ADHII Final Review
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. The client is symptomatic due to the slow heart rate. The most appropriate nursing diagnosis for this client would be which of the following?
Decreased cardiac output
After evaluating a client for hypertension, a physician orders atenolol (Tenormin), 50 mg P.O. daily. Which therapeutic effect should atenolol have?
Decreased cardiac output and decreased systolic and diastolic blood pressure
A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time?
Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction
After observing a code blue situation, a nursing student asks a member of the code team what the treatment of choice is for witnessed ventricular fibrillation. The best response by the nurse is which of the following?
Defibrillation
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
Extreme anxiety
A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) for a client with a disorder of the hematopoietic system. Which symptom is the most commonly reported in association with hematologic diseases?
Extreme fatigue
The nurse is working on a telemetry unit, caring for a client who has been in a sinus rhythm for the past 2 days with a heart rate of 88 to 96 beats per minute. The client puts on the call light in the bathroom and reports severe dizziness. The telemetry shows a heart rate of 46 beats per minute. What should the nurse be prepared to do?
Give an IV bolus of atropine
When the postcardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality?
Hyperkalemia
Which of the following is a potential cause of premature ventricular complexes (PVCs)?
Hypokalemia
A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document?
Hypotension
Which could be a potential cause of respiratory acidosis?
Hypoventilation
While assessing a client, the nurse finds a heart rate of 120 beats per minute. The nurse recalls that causes of sinus tachycardia include which of the following?
Hypovolemia and fever
The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?
Immediate defibrillation
When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition?
Inadequate fluid volume
Which is the most important postoperative assessment parameter for a client recovering from cardiac surgery?
Inadequate tissue perfusion
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
Instruct the client to breathe into a paper bag
A nursing student is giving to a client with heart failure a medication with a positive inotropic effect on the heart. The student asks what a "positive inotropic" effect is. The correct response would be which of the following?
It increases the force of the myocardial contraction
A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?
Lie down or sit in a chair for 5 to 10 minutes after taking the drug
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
Light-headedness or paresthesia
Which term refers to a form of white blood cell involved in immune response?
Lymphocyte
A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia?
Magnesium and potassium
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?
Metabolic acidosis
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?
Metabolic alkalosis
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic alkalosis
You are caring for a 65-year-old male patient admitted to your unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission has been on low intermittent suction ever since. You notice that the patient's potassium is very low. What would you be concerned that the patient may be at risk for?
Metabolic alkalosis
Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?
Monitor the site for bleeding or hematoma.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?
Myeloid stem cell
A female patient is being seen in the ER complaining of fatigue and shoulder blade discomfort. She is also short of breath. Based on these symptoms, the nurse should suspect which of the following?
Myocardial infarction (MI)
Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of:
Myocardial necrosis
The body responds to infection by increasing the production of white blood cells (WBCs). The nurse knows to evaluate the differential count for the level of __________, the first WBCs to respond to an inflammatory event.
Neutrophils
Which is a symptom of severe thrombocytopenia?
Petechiae
When the nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II and observes a bizarre, abnormal shape to the QRS complex, the nurse has likely observed which of the following ventricular dysrhythmias?
Premature ventricular contraction (PVC)
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
Providing a solution of viscous lidocaine for use as a mouth rinse
A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next?
Question the client about alcohol and illicit drug use.
An older adult patient presents to the physician's office with a complaint of exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?
RBC count
The nurse reviews the ECG strip, which indicates extended time between ventricular depolarization and repolarization. He checked the ventricular rate and rhythm again. To do that, the nurse would have to check which of the following?
RR interval
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis?
Red, open sores on the oral mucosa
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?
Respiratory acidosis
A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?
Respiratory acidosis
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?
Respiratory alkalosis
A patient with anxiety presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?
Respiratory alkalosis
The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter?
Sawtooth
Which of the following arterial blood gas results would be consistent with metabolic alkalosis?
Serum bicarbonate of 28 mEq/L
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure ulcer on the left heel
A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately
Stops the chemotherapeutic infusion
The client has received chemotherapy and 1 week later is at home experiencing nausea and vomiting. The first action of the nurse is to recommend
Taking prescribed ondansetron (Zofran)
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?
The client demonstrates ability to tolerate more activity without chest pain.
The client has just been diagnosed with a dysrhythmia. The client asks the nurse to explain normal sinus rhythm. What would the nurse explain is the characteristic of normal sinus rhythm?
The sinoatrial (SA) node initiates the impulse.
Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low?
U wave
A new nurse is admitting a patient with a history of emphysema. The new nurse's preceptor is going over the patient's past lab reports with the new nurse. The nurse takes note that the patient's PaCO2 has been between 56 and 64mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurse's best response?
Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia
A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?
Wear personal protective equipment when handling blood, body fluids, and feces
A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase (Activase). This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?
Within 6 hours
Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur?
Worsening angina
A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will require long-term administration of:
aspirin or clopidogrel (Plavix)
The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. The nurse includes which of the following information about managing this condition? Choose all that apply.
balance rest with activity, stop smoking, carry NTG at all times
A nurse is teaching a client how to take nitroglycerin to treat angina pectoris. The client verbalizes an understanding of the need to take up to three sublingual nitroglycerin (Nitrostat) tablets at 5-minute intervals, if necessary, and to notify the physician immediately if chest pain doesn't subside within 15 minutes. The nurse tells the client that, after taking the nitroglycerin, he may experience:
headache, hypotension, dizziness, and flushing.
A physician orders esmolol (Brevibloc) for a client with supraventricular tachycardia. During esmolol therapy, the nurse should monitor the client's:
heart rate and blood pressure.
According to the TNM classification system, T0 means there is
no evidence of primary tumor.
Premature ventricular contractions (PVCs) are considered precursors of ventricular tachycardia (VT) when they:
occur at a rate of more than six per minute
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?
pH 7.48
Which set of arterial blood gas (ABG) results requires further investigation?
pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
pH, 7.25; PaCO2 50 mm Hg
Palliation refers to
relief of symptoms associated with disease and promotion of comfort and quality of life.
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
respiratory alkalosis
A client with an acute myocardial infarction is receiving nitroglycerin by continuous I.V. infusion. Which client statement indicates that this drug is producing its therapeutic effect?
"My chest pain is decreasing."
A nursing student working today on the cardiac unit asks the instructor why loss of the "atrial kick" causes a decrease in cardiac output, because ventricles are still contracting. The instructor's best answer is which of the following?
"The atrial contraction fills the ventricles and accounts for nearly one third of the volume ejected during ventricular contraction."
A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between ventricular tachycardia and ventricular fibrillation when I look at the EKG strip?" The best reply by the nurse is which of the following?
"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast with wide QRS complexes."
A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin (Coumadin). Which response by the charge nurse is best?
"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."
The nurse is caring for a client with atrial fibrillation. The client's symptoms started about 1 week ago, but he is just now seeking medical attention. The client asks the nurse why he has to wait several weeks before the cardioversion takes place. The best answer by the nurse is which of the following?
"Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion."
Electrocardiogram (ECG) waveforms are printed on graph paper that is divided by light and dark vertical and horizontal lines at standard intervals. When the nurse is interpreting the heart rhythm, he or she understands that each large block equals how many seconds?
0.2
Which PR interval presents a first-degree heart block?
0.24 seconds
A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
Administering metoclopramide and dexamethasone as ordered
Which is a sign or symptom of septic shock?
Altered mental status
Which of the following is a term used to describe the process by which a new blood supply is formed?
Angiogenesis
G-CSF (filgrastim [Neupogen]) is prescribed for a client with bone marrow suppression. What medication administration teaching should the nurse provide to the client?
Assist the client in identifying appropriate subcutaneous injection sites.
The nurse plays an important role in monitoring and managing potential complications in the patient who has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which of the following respiratory complications?
Atelectasis
The nurse cares for a client with a dysrhythmia and understands that the P wave on an electrocardiogram (ECG) represents which phase of the cardiac cycle?
Atrial depolarization
A client has had a pacemaker implanted and the nurse will begin client education upon the client becoming alert. Which postimplantation instructions must be provided to the client with a permanent pacemaker?
Avoid sources of electrical interference.
A client is receiving nitroglycerin ointment (Nitro-Dur) to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?
Blood pressure 84/52 mm Hg
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles?
Cardiac tamponade
