VN 42 CLO 4 FINAL Flashcards
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?
Inactivity and pressure from blood in the pericardium
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?
Instruct to sit on the edge of the bed before rising
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?
A ventricular aneurysm
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?
Protein electrophoresis
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
neurologic examination
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?
measure urine output
The nurse is caring for a client who does not accept blood or blood products. Which nursing actions conserve blood? Select all that apply.
-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
Which symptom is most important in determining the diagnosis and nursing care for a client experiencing pulmonary hypertension?
frothy sputum
Which of the following is a disadvantage of surgical debridement?
bleeding
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?
Educate the client about the disease process
Which zone consists of the area where the injury is most severe and deepest?
coagulation
A mechanical prosthetic heart valve client is admitted with leukopenia and abdominal pain. Which diagnostic lab data would the nurse access first?
Prothrombin time & international normalized ration (PT/INR)
Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent?
Disrupting the heart during the critical period of ventricular repolarization
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?
ventricular aneurysm
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?
Production of antidiuretic hormone & corticosteroid hormones
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?
The older client because of age
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?
within 6 months
When assessing a client, what sign would the nurse know is an early sign of an impending heart failure?
s3 heart sound
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?
tachycardia
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?
Radioallergosorbent blood test (RAST) of 3
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?
Aids in the early treatment of fluid imbalances
What must the nurse be assessing for in order to determine adequate care for a client with aortic stenosis?
angina
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?
Transthoracic pacemakers are used in a client who has had open heart surgery
The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?
Progressive tissue damage without any verifiable etiology
A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?
Decompensation
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?
Review the clients medical record
Which diagnostic study best evaluates different medications ability to restore normal heart rhythm?
Electrophysiology study
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?
Use clients palm size
A nurse caring for a client who has had cardiac or vascular surgery knows to do hourly assessments on which of the following?
Fluid intake and urine output
The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?
3:1
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?
Synvisc
Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply.
-p24 antigen test
-polymerase chain reaction
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?
The clients vital signs are temperature,100.9f; heart rate 88bpm, blood pressure 138/80mm Hg
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?
swan neck deformity
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?
Lung sounds are diminished in the apical area
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.
-cardiogenic shock: Myocardial infarction
-Hypovolemic shock: blood loss
-Anaphylactic shock: nut allergy
-Septic shock: infection
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?
place a bed cradle or sheets over the client
A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?
pancreatitis
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?
the release of antibodies
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?
hyperoxygenate the client with 100% oxygen
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?
pulmonary infarction
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?
“a Concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain.”
What type of cytokine will attract neutrophils and monocytes to remove debris?
lymphonkines
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
Myoglobin in the urine
The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?
Inspect the conjuctiva
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?
Acute retroviral syndrome (ARS)
Which of the following medications does the nurse anticipate administering to a client preparing for cardioversion?
Diazepam
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?
diarrhea and abdominal cramping
The nurse knows that a pacemaker is the treatment of choice for what cardiac dysrhythmia?
complete heart block
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?
Early stage 1
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?
halo sign
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?
keep client hydrated
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?
Bigeminy
Which type of skin graft is more comparable in appearance to normal skin?
Full-thickness graft
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?
foscarnet
Which client symptom change would most likely indicate, to the nurse, a progression of mitral stenosis?
decreased systolic pressure
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?
ventricular fibrillation
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?
epidural hematoma
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?
chronic fatigue syndrome
