Midterm PQs Flashcards

1
Q

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

a. Inspiratory crackles
b. Heart rate 45 beats/min
c. Cool, clammy extremities
d. Temperature 101.2°F (38.4°C)

A

b. Heart rate 45 beats/min

Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

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2
Q

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

a. Increase the rate for the dopamine infusion.
b. Decrease the rate for the nitroglycerin infusion.
c. Increase the rate for the sodium nitroprusside infusion.
d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

A

c. Increase the rate for the sodium nitroprusside infusion.

Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

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3
Q

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?

a. No new heart murmurs
b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure of 92/40 mm Hg

A

c. Warm, pink, and dry skin

Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

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4
Q

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for

a. furosemide
b. nitroglycerin
c. norepinephrine
d. sodium nitroprusside

A

c. norepinephrine

When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

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5
Q

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

a. Auscultate bowel sounds.
b. Ask the patient about nausea.
c. Check stools for occult blood.
d. Palpate for abdominal tenderness.

A

c. Check stools for occult blood.

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

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6
Q

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

a. Check temperature every 2 hours.
b. Monitor breath sounds frequently.
c. Maintain patient in supine position.
d. Assess skin for flushing and itching.

A

b. Monitor breath sounds frequently.

Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

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7
Q

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

a. The patient is receiving low dose dopamine.
b. The patient’s central venous pressure is 3 mm Hg.
c. The patient is in sinus tachycardia at 120 beats/min.
d. The patient has had no urine output since being admitted.

A

b. The patient’s central venous pressure is 3 mm Hg.

Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

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8
Q

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?

a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation

A

d. Oxygen saturation

Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

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9
Q

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?

a. The patient’s serum creatinine level is elevated.
b. The patient complains of intermittent chest pressure.
c. The patient’s extremities are cool and pulses are weak.
d. The patient has bilateral crackles throughout lung fields.

A

a. The patient’s serum creatinine level is elevated.

The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient’s diagnosis of cardiogenic shock.

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10
Q

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

a. Give normal saline IV at 500 mL/hr.
b. Give acetaminophen (Tylenol) 650 mg rectally.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

A

a. Give normal saline IV at 500 mL/hr.

Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

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11
Q

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

a. Skin cool and clammy
b. Heart rate of 118 beats/min
c. Blood pressure of 92/56 mm Hg
d. O2 saturation of 93% on room air

A

a. Skin cool and clammy

Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient’s status.

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12
Q

A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?

a. Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form.
b. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit.
c. Explain the risk the client faces if she leaves the facility.
d. Ask the security department to guard the room to the client’s door.

A

c. Explain the risk the client faces if she leaves the facility.

Rationale: The expected reference range for INR while a client is taking warfarin is 2 to 3. The nurse has an obligation to explain to the client that her INR is very high and she is at risk for bleeding.

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13
Q

A nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?

A. Platelets 190,000/mm3
B. Hct 44%
C. PT 45 seconds
D. Hgb 16 g/dL

A

C. PT 45 seconds

PT 45 seconds is above the normal range of 11 to 13.5 seconds. This result indicates that the blood is taking too long to clot, which increases the risk of bleeding. The nurse should notify the provider and expect a decrease in the warfarin dose.

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14
Q

A nurse is caring for an older adult client who has a terminal illness and is ventilator dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client’s wishes is a violation of which of the following ethical principles?

A. Justice
B. Veracity
C. Fidelity
D. Autonomy

A

D. Autonomy

This answer is correct because autonomy is the ethical principle that respects the client’s right to make their own decisions about their health care, even if they are different from the provider’s or the nurse’s recommendations. Autonomy applies to this situation, as the client is expressing their preference to discontinue the ventilator, which is a life sustaining treatment.

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15
Q

A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

A. Instructions on how to change ventilator settings
B. Instructions on mouth care
C. Instructions to suction the client’s tracheostomy every 2 hr
D. Instructions to place the client in a supine position

A

B. Instructions on mouth care

Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.

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16
Q

A nurse in a critical care unit is caring for a client who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

A. Flattened neck veins.
B. Bradycardia.
C. Sudden lethargy.
D. Muffled heart sounds.

A

D. Muffled heart sounds.

This choice is correct because muffled heart sounds are a sign of cardiac tamponade. Muffled heart sounds are heart sounds that are fainter or softer than normal due to reduced transmission of sound waves through fluid-filled pericardial sac. They may indicate that the heart function is compromised by cardiac tamponade and require immediate intervention such as pericardiocentesis (removal of fluid from pericardial sac).

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17
Q

A nurse is collecting data on a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

A. Hypertension
B. Peripheral edema
C. Oliguria
D. Bradycardia

A

C. Oliguria

This is the correct answer. Oliguria, or reduced urine output, is a common finding in hypovolemia. When the body is low on fluids, the kidneys try to conserve water by decreasing urine production.

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18
Q

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis?
SELECT ALL THAT APPLY

A. Vomiting
B. Hypoglycemia
C. Hypertension
D. Altered mental status
E. Elevated WBC’s count

A

A. Vomiting
D. Altered mental status
E. Elevated WBC’s count

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19
Q

A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

A

Semi-Fowlers

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20
Q

Four hours after mechanical ventilation is initiated, a patient’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to

a. increase the FIO2.
b. increase the tidal volume.
c. increase the respiratory rate.
d. decrease the respiratory rate.

A

d. decrease the respiratory rate.

The patient’s PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.

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21
Q

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy?

a. Assessing the patient’s risk for aspiration
b. Suctioning the tracheostomy when needed
c. Educating the patient about self-care of the tracheostomy
d. Determining the need for replacement of the tracheostomy tube

A

b. Suctioning the tracheostomy when needed

Suctioning of a stable patient can be delegated to LPN/LVNs. Assessments and patient teaching should be done by the RN.

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22
Q

Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient’s endotracheal tube. Which action by the nurse is best?

A. Stop and ventilate the patient with 100% oxygen.
B. Check the patient’s potassium level
C. Give prescribed PRN antidysrhythmic medications.
D. Decrease the suction pressure to 80 mm Hg.

A

A. Stop and ventilate the patient with 100% oxygen.

Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.

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23
Q

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates a need for suctioning?

a. The patient’s oxygen saturation is 93%.
b. The patient was last suctioned 6 hours ago.
c. The patient’s respiratory rate is 32 breaths/minute.
d. The patient has occasional audible expiratory wheezes.

A

c. The patient’s respiratory rate is 32 breaths/minute.

The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that is is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest immediate suctioning is needed.

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24
Q

The nurse is weaning a patient who has COPD and Weighs 68 kilograms from mechanical ventilation which finding indicates that the weaning protocol should be stopped?

a. The patient’s heart rate is 97 beats/minute.
b. The patient’s oxygen saturation is 93%.
c. The patient’s respiratory rate is 32 breaths/minute.
d. The patient’s spontaneous tidal volume is 450 mL.

A

c. The patient’s respiratory rate is 32 breaths/minute.

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25
Q

The nurse provides discharge teaching for a client who has two fractured ribs from an automobile accident. Which statement, if made by the client, would indicate that teaching has been effective?

a. “I will use the incentive spirometer every hour or two during the day.”
b. “I can take shallow breaths to prevent my chest from hurting.”
c. “I am going to buy a rib binder to wear during the day.”
d. “I should plan on taking the pain pills only at bedtime, so I can sleep.”

A

a. “I will use the incentive spirometer every hour or two during the day.”

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26
Q

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?

A

c. Use pulse oximetry to check the oxygen saturation.

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27
Q

For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately?

a) Blood pressure (BP) 192/102 mm Hg
b) Report of constipation
c) Anxiety
d) Heart rate 52 beats/min

A

a) Blood pressure (BP) 192/102 mm Hg

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28
Q

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing an immediate medical evaluation?

a. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness
b. A 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C)
c. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness
d. A 70-year-old with a history of diabetes who has “tearing” back pain and is diaphoretic

A

d. A 70-year-old with a history of diabetes who has “tearing” back pain and is diaphoretic

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29
Q

The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse?

a) Urine output of 20 mL over 2 hours
b) Blood pressure of 106/58 mm Hg
c) +3 pedal pulses
d) Absent bowel sounds

A

a) Urine output of 20 mL over 2 hours

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30
Q

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?

a. Assesses the client for back pain
b. Auscultates over abdominal bruit
c. Measures the abdominal girth
d. Palpates the abdomen in four quadrants

A

d. Palpates the abdomen in four quadrants

Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this.

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31
Q

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?

a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity

A

b. Speech alterations

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32
Q

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings:
Vital Signs Nursing Assessment
Time: 0800
Temperature: 98° F
Heart rate: 68 beats/min
Blood pressure: 135/60 mm Hg
Respiratory rate: 14 breaths/min
Oxygen saturation: 96%
Oxygen therapy: 2 L nasal cannula

Time: 1000
Temperature: 98.2° F
Heart rate: 50 beats/min
Blood pressure: 132/57 mm Hg
Respiratory rate: 16 breaths/min
Oxygen saturation: 95%
Oxygen therapy: 2 L nasal cannula Time: 0800
Client alert and oriented.
Cardiac rhythm: normal sinus rhythm.
Skin: warm, dry, and appropriate for race.
Respirations equal and unlabored.
Client denies shortness of breath and chest pain.

Time: 1000
Client alert and oriented.
Cardiac rhythm: sinus bradycardia.
Skin: warm, dry, and appropriate for race.
Respirations equal and unlabored.
Client denies shortness of breath and chest pain.
Client voids 420 mL of clear yellow urine.
Based on the assessments, which action should the nurse take?

a. Stop the infusion and flush the IV.
b. Slow the amiodarone infusion rate.
c. Administer IV normal saline.
d. Ask the client to cough and deep breathe.

A

b. Slow the amiodarone infusion rate.

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33
Q

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

a. Monitor the quality and presence of the pedal pulses.
b. Teach the patient the signs of possible wound infection.
c. Check the lower extremities for strength and movement.
d. Help the patient to use a pillow to splint while coughing.

A

d. Help the patient to use a pillow to splint while coughing.

34
Q

A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient?

a. Promote rest to decrease myocardial oxygen demand.
b. Teach the patient about the need for anticoagulant therapy.
c. Teach the patient to use sublingual nitroglycerin for chest pain.
d. Raise the head of the bed 60 degrees to decrease venous return.

A

a. Promote rest to decrease myocardial oxygen demand.

35
Q

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

A. Systolic blood pressure is increased
B. Radial heart rate is increased
C. Cardiac output is reduced
D. Urine output is reduced

A

A. Systolic blood pressure is increased

36
Q

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?

a. The patient’s PaO2 is 45 mm Hg.
b. The patient’s PaCO2 is 33 mm Hg.
c. The patient’s respirations are shallow.
d. The patient’s respiratory rate is 32 breaths/min.

A

a. The patient’s PaO2 is 45 mm Hg.

37
Q

After receiving change-of-shift report on a medical unit, which patient should the nurse
assess first?

a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has crackles bilaterally in the lung bases
c. A patient with emphysema who has an oxygen saturation of 90% to 92%
d. A patient with septicemia who has intercostal and suprasternal retractions

A

d. A patient with septicemia who has intercostal and suprasternal retractions

38
Q

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient’s caregiver is accurate?

a. “PEEP will push more air into the lungs during inhalation.”
b. “PEEP prevents the lung air sacs from collapsing during exhalation.”
c. “PEEP will prevent lung damage while the patient is on the ventilator.”
d. “PEEP allows the breathing machine to deliver 100% O2 to the lungs.”

A

b. “PEEP prevents the lung air sacs from collapsing during exhalation.”

By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

39
Q

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway?

a. Weak cough effort
b. Profuse green sputum
c. Respiratory rate of 28 breaths/min
d. Resting pulse oximetry (SpO2) of 85%

A

a. Weak cough effort

The weak cough effort indicates that the patient is unable to clear the airway effectively. The other data suggest problems with gas exchange and breathing pattern.

40
Q

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

A. The patient has no cough reflex when suctioned.
B. The patient’s oxygen saturation is 90% to 93%
C. The patient does not respond to voice.
D. No sedative is ordered for the patient

A

D. No sedative is ordered for the patient

41
Q

The nurse notes that a patient’s endotracheal tube (ET), which was at the 22-cm mark, is now at the 25 cm mark and the patient is anxious and restless. Which action should the nurse take next?

a. Offer reassurance to the patient.
b. Bag the patient at an FiO2 of 100%.
c. Listen to the patient’s breath sounds.
d. Notify the patient’s HCP.

A

c. Listen to the patient’s breath sounds.

42
Q

A nurse is reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

A. Hematocrit 45%
B. Platelets 74,000/mm3
C. Partial thromboplastin time (PTT) 65 seconds
D. White blood cell count 8,000/mm3

A

B. Platelets 74,000/mm3

43
Q

A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?

A. Administer IV morphine.
B. Start an IV infusion of lactated Ringer’s.
C. Begin oxygen therapy.
D. Initiate cardiac monitoring.

A

C. Begin oxygen therapy.

44
Q

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, which of the following findings should the nurse use to determine that the procedure was effective?

A. Decreased respiratory rate
B. Stable oxygen saturation
C. Clear breath sounds
D. Pink capillary refill

A

C. Clear breath sounds

45
Q

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

A

assess the client’s airway

46
Q

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

A. Excessive thrombosis and bleeding
B. Increased clotting factors
C. Progressive increase in platelet production
D. Immediate sodium and fluid retention

A

A. Excessive thrombosis and bleeding

47
Q

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

A. Decreased heart rate
B. Increased blood pressure
C. Weak pulse
D. Dyspnea

A

C. Weak pulse

48
Q

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

A. Sinus bradycardia
B. Sinus tachycardia
C. Atrial fibrillation
D. First-degree AV block

A

C. Atrial fibrillation

49
Q

A nurse is assessing a client who is receiving continuous IV infusion of dopamine which of the following findings should the nurse recognize as a therapeutic effect?

A

Increased MAP of patient

50
Q

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

A. Increased urine output
B. Decreased blood glucose level
C. Decreased blood pressure
D. Increased heart rate

A

A. Increased urine output

51
Q

A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?

A. Prevents dysrhythmias
B. Relieves pain
C. Dissolves blood clots
D. Slows intestinal motility

A

A. Prevents dysrhythmias

52
Q

A nurse is reviewing a client’s laboratory report of ABG findings pH 7.28 HCO 318 MEQ per liter PA CO2 36 which of the following conditions should the nurse anticipate when interpreting these findings

A

metabolic acidosis

53
Q

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication?

a. 5% albumin infusion
b. furosemide (Lasix) IV
c. epinephrine (Adrenalin) drip
d. hydrocortisone (Solu-Cortef)

A

b. furosemide (Lasix) IV

54
Q

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous
pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3
hours. Which order by the health care provider should the nurse question?

a. Administer furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Give hydrocortisone (Solu-Cortef) 100 mg IV.
d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.

A

a. Administer furosemide (Lasix) 40 mg IV.

55
Q

Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient’s left ventricular afterload?

a. Mean arterial pressure (MAP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)

A

b. Systemic vascular resistance (SVR)

SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored but do not reflect afterload as directly.

56
Q

After change-of-shift report in the progressive care unit, who should the nurse care for first?

a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute
d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

A

b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

57
Q

A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question?

a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg.
d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.

A

a. Infuse normal saline at 250 mL/hr.

58
Q

Following surgery for an abdominal aortic aneurysm, a patient’s central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?

a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Document the CVP and continue to monitor.
d. Elevate the head of the patient’s bed to 45 degrees.

A

b. Increase the IV fluid infusion per protocol.

59
Q

A nurse is assessing a client for suspected anaphylactic reaction following a CT scan with contrast media for which of the following client findings should the nurse intervene first

A

stridor

60
Q

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

A. The laboratory values are within the expected reference range.
B. The laboratory values are prolonged.
C. The laboratory values are the same as the previous test values.
D. The laboratory values are decreased.

A

B. The laboratory values are prolonged.

61
Q

A nurse is caring for a client who experiences anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

A. Albuterol
B. Hydrocortisone sodium succinate
C. Diphenhydramine
D. Epinephrine

A

D. Epinephrine

62
Q

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to the client?

A. Cryoprecipitates
B. Albumin
C. Platelets
D. Packed RBCs

A

D. Packed RBCs

63
Q

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?

A. Widening pulse pressure
B. Increased heart rate
C. Increased deep tendon reflexes
D. Pulse oximetry 96%

A

B. Increased heart rate

64
Q

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?

A. Confusion
B. Blood pressure 84/50 mm Hg
C. Anuria
D. Petechiae

A

A. Confusion

Rationale: Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

65
Q

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

A. Decreased level of consciousness
B. Increased respiratory rate
C. Hypotension
D. Anuria

A

B. Increased respiratory rate

66
Q

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

A. Heart rate 180/min
B. Motled skin
C. Hypokalemia
D. Blood pressure 115/68 mm Hg

A

D. Blood pressure 115/68 mm Hg

67
Q

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

A. Hypertension
B. Bradypnea
C. Oliguria
D. Flushing of the skin

A

C. Oliguria

68
Q

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A. “DIC is controllable with lifelong heparin usage.”
B. “DIC is caused by abnormal coagulation involving fibrinogen.”
C. “DIC is a genetic disorder involving a vitamin K deficiency.”
D. “DIC is characterized by an elevated platelet count.”

A

B. “DIC is caused by abnormal coagulation involving fibrinogen.”

69
Q

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

A. Decrease in the urinary output from 50 mL to 30 mL per hour.
B. Increase in the heart rate from 88 to 110/min.
C. Decrease in the respiratory rate from 20 to 16/min.
D. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).

A

B. Increase in the heart rate from 88 to 110/min.

70
Q

The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states

a. “It will be several weeks before I can return to my usual activities.”
b. “I will avoid cooking with a microwave oven or being near one in use.”
c. “I will notify the airlines when I make a reservation that I have a pacemaker.”
d. “I won’t lift the arm on the pacemaker side until I see the health care provider.”

A

d. “I won’t lift the arm on the pacemaker side until I see the health care provider.”

71
Q

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next?

A

Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

72
Q

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient’s cardiac rhythm as

a. atrial flutter.
c. ventricular fibrillation.
b. sinus tachycardia.
d. ventricular tachycardia.

A

d. ventricular tachycardia.

73
Q

A nurse is caring for a client who has acute respiratory distress and requires mechanical ventilation the client received a prescription for vacuum the nurse recognizes that this medication is for which of the following purposes

A

suppressed respiratory effort

74
Q

A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

A. Respiratory alkalosis
B. Increased venous return
C. Decreased cardiac output
D. Dilated ventricles

A

C. Decreased cardiac output

75
Q

A nurse and a newly licensed nurse are providing care for a client who has distributive shock. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?

A. “Distributive shock occurs due to loss of myocardial contractility.”
B. “Distributive shock occurs due to loss of blood volume.”
C. “Distributive shock occurs due to systemic vasodilation.”
D. “Distributive shock occurs due to increased systemic vascular resistance.”

A

C. “Distributive shock occurs due to systemic vasodilation.”

76
Q

A nurse is providing care for a client experiencing obstructive shock. Which of the following diagnoses should the nurse expect?

A. Third spacing
B. Cardiomyopathy
C. Cardiac tamponade
D. Ruptured aneurysm

A

C. Cardiac tamponade

77
Q

A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)

A. A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min.
B. A client who has a heart rate of 132/min and a respiratory rate of 30/min.
C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min.
D. A client who has bradypnea and a white blood cell (WBC) count of 10,000/mm³ (normal range: 5,000 to 10,000/mm³).
E. A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min.

A

B. A client who has a heart rate of 132/min and a respiratory rate of 30/min.
C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min.

78
Q

A decrease in level of consciousness and a heart rate greater than 130 beats per minute select 3 findings that require immediate follow up

A

oxygen saturation on day 2
tracheal secretions
RR

79
Q

A nurse is assisting with the care of a client who has a tracheostomy

drag words from the choices below to fill in each blank in the following sentence

A

Hypoxia
Pneumonia

Rationale: when recognizing cues, the nurse should identify that manifestations of hypoxia include decrease, oxygen, saturation, cyanosis, restlessness, anxiety tachycardia, and increase respiratory rate
Manifestations of pneumonia include elevated temperature prudent pulmonary secretions, adventitious breath and areas of lung inflammation on chest x-ray.

80
Q

A client is receiving mechanical ventilation for the treatment of acute respiratory distress syndrome the charge nurse as a nursing student the possible causes of high pressure alarm which of the following responses indicate understanding of in ventilator alarms

Box 1
Box 2

A

box 1 circulatory status
box 2 level of consciousness

81
Q

Complete the sentence by using the list of options

A

determine cardio pulmonary arrest
call for help and begin CPR

82
Q

NGN bowtie

A

Dx: Atrial Fibrillation

Nursing Actions: 12 lead ECG and anticoagulants

Monitor for: Stroke and PTT/INR