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100
The nurse is caring for a client hospitalized d/t acute COPD exacerbation. What assessment finding would the nurse expect to find?
A. ABG showing a carbon dioxide level of 31 mmHg.
B. An overinflated chest on chest x-ray.
C. Improving oxygen saturation upon exercise.
D. A wide diaphragm on chest x-ray.
B. An overinflated chest on chest x-ray.
Choice B is correct. In clients with COPD, there is a loss of elastic recoil in the lungs leading to hyperinflation of the lungs, as seen on chest x-ray. Prolonged hyperinflation of the lungs causes barrel chest in COPD clients.
100
What action does the nurse perform to follow safe technique when using a portable oxygen cylinder?
A. Check the amount of oxygen in the cylinder before using it.
B. Use a cylinder for a patient transfer that indicates available oxygen is at 500 psi.
C. Place the oxygen cylinder on the stretcher next to the patient.
D. Discontinue oxygen flow by turning the cylinder key counter-clockwise until it is tight.
A. Check the amount of oxygen in the cylinder before using it.
Choice A is correct. The cylinder must always be checked before use to ensure that enough oxygen is available for the patient.
100
The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching?
A. “I will need to take antibiotics for one week following this test.”
B. “This test will determine if I have any blood clots in my heart.”
C. “I will receive general anesthesia for this procedure.”
D. “I may feel a flushing sensation when the contrast dye is given.”
B. “This test will determine if I have any blood clots in my heart.”
Choice B is correct. A transesophageal echocardiogram (TEE) is advantageous because it views the left atrial appendage, which is the major reservoir for thromboembolism. This test may be done before cardioversion to determine if anticoagulation is necessary.
A TEE is a test completed to visualize the posterior heart valves and chambers. Since the heart sits on top of the esophagus, this allows more direct visualization of the heart. This test is often used to visualize the left atrial appendage to determine if any clots exist prior to cardioversion. An advantage of a TEE compared to a standard echocardiogram is that it is more detailed. This procedure requires informed consent, the client to be NPO, and moderate sedation.
100
The nurse has collected a client's VS. She notes an apical pulse of 75 and a radial pulse of 69. The nurse should document this finding as
A. a widened pulse pressure.
B. a pulse deficit.
C. pulsus paradoxus.
D. an expected finding.
B. a pulse deficit.
Choice B is correct. A pulse deficit is a difference between the apical and peripheral pulses. This finding may signal that the client has a dysrhythmia, and the nurse should consider obtaining a 12-lead electrocardiogram and/or continuous telemetry monitoring.
✓ A pulse deficit is the difference between the apical and peripheral pulses. It is not expected that a pulse deficit should occur
✓ A pulse deficit may suggest that the client is experiencing a dysrhythmia such as atrial fibrillation
✓ Assess the client for symptoms related to the pulse deficit, such as dizziness, shortness of breath, chest pain, or fainting. Document any associated symptoms and notify a provider accordingly.
200
The nurse is caring for assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, it would be essential to follow up with which of the following clients?
A. P: 109; R: 26; BP: 110/70 mmHg
B. P: 90; R: 12; BP: 99/54 mmHg
C. P: 100; R: 18; BP: 161/98 mmHg
D. P: 88; R: 14; BP: 166/52 mmHg
A. P: 109; R: 26; BP: 110/70 mmHg
Choice A is correct. The pulse and respiration rate of this client is quite concerning. Tachycardia is the earliest sign of shock, and intervention is necessary before the client further deteriorates.
200
The nurse is assessing a client who has a pneumothorax. Which of the following assessment findings should the nurse expect?
A. Blood-tinged sputum
B. Increased anterior-posterior diameter
C. Reduced breath sounds on the affected side
D. Auscultation of a loud, rough, grating sound
C. Reduced breath sounds on the affected side
Choice C is correct. A pneumothorax has clinical features such as reduced breath sounds on the affected sides, tachypnea, dyspnea, and pleuritic chest pain. Some clients may be asymptomatic, depending on the size of the pneumothorax.
200
An emergency department (ED) nurse establishes continuous cardiac monitoring for a client. The following tracing is observed on the monitor. (SINUS BRADYCARDIA) The nurse should take which initial action?
A. Establish vascular access and request a prescription for atropine
B. Assess the client's blood pressure and level of consciousness
C. Obtain and review the client's current medications
D. Document the findings and reassess the client in one hour
B. Assess the client's blood pressure and level of consciousness
Choice B is correct. The nurse should prioritize assessing the client's vital signs and level of consciousness. This tracing reflects sinus bradycardia. While sinus bradycardia may be benign, if the client should experience unstable blood pressure or dizziness, the nurse will need to act by establishing vascular access and administering atropine. However, this is predicated on the client's overall stability, which can only be discerned by assessment.
200
The nurse is caring for a client with cardiac tamponade. Which vitals signs are expected?
A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg
B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg
C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg
D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg
A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg
EXPLANATION
Choice A is correct. Classic manifestations of cardiac tamponade include tachycardia, tachypnea, jugular venous distention, and hypotension with a narrowed pulse pressure.
Choices B, C, and D are incorrect. Cardiac tamponade would typically cause features of tachycardia, hypotension, tachypnea, and a narrowed pulse pressure.
Cardiac tamponade may be caused by an array of infectious and noninfectious reasons. Immediate treatment of cardiac tamponade would be pericardiocentesis. A needle is inserted to aspirate the pericardial fluid in this ultrasound-guided procedure. The provider may elect to leave a temporary catheter in place in the pericardium to drain more fluid. Nursing care involves reporting any suspicion of cardiac tamponade promptly to the provider.
200
The nurse is caring for a client with Buerger's disease. The nurse plans on suggesting that the client receive a referral for
A. occupational therapy.
B. speech therapy.
C. smoking cessation.
D. group psychotherapy.
C. Smoking cessation
Choice C is correct. Arterial and venous blood flow impediments characterize Buerger's disease. This impediment is caused by inflammation and is significantly worsened by smoking. The nicotine causes vasoconstriction and worsens blood flow. A critical intervention for a client with this condition is discussing smoking cessation with this client.
300
Choice A is correct. The pulse and respiration rate of this client is quite concerning. Tachycardia is the earliest sign of shock, and intervention is necessary before the client further deteriorates.
A. Decrease in blood pressure
B. Increase in temperature
C. Decrease in respiratory rate
D. Increase in blood pressure
A. Decrease in blood pressure
Choice A is correct. Congestive heart failure (CHF) is characterized by the heart's inability to pump sufficient blood to meet the body's demands. It can result in fluid overload and increased pressure in the blood vessels. A potential complication in a client with CHF is decreased cardiac output, which can lead to decreased blood pressure. Initially, the blood pressure may increase. However, a complication is decompensation which may cause the compensatory mechanisms to fail.
300
A 32 y/o M comes into the ED after being hit by a baseball in his chest. The nurse would expect a pneumothorax because of which sign?
A. Decreased respiratory rate
B. Diminished breath sounds
C. Presence of a barrel chest
D. A sucking sound at the injury site
B. Diminished breath sounds
Choice B is correct. A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema.
✓ The symptoms of traumatic pneumothorax can vary depending on the severity of the condition. Common signs and symptoms may include
- Sudden-onset chest pain
- Shortness of breath and difficulty breathing.
- Rapid and shallow breathing
- Cyanosis
- Decreased or absent breath sounds on the affected side of the chest during auscultation.
- Tachycardia
✓ Management of Traumatic Pneumothorax will vary from client to client and can be as simple as observation or as complex as surgery.
✓ Traumatic pneumothorax is a serious medical emergency that requires prompt evaluation and appropriate management. Early recognition and intervention can lead to better outcomes and prevent potential complications associated with lung collapse and respiratory compromise.
300
The nurse is caring for a child diagnosed with a coarctation of the aorta who is scheduled for a surgical repair tomorrow morning. When the nurse auscultates the child's lung sounds, the nurse notes diffuse crackles and rales throughout the lung fields. The nurse interprets this assessment as which of the following?
A. Pulmonary congestion
B. Foreign body aspiration
C. Pneumonia
D. Systemic congestion
A. Pulmonary congestion
Choice A is correct. Crackles and rales are indicative of pulmonary congestion. Because this child has coarctation of the aorta, there is too much blood backing up in the lungs. It is impossible for the left side of the heart to move sufficient blood forward working against the coarctation. This causes the back up of blood in the lungs, and therefore the crackles and rales are indicative of pulmonary congestion.
300
The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
A. Basic metabolic panel (BMP)
B. B-type natriuretic peptide (BNP)
C. Lipid profile
D. Troponin
B. B-type natriuretic peptide (BNP)
Choice B is correct. B-type natriuretic peptide (BNP) is a commonly ordered test for clients who may have heart failure. Elevations indicate worsening of heart failure as it is indicative of fluid retention.
300
The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidenced by the client's
A. hypertension.
B. bronchodilation.
C. increase in heart rate (HR).
D. decrease in heart rate (HR).
D. decrease in heart rate (HR).
Choice D is correct. Upon seeing a sudden, noticeable drop in the client's heart rate, the nurse would notate a vasovagal response. Here, during the bronchoscopy, the involvement of a foreign object (i.e., the scope used in the bronchoscopy) in the client's pharynx likely caused vagus nerve stimulation. This stimulation resulted in a vasovagal response by the client, manifested by a sudden decrease in the client's heart rate.
✓ Increased vagal firing (i.e., increased parasympathetic activity) at the sinus node and the atrioventricular node causes a decrease in heart rate.
✓ This decrease in heart rate can be profound, with asystole lasting as long as several seconds.
✓ Vagal stimulation may result in bradycardia, hypotension, heart block, ventricular tachycardia, or other dysrhythmias.
400
You are caring for a patient with blood clots in the lungs. He is receiving urokinase for treating pulmonary embolism. The urokinase has been infusing for the last 10 hours. As you assess the patient, you note that his BP is 102/64, HR 108, RR 16. The patient asks to use the bedpan. When he is finished you notice that he has passed a medium-sized bloody stool. Your best intervention is:
A. Closely monitor the patient
B. Stop the urokinase and call the physician
C. Administer Vitamin K intramuscularly
D. Slow the administration of urokinase
B. Stop the urokinase and call the physician
Explanation
Choice B is correct. You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders.
400
The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question?
A. Iron sucrose
B. Enoxaparin
C. Sucralfate
D. Hydroxyurea
B. Enoxaparin
Choice B is correct. Enoxaparin is a low-molecular-weight heparin (LMWH). Bleeding is the major risk associated with the use of enoxaparin. The client has anemia and active occult gastrointestinal bleeding. Enoxaparin is contraindicated in clients with any active clinically significant bleeding, including gastrointestinal bleeding. Clients with occult blood in their stool should avoid any type of anticoagulant therapy until the cause of the bleeding is identified and addressed.
400
An emergency department nurse is caring for a client who presented with fatigue, muscular weakness, and dyspnea. Upon assessment, the client was noted to be coughing frequently and sitting in a tripod position. A subseqent diagnosis of left ventricular failure was made. The nurse understands that manifestations of L-sided heart failure presents as a respiratory issue because:
A. There is venous congestion in the liver.
B. There is hypoperfusion of tissue cells.
C. There is pulmonary congestion.
D. Despite normal cardiac output, the heart cannot meet the accelerated demands of the body.
C. There is pulmonary congestion.
Choice C is correct. Heart failure (HF) is a syndrome of ventricular dysfunction. When occurring on the left side, left ventricular (LV) failure (also known as left-sided heart failure) causes shortness of breath and fatigue. In these clients, cardiac output decreases and pulmonary venous pressure increases as the heart failure worsens. As the amount of blood ejected from the left ventricle diminishes, hydrostatic pressure builds in the pulmonary venous system and results in fluid-filled alveoli and pulmonary congestion, which results in a cough. Dyspnea also results from increasing pulmonary venous pressure and pulmonary congestion. The client's tripod positioning (also known as the orthopneic position) is one in which the client is in a forward-bending posture with their arms held forward in an attempt to facilitate breathing.
400
A nurse is caring for a client who recently experienced a non-fatal drowning. The client is now having pulmonary edema. The nurse understands that pulmonary edema is a result of which process?
A. Water washing out the alveolar surfactant.
B. Water introducing bacteria into the lungs and causing infection.
C. Decreased intrathoracic pressure in the lungs.
D. A sudden change in temperature within the lungs.
neumothorax is a serious medical emergency that requires prompt evaluation and appropriate management. Early recognition and intervention can lead to better outcomes and prevent potential complications associated with lung collapse and respiratory compromise.
A. Water washing out the alveolar surfactant.
EXPLANATION
Choice A is correct. Aspiration of salt water or fresh water can lead to surfactant washout, disrupting the alveolar-capillary membrane and increasing its permeability. Surfactant reduces surface tension within the alveoli, increases lung compliance and alveolar radius, and decreases the work of breathing. The loss of surfactant destabilizes the alveoli, causing increased airway resistance. Following the aspiration of salt water or fresh water and the associated surfactant washout, the client is at significant risk of pulmonary edema.
✓ The primary goal of treating pulmonary edema is to address the underlying cause.
✓ Immediate interventions may include providing supplemental oxygen, administering diuretics to reduce fluid overload, and using medications to improve cardiac function and blood flow (if needed).
✓ The duration of submersion and extent of hypoxic injury predicts the ultimate clinical course.
✓ Antibiotics should be reserved for cases of clinical pulmonary infection (e.g., fever, leukocytosis, etc.) or if the client was submerged in grossly contaminated water.
400
The nurse is caring for a client with atrial fibrillation. Which of the following client findings requires immediate follow-up by the nurse?
A. Irregular QRS complexes on telemetry reading
B. Irregular peripheral pulse
C. Reports of intermittent palpitations
D. Blurred vision
D. Blurred vision
Choice D is correct. Blurred vision is an unexpected manifestation of atrial fibrillation and may signify that the client has had a stroke. Ischemic stroke is a significant complication of atrial fibrillation which explains why most clients with atrial fibrillation will be prescribed anticoagulants to prevent this life-threatening complication.
500
An intensive care unit nurse is caring for a client with left-sided heart failure experiencing pulmonary edema as a complication. The nurse identifies a nursing diagnosis of "impaired gas exchange related to ineffective breathing patterns." Which nursing intervention would be the lowest priority based on the nursing diagnosis?
A. Administer oxygen and monitor for drying of the nasal mucus membranes.
B. Place the client in a semi-Fowler's position.
C. Provide a pressure-reducing mattress.
D. Encourage the client to turn, deep breathe, cough, and use the incentive spirometer.
C. Provide a pressure-reducing mattress.
Choice C is correct. Pressure-reduction mattresses and beds are available to decrease the pressure on the client's pressure points when the client is in bed. More specifically, these support surfaces are used to prevent (or treat) pressure ulcers by attempting to redistribute pressure beneath the skin of the client's body to increase blood flow to tissues and relieve skin and soft tissue distortion. However, implementing measures to ease the stress on the pressure points is the lowest priority when managing a client experiencing acute pulmonary edema.
500
The nurse is caring for a client receiving nasal cannula oxygen and prescribed warfarin for venous thromboembolism (VTE) prevention. The unlicensed assistive personnel (UAP) informs the nurse that the client has a nose bleed. The nurse should initially
A. have the unlicensed assistive personnel (UAP) apply water-soluble jelly to nares.
B. review the most recent activated partial thromboplastin time (aPTT).
C. assess the client for bruising and bleeding gums
D. obtain an order to humidify the oxygen.
C. assess the client for bruising and bleeding gums.
Choice C is correct. The nurse's first action should be to assess the client and determine if there are any other sources of bleeding. Nasal dryness is the most common cause of nasal bleeding in clients on oxygen therapy. However, the client is also on anticoagulation with warfarin, and therefore, supratherapeutic international normalized ratio (INR) should be considered in the differential diagnosis of nasal bleeding. At the same time, nasal bleeding alone may be the presenting symptom, and a significantly prolonged INR may present with bleeding from additional sites. Such assessment findings may support the clinical diagnosis of warfarin over-anticoagulation. Subsequently, an INR level should be obtained.
500
The nurse caring for a client with a history of atrial fibrillation is prescribed dofetilide to control the dysrhythmia. What critical assessment parameter should the nurse prioritize before administering the medication?
A. Serum potassium level
B. Liver function tests
C. QT interval on the electrocardiogram (ECG)
D. Blood urea nitrogen (BUN) and creatinine levels:
C. QT interval on the electrocardiogram (ECG)
EXPLANATION
Choice C is correct. Dofetilide can prolong the QT interval, increasing the risk of serious dysrhythmias. Monitoring the QT interval before administration is crucial.
Choice A is incorrect. While hypokalemia can be a concern, it is not the primary consideration before administering dofetilide. This medication poses a risk of QT interval prolongation, making option c more critical.
Choice B is incorrect. Liver function tests are not directly related to the potential adverse effects of dofetilide, which mainly involves cardiac electrophysiology.
Choice D is incorrect. While renal function is important, it is not the primary consideration when assessing the potential risks of dofetilide.
✓ Continuous ECG monitoring is often required during the initiation of dofetilide therapy. This is usually done in a hospital setting to assess the QT interval and monitor for any potential arrhythmias. By monitoring the QT interval before administration, healthcare providers can identify any pre-existing prolongation or conditions that may increase the risk of dysrhythmia. This allows for appropriate risk assessment and may influence the decision to prescribe dofetilide or adjust the dosage.
✓ Maintain close monitoring of electrolyte levels, especially potassium and magnesium, as imbalances can influence the risk of dysrhythmias.
✓ Collaborate with other members of the healthcare team, including pharmacists and providers, to ensure comprehensive care and to address any concerns or complications promptly.
500
The nurse is caring for a client who has the following rhythm. The nurse should anticipate which prescription from the PHCP.
A. captopril
B. atropine
C. adenosine
D. diltiazem
D. diltiazem
QID : 7797
TID : 12783399
The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The nurse should anticipate which prescription from the primary healthcare provider (PHCP)? See the exhibit.
View ExhibitCorrect
A. captopril
[9%]
B. atropine
[19%]
C. adenosine
[31%]
D. diltiazem
[40%]
Statistics
Difficulty level - HARD
40%of peers got it right
Time taken - 10 s
View More
EXPLANATION
Choice D is correct. The tracing in the exhibit shows irregularly irregular rhythm with no identifiable p-waves. This rhythm can be identified as "atrial fibrillation." Diltiazem is a calcium channel blocker (CCB) that controls the atrial fibrillation rate. Atrial fibrillation leads to increased ventricular rate and reduced ventricular diastolic filling. If the ventricular rate is uncontrolled, cardiac output is reduced, resulting in hypotension and congestive heart failure. Initial treatment in atrial fibrillation is aimed at ventricular rate control with calcium channel blockers (diltiazem, verapamil), a beta-blocker (atenolol, metoprolol), or digoxin. If the atrial fibrillation remains persistent, cardioversion is considered.
Choices A, B, and C are incorrect.
- Captopril is an ACE inhibitor used to treat heart failure and hypertension.
- Atropine increases the heart rate and is efficacious for symptomatic sinus bradycardia, not atrial fibrillation.
- Adenosine is approved for supraventricular tachycardia when vagal maneuvers are not efficacious. Note that the term " supraventricular tachycardia (SVT)" refers to a wide variety of atrial arrhythmias (atrial flutter, atrial fibrillation, atrial tachycardia) when the rhythm can not be clearly identified. During an SVT, the heart rate is very high at 150 to 220 beats per minute. The rate needs to be slowed to identify and treat the rhythm appropriately. Vagal maneuvers (carotid sinus massage, Valsalva maneuver) are applied first. IV adenosine is used to slow down or terminate if the SVT is refractory to vagal maneuvers. Adenosine's principal purpose in an SVT is to slow the rate to allow for appropriate rhythm identification. Because the rhythm strip in the exhibit can clearly be identified as atrial fibrillation, adenosine is unnecessary and must be treated with more specific rate-controlling medications (CCBs, beta-blockers).
500
The nurse is caring for a client recovering from myocardial infarction who is presenting with a heart rate of 110 beats per minute, a blood pressure of 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority?
A. Administer medications to increase stroke volume.
B. Provide analgesics.
C. Obtain a STAT electrocardiogram and troponins.
D. Administer fluid replacement to increase blood pressure.
A. Administer medications to increase stroke volume.
EXPLANATION
Choice A is correct. Based on the assessment information, the nurse can determine the client is experiencing cardiogenic shock secondary to myocardial infarction. Since cardiogenic trauma occurs as a result of the heart not pumping effectively, the highest priority is to increase cardiac output to ensure adequate tissue perfusion.
Cardiac Output = Stroke volume x Heart rate.
Medications that improve stroke volume will improve cardiac output in cardiogenic shock. The following agents may be used in the pharmacological management of cardiogenic shock.
- Inotropes: Positive inotropes strengthen the heart contractility (increase stroke volume). Dobutamine has more beta-adrenergic action than alpha activity. It causes peripheral vasodilation while increasing contractility. But in higher doses, it may increase heart rate and exacerbate myocardial ischemia.
- Vasopressors: In severe shock, vasopressors (Dopamine, Norepinephrine) maintain blood pressure but decrease blood flow to organs. They increase afterload and reduce cardiac output. However, they may be needed initially to provide hemodynamic support. Dopamine increases myocardial contractility and maintains blood pressure. If dopamine fails to support blood pressure, norepinephrine is added.
- Vasodilators: Vasodilators (Nitroglycerin) decrease venous return (preload) to the heart and decrease peripheral resistance (afterload). Although vasodilators may drop blood pressure, they sustain cardiac output and help achieve hemodynamic stability when combined with vasopressor support in cardiogenic shock.
- Supplemental oxygen may also be necessary to increase tissue oxygenation.