syn exam 1 prequiz

Which nursing action is a priority before administering prescribed furosemide? - weigh the client - assess skin turgor - review the potassium levels - check the 24-hour intake and output

Review the potassium levels

When a family member of a client with cardiogenic shock asks the nurse for more information about the condition, how would the nurse describe cardiogenic shock? - an irreversible phenomenon - a failure of the circulatory pump - usually a fleeting reaction to tissue injury - generally caused by decreased blood volume

a failure of the circulatory pump

When a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a RR of 32 breaths/minute, which action would the nurse take first? - elevate the HOB to 75 degrees - obtain the apical pulse and blood pressure - notify the hospital rapid response team - check oxygen saturation with the pulse ox

Elevate the HOB to 75 degrees

Which type of shock is associated with a ruptured abdominal aneurysm? - vasogenic - neurogenic - cardiogenic - hypovolemic

hypovolemic shock

Which activities might cause chest pain in a client with stable angina? SATA - deep breathing during meditation - walking outside on a cold day - sexual activity - taking an afternoon nap - smoking a cigarette - use of oral decongestant

- walking outside on a cold day - sexual activity - smoking a cigarette - use of an oral decongestant

Which type of shock would the nurse suspect when a client is admitted to the emergency department after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 mm Hg to 60/40 mm Hg, and a heart rate increase from 82 bpm to 121 bpm? - septic shock - cardiogenic shock - hemorrhagic shock - neurogenic shock

hemorrhagic (in cardiogenic, they would also have low BP and high HR, but they would have chest discomfort and dyspnea)

When caring for a client who has heart failure, with blood pressure 102/70 mm Hg, pulse 106 bpm, and bilateral lung crackles, which prescribed action would the nurse QUESTION? - infuse normal saline at 100 mL/hr - give furosemide 40 mg intravenous now - administer potassium chloride 10 mEq orally now - titrate oxygen by mask to keep oxygen saturation 93% or higher

infuse normal saline at 100 mL/hr

Which nursing action has the highest priority when caring for a client who has had an acute myocardial infarction (MI)? - prevent nausea and vomiting - monitor for cardiac dysrhythmias - use prescribed medication to lower fever - teach about the phases of cardiac rehabilitation

monitor for cardiac dysrhythmias

When a client who is admitted for coronary artery bypass graft (CABG) surgery asks the nurse about the purpose of pacemaker wires inserted during surgery, which explanation will the nurse give? - defibrillation of the heart after surgery - prevention of slow heart rate after surgery - maintenance of rate of at least 100 beats/minute during surgery - inhibition of too-rapid heart rate during the postoperative period

prevention of slow heart rate after surgery

Which finding for a client who has just arrived in the emergency department and has a history of heart failure requires the most rapid action by the nurse? - irregular apical pulse - O2 sat 86% - crackles at both lung bases - atrial fibrillation on a cardiac monitor

- oxygen saturation 86%

When caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI), which laboratory result will the nurse expect? - decrease WBC count - elevated serum troponins I and T - decreased creatinine kinase-MB - decreased b-type natriuretic peptide (BNP)

Elevated serum troponins I and T

A client whose spinal cord was severed in an accident 1 month ago asks the nurse what is causing the severe leg spasms. Which response would the nurse make? - "you have developed thrombophlebitis, which causes leg spasms. which response would the nurse make?" - "motor function is returning now that the edema is subsiding" - "spinal shock has subsided, and your reflexes are hyperactive" - "the nerves are regenerating, and your motor function is returning"

Spinal shock has subsided, and your reflexes are hyperactive

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? - to prevent dyspnea - to prevent cyanosis - to increase oxygen concentration to heart cells - to increase oxygen tension in the circulating blood

to increase oxygen concentration to heart cells

Which signs of hypokalemia would the nurse monitor in the postoperative surgical client with a nasogastric tube attached to continuous low suction? SATA - irritability - dysrhythmias - muscle weakness - abdominal cramps - acidosis

dysrhythmias muscle weakness (others: weak pulse, dec. BP)

When caring for a client who has a blood pressure of 80/60 mm Hg and heart rate of 120 beats/minute after a motor vehicle accident, the nurse anticipates the need to rapidly implement which type of collaborative action? - increase circulating blood volume - administer arterial vasopressors - stimulate increased heart rate - correct electrolyte disturbances

increase circulating blood volume (vasopressors would also increase HR)

The nurse will anticipate the need to administer which type of medication when a client with cardiogenic shock has an increased pulmonary artery wedge pressure reading of 30 mm Hg? - vasopressor - loop diuretic - antidysrhythmic - beta blocker

loop diuretic (diuretics decrease preload)

A medical-surgical nurse completes the admission assessment on a client diagnosed with a urinary tract infection. The client's admitting weight is 165 lb (74.8 kg). The vital signs are: temperature 96 degrees, pulse 110 bpm, respirations 20 per minute, and blood pressure 88/56. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL with a urinary drainage system. Which intervention would the nurse recommend to the primary care provider? - transfer the client to a critical care unit - discontinue the urinary catheter immediately - administer another 1 L bolus of sodium chloride - begin a dopamine hydrochloride drip for renal perfusion

transfer the client to a critical care unit

Which pulse site is used for the Allen test? - ulnar - popliteal - brachial - femoral

ulnar (it is used to test the circulation to the hands)

How can the nurse describe heart failure to a client? - a cardiac condition caused by inadequate circulating blood volume - an acute state in which the pulmonary circulation pressure decreases - an inability of the heart to pump blood in proportion to metabolic needs - a chronic state in which the systolic blood pressure drops below 90 mm Hg

an inability of the heart to pump blood in proportion to metabolic needs

When assessing a client who has lost a large amount of blood after an automobile collision, which finding would the nurse expect? - urine output of 50 mL/hr - blood pressure of 150/90 mm Hg - apical heart rate of 142 beats/minute - respiratory rate of 16 breaths/minute

apical heart rate of 142 beats/minute

When the nurse is caring for a client who has just arrived in the intensive care unit after coronary artery bypass graft surgery, which finding would be of most concern? - blood pressure 152/92 mm Hg - blood glucose 120 mg/dL (6.68 mmol/L) - atrial fibrillation, rate 112 beats/minute - 100 mL of blood in the chest drainage system

atrial fibrillation, rate 112 beats/minute

When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first? - attach the cardiac monitor - auscultate the heart sounds - check the intravenous fluid rate - assess alertness and orientation

attach the cardiac monitor

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? SATA - bradycardia - hypotension - spastic paralysis - urinary retention - increased pulse pressure

bradycardia hypotension urinary retention

When a client who has had a myocardial infarction suddenly develops a heart rate of 120 bpm, which action would the nurse take first? - offer reassurance - check blood pressure - call for an electrocardiogram (ECG) - activate the hospital rapid response team

check blood pressure (want to check and see if they are perfusing adequately)

Two hours after a cardiac catheterization that was accessed through the right femoral route, a client reports numbness and pain in the right foot. Which action will the nurse take first? - call the primary healthcare provider - check the client's pedal pulses bilaterally - take the client's blood pressure and pulse - teach about postcatheterization embolus

check the client's pedal pulses bilaterally

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? - slow heart rate - cool skin temperature - bounding radial pulses - increased urine output

cool skin temperature

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? - body weight control - decreased fluid retention - lowering of blood pressure - prevention of hypernatremia

decreased fluid retention

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? - urticaria (hives) - tachycardia - restlessness - laryngeal edema

laryngeal edema

Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)? - monitor for cardiac dysrhythmias - inquire about changes in bowel patterns - assess for leg muscle twitching or weakness - assess for signs and symptoms of dehydration

monitor for cardiac dysrhythmias

For the first hour after a client has a cardiac catheterization using the brachial artery, which action would the nurse take? - monitor the vital signs every 15 minutes - maintain the client in the supine position - keep the client's lower extremities in extension - ensure that the client is able to swallow clear liquids

monitor vital signs every 15 minutes

A client undergoes a subtotal gastrectomy. After surgery, the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? SATA - oliguria - bradypnea - diaphoresis - tachycardia -hypertension

oliguria diaphoresis tachycardia

When a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the client's left ventricular pressure? - right atrial pressure - central venous pressure - pulmonary artery diastolic pressure - pulmonary artery wedge pressure

pulmonary artery wedge pressure

The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock? - respirations of 10 - urine output of 30 mL/hour - lethargy - restlessness

restlessness

Which assessment finding indicates a need for the nurse to consult with the health care provider before administering the prescribed metoprolol to a client with stable angina? - blood pressure 142/90 mm Hg - report of chest pain when walking - sinus bradycardia, rate 54 on monitor - large Q waves on the electrocardiogram

sinus bradycardia, rate 54 on monitor

Which clinical manifestations would the nurse observe in a client experiencing a full-blown anaphylactic shock from a type 1 latex allergic reaction? SATA - stridor - fissuring - hypotension - dyspnea - cracking of the skin

stridor hypotension dyspnea