Quiz 1 Neuro/ Cardiac NUR258

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

The P wave falls before the QRS complex

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of Hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P Wave

A. Abnormally prominent U wave Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) A. Count your pulse for 1 min each morning. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not wear tight clothing over the insertion area. D. Request to be scanned with a handheld metal detector when in the airport. E. Do not have a microwave oven in the home.

A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area.

a nurse is caring for a client 4 hr. following a cardiac catherization. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Keep the affected leg slightly flexed. C. Elevate the head of the bed 45 Degrees. D. Keep the client NPO for 4 Hr.

A. Have the client lie flat in bed.

A nurse is assessing a client who has fluid overload. Which of the following should the nurse expect? (Select all that apply.)

A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 seconds, but they are irregular, with a rate of 120 BPM. The nurse interprets this rhythm as?

AFIB

A client has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin given due to which of the following actions of the medication?

Antiplatelet aggregate

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. "Cardiac enzymes will identify the location of the MI" B. "These tests help determine the degree of damage to the heart tissues." C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves."

B. "These tests help determine the degree of damage to the heart tissues."

A nurse is caring for a client who has T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? A. The client states having a severe headache. B. The client's bladder becomes distended C. The client's blood pressure becomes elevated D. The client states having nasal congestion

B. The client's bladder becomes distended

A nurse is caring for a client who has cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? A. Epinephrine B. Magnesium C. Atropine D. Sodium bicarbonate

C. Atropine The team administers atropine during CPR if the client has symptomatic bradycardia, hemodynamically unstable.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? A. Encourage brief exercise before meals to promote appetite. B. Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Place the client with the head reclined back to facilitate swallowing.

C. Encourage the client to take small bites.

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr. postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? A. Myringotomy B. Laparoscopic appendectomy C. Hip arthroplasty D. Cataract extraction

C. Hip arthroplasty

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding

C. Irregular

A nurse is caring for an older adult client who has left sided heart failure which of the following assessment findings should the nurse expect?

Frothy sputum

A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following non-modifiable risk factors should the nurse include in teaching?

Genetics

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication?

Grapefruit juice

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: Blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2 degree C (100.8 degree F) Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

The nurse is caring for a client who has had a stroke involving the right hemisphere . Which of the following alterations in function should the nurse expect?

Inability to recognize his family members

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

Increasing my intake of foods containing trans fatty acids can lower my risk

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Intellectual impairment

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider?

K 2.3 mEq/L

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by a severe headache A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Obtain a 12 lead ecg

A nurse is caring for a client with ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitoring strip?

Pacemaker spikes before each QRS complex

A nurse is interpreting a clients ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

QT interval

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a MI? A. Check the client's BP B. Auscultate heart tones C. Perform a 12-lead ECG D. Determine if pain radiates to the left arm

C. Perform a 12-lead ECG The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a MI.