Exam 1
2. A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.)a. Until your incision is healed, do not submerge your pacemaker. Only take showers.b. Report any pulse rates lower than your pacemaker settings.c. If you feel weak, apply pressure over your generator.d. Have your pacemaker turned off before having magnetic resonance imaging (MRI).e. Do not lift your left arm above the level of your shoulder for 8 weeks.
ANS: A, B, EThe client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.
1. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)a. Decrease in cardiac outputb. Increase in cardiac outputc. Decrease in blood pressured. Increase in blood pressuree. Decrease in urine outputf. Increase in urine output
ANS: A, D, EElevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.
14. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?a. Mid-sternal chest painb. Increased urine outputc. Mild orthostatic hypotensiond. P wave touching the T wave
ANS: AChest pain, possibly angina, indicates that tachycardia may be increasing the clients myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.
16. The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed?a. I am thrilled that I can continue to eat fast food.b. I will cut out bacon with my eggs every morning.c. My cooking style will change by not adding salt.d. I will probably lose weight by cutting out potato chips.
ANS: AFast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.
12. A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best?a. Obtain daily weights of the client.b. Auscultate heart and breath sounds.c. Palpate the clients abdomen.d. Assess the clients diet history.
ANS: AFurosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the clients abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.
8. A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse?a. Blood pressure of 76/58 mm Hgb. Sodium level of 138 mEq/Lc. Potassium level of 5.5 mEq/Ld. Pulse rate of 90 beats/min
ANS: AHypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The specially trained nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 90 beats/min is normal.
15. A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching?a. Minimize or abstain from caffeine.b. Lie on your side until the attack subsides.c. Use your oxygen when you experience PACs.d. Take amiodarone (Cordarone) daily to prevent PACs.
ANS: APACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.
15. A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern?a. Albumin level of 2.5 g/dLb. Phosphorus level of 5 mg/dLc. Sodium level of 135 mmol/Ld. Potassium level of 5.5 mmol/L
ANS: AProtein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the clients metabolic needs. The electrolyte values are not related to the protein-restricted diet.
13. A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?a. Medication reconciliationb. Immunization historyc. Religious beliefsd. Nutrition preferences
ANS: AThe home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.
11. A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?a. Discuss what the treatment regimen means to him.b. Refer the client to a mental health nurse practitioner.c. Reschedule the appointments to another date and time.d. Discuss the option of peritoneal dialysis.
ANS: AThe initial action for the nurse is to assess anxiety, coping styles, and the clients acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the clients acceptance of the treatment should come first.
6. A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?a. Place the client on a cardiac monitor immediately.b. Teach the client to limit high-potassium foods.c. Continue to monitor the clients intake and output.d. Ask to have the laboratory redraw the blood specimen.
ANS: AThe priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.
3. A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this clients history?a. Have you been taking any aspirin, ibuprofen, or naproxen recently?b. Do you have anyone in your family with renal failure?c. Have you had a diet that is low in protein recently?d. Has a relative had a kidney transplant lately?
ANS: AThere are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.
18. A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?a. Check the clients digoxin (Lanoxin) level.b. Administer an anti-nausea medication.c. Ask if the client is able to eat crackers.d. Get a referral to a gastrointestinal provider.
ANS: AThese signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the clients symptoms but do not lead to the cause of the symptoms.
2. A marathon runner comes into the clinic and states I have not urinated very much in the last few days. The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority?a. Give the client a bottle of water immediately.b. Start an intravenous line for fluids.c. Teach the client to drink 2 to 3 liters of water daily.d. Perform an electrocardiogram.
ANS: AThis athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the clients degree of dehydration is assessed. An electrocardiogram is not necessary at this time.
17. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?a. Clean the skin and clip hairs if needed.b. Add gel to the electrodes prior to applying them.c. Place the electrodes on the posterior chest.d. Turn off oxygen prior to monitoring the client.
ANS: ATo ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.
3. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease
ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.
2. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.
ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.
4. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity
ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
8. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next?a. Administer intravenous diltiazem (Cardizem).b. Assess vital signs and level of consciousness.c. Administer sublingual nitroglycerin.d. Assess capillary refill and temperature.
ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.
5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition?a. Sotalol (Betapace)b. Warfarin (Coumadin)c. Atropine (Sal-Tropine)d. Lidocaine (Xylocaine)
ANS: BAtrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.
20. The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse?a. My sodium level changes by movement from the blood into the dialysate.b. Dialysis works by movement of wastes from lower to higher concentration.c. Extra fluid can be pulled from the blood by osmosis.d. The dialysate is similar to blood but without any toxins.
ANS: BDialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.
12. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?a. Administer intravenous adenosine.b. Turn off oxygen therapy.c. Ensure a tongue blade is available.d. Position the client on the left side.
ANS: BFor safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.
9. The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding?a. Woman with a blood pressure of 158/90 mm Hgb. Client with Kussmaul respirationsc. Man with skin itching from head to toed. Client with halitosis and stomatitis
ANS: BKussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.
1. The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history?a. Pyelonephritisb. Myocardial infarctionc. Bladder cancerd. Kidney stones
ANS: BPre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.
10. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?a. I should wear a snug-fitting shirt over the ICD.b. I will avoid sources of strong electromagnetic fields.c. I should participate in a strenuous exercise program.d. Now I can discontinue my antidysrhythmic medication.
ANS: BThe client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.
4. A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this clients care?a. Edema and painb. Electrolyte and fluid imbalancec. Cardiac and respiratory statusd. Mental health status
ANS: BThis client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the clients cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.
7. A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?a. Pulmonary auscultationb. Pulse strength and amplitudec. Level of consciousnessd. Mobility and gait stability
ANS: CA heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the clients level of consciousness is the priority.
6. A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?a. Decreased intraocular pressureb. Increased heart ratec. Short period of asystoled. Hypertensive crisis
ANS: CClients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.
11. A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?a. Administer oxygen therapy at 2 liters per nasal cannula.b. Provide the client with a sleeping pill to stimulate rest.c. Schedule periods of exercise and rest during the day.d. Ask unlicensed assistive personnel to help bathe the client.
ANS: CClients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.
16. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond?a. Substance abuse puts clients at risk for many health issues.b. The hospital requires that I ask you about cocaine use.c. Clients who use cocaine are at risk for fatal dysrhythmias.d. We can provide services for cessation of substance abuse.
ANS: CClients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the clients question.
19. The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse?a. Administer fluid to increase blood pressure.b. Check the white blood cell count.c. Monitor the clients temperature.d. Connect the client to an electrocardiographic (ECG) monitor.
ANS: CDuring hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The clients temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.
17. A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time?a. Decreased calcium levelsb. Increased phosphorus levelsc. No adventitious sounds in the lungsd. Increased edema in the legs
ANS: CThe absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the clients body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.
10. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?a. Registered nurse who just floated from the surgical unitb. Registered nurse who just floated from the dialysis unitc. Registered nurse who was assigned the same client yesterdayd. Licensed practical nurse with 5 years experience on this floor
ANS: CThe client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The float nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.
13. A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema?a. Maintaining oxygen saturation of 89%b. Minimal crackles and wheezes in lung soundsc. Maintaining a balanced intake and outputd. Limited shortness of breath upon exertion
ANS: CWith an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.
1. A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.
14. A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)?a. Antibioticb. Histamine blockerc. Bronchodilatord. Angiotensin-converting enzyme (ACE) inhibitor
ANS: DACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension.
22. A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority?a. Hold pressure over the clients nose for 10 minutes.b. Take the clients pulse, blood pressure, and temperature.c. Assess for a bruit or thrill over the arteriovenous fistula.d. Prepare protamine sulfate for administration.
ANS: DHeparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the clients system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.
7. A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?a. Use the catheter for the next laboratory blood draw.b. Monitor the central venous pressure through this line.c. Access the line for the next intravenous medication.d. Place a heparin or heparin/saline dwell after hemodialysis.
ANS: DThe central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.
5. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action?a. Calculate the mean arterial pressure (MAP).b. Ask for insertion of a pulmonary artery catheter.c. Take the clients pulse.d. Slow down the normal saline infusion.
ANS: DThe nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the clients hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.
9. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client?a. Make sure the defibrillator is set to the synchronous mode.b. Administer 1 mg of intravenous epinephrine.c. Test the equipment by delivering a smaller shock at 100 joules.d. Ensure that everyone is clear of contact with the client and the bed.
ANS: DTo avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.
