1) A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to
administration, what action should the nurse perform?
251436: Order first, obtained v/s and IV is patent, then to the blood, asked
another license nurse, infused RBCP monitor for the first 15 minutes.
(Sequential: consent, vs baseline, IV line, obtain blood, verify with other nurse, run for
15 mins, then again run while monitoring)
2) First degree AV Block patient PRN interval in the question you haven't seen the patient. You
are looking at an ECG strip.
- ASSESS the patient first
3) An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and
coolness in the right leg. The nurse should notify the health care provider and immediately
a. Measure the abdominal girth and check pulses.
b. Raise the head of the bed to 90 degrees.
c. Assess cardiac output and blood pressure.
d. Auscultate and then palpate the abdomen.
ANS: A
Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse
should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue
color in the flanks, and severe pain. Elevating the head of the bed would place too much pressure
on the surgical site. The other two options are not warranted.
4) The staff educator is presenting a workshop on valvular disorders. When discussing the
pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic
regurgitation causes what?
A) Cardiac tamponade
B) Left ventricular hypertrophy
C) Right-sided heart failure
D) Ventricular insufficiency
Ans: B
Feedback:
Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood
from
the aorta returns to the left ventricle during diastole in addition to the blood normally delivered
by the
left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood.
Aortic
regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular
insufficiency
, 5) Assess patient first the one with a MAP that is low use the ABC pattern. Is a circulation
pattern.
6) Atrial fibrillation ECG strip. A patient is discharge with warfarin, what is the teaching
instructions
-Check PT- (INR) not PTT
- avoid food rich in Vit. K.
-you don't have to check pulse
7) A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular
response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute
with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The
nurse caring for the patient understands that the main goal of treatment is what?
A) Decrease SA node conduction
B) Control ventricular heart rate
C) Improve oxygenation
D) Maintain anticoagulation
Ans: B
Feedback:
Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a
priority because it directly affects cardiac output. A rapid ventricular response reduces the time
for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial
treatment of choice, followed
by anticoagulation with heparin and then Coumadin
8) The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse
in the step- down unit should prioritize what assessment?
A) Cardiac monitoring
B) Monitoring the implanted device signal
C) Pain assessment
D) Monitoring the patients level of consciousness (LOC)
Ans: A
Feedback:
Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia
does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid
and important assessments. Ablation does not involve the implantation of a device.
9) After receiving information about four patients during change-of-shift report, which patient
should the nurse assess first?
a. Patient with acute pericarditis who has a pericardial friction rub
b. Patient who has just returned to the unit after balloon valvuloplasty
c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116
d. Patient with a mitral valve replacement who has an anticoagulant scheduled
administration, what action should the nurse perform?
251436: Order first, obtained v/s and IV is patent, then to the blood, asked
another license nurse, infused RBCP monitor for the first 15 minutes.
(Sequential: consent, vs baseline, IV line, obtain blood, verify with other nurse, run for
15 mins, then again run while monitoring)
2) First degree AV Block patient PRN interval in the question you haven't seen the patient. You
are looking at an ECG strip.
- ASSESS the patient first
3) An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and
coolness in the right leg. The nurse should notify the health care provider and immediately
a. Measure the abdominal girth and check pulses.
b. Raise the head of the bed to 90 degrees.
c. Assess cardiac output and blood pressure.
d. Auscultate and then palpate the abdomen.
ANS: A
Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse
should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue
color in the flanks, and severe pain. Elevating the head of the bed would place too much pressure
on the surgical site. The other two options are not warranted.
4) The staff educator is presenting a workshop on valvular disorders. When discussing the
pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic
regurgitation causes what?
A) Cardiac tamponade
B) Left ventricular hypertrophy
C) Right-sided heart failure
D) Ventricular insufficiency
Ans: B
Feedback:
Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood
from
the aorta returns to the left ventricle during diastole in addition to the blood normally delivered
by the
left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood.
Aortic
regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular
insufficiency
, 5) Assess patient first the one with a MAP that is low use the ABC pattern. Is a circulation
pattern.
6) Atrial fibrillation ECG strip. A patient is discharge with warfarin, what is the teaching
instructions
-Check PT- (INR) not PTT
- avoid food rich in Vit. K.
-you don't have to check pulse
7) A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular
response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute
with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The
nurse caring for the patient understands that the main goal of treatment is what?
A) Decrease SA node conduction
B) Control ventricular heart rate
C) Improve oxygenation
D) Maintain anticoagulation
Ans: B
Feedback:
Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a
priority because it directly affects cardiac output. A rapid ventricular response reduces the time
for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial
treatment of choice, followed
by anticoagulation with heparin and then Coumadin
8) The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse
in the step- down unit should prioritize what assessment?
A) Cardiac monitoring
B) Monitoring the implanted device signal
C) Pain assessment
D) Monitoring the patients level of consciousness (LOC)
Ans: A
Feedback:
Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia
does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid
and important assessments. Ablation does not involve the implantation of a device.
9) After receiving information about four patients during change-of-shift report, which patient
should the nurse assess first?
a. Patient with acute pericarditis who has a pericardial friction rub
b. Patient who has just returned to the unit after balloon valvuloplasty
c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116
d. Patient with a mitral valve replacement who has an anticoagulant scheduled
