F
Which info about a patient receiving thrombolytic therapy for AMI is most important for the nurse to communicate to HCP?
A. large bruise at IV site
B. New development of 1st degree block on ECG
C. increase in troponin from baseline
D. no change in patient reported chest pain level
D. no change in patient reported chest pain level
Which patient in the cardiovascular clinic requires immediate attention?
A. Patient with chronic HTN whose BP today is 172/98 mmHg
B. Patient with T2DM whose current blood glucose is 145 mg/dL
C. Patient with stable angina whose chest pain has recently increased in frequency
D. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL
C. Patient with stable angina whose chest pain as recently increased in frequency
When analyzing the rhythm of a patient's ECG, the nurse will need to investigate further upon finding:
A. PR interval 0.18 sec
B. QT interval 0.38 sec
C. QRS interval 0.14 sec
D. Isoelectric ST segment
C. QRS interval 0.14 sec
A nurse assess a client with A-Fib. Which manifestation should alert the nurse to possibility of a serious complication from this condition?
A. Bleeding gums
B. Speech alterations
C. Sinus tachycardia
D. Dyspnea with activity
B. speech alterations
A nurse assesses a patient with mitral valve stenosis. What clinical manifestation should alert the nurse to possibility that patient's stenosis is progressing?
A. generalized weakness
B. muted systolic murmur
C. dyspnea on exertion
D. Oxygen saturation of 92%
C. dyspnea on exertion
A nurse cares for a patient with end stage CHF who has a regular cardiac rhythm of 128 bpm, which physiologic alterations should the nurse assess? SATA
A. Decrease in BP
B. Decrease in CO
C. Patient manifesting JVD when sitting up
D. Bounding pedal pulse
E. Decrease urine output
F. Skin warm to touch
A, B, E
After receiving change of shift report about the following 4 patients on the cardiac care unit, which patient should the nurse assess first?
A. 65 yr old patient who's status is post CABGx2, 4 days ago, manifesting drainage to the incision site
B. 39 yr old patient with pericarditis who is complaining of sharp, stabbing chest pain
C. 59 yr old patient with unstable angina who just returned from a percutaneous coronary intervention (PCI)
D. 56 yr old patient with angina who has an ST segment depression on the monitor overnight
C. 59 yr old patient with unstable angina who just returned from a percutaneous coronary intervention (PCI)
An admission nurse evaluates prescriptions for a client with chronic A-Fib, which medication should the nurse expect to find on patient's medication administration record to prevent a common complication of this condition?
A. Sotalol (Betapace)
B. Warfarin (Coumadin)
C. Heparin infusions
D. Atropine (Sal-tropine)
B. Warfarin (coumadin)
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires immediate action by the nurse?
A. Weight gain of 1 kg
B. Urine output of 50ml over 2 hrs
C. HR of 106 bpm
D. O2 saturation of 88%
D. O2 saturation of 88%
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take?
A. perform synchronized cardioversion
B. start CPR
C. Provide supplemental O2 via non-rebreather mask
D. Give atropine
B. start CPR
A nurse delegates care for an older adult patient to the unlicensed assistive personnel (UAP), which statements should the nurse include when delegating care?
A. schedule additional time for teaching about prescribed therapies
B. Plan to bathe patient in the evening when patient is most alert
C. Remind patient to look at foot placement when walking
D. Encourage patient to use a cane when ambulating
E. Assess the patient for symptoms r/t to pain and discomfort
B, C, D
Client with myasthenia gravis is prescribed pyridostigmine (mestinon), what teaching should the nurse plan regarding this medication? SATA
A. your urine may turn reddish-orange while on this drug
B. take this drug on an empty stomach for best absorption
C. Do not eat a full meal for 45 minutes after taking this drug
D. The dose may change frequently depending on symptoms
E. Seek immediate care if you develop trouble swallowing
C,D,E
A nurse assesses a patient with a neurological disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?
A. Fasciculation
B. Dysarthria
C. Dysphagia
D. impairment of respiratory muscles
D. impairment of respiratory muscles
A nurse assesses a patient who was admitted with an acid-base imbalance. the patient's ABG values are pH 7.32, PaO2 88, PaCO2 34, and HCO3 16, what action should the nurse take?
A. measure patient's pulse and BP
B. assess patient's rate, rhythm and depth of respiration
C. document findings & continue monitoring
D. notify the health care provide asap
B. assess patient's rate, rhythm and depth of respiration
Which information will the nurse include in the asthma teaching plan for a patient being discharged?
A. inhale slowly and deeply when using a dry powder inhaler
B. tremors are an expected side effect of rapid acting bronchodilators
C. monitor peak expiratory flow rate (PEFR) while feeling short of breath
D. hold your breath for 5 seconds after using bronchodilator inhaler
B. tremors are an expected side effect of rapid acting bronchodilators
The nurse in the emergency department received ABG results for 4 recently admitted patients with obstructive pulmonary disease. Results for which patient requires rapid action by nurse?
A. pH 7.43, PaCO2 33, PaO2 80
B. pH 7.29, PaCO2 30, PaO2 65
C. pH 7.31, PaCO2 58, PaO2 64
D. pH 7.28, PaCO2 50, PaO2 58
D. pH 7.28, PaCO2 50, PaO2 58
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?
A. Use of accessory muscles
B. Peak expiratory flow rate of 240 L/min
C. Pulse oximetry reading of 91%
D. Respiratory rate of 26 breaths per min
A. use of accessory muscles
A nurse assesses a patient who is prescribed fluticasone (flovent) and notes oral lesions, which action should the nurse take?
A. encourage daily use of mouthwash
B. obtain oral specimen for culture and sensitivity
C. Notify health care provider
D. encourage oral rinsing after fluticasone administration
D. encourage oral rinsing after fluticasone administration
A patient with chronic cough is scheduled to have a bronchoscopy with biopsy, which nursing intervention is highest priority?
A. keep patient NPO until gag reflex returns
B. give fluid bolus to encourage hydration
C. ask patient about iodine & shellfish allergy
D. place patient on airborne precautions
A. keep patient NPO until gag reflex returns
The nurse analyzes the laboratory results of a patient, which finding would require immediate action?
A. Serum sodium of 133
B. Serum calcium of 8
C. Partial pressure of oxygen in arterial blood is 59
D. Bicarbonate level 31
C. partial pressure of oxygen in arterial blood is 59
Patient with chronic GERD has difficulty swallowing and has been working with a speech language pathologist, what assessment finding by the nurse indicates the priority goal for this problem is being met?
A. patient reports a decrease on OTC PPI use
B. lungs clear after meals and snacks
C. choosing foods that are easy to swallow
D. properly performing swallowing exercises
B. lungs clear after meals and snacks
A nurse is preparing to administer pantoprazole (protonix) intravenously, What actions by the nurse are most import? SATA
A. administer drug through separate IV line
B. can be infused with peripheral IV
C. administer drug via piggyback with dextrose
D. take vital signs frequently during infusion
E. infuse pantoprazole using IV pump
A,B,E
A nurse assesses a patient with peritonitis related to a GI perforation, which clinical manifestation should the nurse expect to find? SATA
A. hyperactive bowel sounds
B. distended abdomen
C. inability to pass fluids
D. decreased urine output
E. bradycardia
B, C, D
A patient has returned to the nursing unit after an open nissen fundoplication, the patient has an indwelling catheter, an NG tube to low continuous suction and 2 IVs, nurse notes bright red blood in NG tube, what action should nurse take first?
A. take full set of vital signs
B. notify surgeon immediately
C. document findings in chart
D. assess drainage for clots
A. take full set of vital signs
A nurse is providing community education on 7 signs of cancer, which signs are included? SATA
A. near -daily abdominal pain
B. obvious change in a mole
C. indigestion or trouble swallowing
D. a sore that does not heal
E. changes in menstrual patterns
B, C, D, E