CA2 PRELIMS Flashcards
Condition that may result to patient mortality if left unattended in a brief period of time.
A. acute biologic crisis
B. chronic bilogic crisis
C. cardiac arrest
D. code blue
A. acute biologic crisis
Incomplete occlusion of the coronary arteries lead to what?
A. angina
B. myocardial infarction
C. CVA
D. CAD
A. angina
Chest pain can be relieved by what drug?
Morphine
Furosemide
Aspirin
Nitroglycerin
Nitroglycerin
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
A. Palpate extremities for bilateral pulses.
B.Observe the patients respiratory effort.
C. Check the patients level of consciousness.
D. Examine the patient for any external bleeding.
B.Observe the patients respiratory effort.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should?
A. obtain a complete set of vital signs
B. obtain a Glasgow Coma Scale score
C. ask about chronic medical conditions
D. attach a cardiac electrocardiogram monitor
B. obtain a Glasgow Coma Scale score
A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
A. Auscultate heart sounds.
B. Palpate peripheral pulses
C. Auscultate breath sounds.
D. Check pupil reaction to light.
C. Auscultate breath sounds.
A patient with diabetes has had many renal calculi over the past 20 years and now has chronic renal failure. Which substance must be reduced in this patient’s diet?
Carbohydrates
Fats
Protein
Vitamin C
Protein
Which criterion is required before a patient can be considered for continuous peritoneal dialysis?
A. The patient must be hemodynamically stable
B. The vascular access must have healed
C. The patient must be in a home setting
D. Hemodialysis must have failed
A. The patient must be hemodynamically stable
The most common early sign of kidney disease is:
A. Sodium retention
B. Elevated BUN level
C. Development of metabolic acidosis
D. Inability to dilute or concentrate urine
B. Elevated BUN level
A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what ““type 2”” means in relation to diabetes. The nurse explains to the
patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes
A. the patient is totally dependent on an outside source of insulin
B. there is a decreased insulin secretion and cellular resistance to insulin that is produced
C. the immune system destroys the pancreatic insulin-producing cells
D. the insulin precursor that is secreted by the pancreas is not activated by the liver
B. there is a decreased insulin secretion and cellular resistance to insulin that is produced
A 54-year-old patient admitted with type 2 diabetes, asks the nurse what “type 2” means. Which of the following is the most appropriate response
by the nurse?
A. ““With type 2 diabetes, the body of the pancreas becomes inflamed.”
B. “With type 2 diabetes, insulin secretion is decreased and insulin resistance is
increased.”
C. “With type 2 diabetes, the patient is totally dependent on an outside source of
insulin.”
D. “With type 2 diabetes, the body produces autoantibodies that destroy b-cells in the
pancreas.””
B. “With type 2 diabetes, insulin secretion is decreased and insulin resistance is
increased.”
“A client who is started on metformin and glyburide would have initially presented with which symptoms?
A. polydipsia, polyuria, and weight loss
B. weight gain, tiredness, & bradycardia
C. irritability, diaphoresis, and tachycardia
D. diarrhea, abdominal pain, and weight loss
A. polydipsia, polyuria, and weight loss
A client with diabetes mellitus demonstrates acute anxiety when first admitted for the treatment of hyperglycemia. The most appropriate intervention to decrease the client’s anxiety would be to?
A. administer a sedative
B. make sure the client knows all the correct medical terms to understand what is
happening
C. ignore the signs and symptoms of anxiety so that they will soon disappear
D. convey empathy, trust, and respect toward the client
D. convey empathy, trust, and respect toward the client
A 21-year-old female is seen in the Emergency Department for vomiting and diarrhea for 3 days. Her BP is 94/64 and her ECG rhythm shows that she is sinus tachycardia. The best action for the nurse to take initially is to:
A. request pain medication for the patient
B. cardiovert the patient immediately
C. give Adenosine 6 mg IV push
D. start IV and bolus normal saline per protocol
D. start IV and bolus normal saline per protocol
A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that
involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient’s right arm?
A. SuperWcial partial-thickness
B. Deep partial-thickness
C. Full partial-thickness
D. Full-thickness
D. Full-thickness
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse’s priority concern about this patient?
Fluid status
Risk of infection
Body image
Level of pain
Fluid status
The nurse is caring for a patient who has sustained a deep partial thickness burn injury. In prioritizing the nursing diagnoses for the plan of
care, the nurse will give the highest priority to what nursing diagnosis?
Activity intolerance
Anxiety
Impaired nutrition: less than body requirements
Acute pain
Acute pain
The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4 year-old child tip a pot of boiling
water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?
A. Cover the burn with ice and secure with a towel.
B. Apply butter to the area that is burned.
C. Immerse the child in a cool bath.
D. Avoid touching the burned area and seek medical attention.
C. Immerse the child in a cool bath.
Based on your chart review (35 y/o, non-smoker, New York nurse, history of asthma, with influenza), you expect worse outcomes due to which piece of information?
Age
Smoking Status
Occupation as nurse
Asthma
Asthma
The patient is a 70 y.o. male with a history of smoking, emphysema, and recent COVID hospitalization. Today in therapy he is dizzy when sitting up too quickly. The best thing to do in this situation is:
A. call a rapid response
B. immediately lay the patient back down and wait for the dizziness to subside
C. sit at the edge of bed and monitor symptoms until dizziness subsides
D. tell the patient to ignore the symptoms and proceed with therapy
C. sit at the edge of bed and monitor symptoms until dizziness subsides
Which is the primary consideration when preparing to administer thrombolytic therapy to a patient who is experiencing an acute myocardial infarction (MI)?
A. History of heart disease.
B. Sensitivity to aspirin.
C. Size and location of the MI.
D. Time since onset of symptoms.
D. Time since onset of symptoms.
A 55-year-old patient who is diagnosed with an evolving myocardial infarction (MI) insists on going home. The cardiac/vascular nurse encourages the patient to be admitted, because the greatest risk within the first 24 hours of sustaining an MI is?
Heart failure.
Pulmonary embolism.
Sudden death.
Ventricular aneurysm.
Sudden death.
A patient with negative troponin and stress test results reports recurring chest pain that is similar to the patient’s pain on admission. According to the American Nurses Association’s scope and standards of practice for cardiovascular nursing, the cardiac/vascular nurse’s next action is to:
A. Activate the cardiac catheterization team.
B. Administer analgesics.
C. Obtain a 12-lead electrocardiogram.
D. Promote relaxation.
C. Obtain a 12-lead electrocardiogram.
Which of the following actions is the first priority care for a client
exhibiting signs and symptoms of coronary artery disease?
A. Decrease anxiety
B. Enhance myocardial oxygenation
C. Administer sublignual nitroglycerin
D. Educate the client about his symptoms
B. Enhance myocardial oxygenation
What is the primary reason for administering morphine to a client with myocardial infarction?
A. To sedate the client
B. To decrease the client’s pain
C. To decrease the client’s anxiety
D. To decrease oxygen demand on the client’s heart
D. To decrease oxygen demand on the client’s heart
Which of the following diagnostic tools is most commonly used to
determine the location of myocardial damage?
Cardiac catheterization
Cardiac Enymes
Echocardiogram
Electrocardiogram
Electrocardiogram
Which factor is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer?
A. the support available to assist the client at home
B. the distance the client lives from the hospital
C. the client’s ability to do home blood pressure monitoring
D. the client’s knowledge of the causes of lung cancer
A. the support available to assist the client at home
A 21-year-old female is seen in the Emergency Department for vomiting and diarrhea for 3 days. Her BP is 94/64 and her EKG rhythm shows that she is sinus tachycardia. The best action for the nurse to take initially is to:
A. request pain medication for the patient.
B. cardiovert the patient immediately.
C. give Adenosine 6 mg IV push.
D. start IV and bolus normal saline per protocol.
D. start IV and bolus normal saline per protocol.
A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment,
the nurse determines the patient is experiencing cardiogenic shock because of which additional finding?
Jugular vein distention
Dry mucous membranes
Poor skin turgor
Thirst
Jugular vein distention
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take?
A. Begin the transfusion as prescribed.
B. Administer an antihistamine and begin the transfusion.
C. Delay hanging the blood and notify the health care provider.
D. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.
C. Delay hanging the blood and notify the health care provider.
