse rate increase, and the nurse observes the pupils dilating. What does the nurse recognize has occurred with this client?

The client is showing the fight-or-flight response The adrenal medulla secretes epinephrine and norepinephrine. These two hormones are released in response to stress or threat to life. They facilitate what is referred to as the physiologic stress response, also known as the fight-or-flight response. Many organs respond to the release of epinephrine and norepinephrine. Responses include increased blood pressure and pulse rate, dilation of the pupils, constriction of blood vessels, bronchodilation, and decreased peristalsis. The client does not demonstrate the signs of infection, dehydration, or hypertensive crisis.

The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts?

Treat pulseless ventricular tachycardia. During CPR, the medications provided will depend upon the client's condition and response to therapy. Amiodarone is used to treat pulseless ventricular tachycardia. Sodium bicarbonate is used to correct metabolic acidosis. Norepinephrine and dopamine are used to prevent the development of hypotension. Magnesium sulfate is used for the client with torsade de pointes.

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

The client requires total parenteral nutrition For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.

A client with heart failure asks the nurse how dobutamine affects the body's circulation. What is the nurse's best response?

The medication increases the force of the myocardial contraction. A positive inotropic medication increases the force of the myocardial contraction. The inotropic medication decreases heart rate; it does not cause the kidneys to retain fluid or produce more urine.

During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?

The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact. The nurse should communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact with the client. Calling out to the client's family members and asking them to sit next to the client may not be the best intervention. The nurse should not distract the dying client's attention and should not administer a pain killer or sedative.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.

While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach?

The system has an air leak. The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

To remove air from the pleural space Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

The nurse is assessing a client with symptomatic bradycardia. What medication does the nurse anticipate will be ordered by the healthcare provider to treat the bradycardia?

atropine The treatment of symptomatic bradycardia includes transcutaneous pacing and atropine. Lidocaine may be used in the treatment of ventricular fibrillation. Diltiazem and adenosine are medications used to treat clients with atrial fibrillation.

The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition?

catheter-related bloodstream infections Catheter-related bloodstream infections (CRBSIs) are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.

The nurse witnesses a client experiencing ventricular fibrillation. What is the nurse's priority action?

defibrillation Advanced cardiac life support recommends early defibrillation for witnessed ventricular fibrillation. A cardioversion is used with a client who has a pulse. Atropine is used for bradycardia and dobutamine is an inotropic medication used to increased cardiac output.