quiz 4 Flashcards
1.A nursing instructor is teaching the class about Addison’s disease. The instructor determines that the class understands the disease process if they indicate which are affected in this disease?
A. Check the clinet’s blood pressure
B. Auscultate heart tones
C. Perform a 12-lead-ECG
D. Determine if pain radiates to the left arm
C. Perform a 12-lead-ECG
2.A nurse is preparing to administer metoprolol 5 mg IV bolus to a client for heart rate control. Available is metoprolol injection 1 mg/mL. How many mL should the nurse administer per dose?
5 ml
- A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?
a. Apical pulse rate is different than the radial pulse rate
b. Decrease in systolic pressure by more than 10 mm Hg during inspiration
c. Increase in heart rate by 20% when moving from sitting to standing
d. Drop in systolic BP by 20 mm Hg when changing positions
b. Decrease in systolic pressure by more than 10 mm Hg during inspiration
- A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate (Kayexalate). If this medication is effective, the nurse should expect which of the following corrections on the client’s ECG?
a. Reduction of T-wave amplitude
b. shortening of P-wave duration
c. widening of the QRS complex
d. restoration of QRS complex amplitude
a. Reduction of T-wave amplitude
5.A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn’t understand why he needs to be there because there is nothing more to do, as the dmagae is done. Which of the following is the correct nursing response?
A. Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.
B.It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.
c. Exercise is good for you and good for your heart.
d. Your doctor is the expert here, and I’m sure he would only recommend what is best for you
A. Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.
- a nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
A. these tests help determine the degree of damage to the heart tissues
B. Cardiac enzymes will identify the location of the MI
c. These tests will enable the provider to determine the heart structure and mobility of the heart valaves.
D.Cardiac enzymes assist in diagnosing the presence of pulmonary congestion
A. these tests help determine the degree of damage to the heart tissues
- A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
A.assess the apical pulse for a full minute
B. Assess the apical pulse with a Doppler device
C.Assess the pedal pulses for a full minute
D.assess the pedal pulses with a Doppler device
A.assess the apical pulse for a full minute
- A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply)
A. Keep the client npo after midnight
B. Inspect the electrode pads
C.Wash the skin with plain water before placing the electrodes.
D.Instruct the client not talk during the test
E. Administer an analgesic prior to the procedure
B. Inspect the electrode pads
D.Instruct the client not talk during the test
- A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nruse should give the client which of the following information about anginal pain?
A. the pain usually last longer than 20 min
b. the pain often radiates to the jaw or the back.
c. the pain persists with the rest organic nitrates
D. extertion and anxiety can trigger the pain
D. extertion and anxiety can trigger the pain
- A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider.
A. Movement of the trachea toward the unaffected side.
b. bubbling of the water in the water seal chamber with exhalation
c. crepitus in the area above and surrounding the insertion site.
d. Eyelets are not visible
A. Movement of the trachea toward the unaffected side.
11. A nurse is assessing a 3-year-old-child who has aortic stenosis. Which of the following findinds should the nurse expect ?( select all that apply) A. hypotension b. bradycardia c. clubbing of the nail beds. d. weak pulses e. murmur
A. hypotension
d. weak pulses
e. murmur
- A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider.
a. splinter hermorrhages to the nails
b. dyspnea
c. fever
d. clusters of petechiae in the mouth
b. dyspnea
- a nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
a. excessive thrombosis and bleeding
b. progressive increase in platelet production
c. immediate sodium and fluid retention
d. increased clotting factors
a. excessive thrombosis and bleeding
- A nurse is teaching a client who has angina pectoris about starting therapy with nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?
a.Take this medication after each meal and at bedtime.
B. Take one tablet every 15 min during an acute attack
C. Take one tablet at the first indication of chest pain
D. Take this medication with 8 ounces of water
C. Take one tablet at the first indication of chest pain
- A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.
a. Orthopnea
b. Headache
c. Nausea
d. Tachycardia
e. Diaphoresis
c. Nausea
d. Tachycardia
e. Diaphoresis
- A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
a. Troponin I
B. Troponin T
C. Plasma low-density lipoproteins (LDL)
D. CPK
E.Myoglobin
a. Troponin I
B. Troponin T
D. CPK
E.Myoglobin
18. A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A. Anorexia B. Ataxia C. Photosensitivity D. Jaundice
A. Anorexia
- The nurse in trauma unit has received report on a client who has multiple injuries following motor vehicle crash. Which of the following actions should the nurse plan to take first?
a. Evaluate chest expansion .
b. Check pupillary response to light
c. Assess the capillary refill.
d. Check client’s response to questions about place and time.
a. Evaluate chest expansion
- A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
a. First- degree AV block
b. Atrial fibrillation
c. Sinus bradycardia
d. Sinus tachycardia
b. Atrial fibrillation
- A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include?
A. “Limit your fluid intake to meal times.
B. “Do not take this medication on an empty stomach.”
C. “ Increase your daily intake of dietary fiber.
D. You can expect swelling of the ankles while taking this medication.
C. “ Increase your daily intake of dietary fiber.
- A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse’s priority?
a. Blood pressure 92/50 mm Hg
b. Heart rate 72 / min
c. Abdominal pain rated 4 on a scale of 0 to 10
d. Respiratory rate 20 / min
a. Blood pressure 92/50 mm Hg
- The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. a.Brachial pulse in the left arm
b. Brachial pulse in the right arm
c. Radial pulse in the left arm
d. Radial pulse in the right arm
C. Radial pulse in the left arm
- A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction Which of the following prescriptions should the nurse take first?
a. Attach the leads for a 12- lead ECG.
b. Obtain a blood sample.
c. Initiate oxygen therapy
C. . Initiate oxygen therapy
- A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration ?
a. Continue to monitor the client
b. Immediately notify the provider.
c. Reposition the client toward the left side.
d. Clamp the chest tube near the water seal
a. Continue to monitor the client
26. A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? A. Increase the client's wall suction B. Strip the client's chest tube C. Clamp the client's chest tube D. Reposition the client
D. Reposition the client
- A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding Which of the following actions should the nurse take?
A. Ambulate the client four times per day
B. Encourage the client to consume clear liquids
C. Provide frequent oral and nares care
D. Keep the client in a supine position.
C. Provide frequent oral and nares care