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A post-operative client with a central venous pressure of 2 mmHg and a heart rate of 98 bpm is being managed in the ICU. What would be the most appropriate initial intervention?
A. Administer normal saline
B. Start vasopressin
C. Infuse 5% dextrose in half-normal saline
D. Administer epinephrine
A. Administer normal saline
The client’s low central venous pressure suggests hypovolemia. Normal saline is often administered to increase intravascular volume.
A client post-coronary artery bypass grafting (CABG) presents with a blood pressure of 86/70 mmHg, heart rate of 120 bpm, muffled heart tones, and jugular venous distention. What complication should the nurse suspect?
A. Cardiac tamponade
B. Pulmonary embolus
C. Hypovolemic shock
D. Pneumothorax
A. Cardiac tamponade
The clinical signs of hypotension, muffled heart tones, and jugular venous distention (Beck's Triad) are indicative of cardiac tamponade, a life-threatening condition.
A client presents to the emergency department with severe chest pain, hypotension, and a history of a recent coronary artery bypass grafting. What is the nurse’s priority action?
A. Prepare the client for a chest x-ray
B. Assess the client’s blood pressure and temperature
C. Notify the healthcare provider immediately
D. Administer nitroglycerin sublingually
C. Notify the healthcare provider immediately
The client’s symptoms suggest a potential complication such as myocardial infarction, requiring immediate intervention.
A client diagnosed with paroxysmal supraventricular tachycardia (PSVT) is receiving discharge education. Which statement by the client indicates understanding of risk factor management?
A. "I will limit my energy drinks to one per day."
B. "I’ll take potassium supplements with my diuretic."
C. "I’ll only have two alcoholic drinks per day."
D. "I’ll switch to caffeine pills instead of coffee."
B. "I’ll take potassium supplements with my diuretic."
A client with a suspected myocardial infarction is being treated in the emergency department. Which of the following should the nurse prioritize?
A. Administer 0.4 mg nitroglycerin sublingually
B. Prepare to transfer to the cardiac catheterization lab
C. Administer 325 mg chewable aspirin
D. Administer 4 mg morphine intravenously
A. Administer 0.4 mg nitroglycerin sublingually
Nitroglycerin is administered to relieve chest pain and improve coronary perfusion in acute coronary syndrome.
A client recovering from a STEMI presents with hypotension and reduced cardiac output. Which intervention is likely to improve their condition?
A. Give morphine sulfate
B. Start an infusion of 5% dextrose in 0.45% saline
C. Administer a normal saline bolus
D. Start amiodarone
C. Administer a normal saline bolus
Increasing intravascular volume through fluid administration can help improve cardiac output and blood pressure in a hypotensive client.
A client with acute respiratory failure is being monitored in the ICU. Their most recent ABG shows pH 7.30, PaCO2 65 mmHg, HCO3 26 mEq/L, and PaO2 56 mmHg. Which condition is most likely developing?
A. Acute Respiratory Distress Syndrome (ARDS)
B. Chronic obstructive pulmonary disease (COPD) exacerbation
C. Pulmonary embolism
D. Pneumonia
A. Acute Respiratory Distress Syndrome (ARDS)
The worsening hypoxemia and respiratory acidosis are indicative of ARDS progression.
A nurse is caring for a client with acute respiratory failure. The client’s latest ABG results show pH 7.32, PaCO2 62 mmHg, HCO3 30 mEq/L, and PaO2 78 mmHg. What do these results indicate?
A. Partially compensated respiratory acidosis
B. Fully compensated metabolic alkalosis
C. Uncompensated respiratory alkalosis
D. Compensated respiratory acidosis
A. Partially compensated respiratory acidosis
The elevated CO2 and decreased pH indicate respiratory acidosis, while the elevated bicarbonate level shows partial compensation.
A client presents with a rhythm strip showing pulseless ventricular tachycardia (VT). What is the appropriate intervention?
A. Prepare for defibrillation
B. Administer atropine
C. Initiate cardiopulmonary resuscitation (CPR)
D. Administer epinephrine
A. Prepare for defibrillation
Pulseless VT is a shockable rhythm, and defibrillation is the treatment of choice to restore a viable rhythm.
A client with unilateral lung disease is placed on mechanical ventilation. Which positioning strategy should the nurse use to improve oxygenation?
A. Place the client with the healthy lung down
B. Position the client in high-Fowler’s
C. Reposition the client every hour
D. Place the client in reverse Trendelenburg
A. Place the client with the healthy lung down
Placing the healthy lung down helps to optimize oxygenation by promoting better ventilation and perfusion to the functioning lung.
A client post-heart catheterization with a radial artery arterial line requires continuous monitoring. Which action is critical for maintaining the accuracy of blood pressure readings?
A. Perform a daily Allen test
B. Level and zero the transducer at the level of the heart
C. Ensure the client’s wrist is immobilized
D. Label the arterial line as "No Medications"
B. Level and zero the transducer at the level of the heart
Correctly leveling the transducer ensures that the blood pressure readings are accurate and reflect the true hemodynamic status.
A nurse is caring for a client with an arterial line for blood pressure monitoring. Which action should the nurse prioritize to ensure patient safety and for a client with an arterial line?
A. Monitor the insertion site for infection once daily
B. Perform a daily Allen test to assess circulation
C. Level the transducer below the phlebostatic axis before taking readings
D. Ensure the arterial line is labeled as "No Medications"
D. Ensure the arterial line is labeled as "No Medications"
A nurse is caring for a client with a new diagnosis of pneumonia who reports increasing shortness of breath. Which finding should the nurse report to the healthcare provider immediately?
A. Restlessness
B. Respiratory rate of 20 breaths/minute
C. Urine output of 60 mL in one hour
D. Thickening respiratory secretions
A. Restlessness
Restlessness can be an early sign of hypoxia, indicating the need for prompt medical intervention.
A nurse is monitoring a client with acute coronary syndrome who is receiving a nitroglycerin infusion. What should the nurse explain as the primary effect of nitroglycerin in this context?
A. Increases heart rate
B. Dilates coronary arteries
C. Lowers blood pressure
D. Narrows peripheral vessels
B. Dilates coronary arteries
Nitroglycerin dilates the coronary arteries, improving blood flow to the heart and relieving chest pain.
A client with a low-pressure alarm on the ventilator is being monitored. What is the nurse’s priority action?
A. Check for disconnections in the ventilator tubing
B. Increase the tidal volume setting
C. Suction the client’s airway
D. Administer a bronchodilator
A. Check for disconnections in the ventilator tubing
A low-pressure alarm often signals a disconnection or leak in the system, which needs immediate correction.
A client with left-sided heart failure presents with blood pressure of 90/50 mmHg, heart rate of 104 bpm, and central venous pressure of 6 mmHg. Which treatment should the nurse anticipate?
A. Administer an inotropic agent
B. Give a diuretic
C. Administer a beta-blocker
D. Start a 0.9% sodium chloride bolus
A. Administer an inotropic agent
Inotropic agents are indicated for clients with low blood pressure and poor cardiac output to improve myocardial contractility.
A client receiving diltiazem infusion for atrial fibrillation shows a heart rate of 198 bpm and BP of 88/64 mmHg. What should the nurse do next?
A. Contact the provider
B. Increase oxygen flow
C. Prepare for defibrillation
D. Decrease the IV flow rate
A. Contact the provider
The client’s tachycardia and hypotension suggest that the current treatment may not be effective, and the provider needs to be informed for further intervention.
A client presents with severe dyspnea, hypotension, and absent breath sounds on one side. What is the nurse's priority action?
A. Prepare for needle decompression
B. Administer a bronchodilator
C. Place the client in high Fowler’s position
D. Begin high-flow oxygen therapy
A. Prepare for needle decompression
The client’s symptoms are suggestive of a tension pneumothorax, which is a medical emergency requiring immediate intervention.
A client receiving diltiazem for atrial fibrillation reports palpitations and dizziness. What is the nurse's priority action?
A. Check the client's blood pressure and heart rate
B. Administer an additional dose of diltiazem
C. Discontinue the diltiazem infusion
D. Increase the rate of infusion
A. Check the client's blood pressure and heart rate
Monitoring vital signs is critical to assess the client’s hemodynamic status before any further interventions are taken.
A client with pneumonia is reporting increased shortness of breath. Which of the following findings should prompt the nurse to contact the healthcare provider?
A. Restlessness
B. Respiratory rate of 20 breaths/min
C. Urine output of 60 mL/hour
D. Thicker respiratory secretions
A. Restlessness
Restlessness may indicate hypoxia and worsening respiratory status, requiring immediate medical attention.
A client in the ICU with a BP of 88/40 mmHg and a heart rate of 96 bpm has not responded to fluid resuscitation. Which medication should the nurse expect to be prescribed?
A. Nitroglycerine
B. Atropine
C. Norepinephrine
D. Diltiazem
C. Norepinephrine
When fluid resuscitation fails to improve blood pressure, norepinephrine, a vasopressor, may be required to increase vascular tone.
A nurse is monitoring a client with an implanted cardioverter-defibrillator (ICD) who has just returned from surgery. Which assessment should the nurse prioritize?
A. Perform extensive ROM exercises
B. Checking the device settings
C. Ensuring the client has a medical alert card
D. Assessing the level of consciousness
D. Assessing the level of consciousness
A client with a heart rate of 50 bpm, experiencing shortness of breath and diaphoresis, is being evaluated in the emergency department. Which medication should the nurse anticipate administering?
A. Atropine
B. Lidocaine
C. Metoprolol
D. Esmolol
A. Atropine
Atropine is indicated for symptomatic bradycardia to increase the heart rate and improve perfusion.
A client with a history of atrial fibrillation presents with a change in telemetry readings and symptoms of dizziness. What is the nurse’s priority action?
A. Prepare for synchronized cardioversion
B. Administer atropine
C. Initiate cardiopulmonary resuscitation (CPR)
D. Monitor the client closely
A. Prepare for synchronized cardioversion
If the client becomes unstable, synchronized cardioversion may be necessary to restore a normal rhythm.
A client with acute respiratory distress syndrome (ARDS) is being evaluated for prone positioning. Which condition would contraindicate prone positioning?
A. The client has an 8th rib fracture
B. The client is receiving enteral feedings
C. The client’s SpO2 is 85% on 100% FiO2
D. The client requires increased PEEP
A. The client has an 8th rib fracture
Prone positioning may exacerbate pain and cause further injury in clients with rib fractures.