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
