N430 Exam 2 HESIs

Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation? 1. Take pulse apically for a full minute. 2. Monitor blood pressure at least every 2 hours. 3. Ask client to call for assistance when ambulating. 4. Teach client to avoid taking over-the-counter aspirin.

1. Take pulse apically for a full minute.

A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, what does the nurse expect to identify? 1 Chest pain on inspiration 2 Prolonged expiration with use of accessory muscles 3 Signs and symptoms of respiratory alkalosis 4 Decreased respiratory rate

2 Prolonged expiration with use of accessory muscles

A client with an abdominal aortic aneurysm is suddenly pale and reports feeling light-headed and having abdominal pain. Which action would the nurse take first? 1Assess the respiratory rate for hyperventilation. 2Check the blood pressure for hypotension. 3Administer the prescribed morphine for pain. 4Inspect the abdomen for distension and firmness.

2Check the blood pressure for hypotension.

Which response would the nurse give when a client is admitted with chest pain and a family member asks about the purpose of the prescribed 12-lead electrocardiogram (ECG)? Indicates whether a heart attack is occurring Detects changes in the structures in the heart Shows whether the heart muscle is pumping Evaluates for prognosis after heart attack

Indicates whether a heart attack is occurring

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery? a. assist client to use the incentive spirometer b. administer prescribed IV antibiotics c. take client VS every 4 hrs. d. auscultate breath sounds every 4 hrs

a. assist client to use the incentive spirometer

The nurse is providing post-op care to a client who is being weaned from mechanical ventilation. Which is a priority nursing action? a. Assessing lung sounds every 15 mins b. Remaining with the client to evaluate for respiratory distress c. Monitoring the oxygen saturation levels from the monitors at the desk d. Teaching the family about ways to keep the client calm

b. Remaining with the client to evaluate for respiratory distress

The nurse would monitor post-op clients for which clinical manifestations of pulmonary embolus? SATA. a. somnolence b. dyspnea c. hemoptysis d. bronchial wheezes e. feeling of impending doom

b. dyspnea c. hemoptysis e. feeling of impending doom

Which lab result will the nurse expect when caring for a client who presents to the ED with a STEMI? a. decreased WBC b. increased serum troponins I and T c. decreased CK-MB d. decreased BNP

b. increased serum troponins I and T

Which common response would the nurse monitor for in a client who has recently been extubated in the PACU after surgery? a. bradycardia b. restlessness c. constricted pupils d. clubbed fingers

b. restlessness

The nurse is caring for a client with the following ABG values: PO2 89, PCO2 35, pH 7.37. These findings indicate that the client is experiencing which condition? a. respiratory alkalosis b. poor oxygen perfusion c. normal acid-base balance d. compensated metabolic acidosis

c. normal acid-base balance

Which rhythm would the nurse document when observing a following dysrhythmia on a client's monitor? a. atrial flutter b. a-fib c. v-fib d. v-tach

c. v-fib

Which finding in a client seen in the ED with chest pain is most important to communicate to the HCP? a. Severe n/v b. substernal pain 9/10 c. BG 230 d. ST segment elevation on EKG

d. ST segment elevation on EKG

Which part of the ECG represents depolarization of the ventricles? a. p wave b. t wave c. pr interval d. qrs interval

d. qrs interval

when completing an assessment which response would the nurse expect a client experiencing severe acute respiratory distress to exhibit? a. tremors b. anasarca c. bradypnea d. tachycardia

d. tachycardia

Which of these clients in the emergency department would the nurse see first? A client with a head injury A client with a fractured femur A client with ventricular fibrillation A client with a penetrating abdominal wound

A client with ventricular fibrillation

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? Initiate oxygen via a nasal cannula Administer the prescribed morphine Prepare the client for endotracheal intubation Place a nitroglycerin tablet under the client's tongue

Initiate oxygen via a nasal cannula

Which clinical indicator would the nurse expect to identify in a client with ARDS? SATA. a. crackles b. atelectasis c. hypoxemia d. severe dyspnea e. increased pulmonary wedge pressure

a. crackles b. atelectasis c. hypoxemia d. severe dyspnea

When performing a focused respiratory assessment, which action would the nurse take FIRST? a) Examine for any abnormal respiratory patterns b) Inspect for changes in skin color or temperature c) Check for evidence of respiratory distress d) Determine shape & symmetry of chest

c) Check for evidence of respiratory distress

Which is the priority nursing action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation? a. Treating pain b. Assessing respirations c. Initiating defibrillation d. Monitoring blood pressure

c. Initiating defibrillation

Which prescribed action has the highest priority when a client comes to the ED with moderate substernal chest pain that is unrelieved by rest and nitroglycerin? a. Administer morphine sulfate. b. Transfer to the coronary care unit. c. Obtain a 12-lead EKG. d. Have a blood specimen drawn for troponin studies.

c. Obtain a 12-lead EKG.