Acute Care Final Study
OBESE PT IN FOR CABG. THIS PT IS SLOWER TO RECOVER FROM ANESTHESIA BECAUSE:
INHALATION AGENTS ARE ABSORBED AND STORED IN ADIPOSE TISSUE, THUS LEAVING THE BODY MORE SLOWLY
IN SINUS BRADYCARDIA, THE CONDUCTION PATHWAY
IS THE SAME AS SINUS RHYTHM BUT THE SA NODE FIRES AT A RATE LESS THAN 60 BPM
Rt sided HF can result in
liver enlargement and abdominal pain
4 When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a A. typical PA pressure waveform. B. tracing of the systemic arterial pressure. C. tracing of the systemic vascular resistance. D. typical PA wedge pressure (PAWP) tracing.
D
52 A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? A. Verbally coach the patient to breathe with the ventilator. B. Sedate the patient with the ordered PRN lorazepam (Ativan). C. Manually ventilate the patient with a bag-valve-mask device. D. Increase the rate for the ordered propofol (Diprivan) infusion.
A
49 Early recognition of a fat embolism is crucial to prevent a potentially fatal outcome. Symptoms usually occur _________ after injury 24-48 hours 8-12 hours 1-2 hours 48-72 hours
24-48 HRS
47 A client is brought to the emergency department with partial thickness burns to his face, neck, and arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? A. Assess for airway patency B. Administer oxygen as prescribed C. Elevate extremities if no fractures are present D. Apply a petroleum based ointment to the burns
A
49 During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? A. New onset of confusion B. Heart rate 112 beats/minute C. Decreased bowel sounds D. Pale, cool, and dry extremities
A
5 Treatment of hypoglycemia includes following the A. Rule of 15 B. Rule of 9's C. Rule of Robertson D. Rule of 300
A
10 Your patient in room 231 has DM II and recently had a right-sided stroke. Which nursing intervention should you plan to provide to this patient related to expected manifestations of a stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of the mouth
A
11 When measuring the pulmonary artery wedge pressure, the balloon is inflated with 1.5 mL of air, observing when the catheter is wedged, and is measured at the ? A. End of expiration B. Beginning of expiration C. End of inspiration D. Beginning of inspiration
A
12 After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. A patient who is cool and clammy, with new-onset confusion and restlessness B. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. C. A patient who had dizziness after receiving the first dose of captopril (Capoten) D. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62
A
18 The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? A. The patient's PaO2 is 45 mm Hg. B. The patient's PaCO2 is 33 mm Hg. C. The patient's respirations are shallow. D. The patient's respiratory rate is 32 breaths/minute.
A
19 The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? A. The patient has bilateral crackles. B. The patient has bilateral, 4+ peripheral edema. C. The patient has a loud systolic murmur across the precordium. D. The patient has a palpable thrill felt over the left anterior chest.
A
2 Hypokalemia is often associated with _____________ that can lead to _______________ A. hypomagnesaemia, ventricular arrhythmias B. hypermagnesaemia, ventricular arrhythmias C. hyponatremia, bradycardias D. hypernatremia, tachycardias
A
21 The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? A. Immobilization of the affected leg B. Traction for the affected limb C. Guided ambulation immediately after the graft D. Knees cannot be grafted
A
23 A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient's care? A. Sildenafil (Viagra) B. Furosemide (Lasix) C. Captopril (Capoten) D. Warfarin (Coumadin)
A
24 A adult patient has arrived to the emergency department with 2nd & 3rd degree burns to front of both arms and front torso from an industrial accident. The patient weighs 82Kg. What amount of fluids should the patient receive via IV in the first 8 hours? A. 5,904 cc B. 11,808 cc C. 2,952 cc D. 3,936 cc
A
24 A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? A. Generalized muscle aches and pains B. Dizziness when changing positions quickly C. Nausea when taking the drugs before eating D. Flushing and pruritus after taking the medications Response Feedback: Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.
A
25 A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective? A. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. B. Endotracheal suctioning results in clear mucous return. C. Sputum and blood cultures show no growth after 48 hours. D. The skin on the patient's back is intact and without redness.
A
26 A patient who sustained a fractured fibula has developed compartment syndrome. The nurse explains compartment syndrome to the patient knowing that: A. is the buildup of pressure from swelling or bleeding in an enclosed space B. swelling causes blood vessels to hemorrhage C. swelling causes nerve damage, reuslting in numbness D. swelling causes the fractured bone to shrink, resulting in atrophy
A
29 For which dysrhythmia is defibrillation primarily indicated? A. Ventricular fibrillation B. Third-degree AV block C. Uncontrolled atrial fibrillation D. Ventricular tachycardia with a pulse
A
31 A patient presented to your emergency department with a blood sugar of 489, exhibits kussmal respirations, and has a "fruity" breath. The patient was diagnosed with DKA. You know to prepare to give A. 0.1units/kg/hour insulin drip B. units/kg/hour insulin drip C. 10 units/kg/hour insulin drip D. 0.001units/kg/hour insulin drip
A
32 Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. B. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. C. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. D. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.
A
33 Your patient in ICU #4 has suffered a severe head injury and has an intracranial pressure monitor in place with a reading of 23 mmhg. You are aware that the normal ICP is A. 5-15mmHg B. 0-4 mmHg C. 18-25mmHg D. 9-13mmHg
A
35 Your patient in room 421 is recovering from bacterial meningitis and has an ICP monitor in place. You know this patients' nutritional status is both hypermetabolic and hypercatabolic and has an increased need for __________ A. glucose B. electrolytes C. fluids D. lactated ringers
A
36 Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? A. The patient's serum creatinine level is elevated. B. The patient complains of intermittent chest pressure. C. The patient's extremities are cool and pulses are weak. D. The patient has bilateral crackles throughout lung fields.
A
37 In DKA, there is a shift of water and sodium from the intracellular to the extracellular compartment. This is known as: A. dilutional hyponatremia B. hypernatremia C. increased osmotic participates D. increased diabetic potassium syndrome
A
37 To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's A. P wave. B. Q wave. C. P-R interval. D. QRS complex.
A
38 A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the ER. Which finding would a nurse expect to note as confirming this diagnosis? A. Elevated blood glucose level and a low plasma bicarbonate B. decreased urine output C. Increased respirations and an increase in pH D. Comatose state
A
40 A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? A. Allow the student to participate on the soccer team. B. Refer the student to a cardiologist for further diagnostic testing. C. Tell the student to stop playing immediately if any dyspnea occurs. D. Obtain more detailed information about the student's family health history.
A
41 A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication? A. Monitored anesthesia care and amnesia B. Potentiates volatile agents to speed induction C. Analgesia and prevention of intraoperative vomiting D. Relaxation of skeletal muscles and facilitation of endotracheal intubation
A
41 Prevention of a fat emboli requires________________of a long bone fracture being the most important factor A. careful immobilization B. prophylactic antibiotics C. oxygen via nasal cannula at 2L D. prophylactic tetanus IM injection
A
42 The nurse is discussing ways to prevent diabetic ketoacidosis with a client diagnosed with DM I. Which instruction is most important to discuss with this client? A. "Take your prescribed insulin even when unable to eat after checking your blood sugar" B. "Do not take your prescribed insulin even if your blood sugar is 200 on your glucometer" C. "Don't worry about your sugar when you are ill" D. "Double your insulin when you are sick"
A
46 Your patient in room 334 has a skeletal traction in place. You know it s appropriate to A. keep the weights off the floor B. keep the weights aligned on the floor C. keep the weights on the bed D. keep the weights on the floor during the day and off the floor night
A
71 Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? Selected Answers: A. Age B. Blood pressure C. Respiratory rate D. Oxygen saturation E. Presence of confusion F. Blood urea nitrogen (BUN) level
A, B, C, E, F
53 A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? A. Elevate head of bed to 30 to 45 degrees. B. Suction the endotracheal tube every 2 to 4 hours. C. Limit the use of positive end-expiratory pressure. D. Give enteral feedings at no more than 10 mL/hr.
A
54 A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT? A. New ST segment elevation is noted on the cardiac monitor. B. Enteral feedings are being given through an orogastric tube. C. Scattered rhonchi are heard when auscultating breath sounds. D. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.
A
56 The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? A. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg B. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg C. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg D. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
A
57 The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? A. Oxygen saturation is 88%. B. Blood pressure is 145/90 mm Hg. C. Respiratory rate is 22 breaths/minute when lying flat. D. Pain level is 5 (on 0 to 10 scale) with a deep breath.
A
59 Central Venus Pressure (CVP) is considered a direct measurement of: A. Right atrium/vena cava blood pressure B. Left atrium/aorta blood pressure C. Left ventricle/abdominal aorta blood pressure D. Right temporal/right brain ventricle
A
59 During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?? A. Hypertension B. Bradycardia C. Fluid overload D. Mitral valve regurgitation
A
60 Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action? A. The right hand is cooler than the left hand. B. The mean arterial pressure (MAP) is 77 mm Hg. C. The system is delivering 3 mL of flush solution per hour. D. The flush bag and tubing were last changed 3 days previously.
A
61 The family of a patient with third-degree burns wants to know why the "scabs are being cut off" of the patient's leg. What is the most appropriate response by the nurse to this family? A. "The scabs are really old burned tissue and need to be removed to promote healing. B. " I'll ask the doctor to come and talk with you about the treatment plan." C. "The patient asked for the scabs to be removed." D. "The scabs are removed to check for blood flow to the burned area."
A
62 Extremes in high blood sugar due to insulin deficiency causes an _____________ that leads to urinary losses causing _______________ A. osmotic diuresis, dehydration B. increased osmotic pressure, dehydration C. decreased osmotic pressure, dehydration D. osmotic participates, hyperhydration
A
63 A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse ? A. Give PRN furosemide (Lasix) 40 mg IV. B. Increase normal saline infusion to 250 mL/hr. C. Administer hydrocortisone (Solu-Cortef) 100 mg IV. D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
A
64 Which of the following is a hallmark sign of compartment syndrome? A. Pain B. Edema C. Elevated blood pressure D. Numbness
A
67 When assessing a rhythm of an ECG, you need to look at the A. R-R intervals B. ARS-R intervals C. T-T intervals D. P-P intervals
A
7 It is important not to do the following when a plaster cast is applied A. Be sure to cover the cast with an ace wrap immediately after cast application B. Be sure to allow 24-72 hours before weight bearing C. Be sure not to get the plaster cast wet D. Be sure to handle with palms only when first applied
A
72 While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next? A. Increase the oxygen flow rate. B. Suction the patient's oropharynx. C. Instruct the patient to cough and deep breathe. D. Help the patient to sit in a more upright position.
A
74 A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? A. Give normal saline IV at 500 mL/hr. B. Give acetaminophen (Tylenol) 650 mg rectally. C. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. D. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.
A
8 You receive morning report from the night nurse in which he tells you the patient in rom 356 is exhibiting decorticate posturing. Which posturing shown below will you expect to find the patient exhibiting? A. 1 B. 2 C. 3 D. 4
A
9 Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? A. Atelectasis B. Bronchospasm C. Hypoventilation D. Pulmonary embolism
A
EXAM 1 1 The goal of treatment for cardiogenic shock is to A. Maintain tissue oxygenation and perfusion B. Prevent bradycardia C. Increase afterload D. Increase preload
A
OCCURS WHEN THE O2 SUPPLY TO THE HEAR IS NOT SUFFICIENT A ANGINA B MI C LT HF D INCREASE AGE
A
Lt sided HF can result in: (SATA) A DYSPNEA B ORTHOPNEA C MEMORY LOSS D DENTATION PROBLEMS E OSTEOARTHRITIS F PLEURAL EFFUSION/EDEMA G PAROXYSMAL NOCTURNAL DYSPNEA H EATING D/O
A, B, F, G
61 A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to A. administer oxygen. B. obtain a 12-lead electrocardiogram (ECG). C. obtain the blood pressure. D. check the level of consciousness.
A Response Feedback: The initial actions of the nurse are focused on the ABCs-airway, breathing, and circulation-and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.
3 MAJOR MECHANISMS TO COMPENSATE FOR PATHOLOGICAL CHANGES IN CARDIAC OUTUT INCLUDE: (SATA) A VENTRICULAR DIALATION B ATRIAL DIALATION C VENTRICULAR HYPERTROPHY D BRADYCARDIA E TACHYCARDIA F DECREASED SYSTOLIC OUTPUT
A, C, E
19 A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? A. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. B. The patient has subcutaneous emphysema on the upper thorax. C. The patient has bronchial breath sounds in both the lung fields. D. The patient has a first-degree atrioventricular heart block with a rate of 58.
B
20 DKA is most common among type I DM and develops when A. hyperinsulinemia results in the body to maintain sufficient glucose B. hypoinsulinemia fails to meet the body's basic metabolic requirements C. hypoglycemia fails to meet the body's basic metabolic requirements D. glucose is metabolized for energy
B
44 While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best? A. Tell the family members that watching the resuscitation will be very stressful. B. Ask family members if they wish to remain in the room during the resuscitation. C. Take the family members quickly out of the patient room and remain with them. D. Assign a staff member to wait with family members just outside the patient room.
B
50 A complete but temporary loss of motor, sensory, reflexes, and autonomic function which occurs immediately after a spinal injury is called? A. Autonomic Dysreflexia B. Spinal shock C. Cardiogenic shock D. Pseudo-motor neuron dysfunction
B
55 What is the most common acute complication of bacterial meningitis? A. Fever B. Increased ICP C. Hypertension D. Headache
B
56 The most common cause of mortality in DKA is A. hyperkalemia B. cerebral edema C. dehydration D. hyponatremia
B
40 Your patient in room 224 is being treated for diabetic ketoacidosis. Initially, the potassium was 3.8. Today, however, the K is 5.2. You are aware that the K+ level A. is dangerously high and the patient needs kayexalate immediately B. is dangerously high and needs to go to dialysis immediately C. Pt needs to go to the cath lab immediately D. K+ levels may appear to be high due to the transcellular shift of K+ out of the cell
D
42 The foundation of therapy for septic, hypovolemic and/or anaphylactic shock is? A. NSAIDS B. Mechanical ventilataion C. Antibiotics D. Volume expansion
D
27 Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? A. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. B. Oxygen saturation drops from 99% to 95%. C. Heart rate increases from 66 to 92 beats/minute. D. Respiratory rate goes from 14 to 20 breaths/minute.
C
29 Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? A. Fast flush the arterial line. B. Check the left hand for pallor. C. Assess for cardiac dysrhythmias. D. Rezero the monitoring equipment.
C
A FLUTTER RARELY OCCURS IN A ------------- HEART. IT IS ASSOCIATED WITH ------------.
HEALTHY; CAD, HYPERTENSION, MITRAL VALVE D/O
7 A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? A. Assess the feet for pedal edema. B. Palpate the radial pulses bilaterally. C. Auscultate for a pericardial friction rub. D. Check the heart monitor for dysrhythmias.
C
THE OUTPOUCHING/DILATION OF THE AORTIC ARTERIAL WALL IS CALLED -------------- AND IS MORE COMMON IN-------------
AORTIC ANEURYSM, MEN
PT PREPARING FOR HERNIA SURGERY HAS ASTHMA. YOU ARE AWARE THIS PT IS AT HIGH RISK FOR
ATELECTASIS
PROPERTIES OF CARDIAC CELLS ENABLE THE CONDUCTION SYSTEM TO BEGIN AN ELECTRICAL IMPULSE: THESE ARE:
AUTOMATICITY EXCITABILITY CONDUCTIVITY CONTRACTILTY
73 The pressure within the superior vena cava is called? A. SVR B. Pre-hypertension C. Central venous pressure D. Afterload pressure
C
8 Pulmonary artery wedge pressure is increased in what condition? A. Hypovolimic shock B. Right ventricular failure C. Left ventricular failure D. Right aortic dysfunction
C
Your pt has just arrived to ED in ventricular tachycardia. You know that V-tach includes:
Atrial rate cannot be determine Ventricular rate 150-250
11 After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L C. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache D. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough
B
14 The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. based on this level, the nurse would anticipate noting which sign in the client? A. Respiratory distress B. Flushing C. Blue tone to entire body D. Patient will appear to be normal
B
14 Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? A. Generalized muscle aching B. Sudden onset right flank pain C. Janeway's lesions on the palms D. Temperature 100.7° F (38.1° C) Response Feedback: Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions.
B
15 A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care? A. Administer prescribed sedatives or opioids at bedtime to promote sleep. B. Cluster nursing activities so that the patient has uninterrupted rest periods. C. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. D. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.
B
16 A 42 year old female is brought in to the emergency department via EMS after a front end collision, stating she was traveling approx. 55 mph. Pt. has a 5cm deep laceration to her frontal forehead and c/o of a severe headache. You realize the patient is mostly at risk for A. Fractured right ulnar B. Coup-Countrecoup injury C. Pneumonia D. Left ankle injury
B
16 A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate? A. Pain related to permanent joint fixation B. Activity intolerance related to arthralgia C. Risk for infection related to open skin lesions D. Risk for impaired skin integrity related to pruritus
B
17 After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first? A. Patient with acute pericarditis who has a pericardial friction rub B. Patient who has just returned to the unit after balloon valvuloplasty C. Patient who has hypertrophic cardiomyopathy and a heart rate of 116 D. Patient with a mitral valve replacement who has an anticoagulant scheduled
B
17 Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? A. Hemoglobin is within normal limits. B. Urine output is 60 mL over the last hour. C. Central venous pressure (CVP) is normal. D. Mean arterial pressure (MAP) is 72 mm Hg.
B
18 A 20-year old patient is admitted with a head injury after a collision while playing football. After noting that this patient developed a clear nasal drainage, which action by you is appropriate? A. Have the patient gently blow his nose B. Check the drainage for glucose content C. teach the patient that rhinorrhea is expected after a head injury D. Obtain a specimen of the fluid to send for culture and Sensitivity.
B
20 The new nursing student is confused about where the patient's family (who are wearing street clothes) can be with the patient in the surgical suite. Which explanation should the perioperative nurse give to the student nurse? A. The family is not allowed to talk to the nurse at the nursing station. B. The family can be with the patient in the preoperative holding area. C. The family cannot be with the patient until the postanesthesia care unit. D. The family is only allowed in the conference room for preoperative teaching.
B
21 The pulmonary artery catheter measures? A. right ventricle/ascending aorta/left atrium B. left ventricle/pulmonary artery/right atrium C. liver function/descending aorta/left vena cava D. alveoli function/transverse aorta/CO2
B
21 When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include? A. Monitor labs for streptococcal antibodies. B. Arrange for placement of a long-term IV catheter. C. Teach the importance of completing all oral antibiotics. D. Encourage the patient to begin regular aerobic exercise.
B
22 The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? A. A large air leak in the water-seal chamber B. 400 mL of blood in the collection chamber C. Complaint of pain with each deep inspiration D. Subcutaneous emphysema at the insertion site
B
23 Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? A. Mean arterial pressure (MAP) B. Systemic vascular resistance (SVR) C. Pulmonary vascular resistance (PVR) D. Pulmonary artery wedge pressure (PAWP)
B
26 Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? A. Administer ceftriaxone (Rocephin) 1 g IV. B. Order blood cultures drawn from two sites. C. Give acetaminophen (Tylenol) PRN for fever. D. Arrange for a transesophageal echocardiogram.
B
27 The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient's Answers: A. lipase. B. temperature. C. urinary output. D. body mass index.
B
27 When a patient who has a tib-fib fracture first begins to ambulate, the nurse needs to review the A. patient's age and insurance status B. provider's orders regarding weight bearing status C. patient's pain complaints D. provider's orders regarding pain medication
B
28 A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? Selected Answer: A. I B. II C. V2 D. V6
B
28 The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? A. Blood pressure (BP) 92/56 mm Hg B. Skin cool and clammy C. Oxygen saturation 92% D. Heart rate 118 beats/minute
B
3 A 19-year-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? A. Start supplemental O2 at 2 to 3 L/min via nasal cannula. B. Ask the patient about current stress level and caffeine use. C. Ask the patient about any history of coronary artery disease. D. Have the patient taken to the hospital emergency department (ED).
B
30 To receive a diagnosis of HHNS, you know the patient will have a blood sugar of A. <350 mg/dL B. >600 mg/dL C. <500 mg/dL D. <600 mg/dL
B
31 A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? A. "Most patients are able to enjoy intercourse without any complications." B. "Sexual activity uses about as much energy as climbing two flights of stairs." C. "The doctor will provide sexual guidelines when your heart is strong enough." D. "Holding and cuddling are good ways to maintain intimacy after a heart attack."
B
33 When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do next? A. Give analgesics and antibiotics as ordered. B. Discontinue the catheter and culture the tip. C. Change the flush system and monitor the site. D. Check the site more frequently for any swelling.
B
35 After change-of-shift report in the progressive care unit, who should the nurse care for first? A. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases B. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics C. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute D. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg
B
38 Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate? A. "PEEP will push more air into the lungs during inhalation." B. "PEEP prevents the lung air sacs from collapsing during exhalation." C. "PEEP will prevent lung damage while the patient is on the ventilator." D. "PEEP allows the breathing machine to deliver 100% oxygen to the lungs."
B
39 Bacterial meningitis occurs most often in all seasons except ________ and is usually secondary to ___________: A. fall, bacterial infection B. summer, viral respiratory infection C. spring and fall, bacterial infection D. winter, influenza
B
41 The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse A. balances and calibrates the monitoring equipment every 2 hours. B. positions the zero-reference stopcock line level with the phlebostatic axis. C. ensures that the patient is supine with the head of the bed flat for all readings. D. rechecks the location of the phlebostatic axis when changing the patient's position.
B
65 The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled B. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath C. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)
B
66 The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? A. Start a normal saline infusion. B. Give epinephrine (Adrenalin). C. Start continuous ECG monitoring. D. Give diphenhydramine (Benadryl).
B
66 Your patient has been treated in the emergency department for a right humerus fracture. You know this patient should receive all but A. pain medication B. sling C. follow-up appointment with an orthopedic specialist D. cast for immobilization
B
68 You work in an urgent care clinic when a 22 year old male presents with c/o persistent headache and shortened attention span. What would you want to ask first? A. "Do you have insurance?" B. "Have you hit your head over the past week?" C. "Have you had an earache?" D. "Do you have any weakness to your arms or legs?"
B
70 Tidaling indicates fluctuations in the chest tube's water-seal chamber's fluid level that correspond with ______________? A. Heart Rate B. SVR C. Respirations D. Blood pressure
B
9 Your patient in room 325 has been admitted due to developing compartment syndrome to the left arm. You are precepting a new nurse. You overhear her telling the patient the following, knowing you need to educate the new nurse further on compartment syndrome: A. "We need to keep the extremity lower than the level of your heart" B. "We need to elevate the limb to promote circulation" C. " You may need to have a fasciotomy if swelling does not decrease" D. "I know compartment syndrome is very painful. Let me know if you need more pain medicine"
B
EXAM #3 1 It is important to remember that DKA is not just a problem of high blood sugar but also A. hypertension B. dehydration C. hyperglycemia D. hypoglycemia
B
HEART WRITTEN EXAM: Your have a patient in room 335 who has been told his SA node is not "FIRING" properly but that the AV node is responding. You expect that the patients heart rate to be: a. 35 bpm b. 45 bpm c. 75 bpm d. 100 bpm
B
formation of localized necrotic areas within the mycoardium, usually following the sudden occlusion a coronary artery is referred to as A PARADOXYL ANGINA B MYOCARDIAL INFARCTION C LT HF D ANAPHYLYTIC SHOCK
B
50 Key signs of bacterial meningitis includes (select all that apply) A. cough B. fever C. severe headache D. nausea/vomiting E. abdominal pain F. nuchal rigidity G. body aches H. photophobia
B, C, D, F, H
11 Your patient in room 312 is being treated for DKA and had a morning sodium level of 123 mEq/L. You realize your first priority is to A. Call the provider immediately B. prepare to intubate C. realize this can be a false lab reading due to the pathophysiology of DKA D. prepare to give Lasix
C
12 The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem? A. Increase suctioning to every hour. B. Reposition the patient every 1 to 2 hours. C. Add additional water to the patient's enteral feedings. D. Instill 5 mL of sterile saline into the ET before suctioning.
C
15 A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? A. Prepare to perform electrical cardioversion. B. Have the patient perform the Valsalva maneuver. C. Obtain the patient's vital signs including oxygen saturation. D. Prepare to give a b-blocker medication to slow the heart rate.
C
15 You are the nurse for a 67 year old patient who has had a stroke and planning psychosocial support for both the patient and the family. Which factor will most likely have the greatest impact on positive family coping with the current situation? A. Specific ptient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke
C
18 While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates A. decreased fluid volume. B. jugular vein atherosclerosis. C. increased right atrial pressure. D. incompetent jugular vein valves.
C
20 A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? A. The patient's heart rate is 97 beats/min. B. The patient's oxygen saturation is 93%. C. The patient respiratory rate is 32 breaths/min. D. The patient's spontaneous tidal volume is 450 mL.
C
22 A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give? A. Fentanyl 1 mg IV B. IV morphine sulfate 4 mg C. Oral ibuprofen (Motrin) 600 mg D. Oral acetaminophen (Tylenol) 650 mg Response Feedback: The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (NSAIDs) (e.g., ibuprofen) are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.
C
22 Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? A. "The medication is an antibacterial." B. "The medication will help heal the burn." C. "The medication will permanently stain my skin." D. "The medication should be applied directly to the wound."
C
23 In DKA, deficiency of insulin causes the body to metabolize A. glucose B. sodium C. triglycerides/muscles D. potassium
C
25 Hyperosmolar Hyperglycemic Nonketotic syndrome is generally seen in ________patients with type ___________DM whose blood sugar is ___________. A. younger, II, controlled B. older, I, controlled C. older, II, uncontrolled D. younger, I, controlled
C
26 A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? A. Insert two large-bore IV catheters. B. Initiate continuous electrocardiogram (ECG) monitoring. C. Provide oxygen at 100% per non-rebreather mask. D. Draw blood to type and crossmatch for transfusions.
C
3 The nurse working with an overweight client who has a high- stress job and smokes. The client has just received a diagnosis of Type II Diabetes and has just been started on an oral hypoglycemic agent. Which of the following goals for the client which if met, would be most likely to lead to an improvement in insulin efficiency to the point the client would no longer require hypoglycemic agents? A. Comply with medication regimen 100%for 6 months B. Quit the use of tobacco products bye the end of three months C. Lose a pound a week until weight is in normal range for height and exercise 30 minutes daily D. Practice relaxation techniques for at least five minutes a day for at least five months
C
30 The post-anesthesia care unit (PACU) has several patients with endotracheal tubes. Which patient should receive the least amount of endotracheal suctioning? A. Transplantation of a kidney B. Replacement of aortic valve C. Cerebral aneurysm resection D. Formation of an ileal conduit
C
31 Your patient in room 335 was admitted for a new diagnosis of CHF and has developed sepsis. You expect the CVP will be? A. Decreased B. Not applicable C. Increased D. Unmeasurable
C
33 The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? A. The troponin level is elevated. B. The patient denies ever having a heart attack. C. Bilateral crackles are auscultated in the mid-lower lobes. D. The patient has occasional premature atrial contractions (PACs).
C
34 Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? A. The patient's oxygen saturation is 93%. B. The patient was last suctioned 6 hours ago. C. The patient's respiratory rate is 32 breaths/minute. D. The patient has occasional audible expiratory wheezes.
C
34 __________________ fracture is an incomplete fracture with one side splintered and the other side bent. A. Transverse B. Spiral C. Greenstick D. Comminuted
C
36 A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? A. "Do you have any allergies?" B. "Do you take aspirin on a daily basis?" C. "What time did your chest pain begin?" D. "Can you rate your chest pain using a 0 to 10 scale?"
C
36 An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? A. 18% B. 10% C. 36% D. 48%
C
37 A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? A. Inspiratory crackles. B. Cool, clammy extremities. C. Apical heart rate 45 beats/min. D. Temperature 101.2° F (38.4° C).
C
39 A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's priority action will be to A. have the patient recall the dietary intake for the last 3 days. B. ask the patient about the use of the prescribed medications. C. assess the patient for clinical manifestations of acute heart failure. D. teach the patient about the importance of restricting dietary sodium.
C
4 A 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? A. Routine insulin therapy and exercise B. Administer a different antibiotic for the UTI. C. Cardiac monitoring to detect potassium changes D. Administer IV fluids rapidly to correct dehydration.
C
4 A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? A. Obtain a 12-lead electrocardiogram (ECG). B. Notify the health care provider of the change in rhythm. C. Give supplemental O2 at 2 to 3 L/min via nasal cannula. D. Assess the patient's vital signs including oxygen saturation.
C
40 The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next? A. Explain ICU visitation policies and encourage family visits. B. Immediately take the family members to the patient's bedside. C. Describe the patient's injuries and the care that is being provided. D. Invite the family to participate in a multidisciplinary care conference.
C
43 A patient, who is admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? A. Central apnea B. Hypoventilation C. Kussmaul respirations D. Cheyne-Stokes respirations
C
43 During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? A. Give the prescribed PRN sedative drug. B. Offer reassurance and reorient the patient. C. Use pulse oximetry to check the oxygen saturation. D. Notify the health care provider about the patient's status.
C
45 The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? A. Scattered crackles bilaterally in the posterior lung bases. B. Persistent cough that is productive of blood-tinged sputum. C. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy. D. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
D
44 A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? A. Transfusing 1 unit of packed red blood cells B. Administering a diuretic to increase urine output C. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour D. Changing the IV lactated Ringer's solution to one that contains dextrose in water
C
45 A Buck's traction boot is used to immobilize a fracture, prevent hip flexion contractures and ______________ A. prevent infection B. prevent fat embolism C. reduce muscle spasms D. reduce circulation
C
48 Your patient, a 26 year old male, arrives to the emergency department with an altered level of consciousness after being burned in a warehouse mishap. You are aware that A. A burn in of itself can cause altered mental status B. The patient probably received morphine for pain prior to the ED arrival C. Additional causes for this patient's AMS could be due to hypovolemia, CO2 inhalation and/or head injury D. This patient could be faking because he does not want to get into trouble with his boss at work
C
5 The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse take next? A. Offer reassurance to the patient. B. Bag the patient at an FIO2 of 100%. C. Listen to the patient's breath sounds. D. Notify the patient's health care provider.
C
5 While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a A. consult with a psychologist. B. transfer to a long-term care facility. C. referral to a home health care agency. D. arrangements for around-the-clock care.
C
51 Diabetic ketoacidosis (DKA) is caused by a profound deficiency of ___________and is characterized by hyperglycemia, ketosis, acidosis, and _______________. A. glucose, hypovolemia B. potassium, hyponatremia C. insulin, dehydration D. insulin, hypervolemia
C
51 You have a 54 year old male who exhibits tachycardia, hyperventilation, an axillary temp of 39.2, no bowel sounds, a decrease in urine output from approx 60cc/hour to 5cc/hour. You are aware you should prepare to treat this patient for? A. Viral infection B. Anaphylactic shock C. Septic shock D. Urinary tract infection
C
52 300 large squares on ECG paper is equal to A. 1 second B. 20 seconds C. 1 minute D. 0.2 seconds
C
58 What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A. Pulse ox reading of 80% B. Expiratory stridor and nasal flaring C. Cherry red color to the mucous membranes D. Presence of carbonaceous particles in the sputum
C
6 Kyle, age 16, presents to the ED after playing soccer and landing on his wrist after falling. He is in severe pain, and a fracture has been diagnosed. He is now in a cast. What nutritional therapy will you teach Kyle to promote healing? A. high vitamins, high protein, low calcium B. low protein, high calcium, low vitamins C. high protein, high vitamins, high calcium D. low fiber, low protein, low calcium
C
6 The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? A. The patient's heart rate is 58 beats/minute. B. The patient's extremities are warm and dry. C. The patient's IV infusion site is cool and pale. D. The patient's urine output is 28 mL over the last hour.
C
63 In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A. Body temperature readings all within normal limits B. An electrocardiogram showing no arrhythmias C. A urine output consistently above 40 ml/hr D. A weight gain of 4 lb (2kg) in 24 hr
C
64 A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? A. Insulin infusion B. IV administration of epinephrine C. Aggressive IV crystalloid fluid resuscitation D. Administration of nitrates and β-adrenergic blockers
C
65 A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. Which of the following is a possible cause based on the characteristic symptom? A. Ischemic stroke B. Silent migraine C. Cerebral aneurysm D. Recurrent migraine
C
67 Chest tubes are inserted to drain the pleural space to help re-establish _________________, allowing for proper lung expansion A. Positive pressure B. Correction of TSH C. Negative pressure D. To allow pancreas to drain
C
68 The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? A. Give the scheduled IV antibiotic. B. Give the PRN acetaminophen (Tylenol). C. Obtain oxygen saturation using pulse oximetry. D. Notify the health care provider of the patient's vital signs.
C
69 A client sustains a fractured right humerus in an automobile accident. The arm is edematous, is very painful, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures? A. Muscle spasms B. Subluxation C. Compartment syndrome D. Dislocation
C
69 While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings? A. Continue with ambulation since this is a normal response to activity. B. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.
C
46 The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next? A. Activate the rapid response team. B. Provide reassurance to the patient. C. Call the health care provider to reinsert the tube. D. Manually ventilate the patient with 100% oxygen.
D
2 The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which action by the nurse is a priority? A. Decrease the suction pressure to 80 mm Hg. B. Document the dysrhythmia in the patient's chart. C. Stop and ventilate the patient with 100% oxygen. D. Give antidysrhythmic medications per protocol.
C Response Feedback: Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated.
62 When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? A. Increased inflation of the lungs B. Prevention of barotrauma to the lung tissue C. Prevention of alveolar collapse during expiration D. Increased fraction of inspired oxygen concentration (FIO2) administration
C Response Feedback: PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Actually auto-PEEP resulting from inadequate exhalation time may contribute to barotrauma.
47 A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next? A. Increase the tidal volume and respiratory rate. B. Increase the fraction of inspired oxygen (FIO2). C. Perform endotracheal suctioning more frequently. D. Lower the positive end-expiratory pressure (PEEP).
D
WHAT IS THE RESULT FROM SEVERE PAIN OR FROM VASOVAGAL REFLEXES CONDUCTED FROM THE AREA OF DAMAGED MYOCARDIUM TO THE GI TRACT? A DYSURIA C CHOLEOLITHIASIS C HIGH FEVER D NAUSEA AND VOMIT
D
25 A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? A. Recheck the heart rhythm and BP in 5 minutes. B. Have the patient perform the Valsalva maneuver. C. Give the scheduled dose of diltiazem (Cardizem). D. Apply the transcutaneous pacemaker (TCP) pads.
D
28 As a nurse for the patient with ICP, care for this patient includes: A. Sitting the patient at a 90 angle, tell patient to bear down with a bowel movement, and keep two pillows under the head B. Tell the patient to cough frequently to help prevent pneumonia, lay in a fetal position, and keep HOB at a 30 angle C. Allow patient to flex neck while in bed for exercise, cough frequently to expel secretions, allow family members at allhours to promote stimulation D. Keep HOB at a 30-45 angle, turn slowly in bed, avoid hip flexion
D
29 A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? A. Manage patient pain. B. Control the bleeding. C. Maintain fluid balance. D. Manage oxygenation status.
D
3 When caring for the patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next? A. Zero balance the transducer. B. Activate the fast flush system. C. Notify the health care provider. D. Deflate and reinflate the PA balloon.
D
30 After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? A. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain B. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) C. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge D. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
D
32 Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter? A. Determine if the cardiac troponin level is elevated. B. Auscultate heart and breath sounds during insertion. C. Place the patient on NPO status before the procedure. D. Attach cardiac monitoring leads before the procedure.
D
32 Which of the following complications is common for victims of electrical burns? A. Infection B. Inhalation injury C. Hypovolemic shock D. Cardiac dysrhythmias
D
34 The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? A. Weight loss of 2 pounds in 24 hours B. Hourly urine output greater than 60 mL C. Reduction in patient complaints of chest pain D. Reduced dyspnea with the head of bed at 30 degrees
D
35 A 52-year-old female patient has come to the ambulatory surgery center for surgery. When reviewing the assessment record, what test should the nurse seek an order for before this patient has surgery? A. Blood glucose B. Pregnancy test C. Serum albumin D. Serum potassium
D
38 A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? A. Sterility B. Paralysis C. Urine output D. Skin integrity
D
39 Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler? A. "I can rinse my mouth following the two puffs to get rid of the bad taste." B. "I should wait at least 1 to 2 minutes between each puff of the inhaler." C. "Because this medication is not fast-acting, I cannot use it in an emergency if my breathing gets worse." D. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."
D
10 After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? A. Q waves on ECG B. Elevated troponin levels C. Fever and hyperglycemia D. Tachypnea and crackles in lungs
D
10 To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should A. inflate the cuff with a minimum of 10 mL of air. B. inflate the cuff until the pilot balloon is firm on palpation. C. inject air into the cuff until a manometer shows 15 mm Hg pressure. D. inject air into the cuff until a slight leak is heard only at peak inflation.
D
12 A 34 year old female patient has arrived to your emergency department with 47% burns. Your priority is A. Obtaining the patient's history, mechanism of injury, and drug allergies B. Cutting off the patients clothes, removing all jewelry, and removing glasses or contacts C. Getting the patient's insurance card, identification card, and/or passport D. Be sure the patient's airway/breathing/circulation are secure
D
13 A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? A. Myoglobin B. Homocysteine C. C-reactive protein D. Cardiac-specific troponin
D
13 The measurement of the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system is known as? A. PAWP B. SVP C. ICP D. CVP
D
14 After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? A. A patient with cystic fibrosis who has thick, green-colored sputum B. A patient with pneumonia who has crackles bilaterally in the lung bases C. A patient with emphysema who has an oxygen saturation of 90% to 92% D. A patient with septicemia who has intercostal and suprasternal retractions
D
16 To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to A. auscultate for the presence of bilateral breath sounds. B. obtain a portable chest x-ray to check tube placement. C. observe the chest for symmetric chest movement with ventilation. D. use an end-tidal CO2 monitor to check for placement in the trachea.
D
17 Bacterial meningitis is a medical emergency and has a mortality rate of nearly _______________ if not treated quickly A. 50% B. 10% C. 15% D. 100%
D
19 A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? A. The bedrails at the head and foot of the bed are both elevated. B. The patient receives a regular diet from the dietary department. C. The lights in the patient's room are turned off and the blinds are shut. D. Unlicensed assistive personnel enter the patient's room without a mask.
D
2 An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? A. Check his chart for intraoperative complications. B. Check which medications were used for anesthesia. C. Check the effectiveness of the analgesics he has received. D. Check his preoperative assessment for previous delirium or dementia..
D
24 After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? A. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator B. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring C. Patient with a central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP) D. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours
D
48 The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? A. The RN increases the FIO2 to 100% before suctioning. B. The RN secures a bite block in place using adhesive tape. C. The RN asks for assistance to reposition the endotracheal tube. D. The RN positions the patient with the head of bed at 10 degrees.
D
53 Atrial fibrillation is responsible for about ______of all strokes; incidence ______ with age.: A. 50%, increases B. 35%, decreases C. 10%, decreases D. 20%, increases
D
54 A female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage
D
55 When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? A. Emergency pericardiocentesis B. Stabilization of the chest wall with tape C. Administration of an inhaled bronchodilator D. Insertion of a chest tube with a chest drainage system
D
57 The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? A. "I will stop taking my insulin if I'm too sick to eat." B. "I will decrease my insulin dose during times of illness." C. "I will adjust my insulin dose according to the level of glucose in my urine." D. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL."
D
58 A patient's daughter asks the nurse what SIMV means on the settings of the mechanical ventilator attached to her father. Which statement best describes this mode of ventilation? A. "SIMV provides additional inspiratory pressure so that your father does not have to work as hard to breathe, thus enabling better oxygenation and a quicker recovery with fewer complications." B. "SIMV is a mode that allows the ventilator to totally control your father's breathing. It will prevent him from hyperventilating or hypoventilating, thus ensuring the best oxygenation." C. "SIMV is a mode that allows your father to breathe on his own, but the ventilator will control how deep a breath he will receive. The ventilator can sense when he wants a breath, and it will deliver it." D. "SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him."
D
6 The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? A. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago B. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due C. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating D. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
D
7 You are caring for an 18 year old male in room 421 who was jumping off cliffs into an unknown body of water. The patient suddenly develops a severe HA, bradycardiam flushing above the level of his injury (T7, T8) but exhibits paleness to the extremities below the level of injury. He also has profuse sweating and piloerection. What do you suspect? A. Cardiogenic shock B. Meningtitis C. Septic Shock D. autonomic Dysreflexia
D
8 Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? A. Blood glucose 243 mg/dL B. Serum chloride 92 mEq/L C. Serum sodium 134 mEq/L D. Serum potassium 2.9 mEq/L
D
9 The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops A. oxygen saturation of 93%. B. respirations of 20 breaths/minute. C. green nasogastric tube drainage. D. increased jugular venous distention.
D
EXAM 2 (Computer Test) 1 A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Evaluation of the patient's response to walking in the hallway B. Completion of the referral form for a home health nurse follow-up C. Education of the patient about the pathophysiology of heart disease D. Reinforcement of teaching about the purpose of prescribed medications
D
YOUR PT CT NOTES VEGETATION ON MITRAL VALVE. THIS IS KNOW AS.
INFECTIVE ENDOCARDITIS
13 If a pediatric patient sustains a large burn, start an IV and bolus fluids to maintain adequate fluid volume. TRUE OR FALSE?
FALSE
IRREGULAR SHAPED MACULES OF VARIABLE SIZE ON HER THENAR EMINENCE. THIS IS SUGGESTIVE OF --------------------- AND THE LESIONS ARE REFERRED TO AS -----------.
INFECTIVE ENDOCARDITIS JANEWAY LESIONS
YOU ARE MONITORING A PT WHO HAS JUST BEEN TRANSFERRED TO POST OP. YOU KNOW TO PLACE PT IN:
LATERAL RECOVERY POSITION
MAJOR RISK FACTOR FOR A DESCENDING ABDOMINAL AORTIC ANEURYSM ARE:
MALE, >65 AGE, SMOKING
PT HYPERTHERMIC WITH RIGIDITY NOTED TO MSK, IS FLUSHED AND HAS DYSPNEA. YOUR PT IS EXPERIENCING:
MALIGNANT HYPERTHERMIA
V TACH IS ASSOCIATE WITH:
MI CARDIOMYOPATHY MITRAL VALVE PROLAPSE DRUG TOXICITY
Whens assessing an EKG for normal sinus rhythm, the _______________________ intervals are regular.
R-R
S/X OF RUPTURES AORTIC ANEURYSM INCLUDE:
SEVERE BACK PAIN HYPOVOLEMIC SHOCK ABDOMINAL TENDERNESS
AS MANY AS 50% OF PT WITH INFECTIVE ENDOCARDITIS WILL EXPERIENCE
SYSTEMIC EMBOLIZATION
A MODIFICATION OF THE APGAR SCORING SYSTEM USED TO DETERMINE A PTS READINESS TO TRANSITION FROM PHASE 1 TO PHASE 2 IN POST OP MONITORING IS CALLED:
THE MODIFIED ALDRETE SCORING SYSTEM.
WHEN ASSESSING AN EKG, YOU SHOULD CHECK TO SEE IF THERE IS A P WAVE BEFORE EVERY QRS. THIS TELLS YOU THAT:
THERE IS NORMAL CONDUCTION FROM THE ATRIA TO THE VENTRICLES
A SEVERE DERANGEMENT OF THE HEART RHYTHM CHARACTERIZED ON AN EKG BY IRREGULAR WAVEFORMS OF VARYING SHAPES AN AMPLITUDE.
V FIB
A patient in V tach has high possibility of converting to ____________________ rhythm that may result in asystole.
V-fib
Occurs when one or more ectopic foci arise within the ventricles:
Ventricle dysrhythmias
The P wave represents ___________________. In a normal EKG, the P wave precedes the ________________.
atrial depolarization QRS complex
60 The most important thing to assess or look at when evaluating an EKG is? A. QRS, T-waves B. P-waves, QRS C. History and clinical picture D. R-R ratio
c
You know that the older pt has less _____________, which is the ability of the heart to __________.
cardiac reserve; adjust to increased demands from stressors
In V tach,
none of the QRS complexes will be preceded by P waves
Atrial dysrhythmias is abnormal electrical activity that results in stimulation outside the SA node but within the atria. This can be caused by several different factors including:
stress hyopkalemia MI ingestion of large meal
