Review exam 1

A client arrives to the ER with possible acute coronary syndrome. Which prescribed action should the nurse take first? A: 12 lead EKG B: draw blood for troponin and CKMB C: ask client about level of intensity of chest pain D: notify cath lab about client

C

Family asks why intubated pt on mechanical ventilation has restraints. A: "restraints will be removed once the client is extubated" B: "we are required to restrain all clients with breathing tubes" C: "restraints are a last resort to prevent accidental extubation" D: "it is routine procedure for us to restrain all intubated clients"

C

When naloxone has been administered, which action is most important for the nurse to take? A: ask pt about pain B: monitor for increased HR C: observe respiratory rate and depth D: check for alertness and orientation

C

Which finding indicates correct functioning of the water-seal chamber? A: contains many small air bubbles B: bubbles vigorously on inspiration C: fluid rises with inspiration and falls with expiration D: remains at a consistent level during respiratory cycle

C

Which medication is used to treat a client in v-tach? A: atropine B: epinephrine C: amiodarone D: sodium bicarb

C

Which medication is used to treat a client whose cardiac monitor reveals several runs of ventricular tachycardia? A: atropine B: epinephrine C: amiodarone D: sodium bicarbonate

C

Which nursing action is the highest priority when a clients chest tube has accidentally dislodged? A: place client in left side laying position B: apply oxygen via nonrebreather C: apply a petroleum glaze dressing over the site D: prepare to insert a new chest tube

C

Which medication indicated for treatment of ventricular dysrhythmias would a nurse recall when caring for a client whose cardiac monitor indicates multiple multi focal premature ventricular complexes (PVCs)? A: amiodarone B: epinephrine C: methyldopa D: hydrochlorothiazide

A

Which potential cause of dysrhythmia would the nurse consider when assessing a client who has sinus tachycardia? SATA. A: anxiety B: caffeine C: exercise D: anemia E: hypothermia

A B C D

Which life threatening wound is treated with hyperbaric oxygen therapy? Select all that apply. A: burns B: skin cancer C: osteomyelitis D: diabetic ulcers E: myocardial infarction

A C D

Which common side effect of nitroglycerin will a nurse monitor for in a client who is treated for a suspected MI with 500mL of 5% dextrose in water (D5W) with 50 mg of nitroglycerine IV? A: bradycardia B: hypotension C: N/V D: leg cramps

B

Which finding for a client who has just returned to the unit after an emergency cardiac catheterization would be most important to report to the primary health care provider? A: anxiety about the results of the procedure B: ST-segment elevation on the EKG C: pain at the femoral artery catheter insertion site D: PACs on the EKG

B

Nurse instructs pt to breathe deeply to open collapsed alveoli. Which explanation explains the relationship between alveoli and improved oxygenation? A: the alveoli need oxygen to live B: the alveoli have no direct effect on oxygenation C: collapsed alveoli increase oxygen demand D: oxygen is exchanged for CO2 in the alveolar membrane

D

When caring for a client who has ARDS, which measure would promote effective airway clearance? A: administer sedatives as frequently as possible B: turn client every 4 hours C: increase vent settings every 2 hours D: suction as needed

D

A client is intubated and receiving mechanical ventilation. Which nursing action indicates that the ventilator was signaling a high-pressure alarm? A: the nurse removes secretions by suctioning B: the nurse lowers the setting of the tidal volume C: the nurse checks that tubing connections are secure D: the nurse obtains ABGs

A

Which client in the ICU should the nurse assess first? A: client with increasingly labored respiratory effort after aspiration of gastric contents 2 days ago B: client who is receiving positive pressure mechanical ventilation after an accidental opioid overdose C: client who is being observed after successful anaphylaxis treatment and has a prednisone dose due D: client who has pneumocystis pneumonia and has iv antibiotic and antiretroviral medications due

A

A client develops bacterial pneumonia. The clients initial PaO2 is 80. When redrawn, the level is 65. Which action would the nurse take first? A: ensure that intubation equipment is available B: increase the oxygen flow rate per facility protocol C: notify the health care provider to request a chest X-ray D: recheck the arterial blood gases to verify accuracy

B

Client with COPD develops pneumothorax and has chest tube inserted. What is the purpose of the tube? A: lessens clients chest discomfort B: restores negative pressure in the pleural space C: drains accumulated fluid from pleural vanity D: prevents subcutaneous emphysema in chest wall

B

A client with COPD is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? A: encourage client to take slow, deep breaths and administer 5L O2 per nasal cannula B: place client in a side-lying position and perform chest physiotherapy using clapping and vibration C: raise the head of the bed to high-Fowler position and administer 2L O2 per nasal cannula D: assist the client in assuming a position of comfort and perform postural drainage

C

A clients respiratory status deteriorates, an endotracheal intubation and positive-pressure ventilation are instituted. The nurse would take which immediate action? A: prepare client for emergency surgery B: facilitate the clients verbal communication C: assess the clients response to the interventions D: maintain sterility of the ventilation system being used

C

Which response by the nurse is best when a client who has had a STEMI asks about the resumption of sex? A: "you can safely resume sex when you are no longer fearful of sex" B: "you will be able to discuss sex with the doctor before discharge" C: "sex can be safely resumed after an exercise stress test with no heart symptoms" D: "many clients wait a few weeks after an MI before having sex"

C

Which statements made by a terminally ill client address primary goals regarding end-of-life nursing care? SATA. A: "i want my children to carry my casket" B: "I've prepaid all my funeral costs so there's no burden on my family" C: "my living will states that i want no heroic measures to prolong life" D: "pain is a concern, so I've discussed that thoroughly with my doctor" E: "I've made arrangements to spend my final days in my own home"

C D E

A client with advanced bone cancer is experiencing cachexia. Nurse reviews nutritional components of palliative care with clients family members. The nurse recognizes that the teaching is designed to achieve which outcome? A: enhance the quality of the clients life B: reduce the likelihood of a respiratory infection C: prevent malabsorption syndrome D: cure the cachexia

A

A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately? A: suction the tracheostomy B: change the tracheostomy tube C: readjust the tracheostomy tube and tighten the ties D: perform a complete respiratory assessment

A

After insertion of a central venous catheter through the left subclavian vein, a client reports chest pain and dyspnea and has decreased breath sounds on the left side. Which action would the nurse take first? A: administer O2 as prescribed B: activate a rapid response C: give the prescribed morphine D: assist client to cough and deep breath

A

BP 90/60, pulse 96, RR 10 for postoperative client receiving hydro morphone by PCA pump. Which action should the nurse take? A: give naloxone IV per protocol B: assess clients pain C: document vital signs D: notify rapid response team

A

The nurse observes the fluid in the water-seal chamber of the chest drainage device no longer fluctuates. Which action should the nurse take? A: assess for obstructions in the chest tube B: increase the amount of continuous suction C: add sterile water to the water-seal chamber D: make preparations to remove the chest tube

A

When admitting a client with acute coronary syndrome (ACS) after cardiac catheterization and PCI, which action would the nurse take first? A: attach the cardiac monitor B: auscultate the heart sounds C: check IV rate D: assess alertness and orientation

A

When providing care for a client receiving mechanical ventilation through an Endotracheal tube, which action would the nurse anticipate when the clients partial pressure of end-tidal CO2 (PETCO2) is 60mm hg? A: increase respiratory rate setting B: prepare for extubation C: increase the FIO2 setting D: administer sedative

A

Which action is essential for the nurse to include in the plan of care for a client with a-fib? A: take pulse apically for 1 full minute B: monitor BP every 2 hours C: ask client to call for assistance when ambulating D: teach client to avoid taking OTC aspirin

A

Which behavior by a client who had an STEMI indicates that the nurses actions to improve client autonomy have been successsful? A: active participation in providing self-care B: verbalizing realistic expectations of care givers C: discussing necessary lifestyle changes with family members D: listing the indicators of recovery after an MI

A

Which finding in a client who has just arrived in the cardiac ICU after having CABG requires the most rapid action by the nurse? A: serum K is 3.1 B: client is confused about date and time of day C: client reports incisional pain 8/10 D: chest tube collection chamber has 150ml bloody fluid

A

Which finding is the nurse most likely to identify when completing a history and physical assessment of a client with a complete heart block? A: syncope B: headache C: tachycardia D: hemiparesis

A

Which finding requires rapid action by the nurse after a client has had a cardiac catheterization? A: HR 114 B: RR 24 C: urine output 1200ml in first hour after procedure D: premature atrial contractions noted on the cardiac monitor

A

Which intervention is the priority nursing care for a client who develops "viselike" chest pain radiating to the neck with a BP of 124/64, an irregular apical pulse of 64, and diaphoresis who is prescribed morphine IV push stat and cardiac monitoring? A: relief of pain B: client teaching C: cardiac monitoring D: maintenance of bed rest

A

Which lung sounds would nurse expect to hear in client who experienced laryngeal swelling after extubation? A: stridor B: wheeze C: crackles D: rhonchi

A

Which possible dysrhythmia would a nurse anticipate testing for after noting that a client in the clinic has an irregularly irregular pulse rhythm at a rate of 88 bpm? A: a-fib B: v-tach C: complete heart block D: SVT

A

Which possible dysrhythmia would the nurse anticipate testing for after noting that a client in the clinic has. An irregularly irregular pulse rhythm at a rate of 88bpm? A: A-fib B: V-tach C: complete heart block D: SVT

A

Which prescribed action would the nurse question when caring for a client who has heart failure, with BP 102/70, pulse 106, and bilateral lung crackles? A: infuse normal saline at 100ml/hr B: give furosemide 40 mg iv now C: administer KCl 10 mEq orally now D: titration oxygen by mask to keep O2 93% or higher

A

Which statement describes a clients tidal volume? A: volume of air inhaled and exhaled with each breath B: amount of air remaining in the lungs after forced expiration C: the additional air forcefully inhaled after normal inhalation D: the additional air forcefully exhaled after normal exhalation

A

Nurse caring for client who is terminally ill. Health care team meets and agrees to provide information to help client make decisions regarding treatment. Which ethical principle is applied in this situation? SATA A: justice B: fidelity C: veracity D: autonomy E: beneficence

A B C D

Which action would the nurse perform when a client is in V-fib? Select all that apply. A: start CPR B: assess EKG C: use defibrillator D: obtain electrolytes E: administer epi

A B C D E

Which manifestation is an adverse effect of IV lorazepam? SATA. A: amnesia B: drowsiness C: sleep driving D: blurred vision E: respiratory depression

A B C D E

When providing comfort to a client during the last hours of life, which would be the nurses primary concern? Select all that apply. A: pain B: nutrition C: elimination D: respiratory status E: cardiovascular status

A D

Client with PE is intubated and placed on mechanical ventilation. Which nursing action is important when suctioning the endotracheal tube? A: applying negative pressure while inserting the suction catheter B: hyperoxygenating with 100% oxygen before and after suctioning C: suctioning two or three times in succession to effectively clear the airway D: using rapid movements of the suction catheter to loosen secretions

B

Client with emphysema becomes more restless, which action should the nurse take first? A: auscultate lung sounds B: check O2 sat C: observe for increased respiratory effort D: ask about any increased SOB

B

What information is needed to determine O2 administration for a client with COPD and O2 sat of 87%? A: LOC B: ABG C: bilateral lung sounds D: CBC

B

When a client who experienced an MI suddenly develops a heart rate of 120 bpm, which action would the nurse take first? A: offer reassurance B: check BP C: call for EKG D: activate rapid response

B

Which action would the nurse take to decrease the risk of VAP for a client receiving mechanical ventilation? A: suction the client on a regular schedule B: elevate the head of the bed to at least 30 degrees C: schedule daily changes of the ventilator tubing D: maintain continuous sedation during ventilator use

B

Which finding requires the most rapid action by the nurse for a patient arriving at the ER with a history of heart failure? A: irregular apical pulse B: O2 sat 86% C: crackles at both lung bases D: A-fib on cardiac monitor

B

Which type of lung sounds would the nurse expect to hear when caring for a client with heart failure? A: stridor B: crackles C: wheezes D: rhonchi

B

After assessing 4 clients with respiratory disorders, which client would the nurse suspect as having metabolic acidosis? A: tachypnea B: pursed-lip breathing C: Kussmaul respirations D: abdominal paradox

C

Client with COPD has pH 7.25 and PCO2 60. Which complication? A: metabolic acidosis B: metabolic alkalosis C: respiratory acidosis D: respiratory alkalosis

C

Diltiazem is used to treat what? A: normal sinus rhythm B: ventricular tachycardia C: atrial fibrillation D: sinus bradycardia

C

For a client admitted after a segmental resection of the right lower lobe of the lung, which action would the nurse take when caring for the chest tube drainage system? A: raise the drainage system to bed level and check its patency B: clamp the tube when moving the client from the bed to a chair C: mark the time and fluid level on the side of the drainage chamber D: secure the chest catheter to the wound dressing with a sterile safety pin

C

For a client receiving mechanical ventilation, which assessment finding would alert the nurse to the client experiencing poor oxygenation? A: PaO2 of 93 B: skin warm and dry C: increased restlessness D: no secretions when suctioned

C

Nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. Which action should the nurse take when caring for this client? A: assess frequently for nasal drying B: keep mask tight against face C: monitor O2 sat levels when client is eating D: set O2 flow at the highest setting pt can tolerate

C

Which action should the nurse take first when caring for a client with a possible PE? A: auscultate the chest B: obtain vital signs C: elevate head of bed D: notify rapid response team

C

Which action would the nurse take first when caring for a client who has just returned after open heart surgery? A: elevate the head of bed to 30 degrees B: suction the client through the ETT C: check the pulse ox for O2 sat D: auscultate the clients heart and lung sounds

C

Which action would the nurse take next after observing a client collapse while walking down the hall, establishes unresponsiveness, and calls for help? A: check for objects in the airway B: begin chest compressions C: check for a carotid pulse D: deliver 2 deep breaths

C

Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization? A: to obtain the pressures in the heart chambers B: to determine the existence of congenital heart disease C: to visualize the disease process in the coronary arteries D: to measure the oxygen content of various heart chambers

C

A chest tube is inserted and attached to a three chamber closed drainage system. Upon assessing the fluid system, which finding indicates the chest tube is functioning properly? A: fluid remains constant in the chest drainage chamber B: fluid is bubbling gently in the chest drainage chamber C: fluid is bubbling vigorously in the suction control chamber D: fluid rises in the tube of the water seal chamber during inspiration

D

After determining that the victim is not responding and the emergency medical system has been activated, which action should the rescuer take? A: identify absence of a pulse B: give 2 rescue breaths with a CPR mask C: perform the head tilt-chin lift maneuver D: perform chest compressions at a rate of 100/min

D

PH 7.30 PaO2 80 PaCO2 55 HCO3 23 How would the nurse interpret these findings? A: hypoxemia B: hypocapnia C: compensated metabolic acidosis D: uncompensated respiratory acidosis

D

When the O2 sat of a client with pneumonia is at 89-90% while using a nonrebreather mask, which collaborative action would the nurse anticipate? A: administration of oxygen using a simple face mask B: use of a Venturi mask for administration of high flow oxygen C: continued oxygen administration with the nonrebreather mask D: oxygen administration with bilevel positive airway (BIPAP)

D

Which manifestation would the nurse expect for a client with right ventricular failure? A: chest pain B: bradypnea C: bradycardia D: peripheral edema

D

Which medical intervention would the nurse anticipate will be included in the management of a client with ARDS? A: chest tube insertion B: aggressive diuretic therapy C: administration of beta blockers D: positive end-expiratory pressure (PEEP)

D

Which part of the EKG represents depolarization of the ventricles? A: P wave B: T wave C: PR interval D: QRS interval

D