N205 Practice Questions

The nurse is assessing a client with a a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseau's sign D. Hypoactive deep tendon reflexes

A. Twitching

A nurse and a nursing student are caring for a client with pericarditis and perform the physical assessment together. The client has a pericardial friction rub audible on auscultation. When the nurse and student leave the room, the student asks how to distinguish a pericardial from a pleural friction rub. The nurse's best response is which of the following? A. "You must listen for at least 4 minutes to distinguish between the two." B. "There is really no way to tell the difference; they both sound exactly alike." C. "Have the client stand while you auscultate; the pleural friction rub will continue, while the pericardial friction rub will stop." D. "Ask the client to hold the breath while you auscultate; the pericardial friction rub will continue, while the pleural friction rub will stop."

D. "Ask the client to hold the breath while you auscultate; the pericardial friction rub will continue, while the pleural friction rub will stop." A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid as a result of inflammation. The audible rub on auscultation is synchronous with the heartbeat. To distinguish between a pleural rub and a pericardial rub, the client should hold the breath. The pericardial rub will continue. Length of auscultation and standing would not assist in distinguishing one kind of rub from the other.

8. Which solution below is NOT a hypertonic solution?* A. 5% Dextrose in 0.9% Saline B. 5% Saline C. 5% Dextrose in Lactated Ringer's D. 0.33% saline (1/3 NS)

D. 0.33% saline (1/3 NS)

The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? A. Begin cardiopulmonary resuscitation (CPR) B. Administer epinephrine C. Administer atropine 0.5 mg D. Defibrillate with 360 joules (monophasic defibrillator)

A. Begin cardiopulmonary resuscitation (CPR) Commonly called flatline, ventricular asystole (Fig. 26-19) is characterized by absent QRS complexes confirmed in two different leads, although P waves may be apparent for a short duration. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Ventricular asystole is treated the same as PEA, focusing on high-quality CPR with minimal interruptions and identifying underlying and contributing factors.

The body regulates the pH of its fluids by what mechanism? Select all that apply. A. Chemical buffer systems of the body fluids B. The liver C. The lungs D. The cardiovascular system E. The kidneys

A. Chemical buffer systems of the body fluids C. The lungs E. The kidneys The pH of body fluids is regulated by three major mechanisms: (1) chemical buffer systems of the body fluids, which immediately combine with excess acids or bases to prevent large changes in pH; (2) the lungs, which control the elimination of CO2; and (3) the kidneys, which eliminate H+ and both reabsorb and generate HCO3-.

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. A. Document presenting signs and symptoms. B. Suction the client's airway. C. Compare ABG findings with previous results. D. Administer IV bicarbonate. E. Maintain intake and output records.

A. Document presenting signs and symptoms. C. Compare ABG findings with previous results. E. Maintain intake and output records. Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.

________ fluids remove water from the extracellular space into the intracellular space.* A. Hypotonic B. Hypertonic C. Isotonic D. Colloids

A. Hypotonic

Which could be a potential cause of respiratory acidosis? A. Hypoventilation B. Diarrhea C. Vomiting D. Hyperventilation

A. Hypoventilation Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in PaO2.

Which conditions place clients at risk for developing respiratory acidosis? Select all that apply. A. Kyphoscoliosis B. Drug overdose C. Pneumonia D. Morbid obesity E. Diabetes mellitus

A. Kyphoscoliosis C. Pneumonia D. Morbid obesity E. Diabetes mellitus

A nurse is checking laboratory results for a patient with TPN and lipids and notes the following: Sodium: 138 mEq/L Potassium: 4.1 mEq/L Calcium: 10.1 mg/dL Albumin: 5.4 g/dL Triglycerides: 426 mg/dL Alkaline Phosphatase: 100 IU/L. Based on these laboratory results, which of the following actions is most appropriate? A. Obtain an order to discontinue the lipid infusion B. Flush the catheter with saline C. Administer a thrombolytic agent as ordered D. Add normal saline solution to the TPN fluid

A. Obtain an order to discontinue the lipid infusion The patient in the scenario has high triglyceride levels, which is a potential complication of TPN administration with lipids. The first action of the nurse would be to discontinue the lipid infusion with the healthcare provider's permission and then monitor the triglyceride levels to see if they return to normal.

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention? A. Partial pressure of arterial oxygen (PaO2) of 69 mm Hg B. Partial pressure of arterial carbon dioxide (PaCO2) of 51 mm Hg C. pH of 7.29 D. Bicarbonate (HCO3-)of 28 mEq/L

A. Partial pressure of arterial oxygen (PaO2) of 69 mm Hg In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

Which patient below would NOT be a candidate for a hypotonic solution?* A. Patient with increased intracranial pressure B. Patient with Diabetic Ketoacidosis C. Patient experiencing Hyperosmolar Hyperglycemia D. All of the options are correct

A. Patient with increased intracranial pressure

What part of the heart delivers unoxygenated blood to the lungs?* A. Pulmonary artery B. Pulmonary vein C. Aorta D. Left Ventricle

A. Pulmonary artery

The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply. A. Skin assessment for edema and turgor B. Nutritional status and diet C. Strength testing for muscle wasting D. Blood pressure, heart rate, and rhythm E. Intake and output, urine volume, and color

A. Skin assessment for edema and turgor D. Blood pressure, heart rate, and rhythm E. Intake and output, urine volume, and color To assess for FVE the nurse measures blood pressure, heart rate and rhythm, and breath sounds; inspects the skin to look for edema and turgor; and inspects neck veins. Intake and output, daily weight, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess.

One form of renal tubular acidosis (RTA) results from aldosterone deficiency or resistance to its action, which leads to impaired reabsorption of which of the following electrolytes? A. Sodium B. Hydrogen C. Potassium D. glucose

A. Sodium One type of RTA results from aldosterone deficiency or resistance to its action that leads to impaired reabsorption of sodium ions with decreased elimination of hydrogen and potassium ions. Glucose is not an electrolyte.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? A. The lungs are not able to blow off carbon dioxide. B. The lungs have ineffective cilia from years of smoking. C. The lungs are unable to breathe in sufficient oxygen. D. The lungs are unable to exchange oxygen and carbon dioxide.

A. The lungs are not able to blow off carbon dioxide. In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, it is the lungs ability to remove the carbon dioxide from the system. Although individuals with COPD frequently have a history of smoking, cilia is not the cause of the acidosis.

The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as A. normal sinus rhythm. B. sinus tachycardia. C. junctional tachycardia. D. first-degree atrioventricular block.

A. normal sinus rhythm. The electrocardiogram (ECG) tracing shows normal sinus rhythm (NSR). NSR has the following characteristics: ventricular and atrial rate: 60 to 100 beats per minute (bpm) in the adult; ventricular and atrial rhythm: regular; and QRS shape and duration: usually normal, but may be regularly abnormal; P wave: normal and consistent shape, always in front of the QRS; PR interval: consistent interval between 0.12 and 0.20 seconds and P:QRS ratio: 1:1.

Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? A. pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 B. pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 C. pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 D. pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15

A. pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia? A. Dobutamine B. Atropine C. Amiodarone D. Lidocaine

B. Atropine I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? A. Lactate B. Bicarbonate C. Nitrogen D. Carbonic acid

B. Bicarbonate Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two IV lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question? A. Add 40 mEq potassium chloride to an infusion of half normal saline solution and infuse at a rate of 10 mEq/hour. B. Change the second IV solution to dextrose 5% in water. C. Hold insulin infusion for 30 minutes. D. Infuse 500 ml of normal saline solution over 1 hour.

B. Change the second IV solution to dextrose 5% in water. The nurse should question the physician's order to change the second IV solution to dextrose 5% in water. The client should receive normal saline solution through the second IV site until his blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and his specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias.

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. A. Bradycardia B. Distended neck veins C. Shortness of breath D. Decreased blood pressure E. Crackles in the lung fields

B. Distended neck veins C. Shortness of breath E. Crackles in the lung fields Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.

What type of fluid would a patient with severe hyponatremia most likely be started on?* A. Hypotonic B. Hypertonic C. Isotonic D. Colloid

B. Hypertonic

Which could be a potential cause of respiratory acidosis? A. Vomiting B. Hypoventilation C. Diarrhea D. Hyperventilation

B. Hypoventilation Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in PaO2.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? A. PR interval B. P wave C. QRS complex D. T wave

B. P wave The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

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? A. Obtain a urine specimen for drug screening. B. Prepare to assist with ventilation. C. Prepare for gastric lavage. D. Monitor the client's heart rhythm.

B. 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

On the right side of the heart, blood flows from the right ventricle to the? A. Tricuspid valve to the pulmonary vein B. Pulmonic valve to the pulmonary artery c. Tricuspid valve to pulmonary artery D. Inferior vena cava to the aorta

B. Pulmonic valve to the pulmonary artery

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3- 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which nursing clinical judgment should the nurse make? A. The client requires oxygen therapy with very low oxygen concentrations. B. The client is severely hypoxic. C. The oxygen level is low but poses no risk for the client. D. The client's PaO2 level is within normal range.

B. The client is severely hypoxic. Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).

Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low? A. T wave B. U wave C. P wave D. QT interval

B. U wave The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a client's serum potassium level is low. The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or "peaked" if a client's serum potassium level is high. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization.

The nurse is assessing blood gas results for a client with diabetes and ketoacidosis and notes a pH level of 7.15. Which dysrhythmis should the nurse closely monitor while treating this client? A. Atrial fibrillation B. Ventricular tachycardia C. First-degree heart block D. Sinus tachycardia

B. Ventricular tachycardia When the pH falls to 7.1 to 7.2, cardiac contractility and cardiac output decrease. The heart becomes less responsive to catecholamines and dysrhythmias, including fatal ventricular dysrhythmias, can develop. Ventricular tachycardia is a lethal dysrhythmia that is a priority for the nurse to monitor.

A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances? A. hypokalemia B. hypernatremia C. carbon dioxide D. magnesium

B. hypernatremia The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia.

A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breaths/min, serum potassium of 2.9 mEq/L (2.9 mmol/L), and arterial blood gas—pH 7.46, PCO2 45 mm Hg (6.0 kPA), PO2 95 mm Hg (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L). The nurse should implement which prescription first? A. Oxygen at 4L per nasal cannula B. Repeat laboratory work in 4 hours C. 5% Dextrose in 0.45% normal saline with KCl D. 40 mEq/L at 125 mL/h 12-lead ECG

C. 5% Dextrose in 0.45% normal saline with KCl The vital signs suggest that the client is dehydrated from the vomiting, and the nurse should first infuse the IV fluids with the addition of potassium. There is no indication that the client needs oxygen at this time since the PO2 is 95 mm Hg (12.6 kPa). Although the client has a rapid and irregular pulse, the infusion of fluids may cause the heart rate to return to normal, and the 12-lead ECG can be prescribed after starting the intravenous fluids.

The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? A. Red blood cell hydrolysis B. Red blood cell crenation C. Cerebral edema D. Renal failure

C. Cerebral edema Explanation: Treatment of hypernatremia consists of a gradual lowering of the serum sodium level by the infusion of a hypotonic electrolyte solution (e.g., 0.3% sodium chloride) or an isotonic nonsaline solution (e.g., dextrose 5% in water [D5W]). D5W is indicated when water needs to be replaced without sodium. Clinicians consider a hypotonic sodium solution to be safer than D5W because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. It is the solution of choice in severe hyperglycemia with hypernatremia. A rapid reduction in the serum sodium level temporarily decreases the plasma osmolality below that of the fluid in the brain tissue, causing dangerous cerebral edema.

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? A. Distended jugular veins B. Cool and pale skin C. Dark, concentrated urine D. Crackles in the lung fields

C. Dark, concentrated urine Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.

The nurse is assessing a patient with a probable diagnosis of first-degree AV block. The nurse is aware that this dysrhythmia is evident on an ECG strip by what indication? A. Irregular rhythm B. P waves hidden within the QRS complex C. Delayed conduction, producing a prolonged PR interval D. Variable heart rate, usually fewer than 90 bpm

C. Delayed conduction, producing a prolonged PR interval

You are an ICU nurse who has just admitted a new client with an acid/base imbalance. What would you do to provide accurate baseline data for this client? A. Record intake and output B. Monitor lab values C. Document presenting signs and symptoms D. Implement medication ordered

C. Document presenting signs and symptoms The nurse carefully documents all presenting signs and symptoms to provide accurate baseline data. Options A, B, and D are incorrect because they do not provide baseline data for this client.

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. A. Suction the client's airway. B. Administer IV bicarbonate. C. Document presenting signs and symptoms. D. Maintain intake and output records. E. Compare ABG findings with previous results.

C. Document presenting signs and symptoms. D. Maintain intake and output records. E. Compare ABG findings with previous results. Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. Na + 130 mEq/L K + 4.6 mEq/L Cl - 94 mEq/L Mg ++ 2.8 mg/dL Ca ++ 13 mg/dL Which of the following alterations is consistent with the client's findings? A. Hyponatremia B. Hyperkalemia C. Hypercalcemia D. Hypermagnesemia

C. Hypercalcemia More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia (greater than 10.2 mg/dL) can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion.

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing? A. Hyperglycemia B. Hypercalcemia C. Hyperkalemia D. Hypernatremia

C. Hyperkalemia Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia.

For which acid-base imbalance will the nurse monitor for a client taking large doses of loop diuretics? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

C. Metabolic alkalosis Loop and thiazide diuretics commonly cause metabolic alkalosis as a result of hydrogen and potassium ion excretion in the urine. This leads to increased reabsorption of bicarbonate leading to metabolic alkalosis.

A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next? A. Instruct the client to hold the breath and bear down. B. Prepare to administer a calcium channel blocker. C. Question the client about alcohol and illicit drug use. D. Place the client on supplemental oxygen.

C. Question the client about alcohol and illicit drug use. The client is experiencing sinus tachycardia. Since the client's findings of tachycardia, dilated pupils, restlessness, anxiety, and excitability can indicate illicit drug use (cocaine), the nurse should question the client about alcohol and illicit drug use. This information will direct the client's plan of care. Causes of tachycardia include medications that stimulate the sympathetic response, stimulants, and illicit drugs. The treatment goals for sinus tachycardia is usually determined by the severity of symptoms and directed at identifying and abolishing its cause. The other interventions may be implemented, but determining the cause of the tachycardia is essential.

The nurse is caring for a client who complains of headache and blurred vision. The nurse recognizes that these symptoms, accompanied by increased plasma partial pressure carbon dioxide (PCO2) level and decreased pH level, are consistent with which diagnosis? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis Respiratory acidosis is reflected in the ABG as an increased PCO2 and decreased pH level as well as headache, blurred vision, irritability, muscle twitching, and psychological disturbances.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care? A. Administer intravenous fluids. B. Provide Kayexalate. C. Restrict fluids. D. Administer intravenous normal saline with furosemide.

C. Restrict fluids. The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution.

The condition of a client with metabolic acidosis from an intestinal fistula is not improving. The pulse is 125 beats/min and the BP 84/56 mm Hg. ABG values are: pH 7.1, HCO3- 18 mEq/L (18 mmol/L), PCO2 57 mm Hg (7.58 kPa). What IV medication should the nurse expect to provide next? A. Epinephrine B. Antibiotics C. Sodium bicarbonate D. Potassium chloride

C. Sodium bicarbonate When a client with acidosis has the pH drop to 7.1 to 7.2 there is a decrease in cardiac contractility and output. The heart is less responsive to catecholamines, and fatal ventricular dysrhythmias may occur. Sodium bicarbonate (NaHCO3) is used to partially correct the acidosis in this type of normal anion gap condition. This improves cardiovascular responsiveness. Antibiotics would be used for sepsis. Potassium would not be appropriate because levels are already elevated in acidosis.

What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused? A. risk of kidney damage B. risk of stroke C. risk of dehydration D. risk of bleeding

C. risk of dehydration As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality.

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? A. "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." B. "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers." C. "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." D. "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."

D. "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 nurse knows that what PR interval presents a first-degree heart block? A. 0.16 seconds B. 0.14 seconds C. 0.18 seconds D. 0.24 seconds

D. 0.24 seconds In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block.

A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on?* A. 5% Dextrose in 0.9% Saline B. 0.33% saline C. 0.225% saline D. 0.9% Normal Saline

D. 0.9% Normal Saline

The nurse is caring for a client with an acid-base imbalance. Which of these does the nurse recognize is correct regarding compensation? A. A decreased pH is demonstrated. B. An increased pH is demonstrated. C. There is no alteration in the blood gas values. D. A pH moves toward the normal range.

D. A pH moves toward the normal range.

The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first? A. Prepare for intubation. B. Start an IV infusion. C. Institute rewarming. D. Administer oxygen.

D. Administer oxygen Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

The nurse is monitoring a patient in the postanesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and "sawtooth" P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm? A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial fibrillation D. Atrial flutter

D. Atrial flutter Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, usually between 250 and 400 bpm and results in P waves that are saw-toothed. Because the atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node. This is an important feature of this dysrhythmia. If all atrial impulses were conducted to the ventricle, the ventricular rate would also be 250 to 400 bpm, which would result in ventricular fibrillation, a life-threatening dysrhythmia. Atrial flutter often occurs in patients with chronic obstructive pulmonary disease, pulmonary hypertension, valvular disease, and thyrotoxicosis, as well as following open heart surgery and repair of congenital cardiac defects (Fuster, Walsh et al., 2011).

A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response? A. Reposition the extremity and turn the client to left side B. Obtain a 12-lead ECG and a portable chest x-ray C. Check the security of all connections and increase the milliamperage D. Document the findings and continue to monitor the client

D. Document the findings and continue to monitor the client Capture is a term used to denote that the appropriate complex is followed by the pacing spike. In this instance, the patient's temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike. The nurse should document the findings and continue to monitor the client. Repositioning the client, placing the client on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture. Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.

The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take? A. Give the client a low concentration of oxygen by nasal cannula. B. Tell the client to take several deep, slow breaths and exhale normally. C. Instruct the client to put the head between the knees. D. Have the client breathe into a paper bag.

D. Have the client breathe into a paper bag. The best way to ease symptoms caused by hyperventilation is to have the client breathe into a paper bag. This helps to raise carbon dioxide level, which encourages deeper, slower breathing. The symptoms of hyperventilation will not be alleviated by having the client put the head between the knees, giving the client low concentrations of oxygen, or having the client take deep, slow breaths and exhaling normally.

A client is receiving a diuretic as the first-line treatment of mild hypertension. The nurse monitors the client for signs and symptoms of hypokalemia with which agent? A. Amiloride B. Spironolactone C. Triamterene D. Hydrochlorothiazide

D. Hydrochlorothiazide Hydrochlorothiazide is a thiazide diuretic that promotes the loss of sodium as well as potassium from the body. Subsequently, the client is at risk for hypokalemia. Amiloride, spironolactone, and triamterene are potassium-sparing diuretics. The client using these diuretics would need to be monitored for hyperkalemia because potassium is not lost along with sodium.

When trying to explain the role of potassium and hydrogen related to acid-base, which statement is most accurate? A. Hyperkalemia will cause the reabsorption of HCO3. B. Acidosis causes an increase in K+ elimination. C. Alkalosis tends to increase H+ elimination. D. Hypokalemia stimulates H+ secretion.

D. Hypokalemia stimulates H+ secretion. Hypokalemia is a potent stimulus for H+ secretion and HCO3 reabsorption. Acidosis tends to increase H+ elimination and decrease K+ elimination, with a resultant increase in plasma potassium levels; conversely, alkalosis tends to decrease H+ elimination and increase K+ elimination, with a resultant decrease in plasma K+ levels.

On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3-, 28 mEq/L. Based on these values, the nurse should prioritize which nursing diagnosis for this client? A. Ineffective airway clearance B. Deficient fluid volume C. Metabolic acidosis D. Impaired gas exchange

D. Impaired gas exchange The client's below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2) support the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a diagnosis of Ineffective airway clearance (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.

The client has been taking famotidine (Pepcid) at home. The nurse prepares a teaching plan for the client indicating that the medication acts primarily to achieve which of the following? A. Improve the mixing of foods and gastric secretions. B. Neutralize acid in the stomach. C. Shorten the time required for digestion in the stomach. D. Inhibit gastric acid secretions.

D. Inhibit gastric acid secretions. Famotidine is useful for treating and preventing ulcers and managing gastroesophageal reflux disease. It functions by inhibiting the action of histamine at the H-2 receptor site located in the gastric parietal cells, thus inhibiting gastric acid secretion.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? A. Administer ordered supplemental oxygen. B. Offer the client fluids frequently. C. Administer an ordered decongestant. D. Instruct the client to breathe into a paper bag.

D. Instruct the client to breathe into a paper bag. The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

When caring for a 12-month-old infant with dehydration and metabolic acidosis, the nurse expects to see: A. shallow respirations. B. a reduced white blood cell (WBC) count. C. a decreased platelet count. D. tachypnea.

D. tachypnea. The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations, altered white blood cell or platelet counts are not specific signs of metabolic imbalance.

The nurse provides instructions to a client with a low potassium level about the food that are high in potassium and tells the client to consume which foods? Select all that apply. A. Peas B. Raisins C. Potatoes D. Cantaloupe E. Cauliflower F. Strawberries

B. Raisins C. Potatoes D. Cantaloupe F. Strawberries

A nurse provides morning care for a client in the intensive care unit (ICU). Suddenly, the bedside monitor shows ventricular fibrillation and the client becomes unresponsive. After calling for assistance, what action should the nurse take next? A. Provide electrical cardioversion B. Prepare for endotracheal intubation C. Begin cardiopulmonary resuscitation D. Administer intravenous epinephrine

C. Begin cardiopulmonary resuscitation

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? A. Sinusoidal B. Triangular C. Sawtooth D. Square

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

The nurse reviews a client's electrolyte lab report & notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the lab value? A. U Waves B. Absent P waves C. Elevated T waves D. Elevated ST segment

A. U Waves

A patient in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate? A. "Fluid has built up between your lungs and the lining that surrounds your lungs." B. "Bacteria have entered the fluid surrounding your lungs and these bacteria must be eliminated." C. "A large amount of fluid has accumulated in your lungs and made it difficult to breathe." D. "The small air sacs that make up your lungs have become infected."

A. "Fluid has built up between your lungs and the lining that surrounds your lungs." A pleural effusion is characterized by an accumulation of fluid in the pleural space. This excess fluid is not located in the lung tissue itself or in the alveoli. A pleural effusion is not normally infectious in etiology.

You're providing education to a patient who will be undergoing a heart catheterization. Which statement by the patient requires you to re-educate the patient about this procedure? A. "The brachial artery is most commonly used for this procedure." B. "A dye is injected into the coronary arteries to assess for blockages." C. "Not all patients who have a heart catheterization will need a stent placement." D. "I will not be completely asleep and will be able to breathe on my own during the procedure."

A. "The brachial artery is most commonly used for this procedure." The femoral or radial artery is used during a heart cath...not the brachial.

A patient who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue and a body temperature of 99.3°F. The urine specific gravity is 1.020. What is the most likely serum sodium value for this patient? A. 155 mEq/L B. 110 mEq/L C. 165 mEq/L D. 140 mEq/L

A. 155 mEq/L In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/ kg (300 mmol/L). The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys). Body temperature may increase mildly, but it returns to normal after the hypernatremia is corrected.

A client has started to exhibit dangerous PVCs in the cardiac postoperative unit. The client has been given a bolus of lidocaine and is under continuous IV infusion, but serious side effects, including hypotension during administration, could occur. What should the nurse be ready to do? A. Adjust the IV infusion. B. Administer additional lidocaine. C. Prepare for defibrillation. D. Call for the doctor and just wait.

A. Adjust the IV infusion. Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient.

A nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response? A. Assess the client and monitor leads. B. Administer a pericardial thump. C. Call for assistance and begin CPR. D. Call a code and obtain the crash cart.

A. Assess the client and monitor leads. The nurse should assess the client and monitor leads first. It is important that the nurse "treat the client, not the monitor." Ventricular asystole may often appear on the monitor when leads are displaced. The other interventions are not necessary.

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent? A. Disrupting the heart during the critical period of ventricular repolarization B. Disrupting the heart during the critical period of atrial repolarization C. Disrupting the heart during the critical period of atrial depolarization D. Disrupting the heart during the critical period of ventricular depolarization

A. Disrupting the heart during the critical period of ventricular repolarization It is similar to defibrillation. One difference is that the machine that delivers the electrical stimulation waits to discharge until it senses the appearance of an R wave. By doing so, the machine prevents disrupting the heart during the critical period of ventricular repolarization. Therefore, the other options are incorrect.

Keeping the patient in question 129 in mind: What type of diagnostic tests will the physician most likely order (at first) for this patient to evaluate the cause of the patient's symptoms? Select-all-that-apply: A. EKG B. Stress test C. Heart catheterization D. Balloon angioplasty

A. EKG B. Stress test If the patient is experiencing STABLE angina (which in question 4 the patient's symptoms are stable) an EKG or stress test would be ordered to investigate if there are any EKG changes (ST depression) during exercise. These tests are usually ordered first and then the doctor may proceed with a heart catheterization. A balloon angioplasty is sometimes performed during a heart cath.

Which of the following electrolyte imbalances occur with adrenal insufficiency? A. Hyperkalemia B. Hypokalemia C. Hyponatremia D. Hypernatremia

A. Hyperkalemia Hyperkalemia occurs with adrenal insufficiency. Hypokalemia occurs with gastrointestinal and renal losses. Hyponatremia occurs with increased thirst and antidiuretic hormone (ADH) release. Hypernatremia results from increased insensible losses and diabetes insipidus.

A patient is receiving treatment for stable coronary artery disease. The doctor prescribes the patient Plavix. What important information will you include in the patient's teaching? Select-all-that-apply: A. If you are scheduled for any planned surgical procedures, let your doctor know you are taking Plavix because this medication will need to be discontinued 5-7 days prior to the procedure. B. A normal side effect of this medication is a dry cough. C. Avoid green leafy vegetables while taking Plavix. D. Notify the doctor, immediately, if you develop bruising, problems urinating, or fever.

A. If you are scheduled for any planned surgical procedures, let your doctor know you are taking Plavix because this medication will need to be discontinued 5-7 days prior to the procedure. D. Notify the doctor, immediately, if you develop bruising, problems urinating, or fever. Patients on Plavix should let their doctor know that they are taking Plavix because it should be discontinued 5 to 7 days before a surgical procedure due to increased risk of bleeding. Also, option D represents signs and symptoms of Thrombotic Thrombocytopenic Purpura a clotting disorder where clots form in the vessels of the body which is a complication of Plavix.

The nurse is assisting a client who had a myocardial infarction 2 days ago during a bath. The client suddenly lost consciousness and the nurse was unable to feel a pulse. Cardiopulmonary resuscitation was begun and the client was connected to the monitor with a gross disorganization without identifiable waveforms or intervals observed. What is a priority intervention at this time? A. Immediate defibrillation B. Synchronized cardioversion C.Applying a transcutaneous pacemaker D. Administration of atropine

A. Immediate defibrillation The classic electrocardiographic pattern of ventricular fibrillation is that of gross distortion without identifiable waveforms or or intervals. When the ventricles do not contract, there is no cardiac output, and there are no palpable or audible pulses. Immediate defibrillation using a nonsynchronized, direct-current electrical shock is mandatory for ventricular fibrillation and for ventricular flutter that has caused loss of consciousness.

The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse's best explanation? A. In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output. B. Sinus bradycardia means your heart is not beating fast enough to keep you alive. C. Sinus bradycardia is nothing to worry about. D. In many clients a heart rate slower than 70 beats per minute is considered to slow to maintain an adequate cardiac output.

A. In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output. A heart rate slower than 60 beats per minute is pathologic in clients with heart disorders, increased intracranial pressure, hypothyroidism, or digitalis toxicity. The danger in sinus bradycardia is that the slow rate may be insufficient to maintain cardiac output.

The nurse working in the emergency room triages a client who comes in reporting chest pain, shortness of breath, sweating and elevated anxiety. The physician suspects a myodardial infarction. The client is given a nitrate, which does nothing for his pain. Which medication should the nurse suspect the doctor will order next for the pain? A. Morphine B. Fentanyl C. Demerol D. Codeine

A. Morphine Although a number of analgesic agents have been used to treat pain of myocardial infarction, morphine is the drug of choice and is usually indicated if chest pain is unrelieved with oxygen and nitrates.

The nurse is caring for a client with aortic regurgitation. The nurse knows to expect what symptoms during the physical examination? A. Orthopnea and dyspnea B. Increased urine output C. Headache and vomiting D. Nausea and low urine output

A. Orthopnea and dyspnea Aortic regurgitation usually manifests as progressive left ventricular failure, resulting from blood flowing backward from the aorta to the left ventricle, and eventually into the lungs. Urine output would be decreased from lower cardiac output. Nausea and vomiting are symptoms of increased gastrointestinal pressure, which would result from right heart failure. Kidney failure could become a problem later if cardiac output became too low, but not initially. CVA and an infarcted bowel would not be caused by mitral regurgitation.

The nurse does an assessment on a patient who is admitted with a diagnosis of right-sided heart failure. The nurse knows that a significant sign is which of the following? A. Pitting edema B. Oliguria C. S3 ventricular gallop sign D. Decreased O2 saturation levels

A. Pitting edema The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response.

A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat. Is this normal?" What is the nurse's best response? A. Premature atrial complex B. Atrial flutter C. Sinus tachycardia D. Ventricular fibrillation

A. Premature atrial complex A premature atrial complex (PAC) is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node.

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? A. Stabbing pain during respiratory movement B. Dullness or flatness on percussion over areas of collected fluid C. Dyspnea and coughing D. Fever and chills

A. Stabbing pain during respiratory movement

Which patient(s) are most at risk for developing coronary artery disease? Select-all-that-apply: A. A 25 year old patient who exercises 3 times per week for 30 minutes a day and has a history of cervical cancer. B. A 35 year old male with a BMI of 30 and reports smoking 2 packs of cigarettes a day. C. A 45 year old female that reports her father died at the age of 42 from a myocardial infraction. D. A 29 year old that has type I diabetes.

B. A 35 year old male with a BMI of 30 and reports smoking 2 packs of cigarettes a day. C. A 45 year old female that reports her father died at the age of 42 from a myocardial infraction. D. A 29 year old that has type I diabetes

A client is scheduled for an elective electrical cardioversion for a sustained dysrhythmia lasting for 24 hours. Which intervention is necessary for the nurse to implement prior to the procedure? A. Administer anticoagulant therapy as prescribed prior to the procedure B. Administer moderate sedation IV and analgesic medication as prescribed C. Maintain the client on NPO status for 8 hours prior to the procedure D. Administer the prescribed digitalis to the client before the scheduled procedure

B. Administer moderate sedation IV and analgesic medication as prescribed Before an elective cardioversion, the client should receive moderate sedation IV as well as an analgesic medication or anesthesia. In contrast, in emergent situations, the client may not be premedicated. Digoxin is usually withheld for 48 hours before cardioversion to ensure the resumption of sinus rhythm with normal conduction. If the cardioversion is elective and the dysrhythmia has lasted longer than 48 hours, anticoagulation performed for a few weeks before cardioversion may be indicated. The client is instructed not to eat or drink for at least 4 hours before the procedure.

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? A. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. B. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. C. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the health care provider. D. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team.

B. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

Which would the nurse stress as a lifelong necessity for a client managing infective endocarditis? A. Exercise regimen B. Antibiotic therapy C. Potassium replacement D. Antihypertensive medication

B. Antibiotic Therapy The nurse informs the client that periodic antibiotic therapy is a lifelong necessity because the client will be vulnerable to diseases for the rest of his life. Antihypertensive therapy is not always prescribed. Limited activity is stressed. Potassium replacement is typical when combined with diuretic therapy.

A patient with mitral valve stenosis and coronary artery disease (CAD) is in the telemetry unit with pneumonia. The nurse assesses a 6-second rhythm strip and determines that the ventricular rhythm is highly irregular at 88, with no discernible P waves. What does the nurse determine this rhythm to be? A. Ventricular flutter B. Atrial flutter C. Sinus tachycardia D. Nonparoxysmal junctional tachycardia

B. Atrial flutter Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, usually between 250 and 400 bpm and results in P waves that are saw-toothed. Ventricular rhythm may be irregular, and P waves may be absent. Ventricular rate usually ranges between 75 and 150 bpm.

A patient calls the cardiac clinic you are working at and reports that they have taken 3 sublingual doses of Nitroglycerin as prescribed for chest pain, but the chest pain is not relieved. What do you educate the patient to do next? A. Take another dose of Nitroglycerin in 5 minutes. B. Call 911 immediately C. Lie down and rest to see if that helps with relieving the pain D. Take two doses of Nitroglycerin in 5 minutes

B. Call 911 immediately If a patient's chest pain is not relieved with 3 doses of Nitroglycerin, taken 5 minutes apart, they should call 911 immediately. The patient should never exceed more than 3 doses of Nitroglycerin or take 2 doses at one time.

The nurse knows that a pacemaker is the treatment of choice for what cardiac dysrhythmia? A. Atrial flutter B. Complete heart block C. Supraventricular tachycardia D. Ventricular fibrillation

B. Complete heart block Pacemaker insertion is the treatment for complete heart block. Treatments for supraventricular tachycardia are: valsalva maneuver, unilateral carotid massage, immersion of face in ice water, administration of IV adenosine, cardioversion, and radiofrequency ablation. Cardioversion and drug therapy are used for the treatment of atrial flutter. Treatment for ventricular fibrillation is defibrillation preceded by or followed with epinephrine.

A nurse is caring for a client with atrial fibrillation. What procedure would the nurse educate the patient about for termination of the dysrhythmia? A. Mace procedure B. Elective cardioversion C. Pacemaker implantation D. Defibrillation

B. Elective cardioversion Atrial fibrillation also is treated with elective cardioversion or digitalis if the ventricular rate is not too slow. Defibrillation is used for a ventricular problem. A Mace procedure is only a distractor for this question. Pacemakers are implanted for bradycardia.

A patient taking Zocor is reporting muscle pain. You are evaluating the patient's lab work and note that which of the following findings could cause muscle pain? A. Elevated potassium level B. Elevated CPK (creatine kinase level) C. Decreased potassium level D. Decreased CPK (creatine kinase level)

B. Elevated CPK (creatine kinase level) Zocor (a statin medication used for lowering cholestorl) can cause increased CPK levels which will lead to a patient experiencing muscle pain. Therefore, CPK levels must be monitored while a patient is taking this medication.

A client with a liver failure and ascites is schedules for a paracentesis. Which action should the nurse anticipate prior to the procedure. Select all that apply. A. insert an NG tube B. Instruct the client to void C. elevate head of the bed D. measure abdominal girth E. obtain informed consent

B. Instruct the client to void C. elevate head of the bed D. measure abdominal girth E. obtain informed consent

A patient is 2 days postoperative after having a permanent pacemaker inserted. The nurse observes that the patient is having continuous hiccups as the patient states, "I thought this was normal." What does the nurse understand is occurring with this patient? A. Fracture of the lead wire B. Lead wire dislodgement C. Faulty generator D. Sensitivity is too low

B. Lead wire dislodgement Phrenic nerve, diaphragmatic (hiccuping may be a sign), or skeletal muscle stimulation may occur if the lead is dislocated or if the delivered energy (mA) is set high. The occurrence of this complication is avoided by testing during device implantation.

A client tells the nurse that the client has been taking Alka-Seltzer (bicarbonate—antacid) four times a day for the past 2 weeks for an upset stomach. Upon assessment of the client, the nurse notes hyperactive reflexes, tetany, and mental confusion. Arterial blood gases reveal pH 7.55; serum HCO3− 37 mEq/L (37 mmol/L). The nurse suspects the client may be experiencing: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Respiratory acidosis

B. Metabolic alkalosis Metabolic alkalosis is characterized by a serum pH greater than 7.45; serum HCO3− greater than 29 mEq/L (29 mmol/L); and a base excess greater than 3.0. Transient or acute alkalosis is common during or immediately following excess oral ingestion of bicarbonate antacids. Respiratory acidosis as well as metabolic acidosis would have a decrease in pH. Respiratory alkalosis would have an increase in pH and a HCO3− less than 24 mEq/L (24 mmol/L).

A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? A. Metabolic alkalosis and hyperkalemia B. Metabolic alkalosis and hypokalemia C. Metabolic acidosis and hyperkalemia D. Metabolic acidosis and hypokalemia

B. Metabolic alkalosis and hypokalemia Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia

Treatment of metabolic acidosis in chronic renal failure includes: A. Sodium bicarbonate supplements B. No treatment C. Hemodialysis D. Peritoneal dialysis

B. No treatment

A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing: A. Pneumonia B. Onset of STEMI C. Gastroesophageal reflux disease (GERD) D. Acute respiratory distress syndrome (ARDS)

B. Onset of STEMI The onset of STEMI involves abrupt and significant chest pain. The pain typically is severe, often described as being constricting, suffocating, and crushing. Substernal pain that radiates to the left arm, neck, or jaw is common, although it may be experienced in other areas of the chest and back. Unlike that of angina, the pain associated with MI is more prolonged and not relieved by rest or nitroglycerin.

A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having? A. Magnesium B. Potassium C. Sodium D. Calcium

B. Potassium Hyperkalemia (high potassium) can result in the following ECG changes: tall peaked T waves, wide QRS, and bradycardia. The nurse should be prepared to administer a diuretic or an ion-exchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose. Imbalances in the other electrolytes listed would not result in peaked T waves.

When administering a hypertonic solution the nurse should closely watch for?* A. Signs of dehydration B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level

B. Pulmonary Edema

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? A. Cough B. Tachypnea C. Hemoptysis D. Syncope

B. Tachypnea Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).

The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated? A. The registered nurse stating to administer digoxin B. The registered nurse administering atropine sulfate intravenously C. The registered nurse stating to hold all medication until the pulse rate returns to 60 beats/minute D. The registered nurse stating to administer all medications except those which are cardiotonics

B. The registered nurse administering atropine sulfate intravenously The licensed practical nurse and registered nurse both identify that client's bradycardia. Atropine sulfate, a cholinergic blocking agent, is given intravenously (IV) to increase a dangerously slow heart rate. Lanoxin is not administered when the pulse rate falls under 60 beats/minute. It is dangerous to wait until the pulse rate increases without nursing intervention or administering additional medications until the imminent concern is addressed.

The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with A. thrombolytics. B. percutaneous coronary intervention (PCI). C. IV nitroglycerin. D. IV heparin.

B. percutaneous coronary intervention (PCI). The client with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: A. metabolic acidosis. B. respiratory alkalosis. C. respiratory acidosis. D. metabolic alkalosis.

B. respiratory alkalosis. This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented? A. infection B. seizure C. neutropenic D. high-risk fall

B. seizure Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included.

The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid?* A. 0.9% Normal Saline B. Lactated Ringer's C. 0.45% Saline D. 5% Dextrose in 0.225% saline

C. 0.45% Saline

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? A. 130 mEq/L B. 145 mEq/L C. 115 mEq/L D. 160 mEq/L

C. 115 mEq/L Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur.

The nurse is caring for a patient with a pituitary tumor. The nurse assesses the urine and reviews the lab results. The urine specific gravity is 1.075 and urine output is minimal. What would the nurse expect the sodium level to be in this patient? A. 135 B. 155 C. 125 D. 140

C. 125; sodium would be low because urine retention is high. Hypervolemic.

Which nursing intervention should a nurse perform when a client with cardiomyopathy receives a diuretic? A. Allow unrestricted physical activity B. Administer oxygen C. Check regularly for dependent edema D. Maintain bed rest

C. Check regularly for dependent edema The nurse should regularly monitor for dependent edema if the client with cardiomyopathy receives a diuretic. Oxygen is administered either continuously or when dyspnea or dysrhythmias develop. Bed rest is not necessary. The nurse should ensure that the client's activity level is reduced and should sequence any activity that is slightly exertional between periods of rest.

The nurse recognizes which as being true of cardioversion? A. Amount of voltage used should exceed 400 watts/second. B. Electrical impulse can be discharged during the T wave. C. Defibrillator should be set to deliver a shock during the QRS complex. D. Defibrillator should be set in the non-synchronous mode so the nurse can hit the button at the right time.

C. Defibrillator should be set to deliver a shock during the QRS complex. Cardioversion involves the delivery of a "timed" electrical current. The defibrillator is set to synchronize with the ECG and deliver the impulse during the QRS complex. The synchronization prevents the discharge from occurring during the vulnerable period of repolarization (T wave), which could result in VT or ventricular fibrillation.

Which of the following does the nurse recognize as the therapeutic goal of radiofrequency catheter ablation for a client with cardiac dysrhythmias? A. Reperfusion of ischemic heart tissue B. Dilation of arterial blood vessels C. Destruction of errant tissue D. Stimulation of the impulse center

C. Destruction of errant tissue The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue, in hopes of allowing impulse conduction to travel over appropriate pathways. The goal does not include dilation of blood vessels or reperfusion of heart tissue. There is no stimulation of the heart.

A patient is admitted with suspected cardiomyopathy. What diagnostic test would be most helpful with the identification of this disorder? A. Phonocardiogram B. Serial enzyme studies C. Echocardiogram D. Cardiac catheterization

C. Echocardiogram The echocardiogram is one of the most helpful diagnostic tools for cardiomyopathy because the structure and function of the ventricles can be observed easily.

The nursing instructor is discussing heart failure with their clinical group. The instructor talks about heart failure in terms of a decreasing ejection fraction of the heart. What diagnostic test is used to measure the ejection fraction of the heart? A. MRI B. Pulmonary arterial pressure C. Echocardiogram D. Nuclear angiography

C. Echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. An MRI, pulmonary arterial pressure, and nuclear angiography do not give diagnostic information about the hearts' ejection fraction.

A nurse is caring for a preschool-age client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/L), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/L), and platelet count of 150,000/μL (150 X 109/L). Based on the child's values, what is the highest priority nursing intervention? A. Prepare to give the child a transfusion of packed red blood cells. B. Prepare to give the child a transfusion of platelets. C. Encourage meticulous handwashing by the client and visitors. D. Encourage mouth care with a soft toothbrush.

C. Encourage meticulous handwashing by the client and visitors A WBC of 2000 mm3 (2 X 109/L) is low and increases the child's risk for infection. Meticulous handwashing is a standard/routine precaution and the first line of defense in combating infection. A platelet count of 150,000 ?L (150 X 109/L) is within normal range, so there is no need to transfuse the child with platelets. Mouth care will help decrease the risk of infection. However, handwashing is the priority because it will have the greatest effects on diminishing the risk of infection. A Hgb of 12.5 g/dL (125 g/L) and a HCT of 36.8% (0.37) are within normal range so there is no need to transfuse packed red blood cells.

A 43-year-old male came into the emergency department where you practice nursing and was diagnosed with atrial fibrillation. It's now 48 hours since his admittance and the dysrhythmia persists. Which of the following medications will the client's healthcare provider most likely order? A. Flecainide (Tambocor) B. Dabigatran (Pradaxa) C. Heparin D. Warfarin (Coumadin)

C. Heparin Heparin is generally prescribed initially if the dysrhythmia persists longer than 48 hours.

Which coronary artery provides blood to the left atrium and left ventricle: A. Right marginal artery B. Posterior descending artery C. Left circumflex artery D. Right coronary artery

C. Left circumflex artery

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? A. Administer every five minutes during cardiac resuscitation B. Keep the client flat for one hour after administration C. Monitor vital signs and cardiac rhythm D. Document heart rate before and after administration

C. 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.

Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. A. Administer the ordered furosemide 60 mg po. B. Administer the ordered potassium 40 mg IV push. C. Offer a diet with fruit juices and citrus fruits. D. Monitor intake and output every shift. E. Administer the ordered Kayexalate enema.

C. Offer a diet with fruit juices and citrus fruits. D. Monitor intake and output every shift. Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output.

Which term is used to describe a tachycardia characterized by abrupt onset, abrupt cessation, and a QRS of normal duration? A. Sinus tachycardia B. Atrial flutter C. Paroxysmal atrial tachycardia D. Atrial fibrillation

C. Paroxysmal atrial tachycardia Paroxysmal atrial tachycardia (PAT) is often caused by a conduction problem in the AV node and is now called AV nodal reentry tachycardia. Sinus tachycardia occurs when the sinus node regularly creates an impulse at a faster-than-normal rate. Atrial flutter occurs in the atrium and creates an atrial rate between 250 to 400 times per minute. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature.

The nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II as well as a bizarre, abnormal shape to the QRS complex. The nurse has likely observed which ventricular dysrhythmia? A. Ventricular bigeminy B. Ventricular tachycardia C. Premature ventricular contraction D. Ventricular fibrillation

C. Premature ventricular contraction A premature ventricular contraction (PVC) is an impulse that starts in a ventricle before the next normal sinus impulse. Ventricular bigeminy is a rhythm in which every other complex is a PVC. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles.

The nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II as well as a bizarre, abnormal shape to the QRS complex. The nurse has likely observed which ventricular dysrhythmia? A. Ventricular bigeminy B. Ventricular tachycardia C. Premature ventricular contraction D. Ventricular fibrillation

C. Premature ventricular contraction A premature ventricular contraction (PVC) is an impulse that starts in a ventricle before the next normal sinus impulse. Ventricular bigeminy is a rhythm in which every other complex is a PVC. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles.

A patient reports during a routine check-up that he is experiencing chest pain and shortness of breath while performing activities. He states the pain goes away when he rests. This is known as: A. Unstable angina B. Variant angina C. Stable angina D. Prinzmetal angina

C. Stable angina Stable angina occurs during activities but goes away when the patient rests. Variant and Prinzmetal angina are the same and occur at rest during cycles. Unstable angina is chest pain felt during rest and is more severe.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus? A. Consume the majority of daily fluid intake prior to bed. B. Wear tight-fitting clothing. C. Tense and relax muscles in the lower extremities. D. Begin estrogen replacement.

C. Tense and relax muscles in the lower extremities. Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

A client with a suspected MI is brought to the emergency department by ambulance. The nurse caring for this client would expect to receive an order for which laboratory test to confirm a diagnosis of MI? A. Calcium level B. Complete blood components C. Troponin level D. Creatine kinase marker

C. Troponin level The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction (MI). The troponin complex, which is part of the actin filament, consists of three subunits (i.e., TnC, TnT, and TnI) that regulate calcium-mediated actin-myosin contractile process in striated muscle TnI and TnT, which are present in cardiac muscle, begin to rise within 3 hours after the onset of MI and may remain elevated for 7 to 10 days after the event. This is especially adventitious in the late diagnosis of MI. The other blood work may be ordered, but not to confirm the diagnosis of MI.

A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi? A. Adenosine B. Amiodarone C. Warfarin D. Atropine

C. Warfarin Because atrial function may be impaired for several weeks after cardioversion, warfarin is indicated for at least 4 weeks after the procedure. Patients may be given amiodarone, flecainide, ibutilide, propafenone, or sotalol prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation

The nurse is assessing the respiratory status of the client following thoracentesis. The nurse would become most concerned with which assessment finding? A. equal bilateral chest expansion B. respiratory rate of 22 breaths per minute C. diminishing breath sounds on affected side D. few scattered wheezes, unchanged from baseline

C. diminishing breath sounds on affected side

A nurse will be providing care for a female client who has a diagnosis of heart failure that has been characterized as being primarily right-sided. Which statement best describes the presentation that the nurse should anticipate? The client: A. has a distended bladder, facial edema, and difficulty breathing during nighttime hours. B. complains of dyspnea and has adventitious breath sounds on auscultation (listening). C. has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain. D. has cyanotic lips and extremities, low urine output, and low blood pressure.

C. has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain. Right-sided failure is associated with peripheral edema, fatigue, and, on occasion, upper right quadrant pain. Abdominal distention can occur with right-side failure when the liver becomes engorged. Facial edema, pulmonary edema, peripheral cyanosis, low urine output and low blood pressure are less associated with right-sided failure. Left-sided failure is primarily associated with pulmonary signs/symptoms like dyspnea, pulmonary edema, frothy pink sputum, and respiratory congestion.

The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as A. junctional tachycardia. B. sinus tachycardia. C. normal sinus rhythm. D. first-degree atrioventricular block.

C. normal sinus rhythm. The electrocardiogram (ECG) tracing shows normal sinus rhythm (NSR). NSR has the following characteristics: ventricular and atrial rate: 60 to 100 beats per minute (bpm) in the adult; ventricular and atrial rhythm: regular; and QRS shape and duration: usually normal, but may be regularly abnormal; P wave: normal and consistent shape, always in front of the QRS; PR interval: consistent interval between 0.12 and 0.20 seconds and P:QRS ratio: 1:1.

An adult is admitted for diagnosis and treatment of a left lung lesion. A bronchoscopy was performed unde local anesthesia. What nursing action is of highest priority when he returns following the bronchoscopy? A. collect all sputum for examination B. assess level of consciousness frequently C. withhold food and fluids until gag reflex has returned D. monitor blood pressure and pulse at 10 minute intervals

C. withhold food and fluids until gag reflex has returned

A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)? A. Intermittent nausea and emesis for 3 days B. Cool, clammy skin and a diaphoretic, pale appearance C. Anxiousness, restlessness, and lightheadedness D. Chest discomfort not relieved by rest or nitroglycerin

D. Chest discomfort not relieved by rest or nitroglycerin Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.

A patient with mitral valve stenosis and coronary artery disease (CAD) is in the telemetry unit with pneumonia. The nurse assesses a 6-second rhythm strip and determines that the ventricular rhythm is highly irregular at 88, with no discernible P waves. What does the nurse determine this rhythm to be? A. Nonparoxysmal junctional tachycardia B. Sinus tachycardia C. Ventricular flutter D. Atrial flutter

D. Atrial flutter Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, usually between 250 and 400 bpm and results in P waves that are saw-toothed. Ventricular rhythm may be irregular, and P waves may be absent. Ventricular rate usually ranges between 75 and 150 bpm

The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor ofthe client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record? A. R-on-T phenomenon B. Multifocal PVCs C. Couplets D. Bigeminy

D. Bigeminy The nurse is correct to note bigeminy on the permanent record when every other beat is a PVC. Couplets are two PVCs in a row. Multifocal PVCs originate from more than one location. R-on-T phenomenon occurs when the R wave falls on the T wave.

A patient who has diabetes will be started on Metoprolol for medical management of coronary artery disease. Which of the following will you include in your discharge teaching about this medication? A. Check your heart rate regularly because Metoprolol can cause an irregular heart rate. B. Check your glucose regularly because this medication can cause hyperglycemia. C. Check your blood pressure regularly because this medication can cause hypertension. D. Check your glucose regularly because this medication can mask the typical signs and symptoms of hypoglycemia.

D. Check your glucose regularly because this medication can mask the typical signs and symptoms of hypoglycemia. This patient needs to be educated to check their glucose levels regularly because this medication can mask the typical signs and symptoms of hypoglycemia. This is very important since the patient is diabetic.

A client who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which manifestation alerts the nurse to a developing complication? A. Diarrhea B. Symmetrical joint pain C. Hypoglycemia D. Decreased level of consciousness

D. Decreased level of consciousness Fibrinolytic therapy is most effective in treating STEMI when administered within 30 minutes after the onset of symptoms. It can still be beneficial up to 12 hours after the onset of ischemic pain. Clients who should not receive fibrinolytic therapy are those with a history of intracranial hemorrhage or significant trauma within the preceding 3 months. The primary complication of fibrinolytic treatment is intracranial bleeding that usually occurs within the first 24 hours following treatment. This would be evident with a change in mental status or level of consciousness (LOC).

A nurse is caring for a client with atrial fibrillation. What procedure would the nurse educate the patient about for termination of the dysrhythmia? A. Defibrillation B. Mace procedure C. Pacemaker implantation D. Elective cardioversion

D. Elective cardioversion Atrial fibrillation also is treated with elective cardioversion or digitalis if the ventricular rate is not too slow. Defibrillation is used for a ventricular problem. A Mace procedure is only a distractor for this question. Pacemakers are implanted for bradycardia.

Lipitor is prescribed for a patient with a high cholesterol level. As the nurse, how do you educate the patient on how this drugs works on the body? A. Lipitor increases LDL levels and decreases HDL levels, total cholesterol, and triglyceride levels. B. Lipitor decreases LDL, HDL levels, total cholesterol, and triglyceride levels. C. Lipitor increases HDL levels, total cholesterol, and triglyceride levels. D. Lipitor increases HDL levels and decreases LDL, total cholesterol, and triglyceride levels.

D. Lipitor increases HDL levels and decreases LDL, total cholesterol, and triglyceride levels. Lipitor is a common "statin" medication used to lower cholesterol in CAD. It works by increasing HDL levels (the "good" cholesterol") and decreases LDL (the "bad" cholesterol"), total cholesterol, and triglyceride levels.

A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia? A. Potassium and calcium B. Calcium and magnesium C. Potassium and sodium D. Magnesium and potassium

D. Magnesium and potassium Hypomagnesemia as well as hypokalemia and hyperkalemia are common causes of ventricular tachycardia. Calcium imbalances cause changes in the QT interval and ST segment. Alterations in sodium level don't cause rhythm disturbances.

The nurse has entered the room of a patient and found the patient diaphoretic, panicked, and clutching his chest. What action should the nurse first perform? A. Assist the patient into a semi-Fowler's position. B. Provide calm reassurance to the patient. C. Administer oxygen at 6 LPM by nasal prongs. D. Perform a rapid assessment of the patient.

D. Perform a rapid assessment of the patient. An emergent cardiac event requires a prompt nursing response that should begin with an efficient assessment of the patient's condition (airway, breathing, circulation, and consciousness). The results of this rapid assessment provide the basis for nurse's decision to call a cardiac arrest code. This assessment is a priority over oxygen supplementation, reassurance, and repositioning, even though each of these measures may be appropriate.

Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure? A. Restrict dietary sodium B. Avoid excess alcohol C. Abstinence from smoking D. Push fluids

D. Push fluids Lifestyle recommendations include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise.

A client has had an acute myocardial infarction (MI). The brother of the client has a history of angina. The client asks how he will know if his brother's pain is angina or if the brother is actually having an MI. Which statement is correct? A. Chest pain with angina only occurs during the day; MI pain is more likely at night. B. Chest pain with angina only occurs at rest; MI pain occurs during a stressful time. C. Pain is more severe and lasts longer with angina than with an MI. D. Rest and intake of nitroglycerin relieve chest pain with angina; they do not relieve chest pain with an MI.

D. Rest and intake of nitroglycerin relieve chest pain with angina; they do not relieve chest pain with an MI. Rest and intake of nitroglycerin relieve chest pain with angina but not with an MI. Pain with angina and MI is a subjective symptom for each client. Pain with angina and MI can occur at a variety of times.

A patient reports having crushing chest pain that radiates to the jaw. You administer sublingual nitroglycerin and obtain a 12 lead EKG. Which of the following EKG findings confirms your suspicion of a possible myocardial infraction? A. absent Q wave B. QRS widening C. absent P-wave D. ST segment elevation

D. ST segment elevation

A patient comes to the emergency department with reports of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing? A. Sinus bradycardia B. Ventricular tachycardia C. Normal sinus rhythm D. Sinus tachycardia

D. Sinus tachycardia Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate. Causes include medications that stimulate the sympathetic response (e.g., catecholamines, aminophylline, atropine), stimulants (e.g., caffeine, nicotine), and illicit drugs (e.g., amphetamines, cocaine, Ecstasy).

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the lab value? A. ST depression B. Inverted T wave C. Prominent U wave D. Tall peaked T waves

D. Tall peaked T waves

A client is admitted to the emergency department with chest pain and doesn't respond to nitroglycerin. The health care team obtains an electrocardiogram and administers I.V. morphine. The health care provider also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? A. Within 12 hours B. Within 24 to 48 hours C. Within 5 to 7 days D. Within 6 hours

D. Within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Health care providers initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem? A. thiazide diuretic B. narcotic C. muscle relaxer D. corticosteroid

D. corticosteroid Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.

A client has just returned from a cardiac catheterization with no complications. The clients vital signs are normal , and stable. Which nursing action is unnecessary in the first hour after the client client returns to the unit? A. keep left leg immobilized B. offer the client something to drink and tell her fluids help eliminate the dye C. check pulses distal to the insertion site D. take a temperature every 15 minutes

D. take a temperature every 15 minutes

A nurse is performing a neurovascular assessment on a client admitted with a fractured right femur. The nurse notices that the pulses are not palpable. What is the nurse's most important action? A. alert the charge nurse immediately B. reassess the pulses again in one hour C. notify the health care provider immediately D. verify the clinical findings with Doppler

D. verify the clinical findings with Doppler

A patient with cerebral edema would most likely be order what type of solution?* A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline

A. 3% Saline A patient with cerebral edema would be ordered a HYPERTONIC solution to decrease brain swelling. The solution would remove water from the brain cells back into the intravascular system to be excreted. 3% Saline is the only hypertonic option.

A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms? A. atrial fibrillation B. atrial flutter C. heart block D. bundle branch block

A. atrial fibrillation In atrial fibrillation, several areas in the right atrium initiate impulses resulting in disorganized, rapid activity. The atria quiver rather than contract, producing a pulse deficit due to irregular impulse conduction to the AV node. The ventricles respond to the atrial stimulus randomly, causing an irregular ventricular heart rate, which may be too infrequent to maintain adequate cardiac output. Atrial flutter, heart block, and bundle branch block would not produce these symptoms.

The nurse is assessing a child with ketoacidosis. The nurse should particularly observe if the client has: A. deep, rapid respirations. B. elevated blood pressure. C. diaphoretic, warm skin. D. slow, bounding pulse rate.

A. deep, rapid respirations. The accumulation of ketones, organic acids that readily release free hydrogen ions causing blood pH to fall, leads to ketoacidosis. To compensate, the respiratory buffering system is activated, which results in the child taking deep, rapid breaths to rid the body of excess carbon dioxide. This characteristic breathing pattern is known as Kussmaul's respirations. Typically with ketoacidosis, the pulse rate would be more rapid and weak due to dehydration and loss of electrolytes. Typically with ketoacidosis, the skin would be dry due to dehydration. With ketoacidosis, hypotension results from the contracted blood volume secondary to dehydration.

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? A. "I need to check to see whether my cola beverage has potassium in it." B. "I will not salt my food; instead I'll use salt substitute." C. "Bananas have a lot of potassium in them; I'll stop buying them." D. "I'll drink cranberry juice with my breakfast instead of coffee."

B. "I will not salt my food; instead I'll use salt substitute." The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.

The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? A. 5% glucose in normal saline solution B. 0.45% sodium chloride C. 5% glucose in water D. 0.9% sodium chloride

B. 0.45% sodium chloride Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.

You are making rounds on your clients. You find one of your clients struggling to breathe, appears confused, has tachycardia, and the skin appears dusky. What should you do to restore normal pH if ventilation efforts are not very successful? A. Give bronchodilators. B. Administer sodium bicarbonate IV. C. Start potassium IV. D. Infuse magnesium sulfate.

B. Administer Sodium Bicarbonate IV When the client makes frantic efforts to breathe, breathes slowly, or stops breathing, and has tachycardia, and the skin appears dusky (cyanosis), the condition is likely to be acute respiratory acidosis. The accumulation of CO2 leads to behavioral changes, including confusion. Excess carbonic acid pulls pH below 7.35. The nurse should administer sodium bicarbonate IV to balance the acid and bring the pH to a normal level. Bronchodilators may be useful in chronic respiratory acidosis but not in the acute version. Potassium (needed in hypokalemia) and magnesium sulfate (needed in hypomagnesemia) have no role in acute respiratory acidosis

Which of the following is not a hypertonic fluid?* A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W) D. 5% Dextrose in Lactated Ringer's

B. D5W

Isotonic fluids cause shifting of water from the extracellular space to the intracellular space.* A. True B. False

B. False HYPOTONIC fluids cause shifting of water from the extracellular space to the intracellular space (not isotonic)

A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be? A. Ventricular tachycardia B. Ventricular fibrillation C. Third-degree heart block D. Atrial fibrillation

B. Ventricular fibrillation The most common dysrhythmia in patients with cardiac arrest is ventricular fibrillation, which is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. No atrial activity is seen on the ECG. The most common cause of ventricular fibrillation is coronary artery disease and resulting acute myocardial infarction. Ventricular fibrillation is always characterized by the absence of an audible heartbeat, a palpable pulse, and respirations.

Which factor increases blood urea nitrogen (BUN)? A. Hypothermia B. Decreased protein intake C. Gastrointestinal bleeding D. Overhydration

C. Gastrointestinal bleeding Factors that increase BUN include gastrointestinal bleeding, decreased renal function, dehydration, increased protein intake, fever, and sepsis.

Which condition below could lead to cell lysis, if not properly monitored?* A. Isotonicity B. Hypertonicity C. Hypotonicity D. None of the options are correct

C. Hypotonicity

A client is being treated in the emergency department after being exposed to caustic vapours in a workplace accident. The client's arterial blood gases indicate severe hypoxemia and hypercapnia, so the nurse knows that the client will: A. develop acute pulmonary hypertension unless intubated and placed on a ventilator. B. be synthesizing more erythropoietin than usual, causing increased red cell production. C. have elevated lactic acid levels due to anaerobic metabolism. D. have varied parasympathetic responses, including increased heart rate and respiratory rate.

C. have elevated lactic acid levels due to anaerobic metabolism. In cases of severe hypoxemia, aerobic metabolism ceases and anaerobic metabolism takes over, with formation and release of lactic acid. Increased erythropoietin and red cell production occurs in response to chronic, not acute, hypoxemia. The sympathetic, not parasympathetic, nervous system is activated. Acute hypoxemia is not the cause of pulmonary hypertension.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? A. pH 7.35, PaCO2 48 mm Hg B. pH 7.46, PaO2 80 mm Hg C. pH 7.28, PaO2 50 mm Hg D. pH 7.36, PaCO2 32 mm Hg

C. pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

The blood enters on the left side of the heart through the ______________ and enters the left atrium. It then passes through the _____________to enter the left ventricle. A. pulmonary artery, mitral valve B. pulmonary vein, tricuspid valve C. pulmonary vein, mitral valve D. pulmonary artery, aortic valve

C. pulmonary vein, mitral valve

_______ solutions cause cell dehydration and help increase fluid in the extracellular space.* A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic

D. Hypertonic

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? A. Keep the client flat for one hour after administration B. Administer every five minutes during cardiac resuscitation C. Document heart rate before and after administration D. Monitor vital signs and cardiac rhythm

D. 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 reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? A. hyperkalemia B. hypocalcemia C. hypercalcemia D. hypokalemia

D. hypokalemia Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.

Early signs of hypervolemia include A. a decrease in blood pressure. B. thirst. C. moist breath sounds. D. increased breathing effort and weight gain.

D. increased breathing effort and weight gain. Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.

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. A. Administering oxygen B. Inserting a Foley catheter C. Administering Furosemide (Lasix) D. Administering morphine sulfate intravenously E. Transporting the client to the coronary care unit F. Placing the client in a low Fowler's side-lying position

A. Administering oxygen B. Inserting a Foley catheter C. Administering Furosemide (Lasix) D. Administering morphine sulfate intravenously

The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart? A. Altered patterns frequently affect the heart's ability to pump blood effectively. B. Altered patterns frequently cause a variety of home safety issues. C. Altered patterns frequently turn into life-threatening arrhythmias. D. Altered patterns frequently produce neurological deficits.

A. Altered patterns frequently affect the heart's ability to pump blood effectively.

An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not dehydrated? A. Assess the urine for osmolality. B. Ask the physician for an order to begin intravenous fluid replacement. C. Ask the physician to order a chest x-ray. D. Ask the physician for an order for a brain scan.

A. Assess the urine for osmolality. The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration & hyperosmolality. The nurse should check the pt's urine for osmolality as a 1st step in determining hydration status before other detailed & invasive testing is done.

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillary waves before each QRS complex. How should the nurse correctly interpret the client rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia

A. Atrial fibrillation

D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution because after the body metabolizes the dextrose the solution acts as a hypotonic solution.* A. True B. False

A. True D5W is classified as a ISOTONIC fluid BUT after adminstration the body metabolizes the dextrose and the fluid left over is a hypotonic solution.

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance? A. metabolic alkalosis B. respiratory acidosis C. respiratory alkalosis D. metabolic acidosis

A. metabolic alkalosis Metabolic alkalosis occurs because of the excessive loss of potassium, hydrogen, and chloride in the vomitus. Chloride loss leads to a compensatory increase in the number of bicarbonate ions. The bicarbonate side of the carbonic acid-base bicarbonate increases, and the pH becomes more alkaline. Respiratory alkalosis is caused by conditions such as hyperventilation that result in loss of partial pressure of arterial carbon dioxide (PaCO2).

A patient has been brought in to the emergency department where the physician orders a bolus of colloid solution. Which of the following types of solutions are considered to be colloids? Select all that apply. A. Ringer's lactate B. 0.9% Normal Saline C. Albumin D. High molecular weight dextran E. Hetastarch

C. Albumin D. High molecular weight dextran E. Hetastarch Colloid solutions are those that are known as volume expanders. They are given intravenously and they stay within the circulatory system instead of crossing the capillary membrane to enter the tissues. Because of this, they are effective when given for cases of severe bleeding or dehydration. "Ringer's lactate" and "0.9% Normal Saline" are incorrect because these are crystalloid solutions.

When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called?* A. Hypotonic B. Hypertonic C. Isotonic D. Osmosis

C. Isotonic