RN Exam I 2539 fall 2016

First degree Heart block

PR interval > .20 seconds - conduction is delayed at AV node - related to digoxin or vagal stimulation

Code blue Rhythms

VT •VFib •Asystole •Torsades •PEA

For a client with cardiomyopathy, the most important nursing diagnosis is: 1. Decreased cardiac output related to reduced myocardial contractility. 2. Excess fluid volume related to fluid retention and altered compensatory mechanisms. 3. Ineffective coping related to fear of debilitating illness. 4. Anxiety related to actual threat to health status.

1. Decreased cardiac output related to reduced myocardial contractility. RATIONALES: Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although the other options are important nursing diagnoses, they can be addressed when cardiac output and myocardial contractility have been restored.

A client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit? 1. It's a measure of effect, not a standard measure of weight or quantity. 2. It's the smallest measurement in the apothecary system. 3. It's the basis for solids in the avoirdupois system. 4. It's a common measurement in the metric system.

1. It's a measure of effect, not a standard measure of weight or quantity. RATIONALES: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. In the apothecary system, the minim is the smallest liquid unit of measurement and the grain is the smallest solid unit of measurement. In the avoirdupois system, solids include the ounce and pound. In the metric system, the liter is used for liquids, the gram for solids.

The nurse determines that a hockey player hospitalized with bilateral leg fractures is hemodynamically stable and observes the following pattern on the electrocardiogram (ECG) monitor. Which nursing intervention is most appropriate at this time? http://198.146.4.17/nclexrn3500/question-images/ecg3.jpg 1. None; this arrhythmia is benign 2. Administering atropine sulfate, 0.5 mg, as prescribed, to increase the heart rate 3. Continuing to monitor for lengthening PR intervals 4. Evaluating the client's recent serum electrolyte studies

1. None; this arrhythmia is benign RATIONALES: This ECG shows sinus arrhythmia with a rate of 70 beats/minute. In this benign arrhythmia, the rhythm is irregular; the impulse originates in the sinoatrial node and travels down the conduction system normally. The P-P interval is irregular; a P wave precedes every QRS complex; and the R-R interval is irregular, increasing with inspiration and decreasing with expiration. Sinus arrhythmia commonly is associated with vagal inhibition caused by respiration. It seldom causes symptoms and doesn't call for atropine or other treatment. Continuing to monitor for lengthening PR intervals isn't necessary because the PR interval doesn't increase with sinus arrhythmia. Because this arrhythmia isn't caused by an electrolyte imbalance, evaluating serum electrolyte studies isn't warranted.

A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate? 1. Risk for injury 2. Risk for deficient fluid volume 3. Ineffective thermoregulation 4. Risk for peripheral neurovascular dysfunction

1. Risk for injury RATIONALES: Risk for injury is an appropriate nursing diagnosis for a client with HCM because physical exertion may cause syncope or sudden death. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.

After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias. 1. Serum potassium level 2. Serum calcium level 3. Serum sodium level 4. Serum chloride level

1. Serum potassium level RATIONALES: During periods of acidosis, potassium leaves the cell causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.

On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure? 1. Taking daily walks 2. Engaging in anaerobic exercise 3. Reducing daily fat intake to less than 45% of total calories 4. Avoiding foods that increase levels of high-density lipoproteins (HDLs)

1. Taking daily walks RATIONALES: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not avoid, foods that raise HDL levels.

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need? 1. Security 2. Elimination 3. Safety 4. Belonging

2. Elimination RATIONALES: According to Maslow, elimination is a first-level, or physiologic, need and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after the client's first-level needs have been satisfied.

A client is admitted to the medical intensive care unit with a diagnosis of pancreatitis. Which nursing intervention is most appropriate? 1. Providing generous servings at mealtime 2. Reserving an antecubital site for a peripherally inserted central catheter (PICC) 3. Providing the client with plenty of P.O. fluids 4. Limiting I.V. fluid intake according to the physician's order

2. Reserving an antecubital site for a peripherally inserted central catheter (PICC) RATIONALES: Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve the antecubital site for a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.

A client is seen in the clinic with a possible parathormone deficiency. Diagnosis of this condition includes the analysis of serum electrolytes. Which electrolytes would the nurse expect to be abnormal? 1. Sodium 2. Potassium 3. Calcium 4. Chloride 5. Glucose 6. Phosphorous

3. Calcium 6. Phosphorous Correct Answer: 3,6 RATIONALES: A client with a parathormone deficiency has abnormal calcium and phosphorous values because parathormone regulates these two electrolytes. Potassium, chloride, sodium, and glucose aren't affected by a parathormone deficiency.

When testing a client's pupils for accommodation, the nurse should interpret which findings as normal? 1. Constriction and divergence 2. Dilation and convergence 3. Constriction and convergence 4. Dilation and divergence

3. Constriction and convergence Correct Answer: 3 Your Answer: 3 RATIONALES: During accommodation, the pupils should constrict and converge equally on an object. Pupils normally dilate in darkness and when a person stares at an object across a room. Divergence is never a normal response.

The nurse is teaching a client about theophylline toxicity. Which is a sign or symptom of theophylline toxicity? 1. Bradycardia 2. Constipation 3. Nausea 4. Dysuria

3. Nausea RATIONALES: Theophylline toxicity causes GI disturbances, such as nausea, vomiting, abdominal cramps, epigastric pain, anorexia, or diarrhea. It also produces central nervous system reactions, including headache, irritability, restlessness, anxiety, insomnia, and dizziness (rarely). However, theophylline toxicity doesn't result in bradycardia, constipation, or dysuria.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? 1. Infusing I.V. fluids rapidly as ordered 2. Encouraging increased oral intake 3. Restricting fluids 4. Administering glucose-containing I.V. fluids as ordered

3. Restricting fluids RATIONALES: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

A client is admitted to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, the nurse formulates interventions with which goal in mind? 1. Decreasing blood pressure and increasing mobility 2. Increasing blood pressure and reducing mobility 3. Stabilizing the heart rate and blood pressure and easing anxiety 4. Increasing blood pressure and monitoring fluid intake and output

3. Stabilizing the heart rate and blood pressure and easing anxiety RATIONALES: For a client with an aneurysm, nursing interventions focus on stabilizing the heart rate and blood pressure, to avoid aneurysm rupture. Easing anxiety also is important because anxiety and increased stimulation may speed the heart rate and boost blood pressure, precipitating aneurysm rupture. Typically, the client with an abdominal aortic aneurysm is hypertensive, so the nurse should take measures to lower the blood pressure, such as administering antihypertensive agents, as prescribed, to prevent aneurysm rupture. To sustain major organ perfusion, a mean arterial pressure of at least 60 mm Hg should be maintained. Although mobility must be assessed individually, most clients need bed rest initially when attempting to gain stability.

For a diabetic client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client? 1. They contain exudate and provide a moist wound environment. 2. They protect the wound from mechanical trauma and promote healing. 3. They debride the wound and promote healing by secondary intention. 4. They prevent the entrance of microorganisms and minimize wound discomfort.

3. They debride the wound and promote healing by secondary intention. RATIONALES: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry, sterile dressings protect the wound from mechanical trauma and promote healing.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? 1. Vital capacity 2. Functional residual capacity 3. Tidal volume 4. Maximal voluntary ventilation

3. Tidal volume RATIONALES: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

The physician orders supplemental oxygen for a client with a respiratory problem. To provide the highest possible oxygen concentration, the nurse expects to use which oxygen delivery device? 1. Nasal cannula 2. Venturi mask 3. Partial rebreathing mask 4. Nonrebreathing mask

4. Nonrebreathing mask RATIONALES: A nonrebreathing mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A partial rebreathing mask delivers oxygen concentrations up to 90%.

The nurse can auscultate for heart sounds more easily if the client is: 1. supine. 2. on his right side. 3. holding his breath. 4. leaning forward.

4. leaning forward. RATIONALES: The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This enables the nurse to listen after exhalation without the sound of expiration interfering. The supine position is used to visually inspect the precordium, allowing the nurse to watch the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. A left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems.

Third degree Heart block

AV block in which electrical impulses from the atria fail to reach the ventricles inconsistent PR interval AND regular R With this block, no atrial imulses are transmitted to the ventricles. As a result, the ventricules generate an escape impulse, which is independent of the atrial beat. In most cases the atria will beat at 60-100 bpm while the ventricles asynchronously beat at 30-45 bpm.

Second degree Heart block type 1

AV block in which occasional electrical impulses from the SA node fail to be conducted to the ventricles widened QRS the delay of the AV node last long enough that it may not complete the signal to the ventricles; the ventricles will not be stimulated. and the normal "atria-ventricles" pattern will disappear some impulses are blocked but not all. More P waves can be observed vs QRS Complexes on a tracing. Each successive impulse undergoes a longer delay. After 3 or 4 beats the next impulse is blocked. On an EKG tracing, PR Intervals will lengthen progressively with each beat until a QRS Complex is missing. After this blocked beat, the cycle of lengthening PR Intervals resumes. This heart block is also called a Wenckebach block.

Second degree Heart block type 2

Elongated PR interval. Progressively longer or didn't make its way back. Dropped the QRS complex PR interval is constant or regular for every conducted beat Intermittent absence of QRS With Mobitz Type II blocks, the impulse is blocked in the bundle of His. Every few beats there will be a missing beat but the PR Interval will not lengthen. Treatment-02, atropine if patient is symptomatic, epinephrine, dopamine, pacemaker if block continues and symptoms are present

Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis? a) Hypokalemia and hypoglycemia b) Hyperkalemia and hyperglycemia c) Hypernatremia and hypercalcemia d) Hypocalcemia and hyperkalemia

Hypokalemia and hypoglycemia Explanation: Blood glucose needs to be monitored in clients receiving I.V. insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by I.V. insulin administration.

The nurse is performing a cardiac assessment on a client with a suspected murmur. Identify the area where the nurse should place the stethoscope to auscultate the area referred to as Erb's point. http://198.146.4.17/nclexrn3500/question-images/004102.gif

RATIONALES: Erb's point is located at the third left intercostal space, close to the sternum. Murmurs of both aortic and pulmonic origin may be heard at Erb's point.

The nurse is educating a client on diabetes management. The client is asking questions that cause the nurse to be concerned about the client's ability to retain the information. Which of the following would be the best technique for the nurse to use to enhance the retention of information by the client? a) Repeat important information during the presentation. b) Provide the client with a thorough reference list. c) Speak slowly to allow information to be absorbed. d) Conduct the education using a lecture format.

Repeat important information during the presentation. Explanation: Repetition is an effective means of reinforcing critical information and enhancing content retention. The other options will not increase the client's ability to retain information and may decrease the client's concentration and ability to retain critical information.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? a) Reduce fat to 10%. b) Increase calories. c) Restrict sodium. d) Restrict potassium.

Restrict sodium. Explanation: A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.

A client with an arterial line for continuous measurement of systolic, diastolic, and mean blood pressures is admitted to the step-down unit. The nurse is evaluating the waveform. Identify the area that indicates that the aortic valve has closed. http://198.146.4.17/nclexrn3500/images/x.gif

The green rectangle shows the correct answer. RATIONALES: When the pressure in the ventricle is less than the pressure in the aortic root, the aortic valve closes. This event appears as a small notch on the waveform's downside.

A nurse should expect a client with hypothyroidism to report: a) puffiness of the face and hands. b) increased appetite and weight loss. c) thyroid gland swelling. d) nervousness and tremors.

puffiness of the face and hands. Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client? Select all that apply. a) Prevent constipation. b) Check the pupil reaction. c) Monitor coordination while walking. d) Provide food and fluids high in carbohydrate. e) Administer lactulose to reduce blood ammonia levels. f) Encourage physical activity.

• Prevent constipation. • Administer lactulose to reduce blood ammonia levels. • Monitor coordination while walking. • Check the pupil reaction. • Provide food and fluids high in carbohydrate. Explanation: Constipation leads to increased ammonia production. Lactulose is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a byproduct of metabolism, physical activity should be limited, not encouraged.