Nurs 472 Final Prep U Quiz Collection

ABC

A 26-year-old client, who has been diagnosed with paroxysmal supraventricular tachycardia (PSVT), is treated in the emergency department. The client is experiencing occasional runs of PSVT lasting up to several minutes at a time. During these episodes, the client becomes lightheaded but does not lose consciousness. Which maneuver(s) may be used to interrupt the client's atrioventricular nodal reentry tachycardia (AVNRT)? Select all that apply. A.) Performing carotid massage B.) Placing the client's face in cold water C.) Stimulating the client's gag reflex D.) Instructing the client to breathe deeply E.) Instructing the client to vigorously exercise

C.) Heparin

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.) Dabigatran (Pradaxa) B.) Flecainide (Tambocor) C.) Heparin D.) Warfarin (Coumadin)

B.) Aortic insufficiency

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? A.) Unstable angina pectoris B.) Aortic insufficiency C.) Diabetes mellitus D.) Hypertension

B.) Presence of soot around nasal passages

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client? A.) Elevation of blood pressure and heart rate B.) Presence of soot around nasal passages C.) Partial-thickness burns to hands and wrists D.) Fracture of the fibula with displacement

C.) Raise the head of the client's bed.

A client experienced hemorrhage following a gunshot to the chest and received massive amounts of fluids. The client is now stable. The nurse assesses abdominal pressure as 12 mm Hg. The most immediate nursing intervention is to A.) Begin measurements of abdominal girth. B.) Insert a rectal tube for decompression. C.) Raise the head of the client's bed. D.) Turn the client every 2 hours.

B.) Raises the foot of the client's bed

A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse A.) Turns the client to a side-lying position B.) Raises the foot of the client's bed C.) Elevates the head of the client's bed D.) Places the client in a Trendelenburg position

A.) Irrigate the wounds with water.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? A.) Irrigate the wounds with water. B.) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. C.) Do nothing until the chemical agent is identified. D.) Wash the wounds with soap and water and apply a barrier cream.

C.) A lung volume reduction

A client with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform? A.) Lobectomy B.) A wedge resection C.) A lung volume reduction D.) A sleeve resection

C.) "Infuse I.V. fluids at 83 ml/hour."

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? A.) "Draw samples for hemoglobin and hematocrit every 6 hours." B.) "Monitor urine output every hour." C.) "Infuse I.V. fluids at 83 ml/hour." D.) "Administer oxygen by nasal cannula at 3 L/minute."

A.) Administers oxygen by nasal cannula at 2 liters per minute

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next A.) Administers oxygen by nasal cannula at 2 liters per minute B.) Re-assesses the vital signs C.) Contacts the admitting physician D.) Calls the Rapid Response Team

D.) Related to circumferential eschar

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? A.) Related to infection B.) Related to fat emboli C.) Related to femoral artery occlusion D.) Related to circumferential eschar

B.) Urine output of 20 ml/hour

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? A.) Rectal temperature of 100.4° F (38° C) B.) Urine output of 20 ml/hour C.) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg D.) White pulmonary secretions

A.) wrap elastic bandages distally to proximally on dependent areas.

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: A.) wrap elastic bandages distally to proximally on dependent areas. B.) remove bandages with clean gloves. C.)wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. D.) apply maximum bandages to allow for absorption of drainage.

C.) Hemodilution

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? A.) Metabolic acidosis B.) Hemoconcentration C.) Hemodilution D.) Lack of erythropoietin factor

D.) Morphine

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? A.) Codeine B.) Hydromorphone C.) Meperidine D.) Morphine

C.) Catheter ablation therapy

A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for? A.) Insertion of an ICD B.) Maze procedure C.) Catheter ablation therapy D.) Insertion of a permanent pacemaker

A.) Anemic hypoxia

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? A.) Anemic hypoxia B.) Hypoxic hypoxia C.) Stagnant hypoxia D.) Histotoxic hypoxia

C.) 5 days

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame? A.) 3 days B.) 7 to 10 days C.) 5 days D.) 2 days

A.) At bedtime

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? A.) At bedtime B.) When secretions have mobilized C.) When bronchospasms occur D.) Immediately before a meal

The nurse participates in the care of a client requiring emergent defibrillation. Arrange the steps in the order the nurse should complete them. All options must be used.

B.) Apply the multifunction conductor pads to the client's chest. A. Turn on the defibrillator and place it in "not sync" mode. C.) Charge the defibrillator to the prescribed voltage. D.) Call "clear" three times ensuring client and environmental safety. E.) Deliver the prescribed electrical charge.

A.) "The difference is the timing of the delivery of the electric current."

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? A.) "The difference is the timing of the delivery of the electric current." B.) "Cardioversion is done on a beating heart; defibrillation is not." C.) "Cardioversion is always attempted before defibrillation because it has fewer risks." D.) "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not."

D.) Refractory atrial fibrillation

During a client's care conference, the team is discussing whether the client is a candidate for surgery maze procedure. What would be the most important criterion for a client to have this surgery? A.) Decreased activity tolerance related to decreased cardiac output B.) Ventricular fibrillation not responsive to other treatments C.) Angina pectoris not responsive to other treatments D.) Refractory atrial fibrillation

C.) circulatory status.

During the acute phase of a burn, a nurse should assess: A.) the client's lifestyle. B.) tobacco use. C.) circulatory status. D.) alcohol use.

D.) Applying continuous-compression wraps

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? A.) Wearing clothing to protect the burn from the sun B.) Maintaining wound care irrigation C.) Removing eschar from the skin D.) Applying continuous-compression wraps

B.) Disrupting the heart during the critical period of ventricular repolarization.

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. The nurse knows elective cardioversion prevents what? A.) Disrupting the heart during the critical period of atrial repolarization. B.) Disrupting the heart during the critical period of ventricular repolarization. C.) Disrupting the heart during the critical period of ventricular depolarization. D.) Disrupting the heart during the critical period of atrial depolarization.

B.) Mafenide (Sulfamylon)

In a client who has been burned, which medication should the nurse expect to use to prevent infection? A.) Meperidine (Demerol) B.) Mafenide (Sulfamylon) C.) Diazepam (Valium) D.) Lindane (Kwell)

C.) Nitroprusside

In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart? A.) Methoxamine B.) Dopamine C.) Nitroprusside D.) Epinephrine

B.) CPAP allows a lower percentage of oxygen to be used with a similar effect.

The health care provider has prescribed continuous positive airway pressure (CPAP) with the delivery of a client's high-flow oxygen therapy. The client asks the nurse what the benefit of CPAP is. What would be the nurse's best response? A.) CPAP allows a higher percentage of oxygen to be safely used. B.) CPAP allows a lower percentage of oxygen to be used with a similar effect. C.) CPAP allows for the elimination of bacterial growth in oxygen delivery systems. D.) CPAP allows for greater humidification of the oxygen that is given.

C.) Septic

The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock? A.) Cardiogenic B.) Anaphylactic C.) Septic D.) Neurogenic

ACE

The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client? Select all that apply. A.) Wear a medical alert, noting the presence of a pacemaker B.) Refrain from walking through antitheft devices C.) Avoid handheld screening devices in airports D.) Avoid the usage of microwave ovens and electronic tools E.) Check pulse daily, reporting sudden slowing or increase

C.) The defibrillator won't deliver a shock if the synchronizer switch is turned on.

The nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation for what important reason? A.) The defibrillator won't deliver a shock if the synchronizer switch is turned off. B.) The shock must be synchronized with the client's T wave. C.) The defibrillator won't deliver a shock if the synchronizer switch is turned on. D.) The delivered shock must be synchronized with the client's QRS complex.

CDE

The nurse explains to the patient with PACs that there are many causes, some of which are modifiable. Select all that apply. A.) Hyperkalemia B.) Hypovolemia C.) Alcohol D.) Anxiety E.) Hypoxemia

B.) heart block

The nurse is administering propranolol to a client on a telemetry unit. What will the nurse monitor the client for? A.) tachycardia B.) heart block C.) bleeding D.) change in level of consciousness

B.) Wolff-Parkinson-White (WPW) syndrome

The nurse is caring for a client on telemetry. The client's ECG shows atrial fibrillation, wide QRS and a fast, irregular ventricular rhythm. What does this ECG show? A.) Lupus-like syndrome B.) Wolff-Parkinson-White (WPW) syndrome C.) Myocardial infarction D.) Sinus bradycardia

ABC

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.) A.) Frequently evaluate progress. B.) Cough frequently. C.) Hold the breath at the end of inspiration for a few seconds. D.) Prolong the expiratory phase after using the nebulizer. E.) Take rapid, deep breaths.

C.) "I will report if I feel lightheaded and dizzy at my next doctor's appointment."

The nurse is providing discharge instructions for a client with a newly implanted cardiac defibrillator. What statement made by the client indicates the need for further teaching? A.) "I will not be able to have a magnetic resonance imaging study." B.) "I will try to have my family take a cardiopulmonary resuscitation class." C.) "I will report if I feel lightheaded and dizzy at my next doctor's appointment." D.) "I will carry an identification card so I can avoid a handheld security device at the airport."

Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period.

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence. Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period.

A.) Contact the primary care provider and prepare for an escharotomy.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? A.) Contact the primary care provider and prepare for an escharotomy. B.) Document the findings and instruct the client to report numbness of the extremity. C.) Apply an elastic stocking to the extremity and administer SQ heparin per order. D.) Elevate the leg on pillows and reassess the leg in 1 hour.

D.) with an overwhelming bacterial infection.

The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of the client A.) who has had severe allergic reaction to a bee sting. B.) who has lost blood during birth. C.) who has had an overdose of opioids. D.) with an overwhelming bacterial infection.

A.) Procainamide

What is the drug of choice for a stable client with ventricular tachycardia? A.) Procainamide B.) Lidocaine C.) Amiodarone D.) Atropine

D.) Immediate bystander CPR

What is the treatment of choice for ventricular fibrillation? A.) Implanted defibrillator B.) Atropine C.) Pacemaker D.) Immediate bystander CPR

A.) 20 to 25 mm Hg

What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration? A.) 20 to 25 mm Hg B.) 15 to 20 mm Hg C.) 10 to 15 mm Hg D.) 25 to 30 mm Hg

D.) Ineffective airway clearance related to edema of the respiratory passages

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A.) Disturbed sleep pattern related to facility environment B.) Impaired physical mobility related to the disease process C.) Risk for infection related to breaks in the skin D.) Ineffective airway clearance related to edema of the respiratory passages

A.) Aorta

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? A.) Aorta B.) Brachial artery C.) Right ventricular wall D.) Radial artery

B.) Deep partial thickness

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? A.) Superficial B.) Deep partial thickness C.) Full thickness D.) Superficial partial thickness

1

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area?

C.) Increase in compliance

Which finding would indicate a decrease in pressure with mechanical ventilation? A.) Plugged airway tube B.) Kinked tubing C.) Increase in compliance D.) Decrease in lung compliance

A.) Roll the client in a blanket

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? A.) Roll the client in a blanket B.) Place the client with the head positioned slightly below the rest of the body C.) Avoid immediate IV fluid therapy D.) Cover the client with a wet cloth

ACD

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. A.) Tidal volume of 8.5 mL/kg B.) FiO2 45% C.) PaO2 of 64 mm Hg D.) Vital capacity of 13 mL/kg E.) Rapid/shallow breathing index of 112 breaths/min

A.) Modified Trendelenburg

Which positioning strategy should be used for the client diagnosed with hypovolemic shock? A.) Modified Trendelenburg B.) Supine C.) Semi-Fowler's D.) Prone

B.) Progressive

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? A.) Compensatory B.) Progressive C.) Refractory D.) Irreversible

C.) Intermittent mandatory ventilation (IMV)

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? A.) Synchronized intermittent mandatory ventilation (SIMV) B.) Assist control C.) Intermittent mandatory ventilation (IMV) D.) Pressure support

C.) Diphenhydramine (Benadryl)

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? A.) Guaifenesin (Robitussin) B.) Pseudoephedrine (Sudafed) C.) Diphenhydramine (Benadryl) D.) Loperamide (Imodium)

C.) Increases myocardial contractility

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client? A.) Decreases blood return to the heart B.) Decreases carbon dioxide exchange C.) Increases myocardial contractility D.) Contracts bronchioles