exam 2

Question 1

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?

Answer 1

Bradycardia and Systolic Hypertension

Question 2

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

Answer 2

Preparing to help the patient to the bathroom

Question 3

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?

Answer 3

Check pedal pulses

Question 4

Which of the following signs would cause the nurse to suspect a critically ill patient is developing DIC?

Answer 4

Nosebleed

Question 5

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?

Answer 5

Lower the HOB

Question 6

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?

Answer 6

CTA

Question 7

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?

Answer 7

. “You will need to increase your diet high in Potassium foods”

Question 8

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?

Answer 8

Cardiac tamponade

Question 9

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?

Answer 9

Decorticate posturing (toward the body & clenched)

Question 10

What dietary modifications is priority for the nurse to include in teaching a patient who is taking Amlodipine to control their blood pressure?

Answer 10

Eliminate grapefruit

Question 11

The nurse is providing education to a client diagnosed with a small thoracic aneurysm. Which information should the nurse include in the teaching session?

Answer 11

Dyspnea may develop if the aneurysm dilates

Question 12

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?

Answer 12

QRS wave

Question 13

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?

Answer 13

Liver function tests are needed regularly

Question 13

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?

Answer 13

It relaxes the heart and dilates the blood vessels

Question 14

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?

Answer 14

I won’t worry if I have a little swelling around my lips or face

Question 15

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?

Answer 15

The pacemaker fires at a constant rate, not on demand

Question 16

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?

Answer 16

2nd degree

Question 17

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?

Answer 17

You need to check your pulse before taking this medication

Question 18

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?

Answer 18

5

Question 19

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?

Answer 19

Unequal Pupils

Question 20

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?

Answer 20

I won’t be able to drink alcohol while taking this medicine

Question 21

Which assessment finding would the nurse expect to find in a patient diagnosed with a AAA?

Answer 21

A systolic Bruit

Question 22

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?

Answer 22

Lorazepam

Question 23

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?

Answer 23

Enters at external jugular vein, ends at right ventricle

Question 24

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 ?

Answer 24

Return to the ER if the client begins to have vomiting or slurred speech

Question 25

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?

Answer 25

Epinephrine

Question 26

You have a patient that is diagnosed with cardiac tamponade. Which collaborative intervention would the nurse anticipate for the client?

Answer 26

Pericardiocentesis

Question 27

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?

Answer 27

I will need a backup contraceptive method for my birth control pills

Question 28

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?

Answer 28

Absence of brain stem reflex (three cardinal signs)

Coma (three cardinal signs)

Apnea (three cardinal signs)

Question 29

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?

Answer 29

Maintain bed rest with bedpan use (they cant control bladder so this won’t work)

Question 30

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?

Answer 30

A 77 year old with sepsis

Question 31

SATA Which of the following should the nurse review with the client who is being discharged with a permanent pacemaker.

Answer 31

Avoid MRIs

Wear a medic alert ID

Keep cell phones on opposite sides

Question 32

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?

Answer 32

Administer stool softener

Ensure ongoing nutritional support

Anticipate administration of an anticonvulsant

Monitor for HYPOnatremia

Question 33

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?

Answer 33

Mannitol

Question 34

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?

Answer 34

IV Bolus of Atropine

Question 35

The nurse is reviewing the HCP’s orders for a patient with DIC. Which of the following orders should the nurse question?

Answer 35

Administer Vitamin K IM

Question 36

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?

Answer 36

Raise the knee gatch to make the client more comfortable

Question 37

. 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?

Answer 37

Sedative at bedtime

Question 38

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?

Answer 38

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

Question 39

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?

Answer 39

Assess for bladder distention

Question 39

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?

Answer 39

At bedtime

Question 40

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?

Answer 40

To evaluate for atrial thrombi

Question 41

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?

Answer 41

D Dimer
Platelet
PTT

Question 42

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?

Answer 42

Asthma

Question 43

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?

Answer 43

This medication can cause birth defects or fetal death

Question 44

Answer 44

Normal Sinus Rhythm 1st degree AV block

Question 45

Answer 45

Sinus Rhythm/ Sinus tachycardia

Question 46

Answer 46

Asytole

Question 47

Answer 47

Sinus Bradycardia

Question 48

Answer 48

Ventricular Tachycardia

Question 49

Answer 49

Arterial Flutter