exam 2 Flashcards
The ICU is monitoring a patient who has a traumatic brain injury for signs of increased ICP. Which would indicate an EARLY sign of deterioration in the patient’s neurological status?
Bradycardia and Systolic Hypertension
The nurse is caring for a patient with an open AAA repair who is 4 hours post op. Which action by the tech would require the nurse to intervene
Preparing to help the patient to the bathroom
Which of the following nursing interventions are appropriate in the immediate post op care of a patient with an endovascular graft repair of an AAA?
Check pedal pulses
Which of the following signs would cause the nurse to suspect a critically ill patient is developing DIC?
Nosebleed
The nurse is caring for a client who has tetraplegia. When the nurse elevates the HOB to 30 degrees, the patient complains of dizziness and becomes hypotensive. What should the nurse do?
Lower the HOB
The nurse is reviewing the diagnostic tests of a client admitted with a thoracic aneurysm. The client asks the nurse “How does the doctor know that this is an aneurysm?”. The nurse knows that which of the following test results best confirms the diagnosis?
CTA
The charge nurse is observing a new RN providing discharge teaching for a client with hypertension who is being prescribed Analapril. Which of the following comments by the new RN would prompt the charge nurse to intervene?
. “You will need to increase your diet high in Potassium foods”
A client admitted with pericarditis calls the nurses station and complains of difficulty breathing and chest pain. The nurse assesses and reveals the vital signs : T - 99.2, P - 108, RR - 28, BP - 106/94, O2 - 92%. The patient has jugular vein distention. Heart sounds are faint and lungs have faint crackles. The nurse recognizes that these symptoms are consistent with which of the following conditions?
Cardiac tamponade
The nurse is caring for a client who is experiencing ICP. The nurse observes that the client’s body becomes stiff with flexion of the upper extremities with extension and internal rotation of the lower extremities. How will the nurse document?
Decorticate posturing (toward the body & clenched)
What dietary modifications is priority for the nurse to include in teaching a patient who is taking Amlodipine to control their blood pressure?
Eliminate grapefruit
The nurse is providing education to a client diagnosed with a small thoracic aneurysm. Which information should the nurse include in the teaching session?
Dyspnea may develop if the aneurysm dilates
The nurse is assisting with a cardioversion on a client with AFib. The nurse sets the defibrillator to synchronize the ECG on the monitor to make sure the electrical impulse discharges during which part of the patient’s impulse cycle?
QRS wave
A client with a spinal cord injury is having difficulty with muscle spasms and spasticity and the HCP orders dantrolene to manage the symptoms. Which of the following instructions are important for the nurse to inform the client about the drug?
Liver function tests are needed regularly
The physician prescribes Amlodipine for a patient with hypertension and a family history of aneurysms. The patient asks the nurse how the medication works. How should the nurse respond?
It relaxes the heart and dilates the blood vessels
The nurse is provided education to a client who has hypertension and has a new prescription for Captopril. Which statement by the client would indicate that reinforcement is needed?
I won’t worry if I have a little swelling around my lips or face
A cardiac ICU manager is reviewing types of pacemakers with a group of newly hired nurses. Which of the following statements by one of the nurses indicates the understanding of a fixed pacemaker?
The pacemaker fires at a constant rate, not on demand
The ICU nurse is checking the telemetry of a post-op patient who has displayed normal sinus rhythm. The nurse notes a recurrent pattern in which the patient’s PR Interval has become progressively longer followed by a P Wave that is not conducted to the ventricles (No QRS). Which conduction problem would the nurse identify for the patient?
2nd degree
A patient is being discharged on digoxin after being diagnosed with A Fib. When providing medication teaching, the nurse should include which of the following instructions?
You need to check your pulse before taking this medication
The nurse is performing a Glascow Coma Scale assessment on a client who is unconscious. Which total score would indicate to the nurse that the patient probably has a severe brain injury?
5
The nurse is caring for a client with a closed head injury who is emerging from a coma. Which of the following signs would prompt the nurse to notify the HCP immediately?
Unequal Pupils
The nurse is teaching a client with a spinal cord injury who has a new prescription for Baclofen to treat muscle spasms. Which of the following statements by the client indicates an understanding of the teaching?
I won’t be able to drink alcohol while taking this medicine
Which assessment finding would the nurse expect to find in a patient diagnosed with a AAA?
A systolic Bruit
The ICU nurse is caring for a patient diagnosed with a head injury who is intubated and becoming agitated and combative. The nurse prepares to administer which of the following medications to help calm the patient?
Lorazepam
After a patient receives a pacemaker, the patient asks the nurse where the wires from the implanted transvenous pacing lead and pacemaker are located. The nurse explains based on the lead being in which of the following anatomical positions?
Enters at external jugular vein, ends at right ventricle
A client is being discharged from the ER after suffering from a mild concussion. Which of the following discharge instructions should the nurse give the client’s family member ?
Return to the ER if the client begins to have vomiting or slurred speech
The nurse is assisting with defibrillation for a patient with V Fib. After the first attempt is unsuccessful, which medication would the nurse anticipate giving before the next attempt?
Epinephrine
You have a patient that is diagnosed with cardiac tamponade. Which collaborative intervention would the nurse anticipate for the client?
Pericardiocentesis
The nurse is teaching a client who has been taking Phenytoin to prevent seizures related to brain injury. Which of the following statements by the client would indicate understanding of the teaching?
I will need a backup contraceptive method for my birth control pills
SATA The nurse is assisting in the clinical evaluation of a patient who is a potential organ donor due to irreversible brain injury. Which of the following signs would indicate brain death of the patient?
Absence of brain stem reflex (three cardinal signs)
Coma (three cardinal signs)
Apnea (three cardinal signs)
The ICU is caring for a client with a spinal cord injury who is incontinent. Which order from the HCP to manage the incontinent patient should the nurse question?
Maintain bed rest with bedpan use (they cant control bladder so this won’t work)
An ICU nurse is teaching a newly licensed nurse about DIC. Which of the following clients would the nurse identify as having the highest risk for developing DIC?
A 77 year old with sepsis
SATA Which of the following should the nurse review with the client who is being discharged with a permanent pacemaker.
Avoid MRIs
Wear a medic alert ID
Keep cell phones on opposite sides
SATA The nurse is caring for a client following a TBI 5 days ago. Which of the following interventions will the nurse implement to prevent complications?
Administer stool softener
Ensure ongoing nutritional support
Anticipate administration of an anticonvulsant
Monitor for HYPOnatremia
The ICU is caring for a patient with a TBI who develops cerebral edema. Which drug will the nurse expect to administer to the patient to decrease swelling?
Mannitol
The nurse on the cardiac unit is caring for a patient on telemetry who is recovering from a MI and has a history of glaucoma. The patient’s heart rate is 44. The nurse assesses the BP which is 98/60 and the patient is complaining of dizziness and fatigue. The nurse notifies the provider and anticipates which of the following management strategies?
IV Bolus of Atropine
The nurse is reviewing the HCP’s orders for a patient with DIC. Which of the following orders should the nurse question?
Administer Vitamin K IM
The nurse is assisting the tech during morning care of the client with a spinal cord injury at T5. Which of the following actions by the tech would require correction by the nurse?
Raise the knee gatch to make the client more comfortable
. A client has an 8 cm enlarging AAA and is scheduled for surgery in the morning. Which of the following pre-op orders by the HCP should the nurse question?
Sedative at bedtime
SATA A nurse is providing education to a client who is diagnosed with hypertension taking propranolol. The nurse determines that the client wants to stop taking the medication because he doesn’t think it’s working. How should the nurse respond?
Tell me more about why you feel the medication is not working
It is important to not stop the medication suddenly as it may cause chest pain
A client with a chronic spinal cord injury at C3 is admitted to the ER with severe headache and blood pressure of 210/104. Which action by the nurse would be appropriate INITIALLY?
Assess for bladder distention
The nurse is preparing to give the first dose of Zosin to a patient who is post op from an aneurysm repair. The nurse is aware that the ideal time to give this medicine to prevent adverse effects is which of the following?
At bedtime
The nurse is preparing to assist with a cardioversion for a patient with chronic A Fib. The doctor orders a TEE to be done prior to the procedure. The patient asks the nurse why it is needed. The nurse bases her reply on which of the following rationales?
To evaluate for atrial thrombi
SATA The nurse is caring for a patient diagnosed with DIC. The nurse checks STAT labs to see the status of the patient. Which lab values would the nurse expect to be abnormal?
D Dimer
Platelet
PTT
The nurse is reviewing the health history of a patient who is to be prescribed sotalol to control V Tach. Which of the following does the nurse recognize as a contraindication to sotalol?
Asthma
A pregnant client is experiencing gestational hypertension and will need an antihypertensive medication. The client states “my grandmother takes Losartan and her BP is good. Do you think the doctor can prescribe me that?”. How should the nurse respond?
This medication can cause birth defects or fetal death
Normal Sinus Rhythm 1st degree AV block
Sinus Rhythm/ Sinus tachycardia
Asytole
Sinus Bradycardia
Ventricular Tachycardia
Arterial Flutter
