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
A nurse is teaching a client who has mitral valve stenosis that has not responded to pharmacological therapies about other treatment options. Which of the following statements should the nurse include in their teaching?
A. “Pentoxifylline can be administered to help the platelets from sticking together and occluding the vessels.”
B. “A heparin bolus is administered and followed with a continuous infusion to help keep the blood thinner.”
C. “A flexible catheter will be inserted into a vessel of the arm, neck, or groin and advanced to the heart to dilate a narrowed or occluded artery.”
D. “A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated. “
D. “A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated. “
A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur
A. indicates turbulent blood flow through a valve.
B. is an extra sound due to blood entering an inflexible chamber.
C. is a high-pitched sound due to a narrow valve.
D. means that there is some inflammation around the heart.
A. indicates turbulent blood flow through a valve.
A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?
A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta.
B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery.
C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.
D. Abdominal aortic aneurysms might rupture if blood pressure is too low.
C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.
How can a patient who sits for a long time prevent DVT?
Dont cross less
Ambulate after surgery
Get up and move around (plane)
No smoking
Do not discontinue therapy
What are the manifestations of a pulmonary embolism?
Chest pain
SOB
Blood in sputum
(Everything respiratory)
What is the difference between a pulmonary embolism and a DVT?
PE: SOB, tachycardia, blood in sputum, light headed
DVT: Everything but visual disturbances
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism? (SATA)
a. Assess legs for redness
b. Apply elastic compression stockings
c. Perform passive range of motion exercises
d. Place pillows under the client’s knees when in bed massage the calves every shift
a. Assess legs for redness
b. Apply elastic compression stockings
c. Perform passive range of motion exercises
A nurse in an emergency department is caring for a client who has a sunken chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
A. Prepare to insert a central line.
B. Remove the dressing to inspect the wound.
C. Administer oxygen via nasal cannula.
D. Raise the foot of the bed to a 90° angle.
C. Administer oxygen via nasal cannula.
A patient in the ED presents with: Sudden onset of dyspnea while taking a shower. PT is pale, restless, and diaphoretic. Pt keeps saying “I think I am going to die.” Pulse is tachycardia and crackles heard bilaterally in lower base as well as friction rub.
What does the patient have?
What will the nurse monitor and what actions will the nurse take?
dx: pulmonary embolism
monitor: petechiae and cardiac dysrhythmias
action: aPTT and venous access
Bowtie Question aortic stenosis
dx: aortic stenosis
monitor: HR and pulse
action: decreased inflammatory response and ECG every 6-12 months
What will the nurse expect to happen for a patient who was in a car accident? The patient has an increased RR, O2 is low, patient is cyanotic, and displays flail chest?
Intubate patient
Which patient will the nurse assess first?
patient with hx of abdominal aortic aneurysm and high BP (hemodynamic instability)
A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse?
a. Report of chest wall pain
b. Heart rate of 110 beats/min
c. Paradoxical chest movement
d. Large, bruised area on the chest
c. Paradoxical chest movement
What is the most common symptom of pulmonary embolism?
A) Hemoptysis
B) Dyspnea
C) Chest pain
D) Wheezing
B) Dyspnea
A patient is receiving heparin therapy for a pulmonary embolism. Which complication should the nurse monitor for?
A) Hypokalemia
B) Hypovolemia
C) Hemorrhage
D) Thrombocytopenia
C) Hemorrhage
What is the purpose of placing a patient with a pulmonary embolism in a high-Fowler’s position?
A) To reduce blood pressure
B) To increase cardiac output
C) To enhance lung expansion and oxygenation
D) To prevent atelectasis
C) To enhance lung expansion and oxygenation
Which nursing intervention is most appropriate for preventing deep vein thrombosis in a patient at risk for pulmonary embolism?
A) Administering aspirin
B) Encouraging leg exercises and early ambulation
C) Applying ice to the lower extremities
D) Restricting fluid intake
B) Encouraging leg exercises and early ambulation
For a patient with a flail chest, what is the most appropriate nursing intervention?
A) Restricting oral fluids
B) Administering diuretics
C) Providing mechanical ventilation
D) Binding the chest to stabilize it
C) Providing mechanical ventilation
Which complication should the nurse monitor for in a patient with multiple rib fractures?
A) Pulmonary embolism
B) Atelectasis
C) Bronchitis
D) Pleural effusion
B) Atelectasis
What is the main goal of pain management in a patient with rib fractures?
A) To prevent respiratory depression
B) To enable the patient to breathe deeply and cough effectively
C) To reduce fever and prevent infection
D) To maintain a calm environment
B) To enable the patient to breathe deeply and cough effectively
Which of the following interventions is critical for preventing atelectasis in a patient with rib fractures?
A) Providing high-calorie nutrition
B) Encouraging use of an incentive spirometer
C) Administering opioids to suppress cough
D) Restricting fluid intake to reduce edema
B) Encouraging use of an incentive spirometer
A patient with mitral valve stenosis is most likely to develop which complication?
A) Right-sided heart failure
B) Left-sided heart failure
C) Pulmonary embolism
D) Hypertension
A) Right-sided heart failure
What is a key feature of aortic stenosis?
A) Decreased cardiac output
B) Increased venous return
C) Decreased peripheral resistance
D) Reduced systemic blood pressure
A) Decreased cardiac output
Which diagnostic test is most useful for assessing the severity of valvular heart disease?
A) MRI
B) Echocardiogram
C) CT scan
D) ABG analysis
B) Echocardiogram
Which drug class is commonly prescribed to reduce afterload in patients with valvular heart disease?
A) Beta-blockers
B) ACE inhibitors
C) Anticoagulants
D) Calcium channel blockers
B) ACE inhibitors
A patient with mitral valve prolapse is being discharged. What important teaching should the nurse provide?
A) Avoid caffeine and stimulants
B) Increase sodium intake
C) Engage in vigorous exercise
D) Avoid sitting for long periods
A) Avoid caffeine and stimulants
Which of the following findings suggests a thoracic aortic aneurysm?
A) Bradycardia and hypotension
B) Abdominal pain and fever
C) Hoarseness and difficulty swallowing
D) Palpitations and tachycardia
C) Hoarseness and difficulty swallowing
What is the most important nursing intervention for a patient with an aneurysm to prevent rupture?
A) Strict fluid restriction
B) Keep the patient normotensive with antihypertensives
C) Elevate the head of the bed to 90°
D) Encourage frequent physical activity
B) Keep the patient normotensive with antihypertensives
What is the main goal of antihypertensive therapy in a patient with an aortic aneurysm?
A) To prevent fluid overload
B) To prevent an increase in intra-abdominal pressure
C) To reduce the risk of aneurysm expansion or rupture
D) To improve cardiac output
C) To reduce the risk of aneurysm expansion or rupture
A patient with a suspected thoracic aortic aneurysm is complaining of severe back pain and is hypotensive. What is the priority nursing action?
A) Administering pain medication
B) Initiating a rapid infusion of IV fluids
C) Preparing the patient for immediate surgery
D) Placing the patient in a semi-Fowler’s position
C) Preparing the patient for immediate surgery
What is the expected finding during an abdominal assessment of a patient with an abdominal aortic aneurysm?
A) A palpable pulsating mass
B) Hypoactive bowel sounds
C) Ascites
D) Rebound tenderness
A) A palpable pulsating mass
Which patient is at the greatest risk for developing an aortic aneurysm?
A) A 35-year-old male with asthma
B) A 55-year-old male with a history of smoking and hypertension
C) A 30-year-old female with hypothyroidism
D) A 40-year-old female with a history of kidney stones
B) A 55-year-old male with a history of smoking and hypertension
Which complication should the nurse monitor for postoperatively in a patient who underwent thoracic aortic aneurysm repair?
A) Hyperkalemia
B) Graft occlusion or rupture
C) Pneumonia
D) Chronic venous insufficiency
B) Graft occlusion or rupture
