Name that
This assessment of consciousness tool uses verbal, eye opening, and motor to develop a score
Glasgow Coma Scale
A client is admitted to the emergency department with an acute myocardial infarction. Which drug category does the nurse expect to be given to the client early for the prevention of tissue necrosis following blood clot blockage in a coronary or cerebral artery?
a. Anticoagulant agent
b. Antiplatelet agent
c. Thrombolytic agent
d. Low-molecular-weight heparin (LMWH)
c. Thrombolytic agent
The nurse recognizes what absolute contraindication to the administration of a thrombolytic to a patient having an acute myocardial infarction?
History of intracranial hemorrhage
Active peptic ulcer disease
Presenting BP of 180/110 mm Hg
Pregnancy
The nurse recognizes what absolute contraindication to the administration of a thrombolytic to a patient having an acute myocardial infarction?
History of intracranial hemorrhage
Active peptic ulcer disease
Presenting BP of 180/110 mm Hg
Pregnancy
History of intracranial hemorrhage
Thrombolytics are absolutely contraindicated in patients with a history of intracranial hemorrhage, intracranial neoplasms, or intracerebral ischemic effect in the previous 3 months (unless occurring within the last 3 hours, when a thrombolytic would be considered). The other factors are relative contraindications and would require vigilant monitoring.
When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first?
1.Duplex ultrasound
2.Contrast venography
3.Magnetic resonance venography
4.Computed tomography venography
1.Duplex ultrasound
The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.
Which client will the nurse assess first?
a. The client who has been on beta blockers for 1 day.
b. The client who is on a beta blocker and a thiazide diuretic.
c. The client who has stopped taking a beta blocker due to cost.
d. The client who is taking a beta blocker and Lasix (furosemide).
c. The client who has stopped taking a beta blocker due to cost.
Thrombocytopenia, Timing of Platelet Count Fall, Thrombosis, and Other causes of thrombocytopenia
4Ts Score for Heparin-Induced Thrombocytopenia
When a newly admitted client is placed on heparin, the nurse acknowledges that heparin is effective for preventing new clot formation in clients who have which disorder(s)? (Select all that apply.)
a. Coronary thrombosis
b. Acute myocardial infarction
c. Deep vein thrombosis (DVT)
d. Cerebrovascular accident (CVA) (stroke)
e. Venous disorders
a. Coronary thrombosis
b. Acute myocardial infarction
c. Deep vein thrombosis (DVT)
d. Cerebrovascular accident (CVA) (stroke)
e. Venous disorders
A postoperative patient reports pain in the left lower extremity. The nurse notes swelling in the lower leg, which feels warm to touch. The nurse will anticipate giving which medication?
a. Aspirin
b. Clopidogrel (Plavix)
c. Enoxaparin (Lovenox)
d. Warfarin (Coumadin)
C ~ Enoxaparin is a low-molecular-weight heparin and is used in situations requiring rapid onset of anticoagulant effects, such as massive DVT. Aspirin, clopidogrel, and warfarin are useful for primary prevention but are not used when rapid anticoagulation is required.
A patient, who is admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find?
a. Central apnea
b. Hypoventilation
c. Kussmaul respirations
d. Cheyne-Stokes respirations
c. Kussmaul respirations
In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.
What nursing intervention is essential for the client receiving alteplase?
a. Assess for reperfusion dysrhythmias.
b. Monitor liver enzymes.
c. Administer vitamin K if bruising is observed.
d. Monitor blood pressure and stop the medication if blood pressure drops below 110 systolic.
a. Assess for reperfusion dysrhythmias.
tachycardia (heart rate >90 beats/min),
tachypnea (respiratory rate >20 breaths/min),
fever or hypothermia (temperature >38 or <36 °C), and leukocytosis,
leukopenia, or bandemia (white blood cells >1,200/mm3, <4,000/mm3 or bandemia ≥10%)
What is the SIRS criteria?
Which assessment finding in a client taking an HMG-CoA reductase inhibitor will the nurse act on immediately?
a. Decreased hemoglobin
b. Elevated liver function tests
c. Elevated HDL
d. Elevated LDL
b. Elevated liver function tests
-plase ending
(ataplase, tenecteplase, reteplase)
What are Thrombolitics?
You're patient has expressive aphasia. Select all the ways to effectively communicate with this patient?*
A. Fill in the words for the patient they can't say.
B. Don't repeat questions.
C. Ask questions that require a simple response.
D. Use a communication board.
E. Discourage the patient from using words.
C. Ask questions that require a simple response.
D. Use a communication board.
The answers are C and D. Patients with expressive aphasia can understand spoken words but can't respond back effectively or at all. Therefore be patient, let them speak, be direct and ask simple questions that require a simple response, and communicate with a dry erase board etc.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
D. Echocardiogram
What is checking pupil size and pupillary response?
t is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. An echocardiogram is not needed for the client with a thrombotic stroke.
presence of infection, which can be proven or suspected, and 2 or more of the following criteria: Hypotension (systolic blood pressure < 90 mm Hg or fallen by >40 from baseline, mean arterial pressure < 70 mm Hg) Lactate > 1 mmol/L.
What is the Sepsis criteria?
ß blockers should be avoided in which of the following conditions?
A. Bronchoconstriction
B. Hypertension
C. Angina
D. Myocardial Infarction
What is Bronchoconstriction? B, C, and D are indications for the use of ß blockers.
A postoperative patient will begin anticoagulant therapy with rivaroxaban (Xarelta) after knee replacement surgery. The nurse performs a history and learns that the patient is taking erythromycin. The patient's creatinine clearance is 50 mL/min. The nurse will:
a. administer the first dose of rivaroxaban as ordered.
b. notify the provider to discuss changing the patient's antibiotic.
c. request an order for a different anticoagulant medication.
d. request an order to increase the dose of rivaroxaban.
B ~ Patients with impaired renal function who are taking macrolide antibiotics will experience increased levels of rivaroxaban, increasing the risk of bleeding. It is correct to discuss using a different antibiotic if possible. The nurse should not administer the dose without discussing the situation with the provider. The patient's renal impairment is minor; if it were more severe, using a different anticoagulant might be appropriate. It is not correct to increase the dose of rivaroxaban.
This scale was developed to help physicians objectively rate the severity of ischemic strokes. Increasing scores indicate a more severe stroke and has been shown to correlate with the size of the infarction on both CT and MRI evaluation.
What is The National Institutes of Health Stroke Scale (NIHSS)
The nurse is caring for clients on a surgical floor. Which client should be assessed first?
1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating.
2. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine.
3. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged.
4. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.
1. A complication of immobility after
surgery is developing a DVT. This
client with left calf pain should be
assessed for a DVT.
This 10- item scale used (subjective/objective) in the assessment and management of alcohol withdrawal. What is the scale and which parts of the tool are purely objective?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Only 3 of 10 components (tremor, paroxysmal sweats, agitation) can be rated by observation alone. The other 7 components require at least some discussion with the patient.
A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? Select all that apply.
1. Nizatidine (Axid)
2. Ranitidine (Zantac)
3. Famotidine (Pepcid)
4. Cimetidine (Tagamet)
5. Esomeprazole (Nexium)
6. Lansoprazole (Prevacid)
1. Nizatidine (Axid)
2. Ranitidine (Zantac)
3. Famotidine (Pepcid)
4. Cimetidine (Tagamet)
Rationale: H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.
1. Which statement below is incorrect about a deep vein thrombosis (DVT)?
A. "Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral."
B. "DVTs tend to mostly occur in the lower extremities but can occur in the upper extremities too."
C. "A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism."
D. "A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein."
The answer is C. This option is INCORRECT. All the other statements are true about a DVT. Option C is wrong because it should say: "A deep vein thrombosis in the lower extremity has a HIGH (not low) probability of becoming a pulmonary embolism."
A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?"
a) The ostomy bag should be adjusted.
b) Blood supply to the stoma has been interrupted.
c) An intestinal obstruction has occurred.
d) This is a normal finding 1 day after surgery
Correct Answer: (B), Blood supply to the stoma has been interrupted An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interrupted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on the blood supply to the area. An intestinal obstruction also wouldn't change stoma color
What is the nursing priority in the management of a patient with an active upper G.I. bleed?
A. Obtain vital signs.
B. Apply oxygen by nasal cannula.
C. Type and crossmatch the patient for blood products.
D. Notify the physician.
A. Obtain vital signs.
All other interventions can be applied after vital signs have been checked because this will help determine the other intervention...