Quiz 2 Flashcards
A patient presents with multiple rib fractures following a motor vehicle accident. Which symptom would the nurse expect to observe?
A) Shallow respirations and splinting
B) Cyanosis and bradycardia
C) Hyperventilation and tachycardia
D) Chest pain that improves with inspiration
A) Shallow respirations and splinting
A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?
A. Heart murmur
B. Bradycardia
C. Clubbing of the fingers
D. Barrel chest
A. Heart murmur
The nurse is caring for a patient with mitral valve regurgitation. Which information obtained by the nurse would be reported to the health care provider immediately?
a. The patient has 4+ peripheral edema.
b. The patient has diffuse bilateral crackles.
c. The patient has a loud systolic murmur across the precordium.
d. The patient has a palpable thrill felt over the left anterior chest.
b. The patient has diffuse bilateral crackles.
What would the lungs sounds like for mitral valve regurgitation?
wet crackles at base of lungs
What is the difference between mitral valve stenosis and regurgitation?
mitral stenosis - diastolic murmur
mitral regurgitation - systolic murmur
Which valve disorder is characterized by the regurgitation of blood into the left atrium during systole?
A) Aortic stenosis
B) Aortic regurgitation
C) Mitral valve prolapse
D) Mitral regurgitation
D) Mitral regurgitation
Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm?
a. Record hourly chest tube drainage.
b. Monitor fluid intake and urine output.
c. Assess the abdominal incision for redness.
d. Counsel the patient to plan for a long recovery time.
b. Monitor fluid intake and urine output.
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first?
a. Draw blood for laboratory testing.
b. Check the patient‘s blood pressure.
c. Assess the patient for an abdominal bruit.
d. Determine any family history of heart disease.
b. Check the patient‘s blood pressure.
After receiving change-of-shift report, which patient admitted to the emergency department would the nurse assess first?
a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse
b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain
c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride
d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools
b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain
A patient with an abdominal aortic aneurysm (AAA) is likely to exhibit which symptom?
A) Chest pain radiating to the arm
B) Abdominal or back pain
C) Severe headache
D) Dyspnea and cough
B) Abdominal or back pain
Which risk factor would the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm?
a. Male gender
b. Hypertension
c. Age over 60 years
d. Family history of vascular disease
b. Hypertension
What medication would we initially give to patient with pulmonary embolism if the BP is dropping?
Alteplase
A patient is receiving heparin IV for pulmonary embolism, if aPTT is low, what should the nurse do? What is the normal range?
increase rate
normal: 25-35
When administering anticoagulant therapy for a patient with a pulmonary embolism, which lab value should the nurse monitor closely?
A) Serum sodium
B) PT/INR
C) Serum creatinine
D) Blood glucose
B) PT/INR
Which diagnostic test is most commonly used to confirm a pulmonary embolism?
A) Chest X-ray
B) CT pulmonary angiography
C) MRI
D) ABG analysis
B) CT pulmonary angiography
A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain.
The nurse notes that the patient’s chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
A. Flail chest
B. Hemothorax
C. Atelectasis
D. Pneumothorax
A. Flail chest
What is the characteristic sign of flail chest on physical examination?
A) Symmetrical chest movement during respiration
B) Paradoxical chest wall movement
C) Diminished breath sounds
D) Wheezing on expiration
B) Paradoxical chest wall movement
A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following is an early manifestation of an AAA?
A. Lower back or groin pain
B. Hunger after eating
C. Pain in the chest
D. Presence of Cullen’s sign
A. Lower back or groin pain
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
Which of the following are risk factors for abdominal aortic aneurysm (AAA)? (Select all that apply.)
A. Diabetes mellitus
B. Total cholesterol 170 mg/dL (less than 200 mg /Dl
C. HDL cholesterol 65 mg/dL (male greater than 45 mg/dL; female greater than 55 mg/dL)
D. Smoking cigarettes
E. Family history of aneurysm
D. Smoking cigarettes
E. Family history of aneurysm
Which of the following is a risk factor for developing a pulmonary embolism?
A) Hypotension
B) Deep vein thrombosis
C) High HDL levels
D) Increased fluid intake
B) Deep vein thrombosis
A patient had an open surgical repair of an abdominal aortic aneurysm earlier today. The patient‘s total urinary output for the past 2 hours was 45 mL. What would the nurse anticipate will be prescribed?
a. Hemoglobin count
b. Increased IV fluids
c. Additional antibiotics
d. Serum creatinine level
b. Increased IV fluids
