Exam 1 Prep
Which medication is the drug of choice for sinus bradycardia? a) Atropine b) Pronestyl c) Lidocaine d) Cardizem
a) Atropine
A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis? a) Echocardiography b) Computed tomography c) Cardiac catheterization d) Chest x-ray
a) Echocardiography
A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action? a) Report possible signs of aspiration pneumonia to the primary provider. b) Liaise with the dietitian to obtain a feeding solution with lower osmolarity. c) Perform chest physiotherapy. d) Reduce the height of the client's bed and remove the NG tube.
a) Report possible signs of aspiration pneumonia to the primary provider.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? a) Volume-controlled b) Time-cycled c) Negative-pressure d) Pressure-cycled
a) Volume-controlled
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? a) anger b) acceptance c) denial d) bargaining
a) anger
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? a) Flumazenil b) N-acetylcysteine c) Naloxone d) Diazepam
b) N-acetylcysteine
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) bicarbonate (HCO3) c) PaO2 d) PaCO2
c) PaO2
A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.
70 mL/hr
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? a) sputum culture b) total hemoglobin c) red blood cell count d) arterial blood gas (ABG) analysis
d) arterial blood gas (ABG) analysis
The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition? a) hemorrhage b) pneumothorax c) air embolism d) catheter-related bloodstream infections
d) catheter-related bloodstream infections
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? a) increase blood pressure b) bradycardia c) tachycardia d) reduced cardiac output
d) reduced cardiac output
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse a) Consults with the physician about removing the client from the ventilator b) Changes the setting on the ventilator to increase breaths to 14 per minute c) Contacts the respiratory therapy department to report the ventilator is malfunctioning d) Continues assessing the client's respiratory status frequently
d) Continues assessing the client's respiratory status frequently
A nurse enters a client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client? a) IV lidocaine b) Chemical cardioversion c) Electric cardioversion d) Immediate CPR
d) Immediate CPR
The nurse is caring for a client who has a suspected dysrhythmia. What most appropriate intervention should the nurse use to help detect dysrhythmias? a) Palpate the client's pulse and observe the client's response. b) Monitor blood pressure continuously. c) Provide supplemental oxygen. d) Monitor cardiac rhythm continuously.
d) Monitor cardiac rhythm continuously.
Acetaminophen overdose is treated with administration of which medication? a) Flumazenil b) Diazepam c) Naloxone d) N-acetylcysteine
d) N-acetylcysteine
A family member brings a client to the ED following an apparent oxycodone overdose. The client is experiencing severe respiratory depression. Which medication will the nurse administer? a) N-acetylcysteine b) Flumazenil c) Diazepam d) Naloxone hydrochloride
d) Naloxone hydrochloride
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Heart failure b) Myocardial infarction (MI) c) Pulmonary embolism d) Pneumothorax
d) Pneumothorax
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? a) Congestive heart failure b) Pneumonia c) Panic attack d) Pulmonary edema
d) Pulmonary edema
The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse's pressing the discharge button? a) Placing gel on the chest b) Stating "Charging." c) Checking the ECG rhythm d) Shouting "Clear!"
d) Shouting "Clear!"
A client with heart failure asks the nurse how dobutamine affects the body's circulation. What is the nurse's best response? a) The medication increases the heart rate. b) The medication causes the kidneys to retain fluid and increase intravascular volume. c) The medication helps the kidneys produce more urine. d) The medication increases the force of the myocardial contraction.
d) The medication increases the force of the myocardial contraction.
During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations? a) The nurse should ask the client questions about their feelings about death and talk about other things to distract the client's attention. b) The nurse should administer a pain killer and sedative to the client and allow them to sleep. c) The nurse can call out to the client's family members and ask them to sit next to the client. d) The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact.
d) The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The client has a pneumothorax. b) The chest tube is obstructed. c) The system is functioning normally. d) The system has an air leak.
d) The system has an air leak.
The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts? a) Prevent the development of hypotension. b) Correct metabolic acidosis. c) Reduce the development of torsade de pointes. d) Treat pulseless ventricular tachycardia.
d) Treat pulseless ventricular tachycardia.
The nurse is proving discharge instructions for a client with a new arrhythmia. Which statement should the nurse include? a) If you miss a dose of your antiarrhythmic medication, double up on the next dose. b) It is not necessary to learn how to take your own pulse. c) Do not be concerned if you experience symptoms of lightheadedness and dizziness. d) Your family and friends may want to take a CPR class.
d) Your family and friends may want to take a CPR class.
The nurse witnesses a client experiencing ventricular fibrillation. What is the nurse's priority action? a) IV bolus of dobutamine b) IV bolus of atropine c) cardioversion d) defibrillation
d) defibrillation
What is the major clinical use of dobutamine? a) treat hypertension b) treat hypotension c) prevent sinus bradycardia d) increase cardiac output
d) increase cardiac output
The ECG of a new patient shows a P wave slightly different than normal. The nurse is considering the possibility of premature atrial contractions (PAC). The nurse will ask about which factors when taking this client's history? a) All options are correct. b) caffeine c) hyperthyroidism or other metabolic disorders d) nicotine
a) All options are correct.
A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply. a) Dobutamine b) Diphenhydramine c) Vasopressin d) Dopamine e) Nitroglycerin
a) Dobutamine d) Dopamine c) Vasopressin e) Nitroglycerin
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? a) Document that the chest drainage system is operating as it is intended. b) Encourage the client to do deep breathing and coughing exercises. c) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. d) Inform the physician promptly that there is in imminent leak in the drainage system.
a) Document that the chest drainage system is operating as it is intended.
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? a) Increased restlessness b) Increased wakefulness c) Increased urinary output d) Increased eating
a) Increased restlessness
A novice hospice nurse is reviewing the orders of several clients. Which orders will the nurse most likely have to clarify? Select all that apply. a) Infuse TPN at 80 mL/hr via central line. b) Oxygen via NC 2L/min via NC PRN shortness of breath. c) Infuse two units PRBC PRN for hemoglobin <7 g/dL. d) Reposition client every 2 hours and as needed. e) Administer 10 mg morphine sulfate SL every hour PRN pain.
a) Infuse TPN at 80 mL/hr via central line. c) Infuse two units PRBC PRN for hemoglobin <7 g/dL.
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this? a) Maintaining a patent airway b) Maintaining the sterility of the client's airway c) Increasing the client's lung compliance d) Preventing the need for suctioning
a) Maintaining a patent airway
A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? a) Measure blood glucose concentration every 4 to 6 hours b) Monitor for reports of nausea and vomiting c) Auscultate the abdomen for bowel sounds every 4 hours d) Measure abdominal girth every shift
a) Measure blood glucose concentration every 4 to 6 hours
Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? a) Monitor vital signs and cardiac rhythm b) Keep the client flat for one hour after administration c) Document heart rate before and after administration d) Administer every five minutes during cardiac resuscitation
a) Monitor vital signs and cardiac rhythm
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. a) PaCO2 b)vK+ c) Glucose d) Na+ e) pH f) HCO3
a) PaCO2 e) pH f) HCO3
A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess? a) Pinpoint pupils b) Flushed face c) Hyperventilation d) Hypertension
a) Pinpoint pupils
Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? a) Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care b) Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview c) Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice d) Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life
a) Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care
The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter? a) Sawtooth b) Sinusoidal c) Square d) Triangular
a) Sawtooth
The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation? a) Sit with the client's daughter privately and encourage her to express her feelings frankly. b) Insist that the daughter try her best to make the client's final days happy ones. c) Remind the daughter of the client's impending death and the importance of expressing herself. d) Remain focused on the client's needs and care because these are your main responsibilities.
a) Sit with the client's daughter privately and encourage her to express her feelings frankly.
A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply. a) T wave b) P-R interval c) P wave d) QRT wave e) S-Q segment
a) T wave b) P-R interval c) P wave
The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade? Select all that apply. a) Tachycardia b) Distant heart sounds c) Anuria d) Dyspnea e) Jugular vein distention
a) Tachycardia b) Distant heart sounds d) Dyspnea e) Jugular vein distention
A client who is frightened of needles has been told that the client will have to have an intravenous (IV) line inserted. The client's blood pressure and pulse rate increase, and the nurse observes the pupils dilating. What does the nurse recognize has occurred with this client? a) The client is showing the fight-or-flight response. b) The client is having a response to dehydration. c) The client is in a hypertensive crisis. d) The client is developing an infection.
a) The client is showing the fight-or-flight response.
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? a) The client requires total parenteral nutrition b) The client requires infusion of intravenous antibiotics c) The client will require intravenous access for three days d) The client requires infusion of a dextrose 5% water (D5W)
a) The client requires total parenteral nutrition
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? a) To remove air from the pleural space b) To monitor bleeding around the lungs c) To drain copious sputum secretions d) To assist with mechanical ventilation
a) To remove air from the pleural space
A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action: a) Wipes catheter ports from distal end to insertion site b) Uses a circular motion from insertion site outward c) Contaminates gloves and obtains a pair of sterile gloves for use d) Cleanses the insertion site with a chlorhexidine solution
a) Wipes catheter ports from distal end to insertion site
The nurse is assessing a client with symptomatic bradycardia. What medication does the nurse anticipate will be ordered by the healthcare provider to treat the bradycardia? a) atropine b) lidocaine c) adenosine d) diltiazem
a) atropine
A 60-year-old client who has been fighting cancer for more than 20 years has just been diagnosed with metastases to the brain. The client finds it difficult to get out of bed in the morning, has no interest in eating, and no longer finds fulfillment in favorite hobbies. Within which emotional reaction is the client functioning? a) depression b) denial c) anger d) bargaining
a) depression
A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. a) dobutamine b) epinephrine c) nitroglycerin d) dopamine e) nitroprusside
a) dobutamine b) epinephrine d) dopamine
What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle? a) friction rub b) ejection click c) murmur d) opening snap
a) friction rub
Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as a) sodium nitroprusside. b) dopamine. c) furosemide. d) norepinephrine.
a) sodium nitroprusside.
A client has been placed on a ventilator, and the spouse begins to cry during the initial visit. What is the best therapeutic statement for the nurse to communicate? a) "The ventilator gives breaths every timed interval for breathing." b) "Tell me what you are feeling." c) "People on the ventilator do not feel pain." d) "I know this is stressful, but it is the best treatment."
b) "Tell me what you are feeling."
The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour? a) 11 mL/hr. b) 2.7 mL/hr c) 8.0 mL/hr d) 5.5 mL/hr
b) 2.7 mL/hr
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for a) A cut or slice in the tubing from the ventilator b) A kink in the ventilator tubing c) Higher than normal endotracheal cuff pressure d) Malfunction of the alarm button
b) A kink in the ventilator tubing
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? a) The trachea and bronchi b) A puncture at the radial artery c) The pleural surfaces d) A catheter in the arm vein
b) A puncture at the radial artery
When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? a) A diastolic blood pressure that is lower during exhalation b) A systolic blood pressure that is lower during inhalation c) A diastolic blood pressure that is higher during inhalation d) A systolic blood pressure that is higher during exhalation
b) A systolic blood pressure that is lower during inhalation
A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action? a) Stop all emergency measures. b) Administer epinephrine. c) Analyze the arterial blood gas. d) Change oxygen delivery to a mask.
b) Administer epinephrine.
A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the client's cardiopulmonary status, the nurse should prepare to perform what intervention? a) Insert an indwelling urinary catheter. b) Administer naloxone hydrochloride (Narcan). c) Administer a bolus of lactated Ringer. d) Perform a focused neurologic assessment.
b) Administer naloxone hydrochloride (Narcan).
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart? q) elevated temperature b) All options are correct. c) shock d) strenuous exercise
b) All options are correct.
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? a) Applying an oil-based lubricant to the client's mouth and nose b) Assessing the client's respiratory status, orientation, and skin color c) Changing the mask and tubing daily d) Posting a "No smoking" sign over the client's bed
b) Assessing the client's respiratory status, orientation, and skin color
A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? a) Complete blood count results b) Baseline arterial blood gas (ABG) levels c) Fluid intake for the past 24 hours d) Electrocardiogram (ECG) results
b) Baseline arterial blood gas (ABG) levels
The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse? a) Administer epinephrine 1:10,000 10 mL IV push. b) Call for help and begin chest compressions. c) Defibrillate the patient with 360 joules. d) Deliver breaths with a bag-valve mask.
b) Call for help and begin chest compressions.
The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient? a) Creates a positive inotropic effect b) Decreases the sinoatrial node automaticity c) Increases the heart rate d) Increases the atrioventricular node conduction
b) Decreases the sinoatrial node automaticity
The pathophysiology of pericardial effusion is associated with all of the following except: a) Increased right and left ventricular end-diastolic pressures. b) Increased venous return. c) Inability of the ventricles to fill adequately. d) Atrial compression.
b) Increased venous return.
A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? a) Monitoring pleural fluid osmolarity b) Removing excess air and fluid c) Maintaining positive chest-wall pressure d) Providing positive intrathoracic pressure
b) Removing excess air and fluid
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a) See if a kink has developed in the tubing. b) See if there are leaks in the system. c) See if the wall suction unit has malfunctioned. d) See if the chest tube is clogged.
b) See if there are leaks in the system.
The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. What order does the nurse describe? a) SA node, AV node, bundle of His, the Purkinje fibers, and the right and left bundle branches b) Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers c) AV node, SA node, bundle of His, right and left bundle branches, and the Purkinje fibers d) SA node, AV node, right and left bundle branches, bundle of His, and the Purkinje fibers
b) Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers
The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) a) Increases oxygen consumption b) Sustains positive end expiratory pressure (PEEP) c) Decreases patient anxiety d) Prevents aspiration Decreases hypoxemia
b) Sustains positive end expiratory pressure (PEEP) c) Decreases patient anxiety e) Decreases hypoxemia
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? a) Cardiac tamponade b) Tension pneumothorax c) Pulmonary contusion d) Flail chest
b) Tension pneumothorax
A client needs additional information about a heart condition. The client asks the nurse, "What is considered the pacemaker of the heart?" a) The bundle of HIS b) The SA node c) The AV node d) The Purkinje fibers
b) The SA node
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration? a) To exchange atmospheric air between the blood and the cells b) To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells c) To move O2 out of the atmospheric air and into the retained air d) To move CO2 out of the atmospheric air and into the expired air
b) To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a) pH, 7.5; paCO2 30 mm Hg b) pH 7.25; PaCO2 50 mm Hg c) pH, 7.40; PaCO2 35 mm Hg d) pH, 7.35; PaCO2 40 mm Hg
b) pH 7.25; PaCO2 50 mm Hg
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? a) obtain a urine specimen for drug screening b) prepare to assist with ventilation c) prepare for gastric lavage d) monitor the client's heart rhythm
b) prepare to assist with ventilation
The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? a) "Does it feel like there is a tight band around your head?" b) "Are you experiencing any burning or numbness?" c) "Are you hearing anything that is disturbing you?" d) "Are you finding the light is too harsh or bothering your eyes?"
c) "Are you hearing anything that is disturbing you?"
The nurse is administering metoprolol to a client. What type of medication should the nurse educate the client about? a) Diuretic b) Angiotensin-converting enzyme (ACE) inhibitor c) Beta blocker d) Vasodilator
c) Beta blocker
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? a) Left lower lobe b) Anterior bronchioles c) Bilateral lower lobes d) Posterior bronchioles
c) Bilateral lower lobes
Which is a late sign of hypoxia? a) Somnolence b) Restlessness c) Cyanosis d) Hypotension
c) Cyanosis
The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? a) Place gel pads over the apex and posterior chest for better conduction. b) Allow at least 3 minutes between shocks. c) Ensure no one is touching the client at the time shock is delivered. d) Continue to ventilate the client via endotracheal tube during the procedure.
c) Ensure no one is touching the client at the time shock is delivered.
A nurse is caring for a client who has premature ventricular contractions. What sign would the nurse assess in this client? a) Hypotension b) Fever c) Fluttering/heart skipping d) Nausea
c) Fluttering/heart skipping
The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered? a) Dobutrex b) Methotrexate c) Levophed d) Nipride
c) Levophed
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a) Keeping the collection chamber at chest level b) Maintaining continuous bubbling in the water-seal chamber c) Measuring and documenting the drainage in the collection chamber d) Stripping the chest tube every hour
c) Measuring and documenting the drainage in the collection chamber
Which medication reverses severe respiratory depression and coma? a) N-acetylcysteine b) Diazepam c) Naloxone hydrochloride d) Flumazenil
c) Naloxone hydrochloride
It is important for a nurse to be aware of the normal hemodynamics of blood flow to recognize and understand pathology when it occurs. The nurse should know that incomplete closure of the tricuspid valve results in a backward flow of blood from the: a) Right atrium to the right ventricle. b) Aorta to the left ventricle. c) Right ventricle to the right atrium. d) Left atrium to the left ventricle.
c) Right ventricle to the right atrium.
It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur: a) Right ventricular pressure must decrease with systole. b) The atrioventricular valves must open. c) Right ventricular pressure must be higher than pulmonary arterial pressure. d) The pulmonic valve must be closed.
c) Right ventricular pressure must be higher than pulmonary arterial pressure.
A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? a) Risk for functional urinary incontinence related to the presence of a subclavian catheter b) Risk for activity intolerance related to the presence of a subclavian catheter c) Risk for infection related to the presence of a subclavian catheter d) Risk for sleep deprivation related to the presence of a subclavian catheter
c) Risk for infection related to the presence of a subclavian catheter
The nurse assessing a patient with pericardial effusion at 0800 notes the apical pulse is 74 and the BP is 140/92. At 1000, the patient has neck vein distention, the apical pulse is 72, and the BP is 108/92. Which action would the nurse implement first? a) Administer morphine by intravenous push slowly. b) Notify the health care provider immediately. c) Stay with the patient, use a calm voice, and ask for assistance via call light. d) Place the patient in the left lateral recumbent position.
c) Stay with the patient, use a calm voice, and ask for assistance via call light.
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: a) A scheduled time for deflation of the tracheal cuff b) Tracheal cuff pressure set at 30 mm Hg c) Symmetry of the client's chest expansion d) Cool air humidified through the tube
c) Symmetry of the client's chest expansion
While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach? a) The system is functioning normally. b) The chest tube is obstructed. c) The system has an air leak. d) The client has a pneumothorax.
c) The system has an air leak.
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client? a) identifying a code-level status b) maintaining intravenous fluids c) alerting the healthcare provider of the third-degree heart block d) assessing blood pressure and heart rate frequently
c) alerting the healthcare provider of the third-degree heart block
Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: a) are at risk for gallbladder contraction. b) can digest high-fat foods. c) cannot tolerate high-glucose concentration. d) are at risk for hepatic encephalopathy.
c) cannot tolerate high-glucose concentration.
Which set of arterial blood gas (ABG) results requires further investigation? a) pH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, and HCO3- 22 mEq/L b) pH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L c) pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L d) pH 7.38, partial pressure of arterial carbon dioxide (PaCO2) 36 mm Hg, partial pressure of arterial oxygen (PaO2) 95 mm Hg, bicarbonate (HCO3-) 24 mEq/L
c) pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L
The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition? a) pain on exertion b) indigestion c) reduced blood supply to the heart d) high blood pressure
c) reduced blood supply to the heart
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of arrhythmia would the cardiologist likely diagnose? a) sinus bradycardia b) supraventricular bradycardia c) sinus tachycardia d) supraventricular tachycardia
c) sinus tachycardia
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) collection chamber b) air-leak chamber c) water-seal chamber d) suction control chamber
c) water-seal chamber
The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? a) Serum thyroid level findings b) Red blood cells (RBCs) and hemoglobin count findings c) White blood cell count findings d) Arterial blood gas (ABG) findings
d) Arterial blood gas (ABG) findings
You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? a) White blood cell count findings b) Serum thyroid level findings c) Red blood cells (RBCs) and hemoglobin count findings d) Arterial blood gas (ABG) findings
d) Arterial blood gas (ABG) findings
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? a) Observe for mist in the endotracheal tube. b) Listen for breath sounds over the epigastrium. c) Attach a pulse oximeter probe and obtain values. d) Call for a chest x-ray.
d) Call for a chest x-ray.
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following? a) "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." b) "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." c) "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." d) "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers."
b) "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."
The client asks the nurse what urine output has to do with cardiac function. What is the best response by the nurse? a) "High urine output may indicate poor cardiac function." b) "Poor urine output may indicate inadequate blood flow to the kidneys." c) "The heart may be working too hard if there is not enough urine." d) "The heart and kidneys work independently to keep the body's fluids in balance."
b) "Poor urine output may indicate inadequate blood flow to the kidneys."
Which of the following responses is most helpful to the client when in an emergency situation? a) A response by the central nervous system b) A response by the cardiovascular system c) A response by the musculoskeletal system d) A response by the sympathetic nervous system
d) A response by the sympathetic nervous system
The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? a) Increased drainage b) Tension pneumothorax c) Tidaling d) Air leak
d) Air leak
