Sensory Alterations/Resp/Cardiac #1

​A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicate understanding of the teaching?

"I must stop smoking" "I need to monitor my weight" "I am limiting my intake of fast foods"

​A nurse is teaching a client who has emphysema about self-management strategies. Which of the following client statements indicates that the client understands the instructions?

"I will follow a daily diet high in calories and protein."

A nurse is teaching a group of postmenopausal women about activities to reduce the risk of developing coronary artery disease. Which of the following statements by a client requires clarification?

"increasing the intake of foods containing trans-fatty acids in my diet can lower my risk"

​A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following is an appropriate nursing response?

"tell me more about these fears of dying from a heart attack"

A client is requesting information regarding a serum troponin test. Which of the following is the nurse's best response?

"the slightest elevation in troponin levels will prompt treatment to prevent complications of cardiovascular disease"

​A nurse is caring for a client who has COPD. When developing this client's plan of care, the nurse should include which of the following interventions?

instruct the client to use pursed-lip breathing

A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following nursing statements indicates an understanding of the condition?

DIC is caused by abnormal coagulation involving fibrinogen

​A client who has angina pectoris comes to the emergency department reporting chest pain. When assessing the client, which of the following findings should the nurse expect?

weakness in the arms diaphoresis severe apprehension

A client who has angina pectoris is experiencing chest pain and has taken three nitroglycerin tablets sublingually. The client reports relief from the chest pain but now reports a headache. The nurse should explain to the client that this symptom

is an expected side effect of the medication

​A nurse in the ICU is caring for a client who has acute respiratory distress syndrome (ARDS) and is receiving mechanical ventilation via an endotracheal tube. The provider plans to extubate her within the next 24 hr. Which of the following is an important criterion for extubating this client?

adequate tidal volume without positive pressure

What are appropriate interventions for the patient with ICU delirium?

Use clocks and calendars in the patient's room Encourage round-the-clock presence of family at bedside Identify physiologic factors that may be contributing to the patient's confusion and irritability Come back to this one???

Which patient is most likely to experience sensory deprivation?

a 22-year-old isolated in the hospital bc of immune system suppression related to chemotherapy

​A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is

a heart muscle protein that appears in the bloodstream when there is damage to the heart

When gathering data to assist with the assessments of patients, you will find which of the following patients most at risk for sensory overload?

a patient inisolation (not sure go back)

A nurse is providing home care instructions to a client who is being discharged following a cardiac catheterization. Which of the following should the nurse include in the instructions?

a small hematoma at the site is expected

A nurse is caring for a client who enters the emergency department of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction?

perform a 12-lead ECG

A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis?

3+ edema in the lower extremities

​A nurse is caring for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the client's care plan?

position in semi- to high-Fowler's with support to the back

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:

promote oxygen intake

A patient with suspected pulmonary hypertension should be prepared for which of the following tests to confirm the diagnosis?

cardiac catheterization

A patient, who lives alone in the country, was admitted to the hospital two days ago. The patient begins to show signs of confusion and disorientation. You would most suspect which of the following problems as most contributing to the confusion and disorientation?

changes in the quantity and quality of sensory stimuli

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care?

check peripheral pulses in the affected extremity keep the client's hip and leg extended have the client remain in bed up to 6 hr

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?

confusion

A 48-year-old patient is in ICU following coronary artery bypass graft (CABG) surgery for treatment of a myocardial infarction. Thirty-six hours after the procedure, the patient's O2 saturations drop to 90% and he has developed crackles in the lungs. The nurse suspects cardiogenic shock. Which of the following symptoms would the nurse expect the patient to exhibit with cardiogenic shock?

confusion hypotension tachycardia weak pulse

The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?

cor pulmonale (right-sided heart failure)

Pulmonary rehabilitation is designed to reduce symptoms and improve the patient's quality of life. Along with improving exercise capacity, what are the anticipated results of pulmonary rehabilitation?

decreased anxiety decreased depression decreased hospitalizations not sure? go back

A client who weighs 180 lb is prescribed dobutamine at 10 mcg/kg/min, which is available as 250 mg dobutamine in 500 mL of D5W. How many mL per hr should the nurse administer?

180 lb/2.2 + 81.8 kg81.8 kg x 10 mcg per min = 818 mcg/min818 mcg x 60 min per hr + 49080 mcg/hr49080 mcg/1000mcg per mg = 49.08 mg/hr So client needs 49.08 mg/hr You have on hand dobutamine 250 mg per 500 ml =0.5 mg/mL49.08 mg per hr /0.5 mg per mL = 98 mL/hr

A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. Forty-eight hours after the incident, he becomes agitated, confused, and begins to hyperventilate. O2 saturations drop to 80% on O2, therefore the patient is intubated and placed on mechanical ventilation. Which of the following conditions has he most likely developed?

ARDS

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

atrial fibrillation

​A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

barrel

​A nurse on a medical unit is caring for a client who has angina pectoris and reports chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers sublingual nitroglycerin (Nitrostat). After 5 min, the client states that his chest pain is now a 2. Which of the following actions should the nurse take?

administer another nitroglycerin tablet (appropriate to administer another tab 5 min after the first if the client is still reporting pain)

A nurse in an emergency department is preparing to administer alteplase accelerated therapy to a client who is having a myocardial infarction. Which of the following actions should the nurse plan to take?

administer the medication within 30 min of the client's arrival to the department reconstitute the medication with sterile water administer a 15 mg IV bolus assess the client for back pain

What causes pulmonary vasoconstriction leading to the development of cor pulmonale in the patient with COPD?

alveolar hypoxia and hypercapnia

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

antiplatelet aggregate

A nurse is assessing a client who is being admitted to the step-down unit 6 hr following a cardiac catheterization. The nurse notes that the affected leg is cool to the touch, has a decreased pulse, and a hard palpable area in the groin area. Which of the following is an appropriate action by the nurse?

apply pressure to the femoral artery

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to

assign UAP to stay with and reorient the patient

A nurse is caring for a client who had a femoral cardiac catheterization 6 hr prior. The nurse makes the following observations: Urine output for the first 4 hr of the evening shift was three times the intake in the same period. Vital signs are within normal limits and stable. Intravenous fluids are running at 50 mL/hr. Femoral insertion site dressing is intact. Distal pulses are palpable and strong. The nurse should recognize that the discrepancy between the client's intake and output represents a physiologic response to which of the following?

dye utilized for the study

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client?

dyspnea barrel chest clubbing of the fingers shallow respirations

What is a priority nursing intervention that is indicated for the patient in the ICU who has a nursing diagnosis of anxiety related to the ICU environment and sensory overload?

eliminate unnecessary alarms and overhead paging

A nurse is caring for a client who has respiratory failure, is intubated, and is mechanically ventilated. The client pulls out the endotracheal tube. Which of the following is a priority nursing action?

ensure the airway is open

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

epinephrine

​A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time?

evaluate the client's respiratory status

A nurse suspects her patient may be suffering from delirium. What signs does the nurse observe to support this diagnosis?

gradual onset of forgetfulness reported by family members

A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care?

hypercapnic respiratory failure related to decreased ventilatory effort

A nurse is monitoring a client who has an anterior septal myocardial infarction. The client is on a dobutamine hydrochloride (Dobutrex) drip. The nurse understands the rationale for the client's dobutamine drip is to

improve cardiac output

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

increase in the heart rate from 88 to 110 beats per min

A client who has emphysema and has difficulty with mobility is receiving home health care. He spends most of his day in a reclining chair. Which physiological response to prolonged immobility should the nurse expect?

increased calcium excretion

A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?

increased respiratory rate

A client comes to the emergency department via ambulance to report severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?

initiate oxygen therapy

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?

it facilitates the client's deep breathing

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?

lethargy

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

metformin

​A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. Which of the following disorders should the nurse suspect?

mitral valve prolapse

A nurse is caring for a client in the critical care unit following a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following findings supports this suspicion?

muffled heart sounds

​A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

narrowing pulse pressure

A nurse is caring for a client who has hypovolemic shock. Which of the following is an expected finding?

oliguria

A client is receiving positive pressure mechanical ventilation. Which of the following should the nurse implement to prevent complications?

palpate skin for a "popping" sensation give pantoprazole (Protonix) as prescribed reposition the endotracheal tube to the opposite side of the mouth

A patient with a history of COPD and acute coronary syndrome, affecting the anterior wall one year ago, is experiencing shortness of breath, a rapid irregular heartbeat, an O2 saturation of 89%, and is expectorating pink-frothy sputum. The most like cause of these findings is:

pulmonary edema

​A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?

resonance

A client who has emphysema has dyspnea with minimal exertion. The nurse should monitor this client for which of the following complications?

respiratory acidosis

A client who has pulmonary edema develops tachypnea, dyspnea, crackles, and hypoxemia, and oxygen therapy does not help. The provider diagnoses acute respiratory distress syndrome (ARDS). The nurse should monitor this client for which of the following complications?

respiratory acidosis

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following should the nurse include as effective for preventing this disorder?

smoking cessation

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction?

troponin I troponin T CPK myoglobin

A nurse is caring for a client who is postoperative. Which of the following should the nurse include in the postoperative teaching to prevent pulmonary complications?

use of a incentive spirometer