Midterm Critical Care
A nurse in a provider's office is assessing a client who reports dyspnea and fatigue . Physical assessment reveals tachycardia and weak peripheral pulses . The nurse should recognize these findings as manifestations of which of the following conditions ? A. Asthma B. Heart failure C. Aortic stenosis D Aortic valve regurgitation
A & D
A nurse in a provider's office is assessing a client who reports dyspnea and fatigue . Physical assessment reveals tachycardia and weak peripheral pulses . The nurse should recognize these findings as manifestations of which of the following conditions ? A. Asthma B. Heart failure C. Aortic stenosis D. Aortic valve regurgitation
A B
Prevention of ventilator - associated pneumonia ( VAP ) is critical in mechanically ventilated patients . Which of the following are interventions to prevent VAP ? Select all that apply . ) A. Assess readiness of the patient to be extubated . B. Keep the bed flat C. Administer famotidine 20 mg bid as ordered . D. Provide oral care with chlorhexidine at least once daily .
A C D
A nurse is giving a presentation to a community group about preventing atherosclerosis . Which of the following should the nurse include as a modifiable risk factor for this disorder ? ( Select all that apply . ) A. Obesity B. Genetic predisposition C. Smoking D. Hypertension E. Hypercholesterolemia
A C D E
Which of the following are characteristics at the end of life ? Select all that apply . A. cool , clammy skin B. increased urination to excrete waste C. Kussmaul breathing D. tachycardia then bradycardia .
A and D
A nurse is caring for a client who has a new arteriovenous ( AV ) graft in his left forearm . Which of the following techniques should the nurse use to assess the patency of this graft ? A. Auscultate the site for a bruit . B. Measure the client's blood pressure to ensure it is higher in the left arm than the right . C. Auscultate the antecubital fossa using a Doppler stethoscope : D. Check the brachial and radial pulses of the left arm simultaneously .
A. Auscultate the site for a bruit .
A nurse is teaching a client who has pre - dialysis end stage kidney disease about diet . Which of the following instructions should the nurse include ? A. " Eliminate foods high in protein from your diet . " B. " Increase intake of sodium - containing food . " C. " Increase intake of dietary phosphorous . " D. " Reduce intake of foods high in potassium " .
A. " Eliminate foods high in protein from your diet . "
The following are manifestations of acute respiratory distress syndrome except for which finding ? A. 02 Sat 94 % on FiO2 100 % B. Respiratory rate 30 per minute and diffuse crackles C. Decreased level of consciousness D. Hypotension and tachycardia
A. 02 Sat 94 % on FiO2 100 %
A nurse is caring for a patient who came to the emergency department reporting shortness of breath and pain in the lung area . She reports having chronic bronchitis . Her vital signs are : BP 94/42 mm Hg , HR 112 / minute , RR 40 / minute , and SpO2 86 % . Her ABG results are : pH 7.50 , PaCO2 32 mm Hg , PaO2 60 mm Hg , and HCO3 20 mEq / L . Which of the following is a priority intervention ? A. Administer high flow oxygen via facemask . B. Administer a sedative . C. Administer 0.9 % NaCl at 100 ml / hr . D. Monitor for pulmonary embolism .
A. Administer high flow oxygen via facemask .
The nurse assesses a patient admitted for chest trauma who reports dyspnea . The nurse finds tracheal deviation and a pulse oximetry reading of 86 % . What is the priority intervention by the nurse ? A. Administer oxygen and prepare for chest tube insertion . B. Initiate intermittent positive pressure breathing treatment C. Intubate the patient and prepare for mechanical ventilation . B. Notify the health care provider and document the symptoms .
A. Administer oxygen and prepare for chest tube insertion .
The patient has the cardiac rhythm below . What should the nurse assess first to determine if immediate intervention is necessary ? بسلت به A. Blood pressure B. Capillary refill C. Age Brain D. Natriuretic Peptide ( BNP )
A. Blood pressure
A patient presents to the emergency department with pain described as severe sharp , tearing in his chest . The knows this could be an aortic dissection . What complication is the nurse most concerned about ? A. Cardiac tamponade B. Deep vein thrombosis C. Pulmonary D. embolism Stroke
A. Cardiac tamponade
The patient complains of being " lightheaded " and feeling a " fluttering " in his chest . The nurse places the patient on the heart monitor and notices supraventricular tachycardia at a rate of 160 beats per minute . The blood pressure of the patient has dropped from 128/76 to 92/46 . The nurse should anticipate which intervention ? A. Cardioversion B. Dopamin C. Defibrillation D. Digoxin
A. Cardioversion
The nurse assesses a patient who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation . The oxygen saturation of the patient has dropped from 96 % to 92 % . What is the priority action by the nurse ? A. Notify the health care provider and prepare for chest tube insertion . B. Stabilize the chest wall with rib binders . C. Document findings and continue to monitor the patient . D. Encourage the patient to take deep , controlled breaths .
A. Notify the health care provider and prepare for chest tube insertion .
Which of the following will the nurse implement first for a patient who has respiratory distress after eating strawberries ? A. Give epinephrine . B. Prepare for rapid intubation , C. Administer diphenhydramine . D. Start normal saline infusion .
A. Give epinephrine .
A patient is considering whether to request peritoneal dialysis ( PD ) or hemodialysis ( HD ) . Which statement is true about the dialysis options ? A. HD has a high risk for infection when using a temporary access device B. PD requires time for the graft or fistula to grow prior to use C. HD has fewer dietary restrictions D. PD rapidly removes the fluid often causing hypotension
A. HD has a high risk for infection when using a temporary access device
A nurse in a provider's office is assessing a client who reports dyspnea and fatigue . Physical assessment reveals tachycardia and weak peripheral pulses . The nurse should recognize these findings as manifestations of which of the following conditions ? A. Heart failure B. Aortic stenosis C. Asthma D. Aortic valve regurgitation
A. Heart failure
Which nursing intervention for a patient who had repair of abdominal aneurysm 2 days ago is appropriate for the nurse to delegate to an unlicensed assistive personnel ? A. Help the patient to use a pillow to splint incision while coughing . B. Teach the patient signs of possible wound infection . C. Assess the lower extremities of the patient for strength and movement . D. Monitor and assess the quality of the pedal pulses of the patient .
A. Help the patient to use a pillow to splint incision while coughing .
A nurse is providing discharge teaching to a client who has a new prescription for warfarin . Which of the following statements by the client indicates an understanding of the teaching ? A. I'll use my electric razor for shaving . " B. I'll take aspirin for my headaches . " C. I'll be sure to eat more foods with vitamin K " D. It's okay to have a couple of glasses of wine with dinner each evening . "
A. I'll use my electric razor for shaving . "
Tissue plasminogen activator ( tPA ) is initiated on a patient in the emergency department with a large pulmonary embolism . What is the priority action of the nurse ? A. Monitor oxygenation and respiratory pattern of the patient . B. Teach the patient about potential side effects of therapy . C. Monitor IV insertion site for bleeding D. Start packed red blood cell ansfusion
A. Monitor oxygenation and respiratory pattern of the patient .
Which patient should the nurse assess first ? A. Patient with a chest tube complaining of difficulty breathing B. Patient complaining of incisional pain following a coronary artery bypass graft C. Patient for discharge following recovery from acute respiratory distress syndrome D. Patient with a tracheostomy who is on oxygen via tracheostomy mask
A. Patient with a chest tube complaining of difficulty breathing
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis : P waves not visible , PR interval not measurable , ventricular rate 162 , R - R interval regular , and QRS complexes wide . The nurse interprets the cardiac rhythm of the patient as which of the following ? A. Ventricular tachycardia B. Atrial fibrillation C. Elevated ST segment D. Sinus tachycardia
A. Ventricular tachycardia
Which of the following interventions will help prevent ventilator - associated pneumonia ? ( Select all that apply . ) A. Insert an indwelling urinary catheter using sterile technique . B. Provide oral care at least every 4 hrs . C. Administer famotidine 20 mg IV push bid . D. Elevate the head of the bed of the patient at least 30 degrees . Assess the readiness of the patient to be extubated daily .
B C D E
A nurse is teaching client who has chronic kidney failure about planning a low - protein diet . The client states , " Why do I have to be concerned about protein ? " Which of the following responses should nurse make ? A. " A low - protein diet will increase the nitrogenous wastes in the blood . " B. " A low - protein diet reduces the risk for uremia . " C. " A low - protein diet will reduce the risk for hyperkalemia , " D. " A low - protein diet reduces the risk for edema .
B. " A low - protein diet reduces the risk for uremia . "
After receiving change - of - shift report , which patient should the nurse assess first ? A. A patient with heart failure who has crackles in bilateral lung bases B. A patient with COVID who has suprasternal ) retractions : C. A patient with COPD who has an oxygen saturation of 88 % D. A patient with pneumonia who has thick , green colored sputum
B. A patient with COVID who has suprasternal ) retractions :
What is the standard care for the initial treatment of pulseless ventricular tachycardia ? A. Atropine B. Defibrillation C. Epinephrine D. Amiodarone
B. Defibrillation
A nurse is providing teaching to a client who has hypertension and a new prescription for captopril . Which of the following instructions should the nurse provide ? A. Count your pulse rate before taking the medication . B. Do not use salt substitutes high in potassium while taking this medication. C. Expect to gain weight while taking this medication . D. Take the medication with food .
B. Do not use salt substitutes high in potassium while taking this medication.
The nurse is assessing a patient diagnosed with dilated cardiomyopathy for progression of the disease . The nurse would focus questioning on which most common symptom ? A. Peripheral edema B. Dyspnea C. Cyanosis D. Confusion
B. Dyspnea
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations . Which of the following client statements should indicate to the nurse the need for additional teaching ? " A. I will try to anticipate and avoid stressful situations when possible . " B. I will take my medications as needed . " C. " I will complete the smoking cessation program | started . " D. " I will wear gloves when removing food from the
B. I will take my medications as needed . "
A nurse is caring for a patient who has acute respiratory distress syndrome and requires mechanical ventilation . The patient receives a prescription for vecuronium . The nurse recognizes that the primary mode of action of this drug is which of the following ? A. Decrease respiratory secretions . B. Induce paralysis . C. Induce sedation D. Decrease chest wall compliance .
B. Induce paralysis .
Which nursing action should be a priority in the plan of care for a patient who had repair of an abdominal aortic aneurysm ? A. Check abdominal incision for redness . B. Monitor hourly urinary output . C. Record chest tube drainage each shift . D. Teach patient about DVT prophylaxis .
B. Monitor hourly urinary output .
A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone . Which of the following instructions should the nurse provide ? A. Take the medication with meals . B. Rinse the mouth after administration . C. Limit caffeine intake . D. Check the pulse after medication administration .
B. Rinse the mouth after administration .
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 heart muscle protein that appears in the bloodstream when there is damage to the heart . C. Troponin is a lipid whose levels reflect the risk for coronary artery disease .
B. 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 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 heart muscle protein that appears in the bloodstream when there is damage to the heart . D.Troponin is a lipid whose levels reflect the risk for coronary artery disease .
B. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart .
When discussing risk factor modification for a 63 year - old patient who has a 5 - cm abdominal aortic aneurysm , the nurse will focus discharge teaching on which patient risk factor ? A. Abdominal trauma history B. Uncontrolled hypertension C. History of smoking D. History of coronary artery disease
B. Uncontrolled hypertension
A nurse is creating home instructions for a client who has immunodeficiency . Which of the following statements by the client indicates an understanding of the teaching ? A. " I will limit the use of emollient skin cream to once a week . " B. " I might experience harmless white patches in my mouth . " C. " I will avoid receiving live immunizations . " D. " I will expect to have a mild , occasional fever :
C. " I will avoid receiving live immunizations . "
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease . Which of the following statements by the client should indicate to the nurse the need for further teaching ? A. " Adding foods containing omega - 3 fatty acids to my diet can lower my risk * B. Exercising regularly will increase HDL cholesterol levels . " C. " Increasing my intake of foods containing trans - fatty acids can lower my risk . " D. A weight loss program can decrease my LDL cholesterol level
C. " Increasing my intake of foods containing trans - fatty acids can lower my risk . "
A nurse is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension . Which of the following instructions should the nurse include ? A. " Take this medication before bedtime . " B. Avoid grapefruit juice ! C. " Monitor for leg cramps . " D. Reduce intake of potassium - rich foods . "
C. " Monitor for leg cramps . "
A nurse is caring for a client who is receiving peritoneal dialysis . The nurse should monitor the client for which of the following manifestations of peritonitis ? A. Increased urinary output B. Hyperactive bowel sounds C. Abdominal pain and vomiting D. Bradycardia
C. Abdominal pain and vomiting
A client who has a history myocardial infarction ( MI ) is prescribed aspirin 325 mg . The nurse recognizes that the aspirin is given due to which of the following actions of the medication ? A. analgesic B. antipyretic anti C. Anti coagulant D. inflammatory
C. Anti coagulant
The nurse is providing discharge education to a patient after repair of an abdominal aortic aneurysm . What priority instruction should the nurse include ? A. Avoid sleeping on your left side for 6 weeks . B. No restrictions on driving your car are necessary . C. Avoid lifting heavy objects for about 3 months . D. You will have distended abdomen for 6 months .
C. Avoid lifting heavy objects for about 3 months .
A nurse is caring for a client who has HIV . Which of the following laboratory values is the nurse's priority ? A. WBC 5,000 / mm3 B. Positive Western blot test C. CD4 - T - cell count 180 cells / mm3 D. Platelets 150,000 / mm3
C. CD4 - T - cell count 180 cells / mm3
A mother approaches the nurse who is caring for her gravely ill son and asks the nurse what a is POLST . What is the best response by the nurse ? A. Arrange a meeting with physician . B. Consult the ethics committee of the hospital . C. Explain this is a general document to guide future medical care and treatment D. Explain this is a provider order to carry out patient wishes
D. Explain this is a provider order to carry out patient wishes
The following assessment findings would increase the suspicion of the nurse that the patient may have acute pericarditis except A. Pericardial friction rub B. Pleuritic pain C. Distended neck veins . D. Fever
C. Distended neck veins .
The nurse is caring for a patient who has an allergy to seafood . The patient suddenly has difficulty breathing and complains of throat swelling . What should the nurse anticipate administering ? A. Kenalog B. Prednisone C. Epinephrine D. High dose of benadryl
C. Epinephrine
A nurse is assessing a client who has right ventricular failure . Which of the following findings should the nurse expect ? A. Crackles in the lungs B. Dry , hacking cough C. Hepatomegaly D. Dyspnea
C. Hepatomegaly
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 breathing rate B. Decreased blood pressure C. Increased urine output D. Decreased blood glucose level
C. Increased urine output
A patient is admitted to the critical care unit with a diagnosis of acute myocardial infarction . The ECG monitor reveals bradycardia . Based on this information , occlusion of which coronary artery most likely resulted in the bradycardia ? A. There is no correlation of the Mt with bradycardia B. Right coronary artery C. Left anterior descending artery D. Circumflex artery
C. Left anterior descending artery
A nurse is assessing a patient admitted with pneumothorax and has a chest tube in place . The nurse should immediately notify the provider of which priority assessment finding ? A. Crepitus in the area above and surrounding the insertion site B. pH 7.4 . PaCO2 40 mm Hg . PaO2 80 mm Hg . HCO3 24 mEq / L C. Movement of the trachea toward the unaffected side D. Bubbling of the water in the water seal chamber with exhalation :
C. Movement of the trachea toward the unaffected side
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet . Which of the following nursing actions should the nurse take to promote the client's comfort ? A. Rub the client's feet briskly for several minutes . B. Increase the client's oral fluid intake . C. Obtain a pair of slipper - socks for the client . D. Place heating pad under clients feet
C. Obtain a pair of slipper - socks for the client .
A patient has a diagnosis for peripheral arterial disease The nurse should expect which procedures ? A. Ankle Brachial Index and filter placement B. Start a low fat diet and bed rest C. Stent placement and start clopidogrel ( Plavix ) D. Surgical repair with an OAR procedure
C. Stent placement and start clopidogrel ( Plavix )
A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa . Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication ? A. The leukocyte count B. The erythrocyte sedimentation rate ( ESR ) C. The hematocrit ( Hct ) D. The platelet count
C. The hematocrit ( Hct )
A nurse is reviewing a patient medical history and notes the patient has venous stasis evidenced by bilateral lower leg discoloration , a history of cancer increasing his coagulability and a history of venous thromboembolism . The nurse recognizes the patient meets the criteria of : A. He needs an Endovascular Aneurysm Repair procedure B. He has Postural Orthostatic Tachycardia Syndrome POTS ) C. This is Virchow's Triad D. This is Raynaud's Phenomenon
C. This is Virchow's Triad
For which of the following dysrhythmias is defibrillation contraindicated ? A. Puheless ventricular tachycardia B. Ventricular fibrilation C. Ventricular asystole D. All thythms can be shocked
C. Ventricular asystole
Which of the following correctly describes humoral and cellular immunity ? A. cellular reactions have immediate responses B. cellular immunity is made up of lymphocytes C. cellular reactions are delayed D. humoral reaction example is contact dermatitis and anaphylaxis
C. cellular reactions are delayed
A patient with chronic vein insufficiency will need a home health referral for assistance with which of the following ? A. Transportation for regular CT scans for monitoring B. Teaching on anticoagulant therapy C. venous stasis ulcer wound care D. Education on ways to keep the extremities warm to prevent vessel spasms
C. venous stasis ulcer wound care
Which of the following statement BEST describes rejection after transplant ? A. Acute rejection can be treated with antibiotics B. Hyperacute rejection can be treated with large doses of IVIG therapy C. Chronic rejection can be treated with HIV antivirals D. Hyperacute reaction can be avoided if crossmatching is done before transplantion
D. Hyperacute reaction can be avoided if crossmatching is done before transplantion
A nurse is teaching a client who has a new diagnosis of venous insufficiency . Which of the following instructions should the nurse include ? A. " Place your legs in a dependent position while in bed . " B. " Apply ice packs to your legs . " C. " Remain on bed rest . " D. " Use elastic stockings . "
D. " Use elastic stockings . "
A nurse is assessing a patient who is 10 hours postoperative kidney transplant . The patient complains of general discomfort , body aches and chills . The nurse notes that the urine output of the patient in the last 2 hrs is 30 mL . Which of the following should the nurse suspect ? A. Graft versus host disease B. Acute rejection C. Acute kidney failure D. Hyperacute rejection
D. Hyperacute rejection
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 requires clarification ? A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. Bumetanide 1 mg IV bolus every 12 hr D. 0.9 % normal saline IV at 100 mL / hr continuous
D. 0.9 % normal saline IV at 100 mL / hr continuous
When checking a client's capillary refill , the nurse finds that the color returns in 10 seconds . The nurse should understand that this finding indicates which of the following ? A. Within the expected range B. Thrombus formation in the vein C. Venous insufficiency D. Arterial insufficiency
D. Arterial insufficiency
A nurse is teaching a client who has chronic kidney disease about the process of continuous ambulatory peritoneal dialysis ( CAPD ) . Which of the following information should the nurse include in the teaching ? A. CAPD requires the client to follow more dietary and fluid restrictions than hemodialysis requires . B. CAPD is the dialysis treatment of choice for clients who have a history of abdominal surgery . C. CAPD requires a rigid schedule of exchange times . D. CAPD filters the client's blood through an artificial . device called a dialyzer .
D. CAPD filters the client's blood through an artificial . device called a dialyzer .
A nurse is assessing a client who has chronic venous insufficiency . Which of the following findings should the nurse expect ? A. Thick , deformed toenails B.Hair loss C. Dependent rubor D. Edema
D. Edema
A nurse in a cardiac care unit is caring for a client with acute right - sided heart failure . Which of the following findings should the nurse expect ? A. Increased pulmonary artery wedge pressure ( PAWP ) . B. Decreased brain natriuretic peptide ( BNP ) . C. Decreased specific gravity D. Elevated central venous pressure ( CVP ) .
D. Elevated central venous pressure ( CVP ) .
The nurse would anticipate which of the following treatments based on the rhythm below ? wwwwwwww A. Amiodarone 300 mg IV over 10 minutes B. Magnesium sulfate 1 g IV C. Epinephrine 1 mg IVP every 3-5 minutes D. Immediate defibrillation
D. Immediate defibrillation
A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy ( DCM ) . Which information will the nurse plan to teach the patient about managing DCM ? A. Elevate the legs above the heart to relieve dyspnea , B. Discontinue blood pressure medications immediately when you feel tired . C. Schedule a heart transplant as soon as possible . D. Notify the doctor about symptoms of heart failure such as shortness of breath .
D. Notify the doctor about symptoms of heart failure such as shortness of breath .
Clinical manifestations of acute respiratory failure include the following except A.Tachypnea B. Pursed lip breathing C. Retractions D. PaCO2 46 mm Hg and PaO2 90 mm Hg
D. PaCO2 46 mm Hg and PaO2 90 mm Hg
A nurse is caring for a patient 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 monitor strip ? A. Pacemaker spike after each T wave B. Pacemaker spike before each P wave C. Pacemaker spike after each QRS complex D. Pacemaker spike before each QRS complex
D. Pacemaker spike before each QRS complex
While caring for a patient with aortic stenosis , the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow . Which of the following is a priority nursing intervention for this patient ? A. Lower the head of bed 30 degrees to decrease venous return . B. Teach the patient about the need for anticoagulant therapy . C. Teach the patient to use sublingual nitroglycerin for chest pain . D. Promote rest to decrease myocardial oxygen demand .
D. Promote rest to decrease myocardial oxygen demand .
A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure . The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia ? A. Bumex B. Hydrochlorothiazide C. Furosemide D. Spironolactone
D. Spironolactone
The nurse has called for help after seeing the rhythm below . Which of the following should the nurse do next ? A. Identify possible etiology for the dysrhythmia . B. Assess the patients skin for mottling C. Give sodium bicarbonate D. Start cardiopulmonary resuscitation .
D. Start cardiopulmonary resuscitation .
A patients INR result is 6. The knows Vitamin K can be given as an antidote for which medication ? A. apixaban B. heparin C. dabigatran D. warfarin
D. warfarin
A nurse is monitoring a patient who is undergoing a stress test on a treadmill . Which assessment finding requires the most rapid action by the nurse ? A. Patient complaint of feeling tired P B. ulse change from 87 to 110 beats per minute : C. Blood pressure increase from 134/68 to 150/80 mm Hg D.; Newly inverted T - waves on the electrocardiogram
D.; Newly inverted T - waves on the electrocardiogram
