VN 42 CLO 4 FINAL

Question 1

The client presents to the emergency department with blunt trauma causing bruising and bleeding of the heart. The nurse knows that which of the following may help stop the bleeding?

Answer 1

Inactivity and pressure from blood in the pericardium

Question 2

The nurse is caring for a client with a resting heart rate of 150 beats/minute. Which nursing intervention would be the highest priority in plan of care?

Answer 2

Instruct to sit on the edge of the bed before rising

Question 3

One of the nursing students asks the nursing instructor why someone would need cardiac surgery. What would be an appropriate response by the nursing instructor?

Answer 3

A ventricular aneurysm

Question 4

The nurse is caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?

Answer 4

Protein electrophoresis

Question 5

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Answer 5

neurologic examination

Question 6

The nurse is caring for a client with a valvular disorder. The client is at risk for decreased cardiac output. What nursing intervention should a nurse perform for this client?

Answer 6

measure urine output

Question 7

The nurse is caring for a client who does not accept blood or blood products. Which nursing actions conserve blood? Select all that apply.

Answer 7

-Draw minimum blood volume of blood for diagnostic tests
-Administer medication to stimulate bone marrow
-Administer the factor VIII to stimulate coagulation process
-Reinfuse the clients own blood via closed circuit container

Question 8

Which symptom is most important in determining the diagnosis and nursing care for a client experiencing pulmonary hypertension?

Answer 8

frothy sputum

Question 9

Which of the following is a disadvantage of surgical debridement?

Answer 9

bleeding

Question 10

The nurse is caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?

Answer 10

Educate the client about the disease process

Question 11

Which zone consists of the area where the injury is most severe and deepest?

Answer 11

coagulation

Question 12

A mechanical prosthetic heart valve client is admitted with leukopenia and abdominal pain. Which diagnostic lab data would the nurse access first?

Answer 12

Prothrombin time & international normalized ration (PT/INR)

Question 13

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent?

Answer 13

Disrupting the heart during the critical period of ventricular repolarization

Question 14

A client has experienced a myocardial infarction (MI). After the acute stage of the MI, what is the most lethal complication the nurse should be aware can occur?

Answer 14

ventricular aneurysm

Question 15

The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?

Answer 15

Production of antidiuretic hormone & corticosteroid hormones

Question 16

An older adult client, who leads a sedentary lifestyle, and a younger client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?

Answer 16

The older client because of age

Question 17

The client is scheduled for a percutaneous balloon valvuloplasty. The client asks the nurse how long it takes for the opening to close after the procedure. What would be the nurse’s best response?

Answer 17

within 6 months

Question 18

When assessing a client, what sign would the nurse know is an early sign of an impending heart failure?

Answer 18

s3 heart sound

Question 19

A client with aortic valve regurgitation is asking about his disease process. What would the nurse tell the client is the first sign of aortic valve regurgitation?

Answer 19

tachycardia

Question 20

A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder?

Answer 20

Radioallergosorbent blood test (RAST) of 3

Question 21

A nurse caring for a client who has had cardiac surgery must understand how pulmonary artery pressure is monitored. What is important about pulmonary artery pressure?

Answer 21

Aids in the early treatment of fluid imbalances

Question 22

What must the nurse be assessing for in order to determine adequate care for a client with aortic stenosis?

Answer 22

angina

Question 23

The client has returned to the floor with a transthoracic pacemaker ready to be connected. The nurse knows that a transthoracic pacemaker is a temporary pacemaker used in what situation?

Answer 23

Transthoracic pacemakers are used in a client who has had open heart surgery

Question 24

The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?

Answer 24

Progressive tissue damage without any verifiable etiology

Question 25

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

Answer 25

Decompensation

Question 26

A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client' s stage of disease?

Answer 26

Review the clients medical record

Question 27

Which diagnostic study best evaluates different medications ability to restore normal heart rhythm?

Answer 27

Electrophysiology study

Question 28

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?

Answer 28

Use clients palm size

Question 29

A nurse caring for a client who has had cardiac or vascular surgery knows to do hourly assessments on which of the following?

Answer 29

Fluid intake and urine output

Question 30

The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?

Answer 30

3:1

Question 31

A client is receiving treatment for rheumatoid arthritis but states that he is allergic to eggs. What medication would the client not be able to receive?

Answer 31

Synvisc

Question 32

Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply.

Answer 32

-p24 antigen test -polymerase chain reaction

Question 33

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

Answer 33

The clients vital signs are temperature,100.9f; heart rate 88bpm, blood pressure 138/80mm Hg

Question 34

The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as?

Answer 34

swan neck deformity

Question 35

A client with ankylosing spondylitis has a stooped position and is being positioned in the bed prior to the nurse taking vital signs. The nurse listens to the client's lungs after positioning. What finding does the nurse hear when listening to lung sounds?

Answer 35

Lung sounds are diminished in the apical area

Question 36

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply.

Answer 36

-cardiogenic shock: Myocardial infarction -Hypovolemic shock: blood loss -Anaphylactic shock: nut allergy -Septic shock: infection

Question 37

A nurse is required to care for a client with facial burns who is prescribed the open method treatment. Which of the following nursing interventions should a nurse perform?

Answer 37

place a bed cradle or sheets over the client

Question 38

A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?

Answer 38

pancreatitis

Question 39

A client is cutting vegetable for dinner and accidently cuts his finger. What response is desirable to destroy foreign agents such as microorganisms to prevent infection from developing in the finger?

Answer 39

the release of antibodies

Question 40

The nurse listens to the lung sounds of a postoperative client and determines that the client is not able to clear the secretions from the lungs. What intervention should the nurse provide prior to suctioning?

Answer 40

hyperoxygenate the client with 100% oxygen

Question 41

A client has a pulmonary artery catheter for monitoring and to ensure fluid balance. When measuring pulmonary capillary wedge pressure, the nurse forgets to deflate the balloon and leaves it inflated. What outcome can be the result of this action by the nurse?

Answer 41

pulmonary infarction

Question 42

A mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

Answer 42

"a Concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."

Question 43

What type of cytokine will attract neutrophils and monocytes to remove debris?

Answer 43

lymphonkines

Question 44

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?

Answer 44

Myoglobin in the urine

Question 45

The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?

Answer 45

Inspect the conjuctiva

Question 46

A teenaged client with a diagnosis of HIV presents at the public health clinic complaining of pharyngitis, rash on the palms and soles of his feet, and diarrhea. What would the nurse suspect the client is suffering from?

Answer 46

Acute retroviral syndrome (ARS)

Question 47

Which of the following medications does the nurse anticipate administering to a client preparing for cardioversion?

Answer 47

Diazepam

Question 48

A client comes to the clinic to see the physician with the complaint of "I think I ate something that I am allergic to." What symptoms would be appropriate for the nurse to ask the questions about?

Answer 48

diarrhea and abdominal cramping

Question 49

The nurse knows that a pacemaker is the treatment of choice for what cardiac dysrhythmia?

Answer 49

complete heart block

Question 50

A client is suspected to have Lyme disease and has a red macule at the site of the tick bite with a bull's-eye rash with round rings surrounding the center. In addition, the client has a severe headache with neck stiffness. What stage of Lyme disease is the client experiencing?

Answer 50

Early stage 1

Question 51

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of, or leaking of, cerebral spinal fluid?

Answer 51

halo sign

Question 52

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?

Answer 52

keep client hydrated

Question 53

The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor of the client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record?

Answer 53

Bigeminy

Question 54

Which type of skin graft is more comparable in appearance to normal skin?

Answer 54

Full-thickness graft

Question 55

A client with cytomegalovirus (CMV) infection reports difficulty seeing. The physician determines that the client is developing CMV retinitis. What medication does the nurse anticipate the client will receive for this?

Answer 55

foscarnet

Question 56

Which client symptom change would most likely indicate, to the nurse, a progression of mitral stenosis?

Answer 56

decreased systolic pressure

Question 57

The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?

Answer 57

ventricular fibrillation

Question 58

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

Answer 58

epidural hematoma

Question 59

A client comes to the clinic and informs the nurse that he had a mild case of the flu a couple of months ago and "hasn't felt well since." The client tells the nurse that he is fatigued and it gets worse after any physical activity and a recurrent sore throat and joint pain. What does the nurse recognize these symptoms may indicate?

Answer 59

chronic fatigue syndrome