EAQ Practice Questions
Within which period of time would the nurse advise to anticipate pain relief after taking nitro sublingual?
1-3 minutes.
How to describe cardiogenic shock to a family member?
A failure of the circulatory pump
Which client problem would the nurse expect to decrease in response of the administration of serum albumin intravenously to a client with ascites?
Abdominal girth. Increased albumin increased the osmotic effect and pulls the fluid back into the intravascular compartment.
Which change in the clients lab results indicated the client is experiencing septic shock?
An increased serum lactate level.
Which instructions about the use of nitro to prevent angina will the nurse provide?
Before physical activity, place one tablet under the tongue. Repeat in 5 minutes if pain occurs. Max 3
Which lab result will be important for the nurse to review when a client is admitted with a long history of uncontrolled HTN
Blood urea nitrogen. Decreased renal function
During the recovery period for a client treated for a lacerated liver and abdominal hemorrhage, the nurse would monitor the client for which indication of peritonitis?
Boardlike abdomen, abdominal tenderness, decreased bowel sounds.
In the ED, the nurse assess a pt who is unconscious, experiencing severe bleeding due ot a motor vehicle accident and in hypovolemic shock. Which site would the nurse obtain the pts pulse rate?
Carotid and femoral.
Which lab test change leads the nurse to determine that the lactulose administered to the patient with cirrhosis is effective?
Decreased ammonia
The nurse reviews the medical record of a client with ascites. What is a contributing factor to the development of ascites?
Diminished plasma protein level.
Which finding would the nurse expect when assessing a client with left ventricular failure?
Dyspnea on exertion
When assessing a client with cardiogenic shock, which clinical manifestations will the nurse expect to find?
Dyspnea, (SOB) diaphoresis (clammy skin), tachycardia
Why would lactulose be prescribed for a patient with a history of cirrhosis of the liver?
Elevated ammonia levels are able to be lowered
Which lab result will the nurse expect when caring for a pt who presents to the ED with an ST seg elevation MI. (STEMI)
Elevated serum troponins I and T
Which adverse effect would a nurse monitor for in a pt taking clopidogrel?
Epistaxis (bleeding)
Which clinical manifestation would the nurse include when teaching a client with HF about s/s that indicate a need to contact the HCP?
Extreme fatigue, coughing at night, difficulty breathing
Which med side effect will a nurse assess for when caring for a pt with MI receiving intravenous nitro to relieve pain?
Hypotension
Which type of shock is associated with a ruptured abdominal aneurysm?
Hypovolemic shock
Which assessment finding would the nurse expect to observe in a client with severe liver disease?
Icterus (jaundice)
How should a patient eat with COPD and cor pulmonale?
Many small meals a day
Which mechanism of sodium nitroprusside would the nurse recall is responsible for decreasing BP?
Relaxing venous and arterial smooth muscles
Which pt information is important to communicate to the HCP when the nurse is obtaining a health history for a client scheduled for cardiac catheterization?
Reports allergy to most shellfish
Which finding is most important to communicate to the HCP?
ST segment elevations on ECG
Which complication will occur as the result of administering sildenafil to a client who takes isosorbide dinitrate?
Severe hypotension
Which rationale is the basis for planning a nursing intervention when during a health fair, this nurse measures an adults BP at 200/120?
There is increased risk for a cerebrovascular accident. Seek immediate medical intervention
What is the purpose of a scheduled cardiac catheterization with a client with angina?
To visualize the disease process in the coronary ateries.
Which lab test is important for the nurse to monitor when a client is admitted with acute coronary syndrome?
Troponin
Which finding about the clients angina is most important for the nurse to communicate to the HCP
continues after rest and nitro
S/S of cor pulmonale
cyanosis, enlarged liver, JVD, lower extremity edema, etc.
Purpose of nitroglycerin patch
decrease cardiac preload reducing cardiac workload
Common side effects of nitro
headache and low BP
Important fact about nitro
needs to be stored in original dark container.
Which pt indicator would be related to a pt receiving aspirin therapy?
prolonged bleeding time
Which physiological process causes the temperature elevation after a client has had a myocardial infarction?
tissue necrosis and inflammation
What does a client need to expect after a cardiac catheterization?
Lay in bed for several hours after the procedure
Which info can be obtained from monitoring the pulmonary artery pressure?
Left ventricular functioning
Acid base imbalance at the progressive stage of shock
Metabolic acidosis
The nurse assess a pt who is experiencing profound(late) hypovolemic shock. When monitoring the clients arterial blood gas results, which would the nurse expect?
Metabolic acidosis
Which pain relief med would the nurse use with a pt with a MI admitted to the cardiac ICU?
Morphine
Which intervention will relieve the chest pain of the client admitted to the cardiac care unit with a myocardial infarction?
Morphine sulfate 2 mg IV
Which condition would the nurse suspect in an emergency department client with C8 tetraplegia, BP of 80/40 and pulse of 48 BPM.
Neurogenic shock
What is the highest priority with a patient in the ED with unrelieved chest pain after giving nitro?
Obtain a 12 lead ECG
Which response indicates the sublingual nitro prescribed for unstable angina is effective?
Pain subsides as a result of arteriole and venous dilation
Clinical findings with a patient who has cardiogenic shock
Pallor, agitation, tachycardia, narrow pulse pressure
Which clinical manifestation would the nurse expect to find when a client is admitted with right ventricular failure?
Peripheral edema
Which finding by the nurse who is caring for a pt after major abdominal surgery may indicate impending hypovolemic shock?
Pt report of feeling very thirsty Extravascular fluid depletion leads to pt feeling of thirst
Which likely cause would a nurse suspect is responsible for a drop in BP after a pt sustains multiple internal injuries? BP drops from 134/90 to 80/60.
Reduction in circulating blood volume
The nurse is assessing a patient who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock?
Restlessness In the early stage of shock, the patient has increased epinephrine secretion leading to the pt to feel anxious, restless, nervous and irritable
Which clinical finding would the nurse expect for a client with a hypertensive emergency?
Severe pouding headache
What requires immediate action with pulmonary edema?
SpO2 of 82%
Which form of nitro would the nurse give to a pt with midsternal pain with stable vital signs?
Sublingual spray
Which information will the nurse provide when a pt is discharged with a prescription for sustained-release nitro?
Swallow the capsule whole
Which med is indicated to prevent progression of MI for a client admitted to the ED with crushing chest pain?
Aspirin
A client with severe cirrhosis is hospitalized. The nurse discovers fetor hepaticus when the nurse performs which of the following assessments?
Assessing the clients breath
A pt is admitted with pulmonary edema. What is expected?
Crackles at bases of the lungs
Manifestations of a pt with pulmonary edema
Crackles, coughing, orthopnea
A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change?
Inability for the liver to remove normal amounts of bilirubin from the blood
Which explanation would the nurse give to a client with an MI who asks the nurse, "What is causing my pain?"
Inadequate oxygenation of the myocardium
Which nursing action will best evaluate the effectiveness of furosemide in managing a client with HF and acute pulmonary edema?
Auscultating breath sounds
Which client would be at an increased risk for coronary artery disease?
Client with total cholesterol of 250 and LDL of 120
For which sign of hepatic encephalopathy would the nurse assess a client with cirrhosis of the liver?
Mental confusion, flapping hand tremors, musty, sweet breath odor
Which complication will the nurse anticipate when caring for a patient in late hypovolemic shock?
Metabolic acidosis - Decreased cellular oxygen caused by poor perfusion increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis.
Which info would the nurse include in the pre-procedure teaching for a client who requires emergency cardiac catheterization?
Mild sedation is maintained during the procedure.
A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate?
Moderate protein
Which finding will the nurse expect when caring for a patient who is in hypovolemic shock?
Cool skin temperature. Shunting of blood to vital organs leads to cool skin because of decreased skin perfusion.
A client with COPD reports a 5 lb weight gain in 1 week, the nurse will assess for other signs and symptoms of which complicaton?
Cor pulmonale
Which type of collaborative action would the nurse anticipate the need to rapidly implement when caring for a client who has a bp of 80/60 and hr of 120 bpm after a MV accident?
Increase circulating blood volume
Which result would the nurse monitor in a client with acetaminophen overdose?
Liver function tests
When assigned the care of a client arriving in the ED with possible acute coronary syndrome, which prescribed action would the nurse take first?
Obtain a 12 lead ECG
Which finding would the nurse expect when assessing a client with hypovolemic shock?
Oliguria (<20-30 mL/hr urine output)
Pt with pulmonary edema received furosemide. Which is the best indicator that the med was effective?
Oxygen sat is 99%
Which pain characteristic would the nurse expect to observe when a pt is experiencing anginal pain?
Relieved by sublingual nitro
Which description would the nurse expect the client to use to characterize the pain when admitted to the coronary care unit with a diagnosis of ST segment elevation myocardial infarction?
Severe, intense chest pain
What needs to be considered before giving metoprolol to a client with stable angina?
Sinus brady w/ a rate of 54
Which clinical finding in a pt receiving morphine warrants immediate follow up by the nurse?
Unconsciousness, bradycardia, bradypnea
Which condition unrelated to cardiac disease is the major cause of right ventricular failure?
COPD
Which finding in a pt who has been admitted with myocardial infarction is most important to communicate to the HCP?
Urine output of 15 mL/h
When admitting a client to with acute coronary syndrome to the tele unit after cardiac catheterization and PCI, which action should the nurse take first?
Attach the cardiac monitor
Which assessment finding would indicate to the nurse that the treatment for a client with cor pulmonale has been effective?
decreased peripheral edema