Quiz 2 Flashcards
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 (PE)? (SATA)
*Assess legs for redness
*apply elastic compression stockings
*perform passive range motion exercises
NGN: Pulmonary embolism
The nurse should place the client in high-Fowler’s position and obtain venous access because
the client is most likely experiencing a pulmonary embolism (PE). Placing the client in
high-Fowler’s promotes optimal gas exchange and obtaining venous access allows for
medications to treat the PE or complications to be administered.The nurse should monitor for
petechiae on the chest and cardiac dysrhythmias, which can occur with a PE and can be life
threatening. The nurse should also monitor the client’s aPTT prior to the administration of
anticoagulants and also while the client is receiving treatment, as prescribed.
A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client
reports dyspnea and severe pain. The nurse notes that the client’s chest moves inward during inspiration and
bulges out during expiration. The nurse should identify this finding as which of the following?
Flail Chest
Which symptom is of mitral valve stenosis
murmur/swishing or blowing sound (S4 heart sounds
NGN: Bow tie: aortic stenosis
Educate: EKG every 6-12 months and decrease inflammatory response
Monitor: HR, Blood pressure
What will you hear in the lungs with a patient with metal valve insufficiency or mitral valve regurgitation
crackles at the base, wet breath sounds
A patient has had an endovascular abdominal aortic aneurysm repair. What should the RN monitor for
Input and output
A patient comes in with a history of AAA and presents either severe back pain and absent pedal pulses. What should you check first?
Blood pressure: they are hemodynamically unstable
Monitor: increase in BP and administer beta blocker and calcium channel blocker to decrease BP and reduce the risk of ruptures
What patient should the RN see first
A patient that reports sudden back or chest pain that is severe
Modifiable to prevent AAA
diet
BP
smoking
drinking
A patient is experiencing a pulmonary embolism and their BP is dropping causing hemodynamic instability. ABGs are out of range and vitals are elevated. what do we expect the provider to order
Alteplase
Iv
APTT
Run a pulmonary angiography
A patient has been in a car accident. Respirations are fast and O2 is 82% what is the condition and what do you do?
Flail chest: intubate
A nurse in an emergency department is caring for a client who has a sucking 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?
Adminster O2 via NC
Sucking chest wound
open pneumothorax, a penetrating chest wound that creates a hole in the chest which can lead to a collapsed lun
Flail Chest
Defect in the chest wall due to blunt force trauma. Unequal rise and fall of the chest
A patient comes in with chest trauma after a motor vehicle accident. What should the nurse assess for
adequate chest rise and fall
Patient has an AAA. The urine was 45 MLS with in 2-3 hrs. What labs should the nurse assess?
Creatinine levels to assess kidney function. (Not BUN)
What are the treatment options for mitral valve stenosis that did not respond to medication therapy?
Balloon valvuloplasty: insert a small catheter through the groin and inflate a small balloon to keep the valve open
Risk factors of AAA
Family history
smoking
hyperlipidemia
atherosclerosis
HTN
A charge nurse is teaching a newly licensed nurse about deep vein thrombosis (DVT). Which of the following
should the charge nurse include as risk factors for developing DVTs?
Immobility
fractures
AFIB
Estrogen therapy
A nurse is caring for a client who has deep vein thrombosis (DVT). Which of the following findings should cause
the nurse to suspect the client has a pulmonary embolism?
Hemoptysis
Lightheadedness
tachycardia
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
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?
An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.
Where is the pain located with a AAA?
Severe back or groin pain
A nurse is providing teaching to a client about manifestations of pulmonary embolism (PE). Which of the following
findings should the nurse include in the teaching? (SATA)
*Chest pain that worsens with deep breathing
*SOB
*Bloody sputum
An hour 80 year old uncontrolled type 1 DM is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to have what procedure?
Percutaneous transluminal ballon valvuloplast (PTBV)
