Portage Learning Pathophysiology NURS 231 BIOD 331
Final Exam & module 1-10 exams All Versions
(Questions and Answers )
A nurse assesses a client who is recovering after a coronary catheterization.
Which assessment findings in the first few hours after the procedure require
immediate action by the nurse? (Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor - -Answer-: b. Serum potassium of 2.9
mEq/L
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
*In the first few hours postprocedure, the nurse monitors for complications such
as bleeding from the insertion site, hypotension, acute closure of the vessel, dye
reaction, hypokalemia, and dysrhythmias. The clients blood pressure is slightly
elevated but does not need immediate action. Warmth and redness at the site
would indicate an infection, but this would not be present in the first few hours.
,A nurse prepares a client for a pharmacologic stress echocardiogram. Which
actions should the nurse take
when preparing this client for the procedure? (Select all that apply.)
a. Assist the provider to place a central venous access device.
b. Prepare for continuous blood pressure and pulse monitoring.
c. Administer the clients prescribed beta blocker.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this
examination. - -Answer-: b. Prepare for continuous blood pressure and pulse
monitoring.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this
examination.
*Clients receiving a pharmacologic stress echocardiogram will need peripheral
venous access and continuous blood pressure and pulse monitoring. The client
must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine,
which will be administered during the procedure, should be performed. Beta
blockers are often held prior to the procedure.
A nurse prepares a client with acute renal insufficiency for a cardiac
catheterization. The provider prescribes
0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains
gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should
the nurse infuse the fluids? (Record your -Answer-: using a whole number, and
rounding to the nearest drop.) - -Answer-: 31 drops/min
,A student is caring for a client who suffered massive blood loss after trauma. How
does the student correlate
the blood loss with the clients mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.q - -Answer-: ANS: B
Lower blood volume will decrease MAP. The other -Answer-: s are not accurate
nurse is caring for a client after surgery. The clients respiratory rate has increased
from 12 to 18
breaths/min and the pulse rate increased from 86 to 98 beats/min since they
were last assessed 4 hours ago.
What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the clients tissue perfusion further.
c. Document the findings in the clients chart.
d. Increase the rate of the clients IV infusion. - -Answer-: ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases
in heart rate, respiratory rate,
or blood pressure. Even though these readings are not out of the normal range,
the nurse should conduct a
thorough assessment of the client, focusing on indicators of perfusion. The client
may need pain medication, but this is not the priority at this time. Documentation
should be done thoroughly but is not the priority either. The nurse should not
increase the rate of the IV infusion without an order.
, The nurse gets the hand-off report on four clients. Which client should the nurse
assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours - -Answer-: ANS: A
This client has a falling systolic blood pressure, rising diastolic blood pressure, and
narrowing pulse pressure,
all of which may be indications of the progressive stage of shock. The nurse
should assess this client first. The
client with the unchanged oxygen saturation is stable at this point. Although the
client with a change in pulse
has a slower rate, it is not an indicator of shock since the pulse is still within the
normal range; it may indicate
the clients pain or anxiety has been relieved, or he or she is sleeping or relaxing. A
urine output of 40 mL/hr is
only slightly above the normal range, which is 30 mL/hr.
A nurse is caring for a client after surgery who is restless and apprehensive. The
unlicensed assistive
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative
Care 9e 310
personnel (UAP) reports the vital signs and the nurse sees they are only slightly
different from previous
readings. What action does the nurse delegate next to the UAP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
Final Exam & module 1-10 exams All Versions
(Questions and Answers )
A nurse assesses a client who is recovering after a coronary catheterization.
Which assessment findings in the first few hours after the procedure require
immediate action by the nurse? (Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor - -Answer-: b. Serum potassium of 2.9
mEq/L
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
*In the first few hours postprocedure, the nurse monitors for complications such
as bleeding from the insertion site, hypotension, acute closure of the vessel, dye
reaction, hypokalemia, and dysrhythmias. The clients blood pressure is slightly
elevated but does not need immediate action. Warmth and redness at the site
would indicate an infection, but this would not be present in the first few hours.
,A nurse prepares a client for a pharmacologic stress echocardiogram. Which
actions should the nurse take
when preparing this client for the procedure? (Select all that apply.)
a. Assist the provider to place a central venous access device.
b. Prepare for continuous blood pressure and pulse monitoring.
c. Administer the clients prescribed beta blocker.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this
examination. - -Answer-: b. Prepare for continuous blood pressure and pulse
monitoring.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this
examination.
*Clients receiving a pharmacologic stress echocardiogram will need peripheral
venous access and continuous blood pressure and pulse monitoring. The client
must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine,
which will be administered during the procedure, should be performed. Beta
blockers are often held prior to the procedure.
A nurse prepares a client with acute renal insufficiency for a cardiac
catheterization. The provider prescribes
0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains
gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should
the nurse infuse the fluids? (Record your -Answer-: using a whole number, and
rounding to the nearest drop.) - -Answer-: 31 drops/min
,A student is caring for a client who suffered massive blood loss after trauma. How
does the student correlate
the blood loss with the clients mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.q - -Answer-: ANS: B
Lower blood volume will decrease MAP. The other -Answer-: s are not accurate
nurse is caring for a client after surgery. The clients respiratory rate has increased
from 12 to 18
breaths/min and the pulse rate increased from 86 to 98 beats/min since they
were last assessed 4 hours ago.
What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the clients tissue perfusion further.
c. Document the findings in the clients chart.
d. Increase the rate of the clients IV infusion. - -Answer-: ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases
in heart rate, respiratory rate,
or blood pressure. Even though these readings are not out of the normal range,
the nurse should conduct a
thorough assessment of the client, focusing on indicators of perfusion. The client
may need pain medication, but this is not the priority at this time. Documentation
should be done thoroughly but is not the priority either. The nurse should not
increase the rate of the IV infusion without an order.
, The nurse gets the hand-off report on four clients. Which client should the nurse
assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours - -Answer-: ANS: A
This client has a falling systolic blood pressure, rising diastolic blood pressure, and
narrowing pulse pressure,
all of which may be indications of the progressive stage of shock. The nurse
should assess this client first. The
client with the unchanged oxygen saturation is stable at this point. Although the
client with a change in pulse
has a slower rate, it is not an indicator of shock since the pulse is still within the
normal range; it may indicate
the clients pain or anxiety has been relieved, or he or she is sleeping or relaxing. A
urine output of 40 mL/hr is
only slightly above the normal range, which is 30 mL/hr.
A nurse is caring for a client after surgery who is restless and apprehensive. The
unlicensed assistive
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative
Care 9e 310
personnel (UAP) reports the vital signs and the nurse sees they are only slightly
different from previous
readings. What action does the nurse delegate next to the UAP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
