Shock
Which is the most common type of shock?
A. Hypovolemic
B. Cardiogenic
C. Obstructive
D. Distributive
A.
The nurse is caring for a hospitalized infant with a diagnosis of tetralogy of Fallot, awaiting surgical intervention. Which assessment finding would the nurse expect?
A. The child has an increase in dilute, clear urine after feeding.
B. The child has absent bowel sounds in the left upper quadrant of the abdomen.
C. The child has hyperglycemia as a result of the cardiac demand being increased.
D. The child has periods of cyanosis and decreased pulse oximetry readings.
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess?
A. antiembolism stockings.
B. oxygen.
C. diuretics.
D. anticoagulants.
C. diuretics.
Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess.
The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse?
A. Administer epinephrine 1:10,000 10 mL IV push.
B. Deliver breaths with a bag-valve mask.
C. Defibrillate the patient with 360 joules.
D. Call for help and begin chest compressions.
D. Call for help and begin chest compressions.
Following the recognition of unresponsiveness, a protocol for basic life support is initiated. This includes activation of the emergency response team for help and performance of high-quality cardiopulmonary resuscitation (CPR), which includes beginning chest compressions.
The nurse is collecting data on a child who is noted to be lethargic and has inflammation of both eyes and a strawberry-colored tongue. These clinical manifestations suggest the child would likely have which disorder?
A. Kawasaki disease
B. rheumatic fever
C. iron deficiency anemia
D. congestive heart failure
A.
Which of the following clinical manifestations occur in cardiogenic shock?
A. Blood pressure falls
B. Urine output increases
C. Skin is flushed
D. Quick capillary refill
A.
Which of the following are potential complications of untreated hypertension? (Select all that apply)
A. Stroke
B. Myocardial infarction (heart attack)
C. Osteoporosis
D. Chronic kidney disease
E. Peripheral artery disease
F. Diabetes mellitus
G. Aneurysm
Correct Answers:
A, B, D, E, G
Explanation:
Incorrect Answers:
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
A. Tachypnea
B. Pulmonary edema
C. Orthopnea
D. Jugular venous distention
D. Jugular venous distention
A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?
A. Slow
B. Not palpable
C. Irregular
D. Bounding
C. Irregular
A nurse in a clinic is caring for a client who has heart failure and is taking digoxin. Which of the following statements by the client indicates the client is experiencing digoxin toxicity?
A. "I am gaining weight."
B. "I am constipated."
C. "My vision seems yellow."
D. "My tongue is red and beefy."
C. "My vision seems yellow."
A client with chronic heart failure takes a daily thiazide diuretic. The client asks the nurse why it is important to consume potassium-rich foods on a daily basis. What is the most accurate response?
A. Consuming potassium-rich foods replaces what is lost in your urine.
B. Potassium promotes the excretion of excess fluid by your kidneys.
C. Potassium improves the therapeutic action of your diuretic.
D. Your thiazide diuretic may cause significant hypocalcemia.
A.
The nurse is caring for a client newly diagnosed with hypertension. Which statement by the client indicates the need for further teaching?
A. “I will consult a dietician to help get my weight under control.”
B. “I think I’m going to sign up for a yoga class twice a week to help reduce my stress.”
C. “When getting up from bed, I will sit for a short period before standing up.”
D. “If I take my blood pressure and it is normal, I don’t have to take my blood pressure pills.”
D. The client needs to understand the disease process and how lifestyle changes and medications can control hypertension. The client must take all medications as directed. A normal blood pressure indicates the medication is producing the desired effect. The other responses do not indicate the need for further teaching.
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?
A. Frothy sputum
B. Dependent edema
C. Hepatomegaly
D. Ascites
A. Frothy sputum
Tests are ordered for a client to measure the serum electrolytes potassium, sodium, and magnesium. What might an increase or decrease in the level of these electrolytes cause?
A. Cardiac tamponade
B. Cardiac dysrhythmia
C. Myocardial infarction
D. Angina
B. Cardiac dysrhythmia
A nurse is caring for a client who has valvular heart disease. Which of the following prescriptions should the nurse expect to control the client's tachycardia?
A. Diuretic
B. Vasodilator
C. Beta blocker
D. Ace inhibitor
C. Betablocker
A client who has been brought to the ED is unresponsive, and has an elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. The client's labs show an elevated white blood cell count; cultures are forthcoming. What does the nurse suspect may be the cause of the client’s present condition?
A. septic shock
B. anaphylactic shock
C. neurogenic shock
D. cardiogenic shock
A.
The nurse is reviewing a patient’s diet. The patient has been diagnosed with hypertension. The nurse recommends reducing or avoiding caffeine for patients with hypertension because:
A. caffeine increases the heart rate and causes vasoconstriction
B. caffeine reduces the heart rate and leads to a coronary artery disease
C. caffeine reduces the heart rate and causes low blood pressure
D. caffeine increases the heart rate and causes angina
A. caffeine increases the heart rate and causes vasoconstriction
The nurse recommends reducing or avoiding caffeine for the clients with hypertension because caffeine increases the heart rate and causes vasoconstriction. Angina and coronary artery disease are the result of blocked arteries by a substance called plaque.
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?
A. Heart rate of 72 beats/minute
B. Respiratory rate of 20 breaths/minute
C. Blood pressure 80/46 mm Hg
D. Oxygen saturation 94%
C. Blood pressure 80/46 mm Hg
The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the respiratory rate and oxygen saturation.
For which of the following dysrhythmias is defibrillation primarily indicated?
a. Ventricular fibrillation
b. Asystole
c. Atrial fibrillation
d. Ventricular tachycardia with a pulse
A.
A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client’s serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?
A. Administer potassium gluconate 40 mEq orally.
B. Obtain a 12-lead ECG.
C. Restrict fluid intake.
D. Have the laboratory draw a blood sample for a PT-INR.
B. Obtain a 12-lead ECG.
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client’s family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
A. Endotoxins in the system
B. Limited gas exchange
C. Brain death
D. Multiple organ failure
D. In the irreversible stage of shock, significant cells and organs are damaged. The client’s condition reaches a “point of no return” despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
A nurse is reinforcing teaching with a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?
A. Exercise once per week for at least 30 minutes.
B. Limit alcohol consumption to 3 drinks a day when hypertensive.
C. Plan to have potassium blood levels checked when taking a thiazide diuretics.
D. Plan to lower sodium intake to 4,000 mg each day.
C. Plan to have potassium blood levels checked when taking a thiazide diuretics.
Medical management of cardiac failure uses similar methodology whether it is right-sided or left-sided. Measures such as dietary modification, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. The primary goal in the medical management of heart failure is to reduce:
A. cardiac workload.
B. cardiac output.
C. heart rate.
D. oxygenation.
A. cardiac workload.
Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output. There is no reason for reducing pulmonary efficacy. There is no reason for reducing oxygenation.
You are caring for a patient who is post-operative s/p pacemaker insertion. Which of the following signs and symptoms would concern you for cardiac tamponade? Select all that apply.
A. Muffled heart sounds
B. Jugular venous distension
C. Low urine output
D. Pink-frothy sputum
E. Hypotension
A, B, E.
A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take?
A. Weigh the client weekly
B. Monitor the client for ototoxicity.
C. Place the client on a 24-hr urine collection analysis.
D. Monitor for hypoglycemia
B.