NSG 252 exam 2 (exemplars)
To improve the oxygenation of a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position? A. Supine B. Semi-fowlers C. Lateral side D. Prone
D. Prone
Cardiac telemetry shows that a client who is up to the bathroom has converted from normal sinus rhythm with a rate of 72 bpm to atrial fibrillation with a ventricular response rate of 100 bpm. In what order from first to last should the nurse perform these interventions? All options must be used. A. Assess vital signs (2) B. Assist the client to the bed (1) C. Initiate intravenous access (3) D. Obtain a stat 12-lead electrocardiogram (4)
B. Assist the client to the bed A. Assess vital signs C. Initiate intravenous access D. Obtain a stat 12-lead electrocardiogram
The nurse is caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and SpO2 is 90% on 50% face mask. What should the nurse do next? A. Begin chest compressions B. Call the rapid response team C. Remove the family from the room D. Ventilate the client with a bag mask device
B. Call the rapid response team
The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. What should the nurse do next? A. Continue monitoring as usual; this is expected B. Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system C. Decrease the suction and continue observing the system for changes in bubbling during the next several hours D. Notify the health care provider (HCP)
B. Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system
An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after insertion of a permanent pacemaker? A. Maintain skin integrity B. Maintain cardiac conduction stability C. Decrease cardiac output D. Increase activity level
B. Maintain cardiac conduction stability
A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take? A. Administer pain medication concurrently B. Monitor blood pressure continuously C. Evaluate arterial blood gases at least every 2 hours D. Monitor for signs of infection
B. Monitor blood pressure continuously
The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed? A. Adhesive strips B. Petrolatum gauze C. Dry 4x4 gauze D. No dressing is necessary
B. Petrolatum gauze
ACE inhibitors cause HYPOKALEMIA or HYPERKALEMIA?
Hyperkalemia
When assessing a client for early septic shock, the nurse should assess the client for which finding? A. Cool, clammy skin B. Warm, flushed skin C. Increased blood pressure D. Hemorrhage
B. Warm, flushed skin
What is the appropriate position to assess for jugular vein distention?
45 degree fowlers
Which medication is used for symptomatic bradycardia?
Atropine
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? A. Fluid balance B. Anaphylactic reaction C. Pain D. Altered level of consciousness
B. Anaphylactic reaction
Vtach WITHOUT a pulse
Defibrillate (DO NOT synchronize -> don't wait)
To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? A. Administer oxygen every 2 hours B. Turn the client every 4 hours C. Administer sedatives to promote rest D. Suction if cough is ineffective
D. Suction if cough is ineffective
Which medication would be ordered to treat a patient with ventricular dysrhythmias?
Amiodarone
Which medication should be held 48-hours prior to an elective cardioversion for SVT?
Digoxin
A client undergoes surgery to repair lung injuries. Postoperative prescriptions include the transfusion of one unit of packed red blood cells at a rate of 60 mL/h. How long will this transfusion take to infuse? A. 2 hours B. 4 hours C. 6 hours D. 8 hours
B. 4 hours
The rapid response team has been called to manage an unwitnessed cardiac arrest in a client's hospital room. How long should the nurse estimate the maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage? A. 1-2 minutes B. 4-6 minutes C. 8-10 minutes D. 12-15 minutes
B. 4-6 minutes
Which finding is an indication of a complication of septic shock? A. Anaphylaxis B. Acute respiratory distress syndrome (ARDS) C. Chronic obstructive pulmonary disease (COPD) D. Mitral valve prolapse
B. Acute respiratory distress syndrome (ARDS)
A client who underwent a lobectomy and has a water seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. What should the nurse do next? A. Check the tubing to ensure that the client is not lying on it or kinking it B. Increase the suction C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest D. Ensure that the chest tube has two clamps on it to prevent air leaks
A. Check the tubing to ensure that the client is not lying on it or kinking it
Side effects of etomidate
-Hypotension -Bradycardia -Nausea
Vasoactive medications should be administered through what kind of line?
A central line rather than a peripheral intravenous catheter
After undergoing a tetralogy of Fallot repair, a preschool child is transferred to the pediatric floor. Which intervention does the nurse tell the family to expect? A. A reduced sodium diet B. An activity restriction for several days C. Assignment to an isolation room D. Limiting visitation to parents only
A. A reduced sodium diet
A client has atrial fibrillation and a heart rate of 165 bpm. In which order from first to last should the nurse implement these prescriptions? All options must be used. A. Administer oxygen via nasal cannula B. Gather supplies for an IV insertion C. Place client on a cardiac monitor (ECG) D. Obtain vital signs including BP, HR, RR, temp, and O2 saturation
A. Administer oxygen via nasal cannula C. Place client on a cardiac monitor (ECG) D. Obtain vital signs including BP, HR, RR, temp, and O2 saturation B. Gather supplies for an IV insertion
Which finding is a risk factor for hypovolemic shock? A. Hemorrhage B. Antigen-antibody reaction C. Gram-negative bacteria D. Vasodilation
A. Hemorrhage
Which signs and symptoms would lead the nurse to suspect a child has tetralogy of fallot (TOF)? Select all that apply. A. Murmur B. History of squatting C. Bounding pulses D. Cyanosis E. Faint pulse F. Tachypnea
A. Murmur B. History of squatting D. Cyanosis F. Tachypnea
For a client with rib fractures and a pneumothorax, the health care provider prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which finding indicates the goal has been met? A. pain rating of 0 to 2 on a scale of 0 to 10 by the client B. decreased client anxiety C. respiratory rate of 26 breaths/min D. PaO, of 70 mm Hg (9.31 kPa)
A. pain rating of 0 to 2 on a scale of 0 to 10 by the client
The amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation
Afterload
When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principles should the nurse address first? A. Organizing information to be taught in a logical sequence B. Arranging to use actual equipment for demonstrations C. Building the teaching on the child's current level of knowledge D. Presenting the information in order from simplest to most complex
C. Building the teaching on the child's current level of knowledge
Vtach WITH a pulse
Cardiovert (synchronize and sedate first)
A client has a chest tube and water seal drainage system. What should the nurse do to ensure safe and effective use of the drainage system? A. Verify that the air vent on the water seal drainage system is capped when the suction is off B. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs C. Ensure that the chest tube is clamped when moving the client out of the bed D. Make sure that the drainage apparatus is always below the client's chest level
D. Make sure that the drainage apparatus is always below the client's chest level
A child diagnosed with tetralogy of fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic, and the respiratory rate increases to 44 breaths/min. Which action should the nurse do first? A. Obtain a prescription for sedation for the child B. Assess for an irregular heart rate and rhythm C. Explain to the child that it will only hurt for a short time D. Place the child in a knee-to-chest position
D. Place the child in a knee-to-chest position
What level of creatinine indicates a bad kidney?
Creatinine over 1.3
A child with tetralogy of fallot takes prostaglandin 1. The child is cyanotic and weak. Which evaluation would indicate a therapeutic response to the medication?
Cyanosis does not increase
- A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is schedules for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client? A. "You'll continue to take your medications until the morning of the test" B. "You might be sedated during the procedure and won't remember what's happened" C. "This is a noninvasive method of determining the effectiveness of your medication regimen" D. "During the procedure, the health care provider will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms"
D. "During the procedure, the health care provider will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms"
When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum? A. 0.5 inch B. 1 inch C. 1.5 inches D. 2 inches
D. 2 inches
Which intervention is the highest priority for the therapeutic management of a child with congestive heart failure (CHF) caused by pulmonary stenosis? A. Educating the family about the signs and symptoms of infection B. Administering enoxaparin to improve left ventricular contractility C. Assessing heart rate and blood pressure every 2 hours D. Administering furosemide to decrease systemic venous congestion
D. Administering furosemide to decrease systemic venous congestion
The nurse is caring for a 2 day old neonate in the postanesthetia care until 30 minutes after surgical correction for the cardiac defect, transposition of the great vessels. Which finding would alert the nurse to notify the health care provider (HCP)? A. Oxygen saturation of 90% B. Pale pink extremities C. Warm, dry skin D. Femoral pulse of 90 bpm
D. Femoral pulse of 90 bpm
The nurse is planning care for a client with a crushing chest injury. The client is in an intensive care unit, and the client's vital signs have not stabilized. Which finding puts the client at risk for acute respiratory distress syndrome (ARDS)? A. History of smoking B. Low serum potassium C. Hypercapnia D. Hypovolemia
D. Hypovolemia
Which drugs do NOT lower blood pressure
Digoxin and atropine
Patient education for antidysrhythmic medications
Dizziness; slow position changes
What should the nurse include in the immediate post-procedure plan of care for a patient after a coronary angiogram?
Encourage fluids (to protect the kidneys from the contrast dye used in the procedure)
Blood pressure should be monitored how often when taking antidysrhythmic medication?
Every hour
Cardiac tamponade results from...
Excessive blood or fluid inside the pericardium
Positive outcome after administration of dopamine
Increased BP and MAP
Amiodarone is used after _______ is unsuccessful
Lidocaine
What is one of the most important actions to take as a nurse to reduce the acutely ill patient's risk of developing septic shock?
Maintain asepsis when performing invasive procedures
What assessments are priority for lidocaine?
Neuro checks are priority
-Used for sedation during mechanical ventilation or during cardioversion -Monitor serum lipids
Propofol
Children who undergo cardiac surgery (ex: repair of a ventricular septal defect (VSD)) may need prophylactic antibiotic therapy. Why?
To prevent infective endocarditis (more common complications of cardiac surgery
A client who has been given cardiopulmonary resuscitation is transported by ambulance to the hospital's emergency department. Which is the most effective way for the nurse to determine if this client has adequate oxygenation? A. There is a pulse B. Pupils are reacting to light C. Mucous membranes are pink D. Systolic blood pressure is at least 80 mm Hg
B. Pupils are reacting to light
An infant weighing 9 kg is in the pediatric intensive care unit following arterial switch surgery. In the past hour, the infant has had 16 mL of urine output. Which action should the nurse take? A. Notify the health care provider (HCP) immediately B. Record the urine output in the medical record C. Administer a fluid bolus immediately D. Assess for other sings of hypervolemia
B. Record the urine output in the medical record
A nurse is helping a suspected choking victim. When should the nurse perform the Heimlich maneuver? A. The victim starts to become cyanotic B. The victim cannot speak due to airway obstruction C. The victim can make only minimal vocal noises D. The victim is coughing vigorously
B. The victim cannot speak due to airway obstruction
What is the most important goal of nursing care for a client who is in shock? A. Manage fluid overload B. Manage increased cardiac output C. Manage inadequate tissue perfusion D. Manage vasoconstriction of vascular beds
C. Manage inadequate tissue perfusion
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60 mm Hg. What should the nurse do first? A. Prepare for transcutaneous pacing B. Prepare to defibrillate the client at 200 J C. Administer an IV lidocaine infusion D. Schedule the operating room for insertion of a permanent pacemaker
A. Prepare for transcutaneous pacing
A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. What finding should the nurse immediately report to the health care provider? A. Sudden, sharp chest pain B. Wheezing breath sounds over affected side C. Hemoptysis D. Cyanosis
A. Sudden, sharp chest pain
When teaching a client about self-care following placement of a new permanent pacemaker to the left upper chest, the nurse should include which information? Select all that apply. A. Take a record daily pulse rate B. Avoid air travel because of airport security alarms C. Immobilize the affected arm for 4-6 weeks D. Avoid using a microwave oven E. Avoid lifting anything heavier than 3 lb
A. Take a record daily pulse rate E. Avoid lifting anything heavier than 3 lb
aPTT normal range is __-__ seconds. In patients receiving anticoagulant therapy, the aPTT range is __-__ times the control value in seconds
-30-40 seconds -1.5-2.5x
What is etomidate used for?
-IV anesthetic -Sedation during mechanical ventilation
What does xanthine do?
-Improves airflow by relaxing bronchial smooth muscle -Bronchodilator
What does dopamine do?
-Improves blood flow by increasing peripheral resistance and increased HR, which increases blood pressure -Alpha1 and beta1 adrenergic
What medications are used for ventricular fibrillation?
-Lidocaine -Amiodarone -Procainamide
What is morphine sulfate?
-Opiate analgesic -Relieves moderate to severe pain -Do not crush -High abuse potential
Xanthine contraindications
-Uncontrolled cardiac dysrhythmias -Seizure disorders -Hyperthyroidism -Peptic ulcers
A client has the following arterial blood gas values: pH 7.52; PaO2 50 mm Hg; PaCO2 28 mm Hg; HCO3 24 mEq/L. Based upon the clients PaO2, which nursing clinical judgement should the nurse make? A. The client is severely hypoxic B. The oxygen level is low but poses no risk for the client C. The client's PaO2 level is within normal range D. The client requires oxygen therapy with very low oxygen concentrations
A. The client is severely hypoxic
A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding? A. The lung has fully expanded B. The lung has collapsed C. The chest tube is in the pleural space D. The mediastinal space has decreased
A. The lung has fully expanded
Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? A. Urine output >30 mL/h B. Systolic blood pressure >110 mm Hg C. Diastolic blood pressure >90 mm Hg D. Respiratory rate of 20 breaths/min
A. Urine output >30 mL/h
A client suddenly develops paroxysmal supraventricular tachycardia (PSVT) at a rate of 180 bpm. Current vital signs: blood pressure 90/45 mm Hg, heart rate 180 bpm, respirations 30 breaths/min, O2 saturation 90% on room air. The client is diaphoretic and reports dizziness. What should the nurse do first? A. Ask the client about current caffeine use B. Administer atropine per agency protocol C. Prepare defibrillator for synchronized cardioversion D. Start cardiopulmonary resuscitation (CPR)
C. Prepare defibrillator for synchronized cardioversion
A nurse should interpret which finding as an early sign of a tension pneumothorax in a client with chest trauma? A. Diminished bilateral breath sounds B. Muffled heart sounds C. Respiratory distress D. Tracheal deviation
C. Respiratory distress
When caring for a client with a newly diagnosed cardiac dysrthythmia, which laboratory values are the priority for the nurse to monitor? Select all that apply. A. Blood urea nitrogen (BUN) of 20 mg/dL B. Hematocrit of 40% C. Sodium of 124 mEq/L D. Potassium of 3.1 mEq/L E. Hemoglobin of 14 g/dL F. Calcium of 8.5 mEq/L G. Prothrombin time of 12 seconds with INR of 1
C. Sodium of 124 mEq/L D. Potassium of 3.1 mEq/L F. Calcium of 8.5 mEq/L
What instructions should the nurse include in the discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin? Select all that apply. A. Give the medication at regular intervals B. Mix the medication with a small volume of breast milk or formula C. Repeat the dose one time if the child vomits immediately after administration D. Notify the health care provider (HCP) of poor feeding or vomiting E. Make up any missed doses as soon as realized F. Notify the HCP if more than two consecutive doses are missed
A. Give the medication at regular intervals D. Notify the health care provider (HCP) of poor feeding or vomiting F. Notify the HCP if more than two consecutive doses are missed
A client with acute respiratory distress syndrome is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR technique for communication, the nurse calls the health care provider (HCP). What recommendation should the nurse give to the HCP? A. Initiating IV sedation B. Starting a high-protein diet C. Providing pain medication D. Increasing the ventilator rate
A. Initiating IV sedation
The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the health care provider as an indication that the client has low cardiac output? A. Bounding pulses and mottled skin B. Altered level of consciousness and thready pulse C. Capillary refill of 2 seconds and blood pressure of 96/67 mm Hg D. Extremities warm to the touch and pale skin
B. Altered level of consciousness and thready pulse
During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the nurse palpates the radial pulse and notices which signs? A. Two regular beats followed by one irregular beat B. An irregular rhythm with pulse rate >100 bpm C. A pulse rate below 60 bpm D. A weak, thready pulse
B. An irregular rhythm with pulse rate >100 bpm
A nurse hears an irregular heart rate of 110 bpm when listening to a client's chest. After assessing the client and noting new onset shortness of breath, which action should the nurse take next? A. Check availability of medication to relieve anxiety B. Recheck the pulse later in the shift C. Obtain a prescription for a stat electrocardiogram D. Call the radiology service to obtain a stat chest x-ray
C. Obtain a prescription for a stat electrocardiogram
Upon assessment of third-degree heart block on the monitor, what should the nurse do first? A. Call a code B. Begin cardiopulmonary resuscitation (CPR) C. Place transcutaneous pacing pads on the client D. Prepare for defibrillation
C. Place transcutaneous pacing pads on the client
Clubbing of the fingers and toes would be seen in a child diagnosed with which congenital heart defect?
Tetralogy of fallot
A client diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)? A. Arterial oxygen level of 46 mm Hg B. Respirations of 12 breaths/min C. Lack of adventitious lung sounds D. Oxygen saturation of 96% on room air
A. Arterial oxygen level of 46 mm Hg
The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? A. Elevated carbon dioxide level B. Hypoxia not responsive to oxygen therapy C. Metabolic acidosis D. Severe, unexplained electrolyte imbalance
B. Hypoxia not responsive to oxygen therapy
Six hours after pacemaker insertion, a client reports sudden onset of chest pain and shortness of breath with a drop in SpO2 from 98% on 2 LPM of oxygen to 90% on 2 LPM of oxygen. Which action should the nurse take first? A. Assess the client's breath sounds and chest movement B. Notify the health care provider to obtain a chest x-ray C. Check the client's blood pressure and heart rate D. Assess the incision site for redness, pain, drainage, and/or swelling
A. Assess the client's breath sounds and chest movement
A client admitted to the telemetry unit with newly diagnosed atrial fibrillation has been started on warfarin. What should the nurse instruct the client to do when taing this medication? Select all that apply. A. Avoid injury to prevent bruising B. Be careful using a razor or fingernail clippers C. Report any change in color of urine or stool D. Floss the teeth deep into the gums E. Not take the medication if the pulse is below 60
A. Avoid injury to prevent bruising B. Be careful using a razor or fingernail clippers C. Report any change in color of urine or stool
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. A. Monitor serum creatinine and blood urea nitrogen levels B. Administer a sedative C. Keep the head of the bed flat D. Administer humidified oxygen E. Auscultate the lungs
A. Monitor serum creatinine and blood urea nitrogen levels D. Administer humidified oxygen E. Auscultate the lungs
A child has had open heart surgery to repair a tetralogy of Fallot with a patch. Which instructions should the nurse give to the parents? A. Notify all health care providers (HCP) before invasive procedures for the next 6 months B. Maintain adequate hydration of at least 10 glasses of water a day C. Provide for frequent rest periods and naps during the first 4 weeks D. Restrict the ingestion of bananas and citrus fruit
A. Notify all health care providers (HCP) before invasive procedures for the next 6 months
During rescue breathing in cardiopulmonary resuscitation (CPR), how will the nurse evaluate that victim is exhaling? A. Observing normal relaxation of the chest B. Giving gentle pressure from the rescuers hand on the upper chest C. Noting the depth of pressure of cardiac compressions D. Turning the client's head to the side
A. Observing normal relaxation of the chest
A client is undergoing a thoracentesis. What should the nurse monitor the client for during and immediately after the procedure? Select all that apply. A. Pneumothorax B. Subcutaneous emphysema C. Tension pneumothorax D. Pulmonary edema E. Infection
A. Pneumothorax B. Subcutaneous emphysema C. Tension pneumothorax D. Pulmonary edema
A client returns to the nursing unit following successful synchronized cardioversion using transthoracic chest wall patches. What should the nurse assess when the client returns to the room? Select all that apply. A. Vital signs B. Skin of chest wall C. Arterial puncture site D. Level of consciousness E. Cardiac rhythm
A. Vital signs B. Skin of chest wall D. Level of consciousness E. Cardiac rhythm
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first? A. Activate the rapid response team B. Assess the client's orientation and vital signs C. Call the health care provider (HCP) D. Administer a bolus of lidocaine
B. Assess the client's orientation and vital signs
After surgery to correct a tetralogy of Fallot, the child's parents express concern to the nurse that their 4-year-old child wants to be held more frequently than usual. What does the nurse recommend? A. Introducing a new skill B. Beginning play therapy C. Encouraging the behavior D. Having the volunteer hold the child
B. Beginning play therapy
The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, what should the nurse assess? A. Increased renal and mesenteric blood flow B. Increased cardiac output C. Vasoconstriction D. Reduced preload and afterload
B. Increased cardiac output
During cardiopulmonary resuscitation (CPR) for an adult, the rescuer's hands should be placed two fingers' width above the lower end of the sternum. Which organ would be most likely at risk for laceration by forceful compressions over the xiphoid process? A. Lung B. Liver C. Stomach D. Diaphragm
B. Liver
A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? A. Reduce the client's anxiety B. Maintain adequate oxygenation C. Decrease chest pain D. Maintain adequate circulating volume
B. Maintain adequate oxygenation
The nurse has placed the intubated client with acute respiratory syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone position? Select all that apply. A. The family is coming in to visit B. The client has increased secretions requiring frequent suctioning C. The SpO2 and PO2 have decreased D. The client is tachycardic with drop in blood pressure E. The face has increased skin breakdown and edema
C. The SpO2 and PO2 have decreased D. The client is tachycardic with drop in blood pressure E. The face has increased skin breakdown and edema
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? A. An obstruction is present in the chest tube B. The client is developing subcutaneous emphysema C. The chest tube system is functioning properly D. There is a leak in the chest tube system
C. The chest tube system is functioning properly
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. What evidence will indicate to the nurse that the client understands the discharge plan? A. The client selects a low-cholesterol diet to control coronary artery disease B. The client states a need for bed rest for 1 week after discharge C. The client verbalizes safety precautions needed to prevent pacemaker malfunctions D. The client explains signs and symptoms of myocardial infarction (MI)
C. The client verbalizes safety precautions needed to prevent pacemaker malfunctions
A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? A. The ventricular rate is increasing B. The absent pulse is now palpable C. The number of premature ventricular contractions is decreasing D. The find ventricular fibrillation changes to coarse ventricular fibrillation
C. The number of premature ventricular contractions is decreasing
A client is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD). The spouse expresses anxiety about what would happen if the device discharged during physical contact. What should the nurse tell the spouse? A. Physical contact should be avoided whenever possible B. They will not feel the countershock C. The shock would feel like a "tingle," but it would not cause any harm D. A warning device sounds before countershock, so there is time to move away
C. The shock would feel like a "tingle," but it would not cause any harm
When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for the ventricular septal defect, the nurse should expect to include which information? A. Restriction of the child's activities for the next 3 weeks B. Use of sponge baths until the stitches are removed C. Use of prophylactic antibiotics before receiving any dental work D. Maintenance of a pressure dressing until a return visit with the healthcare provider
C. Use of prophylactic antibiotics before receiving any dental work
Which nursing intervention is most appropriate in preventing septic shock? A. Administering IV fluid replacement therapy as prescribed B. Obtaining vital signs every 4 hours for all clients C. Monitoring red blood cell counts for elevation D. Maintaining asepsis of indwelling urinary catheters
D. Maintaining asepsis of indwelling urinary catheters
If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, what should the rescuer do first? A. Try using a bag mask device B. Decrease the rate of compressions C. Intubate the client D. Reposition the airway
D. Reposition the airway
Which finding indicates hypovolemic shock in an adult who has had a 15% blood loss? A. Pulse rate <60 bpm B. Respiratory rate of 4 breaths/min C. Pupils unequally dilated D. Systolic blood pressure <90 mm Hg
D. Systolic blood pressure <90 mm Hg
