Module 5 - ♡ Flashcards
A nurse completed an infusion of a 1000 mL bolus of normal saline to a client with severe sepsis. One hour later, which laboratory result would require the nurse’s immediate attention?
Potassium 3.8 mEq/L
Creatinine 1.0 mg/dL
Sodium 140 mEq/L
Lactate 6 mmol/L
Lactate 6 mmol/L
A client with cardiogenic shock is being treated with an infusion of dobutamine. The physician’s order indicates to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5 L/min/m2. The nurse measures a cardiac output and notes that the calculated cardiac index for your patient is 4.9 L/min/m2. What is the nurse’s priority action?
Order a stat 12-lead electrocardiogram per protocol
Obtain a stat serum potassium level per protocol
Assess your patient’s hourly urine output
Reduce the rate of dobutamine
Reduce rate of dobutamine
A client has severe sepsis with blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 101° F, and a right atrial pressure (RAP) of 1 mm Hg. Which intervention should the nurse carry out first?
IV antibiotic administration
Blood cultures from two sites
Acetaminophen suppository
Isotonic fluid challenge
Isotonic Fluid Challenge
A nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. Your patient’s skin is warm and flushed. What is your best interpretation of these findings?
Allergic reaction
Neurogenic shock
Hyperthermia
Homeostasis
Neurogenic shock
A nurse admits a client following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2)95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the client’s plan of care?
Implementation of universal precautions
Application of cushioned heel protectors
Insertion of an 18-gauge peripheral intravenous line
Implementation of fall precautions
Insertion of an 18-gauge peripheral intravenous line
Which client in the emergency department is the most at risk for developing hypovolemic shock?
A client with a temperature of 102° F and a general dermal rash
A client admitted with abdominal pain and an elevated white blood cell count
A client with slight rectal bleeding from inflamed hemorrhoids
A client with a 2-day history of nausea, vomiting, and diarrhea
A client with a 2-day history of nausea, vomiting, and diarrhea
Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED (select all that apply):
Transfusion of packed red blood cells
Dopamine infusion
Administration of morphine
Administration of nitroglycerin (NTG)
Oxygen therapy
Administration of morphine
Administration of nitroglycerin (NTG)
Oxygen therapy
Which nursing interventions would be appropriate after angioplasty?
Elevate the head of the bed by 45 degrees for 6 hours
Maintain NPO status for 12 hours
Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place
Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours
Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours
A client presents to the emergency department (ED) with chest pain that they have had for the past 2 hours. The client is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question as potentially inappropriate?
Immediate coronary artery bypass graft surgery
Permanent pacemaker insertion
Emergent thrombolytic therapy
Emergent percutaneous coronary intervention
Permanent pacemaker
Which medication classification would a nurse anticipate a provider would prescribe for a client with hyperlipidemia?
Beta blockers
Antibiotics
Nitroglycerin
HMG-CoA reductase inhibitors (statins)
HMG-CoA statins
A client is having a stent placed and asks a nurse why it is necessary after having an angioplasty. Which response by the nurse is best?
“The angioplasty was a failure, so this procedure has to be done to fix the heart vessel.”
“The stent will remove any clots that are in the vessel and protect the heart muscle from damage.”
“The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again.”
“This procedure is being done instead of using cholesterol-lowering medication to help keep the heart vessel open.”
“The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again.”
A client is admitted with an acute myocardial infarction (AMI). A nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process?
Tachycardia
Myocardial remodeling
Myocardial stunning
Hibernating myocardium
Myocardial Remodeling
A nurse is providing care to a client who is on fibrinolytic therapy. What statement from the client warrants further assessment and intervention by the critical care nurse?
“Look at the bruises on my arms!”
“There is blood on my toothbrush!”
“I have an incredible headache!”
“My arm is bleeding where my IV is!”
I have an incredible headache
A client is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers?
12-lead electrocardiogram
Echocardiogram
Electrophysiology study
Cardiac catheterization
Echocardiogram
A nurse is caring for a client in the ED who came in via ambulance after a severe motor vehicle accident. Suddenly, the client shouts with difficulty, “Awe! I have severe chest pain that goes around to my back! Please help me!” What type of aneurysm would the nurse anticipate to cause this symptom?
Saccular aneurysm
Dissecting aneurysm
Pseudoaneurysm
Fusiform aneurysm
Dissecting aneurysm
