EXAM 3 NR 324
A client is brought to the emergency department with partial thickness burns to his face, neck, arms,
and chest after trying to put out a car fire. The nurse should implement which nursing actions for this
client? Select all that apply.
1. Restrict fluids.
2. Assess for airway patency.
3. Administer oxygen as prescribed.
4. Place a cooling blanket on the client.
5. Elevate extremities if no fractures are present.
6. Prepare to give oral pain medication as prescribed.
2. Assess for airway patency.
3. Administer oxygen as prescribed.
5. Elevate extremities if no fractures are present.
A client with no history of respiratory disease is admitted to the hospital with respiratory failure.
Which results on the arterial blood gas report should the nurse expect to note, that are consistent
with this disorder?
1. Pao2 58 mm Hg, Paco2 32 mm Hg
2. Pao2 60 mm Hg, Paco2 45 mm Hg
3. Pao2 49 mm Hg, Paco2 52 mm Hg
4. Pao2 73 mm Hg, Paco2 62 mm Hg
3. Pao2 49 mm Hg, Paco2 52 mm Hg
A client is admitted to an emergency department with chest pain that is consistent with myocardial
infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the
client's chart. The nurse should alert the health care provider because these changes are most
consistent with which complication?
1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm
1. Cardiogenic shock
A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a
blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?
1. Defibrillate the client.
2. Administer digoxin (Lanoxin).
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing.
4. Prepare for transcutaneous pacing.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops
extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse
, immediately asks another nurse to contact the health care provider and prepares to implement which
priority interventions? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and
begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when
auscultating the client's breath sounds?
1. Stridor
2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds
2. Crackles
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial
ischemia, what condition should the nurse carefully assess the client for?
1. Bradycardia
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Falling central venous pressure
2. Ventricular dysrhythmias
Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-
sided heart failure?
1. Cardiac output of 5 L/min
2. Right atrial pressure of 9 mm Hg
3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg
4. Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg
3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are
no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140
beats/minute. The nurse determines that the client is experiencing which dysrhythmia?
1. Sinus tachycardia
2. Ventricular fibrillation
A client is brought to the emergency department with partial thickness burns to his face, neck, arms,
and chest after trying to put out a car fire. The nurse should implement which nursing actions for this
client? Select all that apply.
1. Restrict fluids.
2. Assess for airway patency.
3. Administer oxygen as prescribed.
4. Place a cooling blanket on the client.
5. Elevate extremities if no fractures are present.
6. Prepare to give oral pain medication as prescribed.
2. Assess for airway patency.
3. Administer oxygen as prescribed.
5. Elevate extremities if no fractures are present.
A client with no history of respiratory disease is admitted to the hospital with respiratory failure.
Which results on the arterial blood gas report should the nurse expect to note, that are consistent
with this disorder?
1. Pao2 58 mm Hg, Paco2 32 mm Hg
2. Pao2 60 mm Hg, Paco2 45 mm Hg
3. Pao2 49 mm Hg, Paco2 52 mm Hg
4. Pao2 73 mm Hg, Paco2 62 mm Hg
3. Pao2 49 mm Hg, Paco2 52 mm Hg
A client is admitted to an emergency department with chest pain that is consistent with myocardial
infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the
client's chart. The nurse should alert the health care provider because these changes are most
consistent with which complication?
1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm
1. Cardiogenic shock
A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a
blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?
1. Defibrillate the client.
2. Administer digoxin (Lanoxin).
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing.
4. Prepare for transcutaneous pacing.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops
extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse
, immediately asks another nurse to contact the health care provider and prepares to implement which
priority interventions? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and
begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when
auscultating the client's breath sounds?
1. Stridor
2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds
2. Crackles
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial
ischemia, what condition should the nurse carefully assess the client for?
1. Bradycardia
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Falling central venous pressure
2. Ventricular dysrhythmias
Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-
sided heart failure?
1. Cardiac output of 5 L/min
2. Right atrial pressure of 9 mm Hg
3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg
4. Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg
3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are
no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140
beats/minute. The nurse determines that the client is experiencing which dysrhythmia?
1. Sinus tachycardia
2. Ventricular fibrillation
