CC Exam 3
Which observation would the nurse associate with a cerebrospinal fluid (CSF) leak when a patient with a suspected traumatic brain injury (TBI) develops a bloody nasal drainage? a. A halo sign on the nasal-drip pad b. Decreased BP and urinary output c. A positive reading for glucose on a test-tape strip d. Clear nasal drainage along with the bloody discharge
a. A halo sign on the nasal-drip pad When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. MS pg 1312
A patient's electrocardiogram (ECG) now shows no P waves, fine and wavy lines between the QRS complexes, QRS complexes that measure 0.08 sec, and QRS complexes that occur irregularly with a rate of 120 beats/minute. Which interpretation of the rhythm would the nurse make? a. Atrial fibrillation b. Sinus tachycardia c. Ventricular fibrillation d. Ventricular tachycardia
a. Atrial fibrillation Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not contracting truly, just fibrillating. MS pg 763
Which manifestations in a patient with a T4 spinal cord injury alerts the nurse to the possibility of autonomic dysreflexia? a. Headache and increased BP b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds
a. Headache and increased BP Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. MS pg 1415
Which cardiac problem is an indication for placement of a permanent pacemaker? a. Heart failure b. Edema after open-heart surgery c. Evaluation of tachydysrhythmias d. Acute inferior myocardial infarction
a. Heart failure MS pg 772
A nurse is caring for a client in the ICU who has a history of cardiac dysrhythmias. The client goes into a state of ventricular tachycardia and the nurse is unable to find a pulse. The code team arrives and delivers a shock of defibrillation to the client at 360 Joules. Which step would the nurse perform next? a. Immediately resume chest compressions b. Assess the client's pulse c. Provide two manual breaths with a bag and mask d. Administer 1 mL of IV epinephrine
a. Immediately resume chest compressions A client who is in ventricular fibrillation or pulseless ventricular tachycardia has a shockable rhythm and the healthcare staff can perform defibrillation. Immediately after providing the first shock to the client, the team should restart chest compressions without stopping to check a pulse. The nurse should perform CPR for 2 minutes before stopping to assess the client's heart rhythm. NRSG
A patient with a new cervical spinal cord injury is hospitalized. The nurse identifies that which interventions are appropriate to include in the patient's nutrition plan? Select all that apply. a. Insert a nasogastric tube. b. Evaluate swallowing before starting oral feeding. c. Prescribe a low-protein, low-carbohydrate diet. d. If oral feeding is not possible, enteral nutrition must be provided. e. Gradually introduce oral food and fluids, irrespective of bowel sounds.
a. Insert a nasogastric tube. b. Evaluate swallowing before starting oral feeding. d. If oral feeding is not possible, enteral nutrition must be provided. During the first 48 to 72 hours after the injury, the gastrointestinal (GI) tract may stop functioning (paralytic ileus), and hence a nasogastric tube should be inserted. In patients with high cervical cord injuries, evaluate swallowing before starting oral feedings. If the patient is unable to resume eating, then enteral nutrition may be used to provide nutritional support. MS pg 1413
A patient with a history of unstable angina reports a sudden onset of retrosternal chest heaviness and tightness, fatigue, shortness of breath, and nausea. Which actions would the nurse take? Select all that apply. a. Obtain a 12-lead electrocardiogram (ECG). b. Administer sublingual nitroglycerin. c. Place the patient in a supine position. d. Apply high-flow oxygen by face mask. e. Auscultate for a pericardial friction rub
a. Obtain a 12-lead electrocardiogram (ECG). b. Administer sublingual nitroglycerin. Initial management of the patient with chest pain includes the following: Obtain a 12-lead ECG and start continuous ECG monitoring. Position the patient in an upright, not supine, position unless contraindicated, and initiate oxygen by nasal cannula (not high-flow by face mask) to keep oxygen saturation above 93%. Establish an IV route to provide an access for emergency drug therapy. Give sublingual nitroglycerin and aspirin (chewable). Morphine sulfate is given for pain unrelieved by nitroglycerin (NTG). MS pg 722
Which therapy would the nurse anticipate administering for emergency care of a patient with a suspected myocardial infarction (MI)? a. Oxygen, nitroglycerin, aspirin, and morphine b. Aspirin, nitroprusside, dopamine, and oxygen c. Nitroglycerin, lorazepam, oxygen, and warfarin d. Oxygen, furosemide, nitroglycerin, and meperidine
a. Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. MS pg 712
The nurse is caring for a patient two days after the patient experienced a myocardial infarction. For which complications will the nurse monitor the patient? Select all that apply. a. Pericarditis b. Heart failure c. Dysrhythmia d. Dressler syndrome e. Cardiogenic shock
a. Pericarditis b. Heart failure c. Dysrhythmia e. Cardiogenic shock Dysrhythmia, heart failure, pericarditis, and cardiogenic shock are all serious complications that can arise immediately and several days after myocardial infarction. MS pg 720
The nurse is caring for a client with a head injury. The client is experiencing increasing intracranial pressure (ICP). Which of the following findings is most consistent with this condition? a. Systolic blood pressure increases and diastolic blood pressure decreases b. Diastolic blood pressure increases while systolic blood pressure remains the same c. The client's blood pressure continues to progress to hypertensive crisis d. The client's blood pressure continues to decrease until the pulse is thready and nonpalpable
a. Systolic blood pressure increases and diastolic blood pressure decreases A widening pulse pressure is consistent with increasing ICP. Pulse pressure is the difference between the systolic and diastolic blood pressure reading. NRSG
A client is in ventricular fibrillation. The nurse understands that which of the following is true of ventricular fibrillation? Select all that apply. a. The client has no cardiac output b. The ventricle rate is >160 beats per minute c. The nurse must start CPR immediately d. The nurse must call for a stat EKG e. The client experiences heart palpitations
a. The client has no cardiac output c. The nurse must start CPR immediately Ventricular fibrillation is a life-threatening medical emergency. The ventricles are quivering, not beating. The client has no cardiac output, and death is imminent without immediate medical intervention. Following ACLS guidelines, the nurse would check for a pulse, call for help, and begin CPR right away. Early defibrillation is the only chance the client will have to get a normal sinus rhythm back. NRSG
Which intervention does the nurse perform in the acute care of a patient with autonomic dysreflexia? a. Urinary catheterization b. Administration of benzodiazepines c. Suctioning of the patient's upper airway d. Placement of the patient in the Trendelenburg position
a. Urinary catheterization Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. MS pg 1415
An early sign of increased intracranial pressure includes which of the following? a. altered LOC b. elevated ammonia level c. decreased respiratory rate d. tachycardia
a. altered LOC An early sign of increased intracranial pressure include an altered level of consciousness, blurry vision, and a headache. NRSG
The nurse is caring for a client with newly diagnosed atrial fibrillation. Which medication class does the nurse anticipate the client will need to take to prevent the formation of blood clots? a. anticoagulants b. thrombolytics c. antipyretics d. analgesics
a. anticoagulants Anticoagulants prevent the formation of blood clots, and are prescribed for clients with atrial fibrillation. Two types of anticoagulants are heparin and warfarin. NRSG
While caring for a pt, the nurse notes an irregular pulse & obtains an ECG, which shows a-fib at a rate of 148. The pt reports experiencing an irregular heartbeat for several days. Which intervention should the nurse perform first? a. auscultate heart sounds for murmur/adventitious sounds b. electrical cardioversion c. administer anticoagulant d. administer beta blocker
a. auscultate heart sounds for murmur/adventitious sounds nurse think pg 89
While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? Select all that apply. a. bradycardia b. weak pulse c. irregular respirations d. increasing systolic BP e. decreasing systolic BP
a. bradycardia c. irregular respirations d. increasing systolic BP Cushing's triad consists of bradycardia, irregular respiration, and a widening pulse pressure (increasing systolic pressure). The pulse is full and bounding, not weak. The systolic BP increases, not decreases. MS pg 1303
Which of the following is the first medication given for a client in ventricular fibrillation? a. epi b. atropine c. bretyllium d. lidocain
a. epi This is the first medication given for ventricular fibrillation, which is a medical emergency. The order of care for ventricular fibrillation is CPR, then defibrillation, then epinephrine, then amiodarone. NRSG
A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care? a. tadalafil (cialas) b. furosemide (lasix) c. warfarin (coumadin) d. diltiazem (cardizem)
a. tadalafil (cialas) The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using tadalafil because of the risk of severe hypotension caused by vasodilation.
May develop when chest pain from ischemia is prolonged & not immediately reversible:
acute coronary syndrome (ACS) Caused by the decline of a once-stable atherosclerotic plaque- plaque ruptures & releases into the vessel, causing platelet aggregation & thrombus formation. Vessel can become partially occluded (NSTEMI, UA) or totally occluded (STEMI). MS pg 717
Heart rhythm characterized by a total disorganization of atrial electrical activity:
atrial fibrillation
Atrial tachydysrhythmia identified by recurring, regular, sawtooth-shaped flutter waves:
atrial flutter
Sudden, exaggerated autonomic response to stimuli in people with spinal cord injuries/dysfunction:
autonomic dysreflexia -causes an increase in BP & decrease in HR **medical emergency**
The nurse provides education to a patient who receives a prescription for sublingual nitroglycerin for treatment of angina. Which statement made by the patient indicates the need for further teaching? a. "I cannot take sildenafil and nitroglycerin at the same time." b. "After the bottle is open, the tablets should be replaced every 12 months." c. "After taking a tablet, I may experience a headache, dizziness, or flushing." d. "I can take a tablet 5 to 10 minutes before starting an activity that causes angina."
b. "After the bottle is open, the tablets should be replaced every 12 months." After the bottle is open, the tablets lose potency and should be replaced every 6 months. Patients should be instructed not to combine nitroglycerin with drugs used for erectile dysfunction (e.g., sildenafil [Viagra]) because severe hypotension can occur. Headache, dizziness, or flushing may occur after taking the medication. The patient can take the medication prophylactically before starting an activity that is known to cause angina. In these cases, the patient can take a tablet or spray 5 to 10 minutes before beginning the activity. MS pg 711
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. 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. "Sexual activity uses about as much energy as climbing two flights of stairs." Sexual activity places about as much physical stress on the cardiovascular system as moderate-energy activities, such as climbing two flights of stairs.
The nurse is caring for a pt admitted with a possible diagnosis of GBS. What statement by the pt requires immediate follow-up? a. "i had the flu about a month ago and thought i was over it" b. "im having difficulty breathing and feel like i cant catch my breath" c. "i am having trouble doing ADLs" d. "my hands and feet are numb and feel very heavy"
b. "im having difficulty breathing and feel like i cant catch my breath" nurse think pg 385
A patient experiences prolonged chest pain that is not immediately reversible. The patient's health care provider explains that the cause of the pain is that a once-stable atherosclerotic plaque has ruptured, causing platelet aggregation and thrombus formation. Which condition is consistent with this explanation? a. Unstable angina b. Acute coronary syndrome (ACS) c. ST-segment-elevation myocardial infarction (STEMI) d. Non-ST-segment-elevation myocardial infarction (NSTEMI)
b. Acute coronary syndrome (ACS) When ischemia is prolonged and not immediately reversible, ACS develops. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as STEMI. MS pg 717
Which clinical manifestations in a patient with chest pain are associated with myocardial infarction (MI)? Select all that apply. a. Flushing b. Ashen skin c. Diaphoresis d. S3 or S4 heart sounds e. Nausea and vomiting
b. Ashen skin c. Diaphoresis d. S3 or S4 heart sounds e. Nausea and vomiting During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy as a result of this response. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Skin is ashen and clammy rather than flushed. MS pg 719
The nurse is concerned that a client with atrial fibrillation is not on any anticoagulants and notifies the healthcare provider. The nurse knows that which of the following is a reason why a client with atrial fibrillation is at an increased risk for a stroke? a. There is increased blood since the atria are contracting faster b. Blood pools in the atria due to their quivering which increases the risk for clots c. Blood contracts faster so it clots easier d. The rapid ventricular response increases the risk for blood clots
b. Blood pools in the atria due to their quivering which increases the risk for clots Blood pools in the atria because of the quivering and forms a clot. NRSG
A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the 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. Check the drainage for glucose content. Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose.
The nurse is caring for a patient who develops atrial fibrillation. Which treatments may be included the patient's treatment plan? Select all that apply. a. Atropine injection b. Electrical cardioversion c. Anticoagulation therapy d. Implantable cardioverter-defibrillator (ICD) e. Radiofrequency catheter ablation
b. Electrical cardioversion c. Anticoagulation therapy e. Radiofrequency catheter ablation Electrical cardioversion converts the atrial fibrillation into normal sinus rhythm. If a patient is in atrial fibrillation for more than 48 hours, anticoagulation therapy with warfarin will be required for three to four weeks. This should commence before the cardioversion and has to be continued for several weeks after successful cardioversion. For patients with drug-refractory atrial fibrillation or those who do not respond to electrical conversion, radiofrequency catheter ablation may be done. MS pg 764
The nurse provides postoperative care for a patient after a cervical spine stabilization surgery. The nurse recognizes that which interventions will help stabilize the spine? Select all that apply. a. Avoid "logrolling" the patient. b. Ensure that the patient's body is correctly aligned. c. Use a sternal-occipital-mandibular immobilizer brace. d. Keep a soft cervical collar in place. e. Turn the patient as a unit.
b. Ensure that the patient's body is correctly aligned. c. Use a sternal-occipital-mandibular immobilizer brace. e. Turn the patient as a unit. Proper immobilization of the neck involves the maintenance of a neutral position. After cervical fusion or other stabilization surgery, the patient may have a hard cervical collar or sternal-occipital-mandibular immobilizer brace. The nurse should always keep the patient's body in correct alignment. The patient should be turned as a unit (e.g., logrolling) to prevent movement of the spine. MS pg 1411
The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) a. judgment b. Eye opening c. Abstract reasoning d. Best motor response e. Best verbal response f. Cranial nerve function
b. Eye opening d. Best motor response e. Best verbal response The three dimensions of the GCS are eye opening, best verbal response, and best motor response. MS evolve resources
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours. d. Apply cold packs intermittently to face.
b. Insert nasogastric tube to low suction. Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis.
The nurse is assessing a patient with a T2 level spinal cord injury (SCI). The nurse notes that there is a kink in the catheter, the bladder is distended, and the BP is 220/100 mm Hg. Which interventions does the nurse implement? Select all that apply. a. Lower the head of the bed. b. Monitor BP regularly. c. Place the patient in a flat-lying position. d. Notify the primary health care provider. e. Check for the presence of bowel impaction. f. Remove the kink in the catheter and drain the bladder.
b. Monitor BP regularly. d. Notify the primary health care provider. e. Check for the presence of bowel impaction. f. Remove the kink in the catheter and drain the bladder. The patient is evidencing signs of autonomic dysreflexia (AD), which is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system (SNS). It involves stimulation of sensory receptors below the level of the SCI. The intact SNS below the level of injury responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP. Nursing interventions in a serious emergency like AD include notifying the primary health care provider and determining the cause. The BP should be regularly monitored; administration of an α-adrenergic blocker or an arteriolar vasodilator is required. Contractions of the rectum are also a cause; therefore, the nurse should check for bowel impaction and treat it accordingly. The most common cause is bladder distention. If a catheter is present, then the presence of any kinks or folds should be checked. However, the most important nursing intervention in this case is elevating the head of the bed 45 degrees or higher to make the patient sit upright; this would lower the BP. MS pg 1414
An experienced nurse teaches a group of new graduate nurses about temporary pacemakers. Which information would the nurse include about indications for a temporary pacemaker? Select all that apply. a. Heart failure b. Prophylaxis after open heart surgery c. Atrial fibrillation with slow ventricular response d. Acute anterior myocardial infarction (MI) with second- or third-degree atrioventricular (AV) block e. Acute inferior MI with symptomatic bradycardia and AV block
b. Prophylaxis after open heart surgery d. Acute anterior myocardial infarction (MI) with second- or third-degree atrioventricular (AV) block e. Acute inferior MI with symptomatic bradycardia and AV block A temporary pacemaker helps to maintain the normal pace of the heart when its electrical pathways are damaged. The power source of this device is placed outside the body. Temporary pacemakers are used after open heart surgery as prophylaxis. They are also indicated for use in patients with acute anterior MI with second- or third-degree heart block or bundle branch block or symptomatic bradycardia and AV block. MS pg 772
A patient's electrocardiogram (ECG) shows a heart rate of 150 beats/minute and a normal P wave preceding each QRS complex. Which interpretation would the nurse make of these findings? a. Atrial fibrillation b. Sinus tachycardia c. Ventricular fibrillation d. Premature atrial contractions
b. Sinus tachycardia Sinus tachycardia includes a heart rate of 101 beats to 180 beats per minute. The electrocardiographic study of sinus tachycardia shows a normal P wave preceding each QRS complex with normal time and duration. MS pg 760
Metoprolol 25 mg bid PO has been prescribed. Which VS would require the nurse to hold the medication? a. T 98.1, RR 18, HR 88, BP 100/68 b. T 98.5, RR 16, HR 50, BP 98/64 c. T 100.4, RR 20, HR 100, BP 148/88 d. T 99.2, RR 16, HR 80, BP 96/76
b. T 98.5, RR 16, HR 50, BP 98/64 nurse think pg 88
After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? a. Pulse of 102 beats/min b. Temperature of 101.6° F c. Intracranial pressure of 15 mm Hg d. Mean arterial pressure of 90 mm Hg
b. Temperature of 101.6° F Infection is a serious complication of ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor.
For the patient admitted for observation after a minor head injury, which assessment findings would support the nurse's suspicion of an increasing intracranial pressure? Select all that apply. a. The patient is alert and oriented. b. The patient is experiencing hemiplegia. c. The patient has unilateral pupil dilation. d. The patient has a regular respiratory rate of 14 breaths/min. e. The patient is vomiting without preceding nausea.
b. The patient is experiencing hemiplegia. c. The patient has unilateral pupil dilation. e. The patient is vomiting without preceding nausea. Unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial pressure. A patient with increased intracranial pressure would likely have an impaired level of consciousness rather than being alert and oriented. He or she would also have an irregular, not regular, respiratory rate. MS pg 1304
Which medication is used to manage a complication of atrial fibrillation? a. Digoxin b. Warfarin c. Diltiazem d. Metoprolol
b. Warfarin A complication of atrial fibrillation is clot formation in the atria due to blood pooling. Warfarin is an anticoagulant to prevent this complication. MS pg 764
A pt reporting dizziness & SOB is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the pt for asystole? a. digoxin b. adenosine c. metoprolol d. atropine sulfate
b. adenosine IV adenosine is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's electrocardiogram continuously because a brief period of asystole after adenosine administration is common and expected. MS evolve resources
The nurse is reviewing a client's medications and notes the client is taking warfarin sodium. Which of the following medications should the nurse tell the client to avoid? a. enalapril b. aspirin c. promethazine d. metoprolol
b. aspirin Taking warfarin and salicylates concurrently can increase the risk of bleeding, so this should be avoided. NRSG
The nurse is caring for a telemetry client. Upon entering the room, the nurse notices a few premature ventricular contractions on the cardiac monitor. As the nurse begins an assessment, the client goes into ventricular tachycardia on the monitor. Which of the following nursing actions is most appropriate? a. call a code blue b. check for pulse c. call for help d. notify HCP
b. check for pulse The first step for a client in ventricular tachycardia is to check a pulse. If there isn't a pulse, then using the ACLS algorithm, the client would be treated with defibrillation. NRSG
The nurse is caring for a client with a brain tumor. The client has an altered level of consciousness and is experiencing bradycardia, bradypnea, and a widening pulse pressure. Which of the following interventions are appropriate for this client? Select all that apply. a. inducing shivering b. decrease stimuli c. avoiding trendelenburg position d. HOB elevated 30 degrees e. maintaining O2 between 80-88%
b. decrease stimuli c. avoiding trendelenburg position d. HOB elevated 30 degrees This client's intracranial pressure (ICP) is increasing, so all interventions should be aimed at lowering ICP. Elevating the head of the bed to 30-40 degrees is appropriate. Stimuli can increase ICP, so decreasing stimuli is an appropriate nursing intervention. Trendelenburg position will increase ICP, so the nurse must avoid placing the client in this position. NRSG
Female pt who sustained a cervical spinal cord injury w/ quadriplegia states she has a headache. Which is the first nursing action? a. comprehensive pain assessment b. palpate & bladder scan the lower abdomen c. turn the pt to the side d. assess temp
b. palpate & bladder scan the lower abdomen Could be a sign of autonomic dysreflexia nurse think pg 384
A patient is recovering from an uncomplicated myocardial infarction (MI). Which instructions will the nurse include about physical activity? "a. Start out with 30-minute sessions." b. "Be sure to perform physical activity at least twice a week." c. "Physical activity should be regular, rhythmic, and repetitive." d. "Your heart rate during exercise should only be 30 beats over your resting rate."
c. "Physical activity should be regular, rhythmic, and repetitive." Physical activity should be regular, rhythmic, and repetitive, using large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Instruct the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes. Encourage the patient to perform physical activity on most days of the week. Activity intensity is determined by the patient's heart rate. If an exercise stress test has not been performed, the heart rate of the patient recovering from an MI should not exceed 20 beats/min over the resting heart rate. MS pg 704
A patient phones a health care provider's office and states, "I am having severe chest tightness that won't go away even when I lie down." In addition to contacting emergency responders, which instruction would the nurse provide to the patient? a. "Lie down with your feet elevated." b. "Go to a neighbor's house to get assistance." c. "Take chewable aspirin. The total dose should be 325 mg." d. "Take your blood pressure. It will be useful to know for your care."
c. "Take chewable aspirin. The total dose should be 325 mg." The symptoms described by the patient may be due to acute coronary syndrome (ACS). Advise the patient to take chewable aspirin; the dose is 162 to 325 mg (typically 4 baby aspirin or 2 adult aspirin). The patient's BP may be elevated, and lying with the feet elevated will most likely increase the BP. The patient should not increase oxygen demand by walking to a neighbor's house or by taking the BP. MS pg 722
The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? a. A 62-yr-old man with a fever and sinus tachycardia with a rate of 110 beats/min b. A 72-yr-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute c. A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute d. A 42-yr-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/min
c. A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute Frequent premature ventricular contractions (PVCs) (>1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. MS evolve resources
A patient who is being discharged from the hospital after acute coronary syndrome will be participating in cardiac rehabilitation. Which information will the nurse provide about the early recovery phase of rehabilitation? a. Activity level depends on severity of angina or myocardial infarction (MI). b. Therapeutic lifestyle changes should become lifelong habits. c. Activity level is increased gradually with supervision and with electrocardiogram (ECG) monitoring. d. The focus will be on management of chest pain, anxiety, dysrhythmias, and other complications.
c. Activity level is increased gradually with supervision and with electrocardiogram (ECG) monitoring. In the early recovery phase after the patient is dismissed from the hospital, the activity level is increased gradually under supervision and with ECG monitoring. MS pg 726
For which problem is percutaneous coronary intervention (PCI) initially indicated? a. Chronic stable angina b. Left-sided heart failure c. Acute myocardial infarction d. Coronary artery disease (CAD)
c. Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. MS pg 712
A patient develops symptomatic sinus tachycardia. Which drug will likely be included in the patient's treatment plan? a. Atropine b. Dopamine c. Adenosine d. Epinephrine
c. Adenosine Hypotension, dizziness, and dyspnea are symptoms of sinus tachycardia. Sinus tachycardia manifests as increased heart rate from 101 beats/minute to 180 beats/minute. Adenosine is used in the treatment of sinus tachycardia. Adenosine decreases the heart rate caused by inhibition of the vagus nerve and myocardial oxygen consumption. MS pg 762
A 19-year-old student comes to the student health center at the end of the semester stating, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a. Insert an IV catheter for emergency use. b. Start supplemental O2 at 2 to 3 L/min via nasal cannula. c. Ask the patient about current stress level and caffeine use. d. Have the patient taken to the nearest emergency department (ED).
c. Ask the patient about current stress level and caffeine use. In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors.
To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist to plan a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.
c. Assist to plan a prescribed bowel program. Fecal impaction is a common stimulus for autonomic hyperreflexia.
Which symptoms in a 55-year-old female patient would the nurse recognize as possibly indicating unstable angina? a. Dyspnea, hyperglycemia, and polyuria b. Altered mentation with difficulty breathing c. Fatigue, indigestion, and shortness of breath d. Peripheral edema with decreased urinary output
c. Fatigue, indigestion, and shortness of breath An adult female with fatigue, indigestion, and dyspnea may be experiencing an unstable anginal (UA) attack. MS pg 719
The nurse is caring for a client who has suddenly gone into ventricular fibrillation. Which of the following is true about this condition? Select all that apply. a. The blood pressure is usually normal b. The client will feel an irregular heartbeat c. It is the most severe of all dysrhythmias d. It can be caused by a myocardial infarction e. Blood flow must be restored or there will be death in 1-5 minutes
c. It is the most severe of all dysrhythmias d. It can be caused by a myocardial infarction e. Blood flow must be restored or there will be death in 1-5 minutes Ventricular fibrillation is the most severe of all dysrhythmias and can be caused by a myocardial infarction. The client is unconscious with no blood pressure and blood flow must be restored or death will occur in 1-5 minutes. NRSG
Which clinical manifestations would the nurse anticipate identifying in a patient who is comatose? Select all that apply. a. Patient can cough and swallow. b. Patient has bowel and bladder control. c. Patient does not respond to painful stimuli. d. Patient has incontinence of urine and feces. e. Patient's corneal and pupillary reflexes are absent.
c. Patient does not respond to painful stimuli. d. Patient has incontinence of urine and feces. e. Patient's corneal and pupillary reflexes are absent. A coma is the deepest state of unconsciousness in which the corneal and pupillary reflexes are absent. A comatose patient is also incontinent of urine and feces and does not respond to painful stimuli. The comatose patient is not able to cough and swallow and does not have any bowel and bladder control. MS pg 1303
The electrocardiogram (ECG) monitor of a patient in the cardiac care unit after myocardial infarction (MI) indicates ventricular fibrillation. Which action would the nurse take immediately? a. Perform synchronized cardioversion. b. Administer IV amiodarone. c. Perform cardiopulmonary resuscitation (CPR). d. Prepare for insertion of a temporary transvenous pacemaker
c. Perform cardiopulmonary resuscitation (CPR). Treatment consists of immediate initiation of CPR and advanced cardiac life support (ACLS) with the use of defibrillation and definitive drug therapy (e.g., epinephrine, vasopressin). There should be no delay in using a defibrillator once available. MS pg 768
Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient's sacral area skin is reddened. b. The patient reports severe pain in the feet. c. The patient is continuously drooling saliva. d. The patient's blood pressure (BP) is 150/82 mm Hg.
c. The patient is continuously drooling saliva. Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation.
The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.
c. The staff nurse suctions the patient routinely every 2 hours. Suctioning increases intracranial pressure and should only be done when the patient's respiratory condition indicates it is needed.
Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? a. Administer 250 mL of 0.9% saline solution IV by rapid bolus. b. Assess the apical pulse, blood pressure, and bilateral neck vein distention. c. Turn the synchronizer switch to the "off" position and recharge the device. d. Ask the patient if there is any chest pain or discomfort and administer morphine sulfate.
c. Turn the synchronizer switch to the "off" position and recharge the device. Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. MS evolve resources
The nurse is caring for a pt who is 24 hours post pacemaker insertion. Which intervention is appropriate at this time? a. reinforcing the pressure dressing as needed b. encouraging ROM exercises of the involved arm c. assessing incision for any redness, swelling, or discharge d. applying wet-to-dry dressings q4hr to the insertion site
c. assessing incision for any redness, swelling, or discharge After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement. MS evolve resources
Postop care for a pt undergoing CABG surgery includes monitoring for which common complication? a. dehydration b. paralytic ileus c. atrial dysrhythmias d. ARDS
c. atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. MS evolve resources
A client has developed bradycardia and symptoms of shock. Which of the following medications would the nurse most likely administer to correct this situation? a. adenosine b. verapamil c. atropine d. amiodarone
c. atropine Atropine is a medication used in the treatment of severe bradycardia, and is one of the first drugs administered for very low heart rate during advanced cardiac life support. When a client develops bradycardia and shows symptoms of poor perfusion, atropine is most likely going to be ordered to be administered to regulate the heart rate. NRSG
Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities? a. stroke b. decerebrate posturing c. decorticate posturing d. epileptic seizure
c. decorticate posturing Decorticate posturing—described as flexion of the arms, wrists, and fingers—and adduction of the upper extremities indicate damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. MS pg 1304
The nurse observes a flat line on the patient's monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer? a. lidocaine or amiodarone b. digoxin & procainamide c. epi & vasopressin d. beta blockers & dopamine
c. epi & vasopressin Normally, the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine or vasopressin may prompt the return of depolarization and ventricular contraction. MS evolve resources
A client is being cared for after a traumatic brain injury. During an initial assessment, the nurse performs the Glasgow Coma Scale and gives the client a score of 8. Which of the following responses from the nurse is appropriate to manage the client's respiratory rate? a. administer O2 via nasal cannula b. administer O2 via non-rebreather c. prepare for intubation d. remove O2 & assess SpO2
c. prepare for intubation A GCS score less than 9 indicates that the client is impaired enough that he may not be able to breathe on his own without assisted ventilation. When the score is less than 9, the nurse should prepare for intubation (which will be at the discretion of the provider). NRSG
After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? a. A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain. b. A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia). c. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge. d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).
d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI). After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately.
Which action would the nurse implement when a patient's assessment reveals an increased intracranial pressure (ICP) and the patient has a lumbar puncture scheduled? a. Prepare the patient and assist with the lumbar puncture. b. Reschedule the lumbar puncture for the next business day. c. Administer IV fluids before the lumbar puncture. d. Cancel the lumbar puncture and contact the prescribing provider.
d. Cancel the lumbar puncture and contact the prescribing provider. Lumbar puncture may cause cerebral herniation due to the sudden release of pressure in the skull from the area above the punctured site and is contraindicated in a patient with increased ICP, so cancel the procedure and contact the prescribing provider. MS pg 1304
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 is most specific for the nurse to monitor in determining whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin
d. Cardiac-specific troponin Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI.
A client who has experienced a head injury is being cared for by the nurse in the ICU. The client has a monitor in place to check intracranial pressure and the nurse notes that the pressure is increasing. Which of the following interventions by the nurse should be done to control increasing intracranial pressure? a. Reposition the intracranial monitor b. Elevate the head of the bed to 90 degrees c. Instruct the client to perform the Valsalva maneuver d. Maintain oxygen delivery to prevent hypoxia
d. Maintain oxygen delivery to prevent hypoxia If a client is experiencing increased intracranial pressure, the nurse should take measures to reduce it or prevent it from worsening. In this case, the nurse should increase oxygen to the client, because increased ICP leads to hypoxia which can further contribute to increased intracranial pressure as the body responds by increasing blood flow to the brain. NRSG
After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care? a. Cluster nursing activities to allow longer rest periods. b. Turn and reposition the patient side to side every 2 hours. c. Position the bed flat and log roll to reposition the patient. d. Perform range-of-motion (ROM) exercises every 4 hours.
d. Perform range-of-motion (ROM) exercises every 4 hours. ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
A patient's electrocardiogram (ECG) tracing shows occasional wide and distorted QRS complexes. Which rhythm does this finding indicate? a. Sinus tachycardia b. Ventricular fibrillation c. Junctional dysrhythmias d. Premature ventricular contractions
d. Premature ventricular contractions Premature ventricular contractions are caused by premature impulses originating from the ventricles of the heart and not from the sinoatrial node. This causes the QRS complex to be wide and distorted. MS pg 766
Pt sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased & enteral feedings started? a. free water should be avoided b. sodium restrictions can be managed c. dehydration can be better avoided with feedings d. malnutrition promotes continued cerebral edema
d. malnutrition promotes continued cerebral edema A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. MS evolve resources
A patient who has received a maximum dose of nitroglycerin continues to report chest pain. Which medication would the nurse anticipate administering to this patient next? a. esmolol b. docusate c. ticagrelor d. morphine sulfate
d. morphine sulfate Morphine sulfate is the drug of choice for a patient with unrelieved chest pain, even after the administration of nitroglycerin. MS pg 722
Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)? a. sims b. prone c. trendelenburg d. semi-fowlers
d. semi-fowlers Position a patient with an increased ICP with his or her head elevated, as in semi-Fowler's position (typically at 30 degrees). MS pg 1311
Stiff extension, adduction, & hyperpronation of the arms & hyperextension of the legs with plantar flexion of the feet
decerebrate posturing
Internal rotation & adduction of the arms with flexion of elbows, wrists, & fingers:
decorticate posturing
Run of 3 or more PVCs:
ventricular tachycardia -ECG has tombstone appearance
Most common complication after an MI:
Dysrhythmias The nurse must be most alert for dysrhythmias, which may signal another MI or impending complications. MS pg 720
CI in pt with skull fracture:
NG tubes & NT suctioning
Total absence of ventricular electrical activity:
asystole
Heart rhythm that follows the normal conduction pathway at a rate of <60 bpm:
bradycardia
Compensatory mechanisms for changes in ICP:
-Displacement of CSF into subarachnoid space -Distention or compression of brain tissue -Vasoconstriction or vasodilation Sustained increases in ICP results in brainstem compression & herniation
3. A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees
A. Coughing B. Sneezing D. Valsalva maneuver E. Vomiting These activities can increase ICP. RN
A client with suspected myocardial infarction is triaged in the emergency department. Upon review of the EKG, the nurse would expect which of the following findings consistent with the suspected condition? a. increased ST segment amplitude b. increased amplitude of P wave c. widened QRS complex d. increased PR interval
a. increased ST segment amplitude If the ST segment has an increased amplitude, this indicates an ST-elevated myocardial infarction (STEMI). This is a medical emergency requiring immediate treatment.
18. During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing D. Proning
B. Decerebrate posturing RN
19. While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips
D. Flexion of the hips Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP. RN
20. During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to side. This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign. RN
Occurs d/t an abrupt stoppage of blood flow through a coronary artery w/ a thrombus caused by platelet aggregation:
MI
When patients first present with chest pain, ST-elevations on the 12-lead ECG indicate:
STEMI ST-elevation represents myocardial injury that is potentially reversible, but if not treated will evolve to permanent necrosis of the myocardium. MS pg 717
When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data? a. 5-15 mmhg b. 25-35 mmhg c. 45-60 mmhg d. 80-120 mmhg
a. 5-15 mmhg A normal ICP reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention. MS pg 1301
Acute inflammatory demyelinating polyradiculonephropathy- involves a rapidly progressive, ascending peripheral nerve dysfunction, which leads to paralysis that may produce respiratory failure:
guillain-barre syndrome
Goal of emergency treatment of STEMI:
limit the infarct size by opening the artery w/in 90 min of presentation to restore BF & O2 to the heart muscle -PCI is first-line treatment -Thrombolytic therapy w/in 30 min if cath lab is not available MS pg 718
Heart rhythm originating in the SA node at a rate of 60-100 bpm & follows the normal conduction pathway:
normal sinus rhythm
Cardiac rhythm that is controlled by an electrical impulse from a cardiac pacemaker:
paced rhythm
Premature occurrence of QRS complex:
premature ventricular contraction (PVC) -ECG will show widened QRS
Organized electrical activity is seen on ECG, but there is no mechanical heart activity:
pulseless electrical activity (PEA)
Cushing's triad:
systolic HTN, bradycardia, & irregular respirations -Indicates brainstem compression & impeding death
New onset chest pain that occurs at rest, occurs with increasing frequency, duration, or less effort:
unstable agina UA is unpredictable & must be treated immediately. ECG changes include ST-depression &/or T wave inversion. MS pg 717
Severe derangement of the heart rhythm characterized by irregular waveforms of varying shapes & amplitude:
ventricular fibrillation
