O2, Perfusion, and Cardiac Flashcards

1
Q

The nurse is reviewing client education with a parent and their teenager. Which interventions should help minimize the occurrence of sickle cell crisis? Select all that apply.

  1. Receive a yearly pneumonia vaccination.
  2. Always wear socks and gloves when outside on cold days.
  3. Engage in vigorous aerobic exercise at least 3-4 times a week.
  4. You should drink at least 3-4 liters of non-caffeinated liquid a day.
  5. Avoid cigarettes and/or tobacco products and second hand smoke.
A

2, 3, 5

Rationale
In order to help minimize the occurrence of a sickle cell crisis, the client should be instructed to: drink 3-4 liters of non-caffeinated liquid/day; avoid alcoholic beverages; avoid cigarettes and/or tobacco to include second-hand smoke; receive an annual flu shot; a pneumonia shot every 5 years or according or the CDC guidelines; avoid being too hot or cold; wear socks and gloves outside on cold days; avoid high altitudes; avoid strenuous exercise; and engage in mild, low impact exercise 3xs/week when not in a crisis.

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2
Q

The nurse reviews in the client’s medical history the following: congestive heart failure, weight gain of 15 pounds (6.8kg) in the last 72 hours, crackles in lungs bilaterally, shortness of breath at rest, respiration at 24 breaths per minute, O2 saturations 96% on 2 lpm of oxygen (O2), and pedal edema +3. The admitting lab values are Na: 139mEq/L, K: 2.9mEq/L, Cl : 98mEq/L, and Mg: 1.7mEq/L. Which client outcomes indicate that spironolactone is effective?

  1. Respiration at 18 breaths per minute.
  2. Pedal edema +1.
  3. Potassium level of 5.2mEq/L.
  4. Weight loss 5 pounds (2.3kg).
  5. O2 saturations 96% on 3 lpm O2.
A

1, 2, 4

Rationale
Spironolactone is a potassium-sparing diuretic. Positive outcomes include less pedal edema, improved respiratory effort, and weight loss indicating fluid volume decrease.

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3
Q

Which assessment finding should the nurse anticipate in a client experiencing an acute asthma exacerbation?

  1. Decreased nasal secretions.
  2. Frequent productive cough.
  3. Answering questions in full sentences.
  4. Prolonged phase of forced expiration.
A

4

Rationale
The nurse should expect to observe a prolonged phase of force expiration, frequent unproductive cough, increased nasal secretions, and breathlessness in the client experiencing acute asthma exacerbation.

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4
Q

The nurse writes the following goal for the unit: “Within 3 hours of the start of shift, the temperature, pulse, respirations, and blood pressure for all 15 clients will be documented, reviewed, and signed in the electronic medical record.” Which category of SMART goals is missing from this statement?

  1. Specific.
  2. Measurable.
  3. Time-bound.
  4. Realistic.
A

3

SMART goals are specific, measurable, achievable, realistic, and time-bound. To make this statement a SMART goal, the nurse should note that the temperatures, pulses, respirations, and blood pressures (specific vital signs) should be documented (achievable) and reviewed between 7 a.m. and 10 a.m. (time-bound) for 15 clients (realistic). The nurse is delegated a task and specifying what is to be done and the time frame it should be completed.

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5
Q

A client’s admitted to the intensive care unit diagnosed with stage 5 chronic kidney disease assessment includes crackles in the lungs, periorbital edema, anuric, muscle cramps and paresthesia. The nurse should anticipate the health care provider to prescribe which treatment?

  1. Renal dialysis.
  2. Nitroglycerin.
  3. Albuterol inhalation.
  4. Furosemide intravenously.
A

1

Diuretics can be used in clients with chronic kidney disease stages 1-4. Clients who have advance to stage 5, diuretics will not work; these clients will need to receive renal dialysis treatment to remove the excess fluids from their system.

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6
Q

A client is diagnosed with restrictive cardiomyopathy. Which should the nurse identify as a known cause of this condition?

  1. Radiation therapy.
  2. Myocarditis.
  3. Hypertension.
  4. Genetic disorder.
A

1

Rationale
Restrictive cardiomyopathy is a heart disease characterized by abnormal filling of the ventricles. Radiation therapy of the chest can cause restricted cardiomyopathy.

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7
Q

A client is scheduled for an echocardiogram the next morning. What instructions should the nurse communicate to the client about this test?

  1. A large bore IV will be inserted.
  2. Pain medication will be administered.
  3. No food or drink will be allowed after midnight.
  4. No special preparation is necessary
A

4

An echocardiogram is a noninvasive test that does not require pre-procedure interventions or preparation.

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8
Q

What should the nurse anticipate will be prescribed for a client with a warfarin (Coumadin) overdose?

  1. Heparin.
  2. Albumin.
  3. Vitamin K.
  4. Protamine sulfate.
A

3

Vitamin K is used in the treatment of a warfarin (Coumadin) overdose. The nurse should be aware that it takes 4 to 6 hours for vitamin K to reverse the properties of warfarin. Plasma, prothrombin complex concentrates, or recombinant factor XII may need to be given until the effects of the vitamin K take effect.

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9
Q

The nurse is caring for a client receiving oxygen via a Venturi mask at 6 L/min. Which nursing intervention ensures that the client is receiving adequate oxygenation?

  1. Keeping the orifice for the Venturi adapter open.
  2. Observing for a mist during inspiration and expiration.
  3. Placing a nasal cannula on the client during mealtimes.
  4. Making sure the valves are patent and rubber flaps are functional.
A

1

The orifice for the Venturi adapter should be kept open and uncovered. If the Venturi orifice is covered, the adapter cannot function properly, and the prescribed amount of oxygen delivery may vary.

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10
Q

Which medication would the nurse anticipate to be prescribed for a client who suffers rhinitis as a result of seasonal allergies?

  1. Fluticasone (Flonase).
  2. Cyclosporine (Restasis).
  3. Ranibizumab (Lucentis).
  4. Brimonidine/timolol (Combigan).
A

1

Fluticasone (Flonase) is a medication that is prescribed for the treatment and management of nasal symptoms of seasonal and perennial allergies.

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11
Q

The nurse is preparing a class about the use of over-the-counter (OTC) medications. Which population of clients does not required special dosing of OTC antitussives and expectorants?

  1. Infants.
  2. Children.
  3. Adult.
  4. Geriatric.
A

3

The dose of antitussives and expectorants should be decreased when used by geriatric clients because of their slower metabolism. According to the FDA, special consideration needs to be taken for children as the age span is quite broad. Medications which are safe for a school-age child may not be safe fo an infant.

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12
Q

A client was prescribed acetylcysteine (expectorant) inhalation therapy for treatment of cystic fibrosis. Which data would indicate the medication has been an effective therapeutic?

  1. The client has decreased amount of secretions suctioned from client’s lungs.
  2. The client coughed up a moderate amount of liquefied secretions.
  3. Client’s breath sounds and wheezing are diminished on auscultation.
  4. Client’s appetite is increased with decreased amount of steatorrhea present.
A

2

The action of acetylcysteine is to decrease the viscosity of secretions making it easier for clients with cystic fibrosis to cough up the thickened secretions from their lungs.

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13
Q

The nurse is caring for a client who is at risk for developing pneumonia. Which action should the nurse take to decrease the risk of infection?

  1. Encourage the client to stay in bed and rest.
  2. Maintain an option suction system when suctioning the client.
  3. Teach the client how to cough and deep breathe.
  4. Implement protective isolation precautions.
A

3

Pneumonia occurs due to an infection in the lungs as the result of consolidation of pulmonary secretions in the lobes of the lungs. In order to reduce the risk of pneumonia infection, the nurse should teach the client how to cough and deep breathe to aid in the removal of these secretions from the lungs.

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14
Q

The nurse is caring for a client in acute respiratory failure. Which goal should the nurse include in the care plan?

  1. Respiratory rate will be 30 breaths/min within 24-48 hours after initiation of treatment.
  2. The client will be weaned from the ventilator within 24-48 hours after initiation of treatment.
  3. Blood pH will be between 7.50-7.60 within 2-4 hours after initiation of treatment.
  4. The client has a PaO2 greater than 80 mmHg within 2-4 hours of initiation of treatment.
A

4

Acute respiratory failure generally results from a primary lung dysfunction. When treating a client with acute respiratory failure, the client should have adequate gas exchange within 2 to 4 hours of initiating treatment. A PaO2 greater than 80 mmHg indicates adequate ventilation.

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15
Q

The nurse is assessing a client who is experiencing shortness of breath, intercostal retractions, nasal flaring, inspiratory and expiratory wheezing, who has not not shown any respiratory improvement after two administrations of albuterol nebulizer treatments. Which is a common trigger for acute asthma exacerbation?

  1. Ingested allergen.
  2. Exposure to warm air.
  3. Hypocapnia.
  4. Inactivity.
A

1

Specific triggers for acute asthma exacerbation vary from client to client. In general, sudden changes in weather (especially exposure to cold air), allergens in the environment or food, expression of intense emotion, and exercise may all trigger acute asthma exacerbation.

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16
Q

Which sign should alert the nurse of a possible pneumothorax in a client with an acute asthma exacerbation?

  1. Hyperresonance found on percussion.
  2. Decreased tactile fremitus.
  3. Wheezing heard on auscultation.
  4. Hyperinflated chest.
A

1

A pneumothorax is a possible complication of acute asthma exacerbation. The presence of hyperresonance upon percussion should alert the nurse to a possible pneumothorax.

17
Q

An arterial blood gas (ABG) analysis is drawn for a client. The results show pH of 7.30; PaCO2 of 68 mm Hg and an HCO3 of 24 mEq/L. What should the nurse interpret this blood gas as?

  1. Compensated metabolic alkalosis.
  2. Uncompensated respiratory acidosis.
  3. Compensated metabolic acidosis.
  4. Uncompensated respiratory alkalosis.
A

2

The nurse should interpret the arterial blood gas (ABG) result as uncompensated respiratory acidosis due to the fact the pH is acidotic and the CO2 is hypercapnic and the sodium bicarbonate is within normal limits. This ABG result is reflective of acute respiratory distress.

18
Q

A client with asthma reports a pain level of 7 out of 10. The health care provider orders morphine 2 mg IV for pain. Which action should the nurse implement?

  1. Question the health care provider’s order.
  2. Administer the medication.
  3. Reassess the pain level.
  4. Measure the client’s respirations.
A

1

Morphine can exacerbate the symptoms of asthma, so this medication should be used with caution in clients with asthma. The nurse should question the health care provider’s order.

19
Q

The nurse is assessing a client who had a thoracentesis earlier in the day. The nurse should alert the health care provider if the client exhibits which finding?

  1. Nasal congestion.
  2. Onset of a nagging cough.
  3. Gag reflex that has not returned.
  4. Decrease in the baseline of the heart rate.
A

2

Pneumothorax may occur within the first 24 hours following a thoracentesis. Manifestations of pneumothorax include the onset of a “nagging” cough.

20
Q

The nurse is caring for a client receiving oxygen via a Venturi mask at 6 L/min. Which nursing intervention ensures that the client is receiving adequate oxygenation?

  1. Keeping the orifice for the Venturi adapter open.
  2. Observing for a mist during inspiration and expiration.
  3. Placing a nasal cannula on the client during mealtimes.
  4. Making sure the valves are patent and rubber flaps are functional.
A

1

Rationale
The orifice for the Venturi adapter should be kept open and uncovered. If the Venturi orifice is covered, the adapter cannot function properly, and the prescribed amount of oxygen delivery may vary.

21
Q

The nurse is assessing an adult client who has aspirated a small foreign object. The nurse should suspect that the object is lodged in which part of the respiratory tract?

  1. Larynx.
  2. Left main bronchus.
  3. Right main bronchus.
  4. Trachea.
A

3

Rationale
The right main bronchus is slightly wider, shorter, and more vertical than the left bronchus. Although larger foreign bodies may become lodged in the trachea or larynx, most objects become lodged in the right main bronchus of an adult client.

22
Q

The nurse is performing an initial assessment on a client with a suspected aortic dissection. Which assessment finding should the nurse anticipate?

  1. Pulse of 150 bpm.
  2. Acute onset of intense pain.
  3. Hot, flushed skin.
  4. SpO2 of 80% on room air.
A

2

Rationale
An aortic dissection is a tear in the aortic wall that is associated with chronic hypertension. A clients with an aortic dissection will typically report intense pain of acute onset.

23
Q

The nurse is caring for a client who just been brought into the emergency department after a myocardial infarction. Which action is the priority for this client?

  1. Administer pain medications.
  2. Begin educating the client about what to expect in the cath lab.
  3. Administer 2-4L oxygen by nasal cannula.
  4. Obtain an electrocardiogram.
A

3

Rationale
Clients experiencing myocardial infarction often experience pain and discomfort. To relieve ischemic pain, the nurse can provide additional oxygen via nasal cannula, which will promote delivery of oxygen to the heart.

24
Q

The nurse is preparing discharge instructions for a client diagnosed with acute coronary syndrome. Which is an expected outcome when effective client education is provided?

  1. The client will verbalize lifestyle changes that are needed.
  2. The client will require additional teaching.
  3. The client will question the need to take hypertensive medications.
  4. The client will refuse to adhere to a cardiac diet.
A

1

Rationale
Within the 24-hour period before discharge from the cardiac care step-down unit, the client should verbalize understanding of the disease, as well as the necessary lifestyle changes that may modify risk factors. It is important that the nurse be aware of expected outcomes and plan for the client’s learning needs.

25
Q

The nurse is attending a lecture on cardiovascular pathology. Which statement by the nurse regarding aortic aneurysm indicates that the teaching has been effective?

  1. “They are classified as true or false.”
  2. “They are most commonly located in the thoracic aorta.”
  3. “They are classified based on their size and severity.”
  4. “They can involve a single layer of the arterial wall.”
A

1

An aortic aneurysm is an increase in the diameter of the vessel by at least 50%. Aortic aneurysms are classified as true or false. A true aneurysm involves all three layers of the arterial wall, whereas a false aneurysm involves only two layers.

26
Q

Which medication should the nurse anticipate the healthcare provider to prescribe for a client who has just undergone a coronary artery stent placement?

  1. Losartan.
  2. Warfarin.
  3. Atropine.
  4. Verapamil.
A

2

Anticoagulants are prescribed following a coronary artery stent placement to help minimize the formation of clots causing blockage at the stent placement site.