Exam 2
The nurse is assessing the clients ecg. what does the p wave on the ecg tracing represent
depolarization of the atria.
Which statement by the nurse when explaining teh purpose of positive end- expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate?
PEEP prevents the lung air sacs from collapsing during exhalation.
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
Provide a low sodium diet
the nurse is assessing a client with left sided heart failure. what conditions does the nurse assess for.
Pulmonary crackles, confusion, restlessness, s3/s4 summation gallop, cough worsens at night
the nurse is assessing clients at a community clinic. which client does the nurse assess most carefully for atrial fibrillation?
a client who is dismissed after a coronary artery bypass surgery
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops.
a systolic BP <90 mm Hg. sodium nitroprusside is a potent vasodilator, and the major adverse effect is sever hypotension.
the nurse is assessing the clients on a cardiac unit. which client does the nurse asses most carefully for developing left sided heart failure.
middle aged women with aortic stenosis,
has a prescription for digoxin and hydrochlorothiazide appropriate instructions for the patient include
notify the health care provider if nausea develops.
The nurse working on the heart failure unit teaching an older female patient with newly diagnosed heart failure is effective when the patient states that
she will call the clinic if her weight goes from 124 to 128 lbs in a week.
The nurse is assistant the hospitalized client with his food selections for breakfast. the client is on a low cholesterol diet. what recommendations are most appropriate for this client?
skim milk, oatmeal, bananna, orange juice, coffee,
the nurse is caring for a client with atrial fibrillation. which manifestation most alerts the nurse to the possibility of serious complications from this condition.
speech alterations
an intubated clients oxygen saturation has dropped to 88% what action by the nurse takes priority?
suction the endotracheal tube
When caring for a client immediately after an MI, the nurse first priority would be.
the procedure will
The client who just started taking isosorbide dinitrate (Imdur) reports a headache. What is the nurse's best action?
Adminsiter PRN acetaminophen
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?
Asses the client for airway patency Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.
The nurse suspects a clients is experiencing left sided heart failure when which of the following is assessed. select all that apply
Decreased basilar lung sounds extra heart sounds, lung crackles, tachycarida,
The nurse is assessing the clients ecg. what does the P wave on the ECG tracing represent.
Depolaration of the ventricles.
The nurse is assessing the ECG. what does the p wace on the ECG tracing represents
Depolarations of the atria.
which of the following would the access in a client with righ sided heart failure.
Distended neck veins,
A nursing student learns about modifiable risk factors for coronary artery disease. which factors does this include
Hypertension, obestiy, smoking, stress,
The nurse is providing discharge instructions for a client with an implantable cardioverter defibrillator (ICD) what statement by the client indicates a good understanding of the instructions.
I will avoid sources of strong electromagnetic fields.
Which statement made by a patient with CAD after the nurse has completed tracking about lifestyle changes.
I will miss being able to eat peanut butter sandwiches.
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
Interrupt the procedure to give oxygen
A nurse is assisting the health care provider who is intubating a client. the provider has been attempting to intubate for 40 seconds. what action by the nurse takes priority?
Interrupt the procedure to give oxygen
A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?
It is hypoxemia that persist even with 100% oxygen administration.
A client has a heart rate averaging 56 beats/min with no adverse symptom. what activity modifications does the nurse suggest to avoid further slowing of the heart rate?
avoid bearing down or straining while having a bowel movement.
a client is being discharged home after a heart transplant with a prescription for cyclosporine ( sandimmune) what priority education does the nurse provide with the clients discharge instructions
avoid large crowds and people who are sick
A client with heart failure is prescribed enalapril (Vasotec) What is the nurse priority teaching for this client?
avoid using salt substitutes.
AN iABP is being used for a patient who is in cardiogenic shock, which assessment data indicate so the nurse that the goals of treatment with IABP are being met.
cardiac output. (CO) of 5 L.min
the nurse is reviewing the menu selections of a client who has ordered a low cholesterol diet. what meal items does the nurse questions
cheesteak sandwhich
the nurse is assessing clients at a community clinic, which client does the nurse asses most carefully for atrial fibrillation
client who is dismissed after coronary artery bypass surgery.
A patient with heart failure has a new order for captopril 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?
I will call for help when I need to get up to use the bathroom. Captopril can cause hypotension, especially after the initial dose, so its important that the patient not get up out of bed without assistance until the nurse has had a change to evaluate the effect.
A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems, what response by the nurse is best.
It will prevent ulcers from the stress of mechanical ventilation."
The Nurse is caring for a patient who has an introartic balloon pump in place. Which actions should be included in the plan of care?
Measure the patients urinary output every hour.
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect?
Mid sternal chest pain Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
Urine output via indwelling urinary catheter is 20 Ml/ hr Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition?
Warfarin (Coumadin)
A client asks the nurse why it is important to be weighed every day if he has right sided heart failure. What is the nurse best response?
Weight is the best indication that you are gaining or losing fluid.
the nurse is assessing clients on a cardiac unit which client does the nurse assess most carefully for developing left sided heart failure.
middle aged woman with aortic stenosis.
the nurse suspect a client is experiencing left sided heart failure when which of the following is assessed.
decreased basilar lung sounds, extra heart sounds, lung crackles, tachycardia,
the nurse is starting a client on digoxin therapy, what intervention is essential to teach this client
do not take this medication within 1 hour of taking an antacid.
the nurse is caring for a client with a temporary pacemaker. the clients bedside monitor shows a spike followed by a QRS complex. that is the nurses best action.
document the finding in the clients chart.
. What priority intervention does the nurse perform before defibrillating a client?
ensure that all personnel are clear of contact with the client and the bed.
A client with pericarditis is admitted to the cardiac unit. what assessment finding does the nurse expect in this client
friction rub at the left lower sternal border.
The nurse is assessing a client in an outpatient clinic. which client statement alerts the nurse to possible left sided heart failure
i have to stop halfway up the stairs to catch my breath.
a patient with heart failure has a new order for captopril 12.5 mg, PO. after administering he first dose and teaching the patient about the drug, which statement by the patient indicates that teachin has been effective
i will call for help when i need to get up to use the bathroom
THe nurse is administering captopril to a client with heart failure. What is the priority intervention for this client
insturct the client to ask for assistance when arising from bed.
A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform?
level of consciousness
