EXAM 3 NR 324

A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents the following pressure. Which readings are within normal limits (WNL) for the client? Select all that apply. 1. 6 mm Hg 2. 8 mm Hg 3. 15 mm Hg 4. 25 mm Hg 5. 32 mm Hg

1. 6 mm Hg 2. 8 mm Hg

A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health care provider. 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the health care provider (HCP). 4. Accompany the client to the emergency department.

1. Apply ice to the affected eye.

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia

1. Atrial fibrillation

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the health care provider (HCP). 2. Reassure the client that this is normal. 3. Turn the client onto his or her operative side. 4. Administer the prescribed pain medication and antiemetic.

1. Call the health care provider (HCP).

A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? 1. Call the health care provider immediately. 2. Re-evaluate the neurovascular status in 1 hour. 3. Increase the rate of intravenous nitroglycerin that is infusing. 4. Document these findings, which are expected because of the catheter size.

1. Call the health care provider immediately.

A client is admitted to an emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication? 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm

1. Cardiogenic shock

The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status had worsened if which is noted on assessment? 1. Diminished breath sounds 2. Wheezing during inhalation 3. Wheezing during exhalation 4. Wheezing throughout the lung fields

1. Diminished breath sounds

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

1. It can develop into ventricular fibrillation at any time.

A client who is experiencing an anaphylactic reaction from eating shellfish is brought to the emergency department. Which immediate action should the nurse implement? 1. Maintain a patent airway. 2. Administer a corticosteroid. 3. Administer epinephrine (Adrenalin). 4. Instruct the client on the importance of obtaining a Medic-Alert bracelet.

1. Maintain a patent airway

When developing a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply. 1. Suction the oral cavity whenever needed. 2. Apply topical antibiotics to the oral cavity. 3. Change the ventilator circuit tubing every 2 hours. 4. Maintain the client in a supine position at all times. 5. Practice frequent oral hygiene, including teeth brushing. 6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube.

1. Suction the oral cavity whenever needed. 5. Practice frequent oral hygiene, including teeth brushing. 6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube.

Which should the nurse do when setting up an arterial line? 1. Tighten all tubing connections. 2. Use macrodrop intravenous tubing. 3. Level the transducer to the ventricle. 4. Raise the height of the normal saline infusion to prevent backup.

1. Tighten all tubing connections.

The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? 1. Urine output of 40 mL/hr 2. Heart rate of 110 beats/min 3. Frequent premature ventricular contractions 4. Central venous pressure (CVP) of 15 mm Hg

1. Urine output of 40 mL/hr

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL most recent). The client's blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority? 1. Check the urine specific gravity. 2. Call the health care provider (HCP). 3. Check to see if the client had a sample for a serum albumin level drawn. 4. Put the intravenous (IV) line on a pump so that the infusion rate is sure to stay stable.

2. Call the health care provider (HCP).

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

2. Crackles

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

2. Ventricular dysrhythmias

The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4° F orally 3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/minute

3. Blood pressure of 198/110 mm Hg

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 1. Heart failure 2. Pulmonary edema 3. Cardiogenic shock 4. Aortic insufficiency

3. Cardiogenic shock

A client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs/symptoms? 1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Hypertension and headache

3. Hypotension and dizziness

A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? 1. Pain 2. Fear 3. Hypoxia 4. Anxiety

3. Hypoxia

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 1. Fat embolism 2. Mediastinal shift 3. Mediastinal flutter 4. Hypovolemic shock

3. Mediastinal flutter

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report should the nurse expect to note, that are consistent with this disorder? 1. Pao2 58 mm Hg, Paco2 32 mm Hg 2. Pao2 60 mm Hg, Paco2 45 mm Hg 3. Pao2 49 mm Hg, Paco2 52 mm Hg 4. Pao2 73 mm Hg, Paco2 62 mm Hg

3. Pao2 49 mm Hg, Paco2 52 mm Hg

The nurse recognizes that which arterial blood gas value indicates impending hypoxemic respiratory failure? 1. Pao2 65 mm Hg 2. Paco2 70 mm Hg 3. Pao2 55 mm Hg 4. Paco2 60 mm Hg

3. Pao2 55 mm Hg

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1. Cardiac output of 5 L/min 2. Right atrial pressure of 9 mm Hg 3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg 4. Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia

3. Ventricular fibrillation

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions

3. Ventricular tachycardia

A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 1. Pain medication 2. Endotracheal intubation 3. Oxygen via nasal cannula 4. 100% humidified oxygen by face mask

4. 100% humidified oxygen by face mask

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1. CO 5 L/min, PCWP low 2. CO 3 L/min, PCWP low 3. CO 4 L/min, PCWP high 4. CO 3 L/min, PCWP high

4. CO 3 L/min, PCWP high

The nurse in the emergency department is caring for a client who was in a motor vehicle crash and is experiencing hypovolemic shock. A pneumatic antishock garment (PASG), also known as shock trousers, is applied for treatment until the client can be transferred to the intensive care unit (ICU). While awaiting client transfer to the ICU, the emergency department nurse should perform which critical assessment? 1. Assessing radial pulses 2. Monitoring hemoglobin and hematocrit levels 3. Assessing vascular status of the upper extremities 4. Monitoring vascular status of the lower extremities

4. Monitoring vascular status of the lower extremities

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1. Defibrillate the client. 2. Administer digoxin (Lanoxin). 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing.

4. Prepare for transcutaneous pacing.