Cardiac/Respiratory
For which client does the nurse remain alert for the possibility of respiratory acidosis?
Client with multiple rib fractures
A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect
Elevated CVP
A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?
Irregular pulsations
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 are a key indicator of cardiac tamponade
A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)
Nausea Tachycardia Diaphoresis
After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?
"I take sodium bicarbonate after every meal to prevent heartburn."
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?
Administer oxygen via face mask.
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?
Assess the client's airway
A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
Confusion
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best?
Cover the insertion site with sterile gauze
A nurse is assessing a client who has infective endocarditis. Which of the following should be the priority for the nurse to report to the provider?
Dyspnea
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?
Irregular
A nurse is caring for a client who has hypovolemic shock. Which of the following is an expected finding?
Oliguria
The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?
Radial pulse in the left arm
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?
Perform pre-oxygenation prior to suctioning
A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. Which of the following ECG results should indicate to the nurse that the medications has been effective?
Reduction of T wave amplitude
Which action will the nurse teach an older client with a respiratory problem to make as an accommodation to promote adequate gas exchange?
Replace at least one meal each day with a high-calorie liquid food supplement.
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition?
Sever dyspnea Decreased level of consciousness Headache Hypotension
A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?
Troponin I
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? (Select all that apply.)
Troponin I Troponin T СРК Myoglobin
Which assessment finding in a client who has had a lobectomy and placement of a chest tube 8 hours ago requires immediate follow-up by the nurse
A 200 mL red drainage from chest tube over 2 hours
A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first?
A 27-year old client with a heart rate of 120 beats/min
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first.
A 52-year old in a tripod position using accessory muscles to breathe.
a nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best?
Administer oxygen and place client on an oximeter. Administer prescribed albuterol inhaler. Assess the client's lung sounds after administering the inhaler
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect
Blood pressure 115/68
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?
Breathlessness
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? (Select all that apply.)
Check peripheral pulses in the affected extremity. Place the client in high-Fowler's position. Keep the client's hip and leg extended.
Which changes in arterial blood gas (ABG) values will the nurse expect in a client with long-term COPD?
Decreased pH, Decreased PaO2, Increased PaCO2, Increased bicarb
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
Ensuring there is a bag-valve-mask in the room
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?
Fatigue
A diabetic patient becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50; PaCO2 30; HCO3: 24; and PaO2 68. What does the nurse recognize as the primary factor causing this the acid-base imbalance?
Hyperventilation due to poor oxygenation
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
Increased heart rate Increased blood pressure Increased respiratory rate
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?
Increased respiratory rate
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
Massaging her legs
A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
Movement of the ET tube into the right main bronchus
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Obtain a 12-lead EKG
a nurse is caring for a client who is post-operative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
dull aching calf pain
