In the ICU, the nurse hears an emergency cardiac monitor go off. The nurse looks at
the telemetry and notices the patient has gone into ventricular tachycardia. The nurse
will likely assess for signs/symptoms of
A) development of hypertension with BP 190/98.
B) oxygen deprivation with O2 saturation decreasing to approximately 90%.
C) decreasing cardiac output due to less ventricular filling time.
D) increasing cardiac index by correlating the volume of blood pumped by the heart
with an individual's body surface area.
Give this one a try later!
, Ans: C
Feedback: One of the dangers of ventricular tachycardia is a reduction in
cardiac output because the heart does not have time to fill adequately.
An elderly patient arrives to the health care provider's office complaining of a "sore"
that would not heal on his lower leg. Upon assessment, the nurse finds thin, shiny,
bluish brown pigmented desquamative skin. It is located medially over the lower leg.
The nurse will educate the patient that the usual treatment is
A) hydrotherapy to facilitate improvement in circulation.
B) compression therapy to help facilitate blood flow back to the vena cava.
C) initiation of Coumadin therapy to maintain an INR of 2 to 3 above norm.
D) long-term antibiotic therapy to facilitate healing of the wound.
Give this one a try later!
Ans: B
Feedback: Treatment of venous ulcers includes compression therapy with
dressings and inelastic or elastic bandages. Medications that help include
aspirin and pentoxifylline. Occasionally skin grafting may be required.
Hydrotherapy, Coumadin therapy, and long-term antibiotic therapy are
usually not required for venous ulcers.
A physician is explaining to a group of medical students the concept of the Virchow
triad as it applies to venous thrombosis. Which of the following clinical observations
of a 50-year-old male client is most likely unrelated to a component of the Virchow
triad?
A) The man has decreased cardiac output and an ejection fraction of 30%.
B) The man's prothrombin time and international normalized ratio (INR) are both low.
,C) The man has a previous history of a dissecting aneurysm.
D) There is bilateral, brown pigmentation.of his lower legs.
Give this one a try later!
Ans: A
Feedback: Cardiac output is not a component of Virchow triad. However,
decreased INR and prothrombin time indicate hypercoagulability; a
dissecting aneurysm is an example of vessel wall injury; and pigmentation in
the lower legs indicates stasis of blood.
All of the following interventions are ordered stat. for a patient stung by a bee who is
experiencing severe respiratory distress and faintness. Which priority intervention will
the nurse administer first?
A) Epinephrine (Adrenalin)
B) Normal saline infusion
C) Dexamethasone (Decadron)
D) Diphenhydramine (Benadryl)
Give this one a try later!
Ans: A
Feedback: Treatment includes immediate discontinuation of the inciting
agent; close monitoring of CV and respiratory function; and maintenance
of respiratory gas exchange, cardiac output, and tissue perfusion.
Epinephrine is given in an anaphylactic reaction because it constricts blood
vessels and relaxes the smooth muscle in the bronchioles.
Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the
nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his
lips are dusty
, blue. Vital signs reveal heart rate of 112, respiratory rate of 36, and pulse oximeter
reading of 81%. He starts coughing up frothy pink sputum. The priority intervention is
to
A) have medical supply department bring up suction equipment.
B) apply oxygen via nasal cannula at 3 lpm.
C) page the respiratory therapist to come give him a breathing treatment.
D) call for emergency assistance utilizing hospital protocol.
Give this one a try later!
Ans: D
Feedback: Mr. V. is experiencing acute pulmonary edema. This is a life-
threatening condition. The person is seen sitting and gasping for air. The
pulse is rapid, the skin is moist, and the lips/nail beds are cyanotic. Dyspnea
and air hunger are accompanied by productive cough with frothy and
often blood-tinged sputum (pink). The patient needs the emergency
responder team (including ICU nurses, physicians, respiratory therapist,
etc.) to intervene. Applying O2 by mask will not increase his oxygen level
fast enough, and he is probably mouth breathing (gasping for air). Suction
equipment may be needed, but getting a physician to give orders for
diuretics and inotropic medications is the priority. Of course respiratory
therapist will arrive with the emergency assistance team.
A client has many residual health problems related to compromised circulation
following recovery from septic shock. The nurse knows that which of the following
complications listed below are a result of being diagnosed with septic shock and
therefore should be assessed frequently? Select all that apply.
A) Profound dyspnea due to acute respiratory distress syndrome
B) Atelectasis resulting in injury to the endothelial lining of pulmonary vessels, which
allows fluid/plasma to build up in alveolar spaces
C) Formation of plaque within vessels supplying blood to the heart causing muscle
damage and chest pain
D) Acute renal failure due to decreased/impaired renal perfusion as a result of low
BPE) Flushed skin and pounding headache that coincides with each heart beat
the telemetry and notices the patient has gone into ventricular tachycardia. The nurse
will likely assess for signs/symptoms of
A) development of hypertension with BP 190/98.
B) oxygen deprivation with O2 saturation decreasing to approximately 90%.
C) decreasing cardiac output due to less ventricular filling time.
D) increasing cardiac index by correlating the volume of blood pumped by the heart
with an individual's body surface area.
Give this one a try later!
, Ans: C
Feedback: One of the dangers of ventricular tachycardia is a reduction in
cardiac output because the heart does not have time to fill adequately.
An elderly patient arrives to the health care provider's office complaining of a "sore"
that would not heal on his lower leg. Upon assessment, the nurse finds thin, shiny,
bluish brown pigmented desquamative skin. It is located medially over the lower leg.
The nurse will educate the patient that the usual treatment is
A) hydrotherapy to facilitate improvement in circulation.
B) compression therapy to help facilitate blood flow back to the vena cava.
C) initiation of Coumadin therapy to maintain an INR of 2 to 3 above norm.
D) long-term antibiotic therapy to facilitate healing of the wound.
Give this one a try later!
Ans: B
Feedback: Treatment of venous ulcers includes compression therapy with
dressings and inelastic or elastic bandages. Medications that help include
aspirin and pentoxifylline. Occasionally skin grafting may be required.
Hydrotherapy, Coumadin therapy, and long-term antibiotic therapy are
usually not required for venous ulcers.
A physician is explaining to a group of medical students the concept of the Virchow
triad as it applies to venous thrombosis. Which of the following clinical observations
of a 50-year-old male client is most likely unrelated to a component of the Virchow
triad?
A) The man has decreased cardiac output and an ejection fraction of 30%.
B) The man's prothrombin time and international normalized ratio (INR) are both low.
,C) The man has a previous history of a dissecting aneurysm.
D) There is bilateral, brown pigmentation.of his lower legs.
Give this one a try later!
Ans: A
Feedback: Cardiac output is not a component of Virchow triad. However,
decreased INR and prothrombin time indicate hypercoagulability; a
dissecting aneurysm is an example of vessel wall injury; and pigmentation in
the lower legs indicates stasis of blood.
All of the following interventions are ordered stat. for a patient stung by a bee who is
experiencing severe respiratory distress and faintness. Which priority intervention will
the nurse administer first?
A) Epinephrine (Adrenalin)
B) Normal saline infusion
C) Dexamethasone (Decadron)
D) Diphenhydramine (Benadryl)
Give this one a try later!
Ans: A
Feedback: Treatment includes immediate discontinuation of the inciting
agent; close monitoring of CV and respiratory function; and maintenance
of respiratory gas exchange, cardiac output, and tissue perfusion.
Epinephrine is given in an anaphylactic reaction because it constricts blood
vessels and relaxes the smooth muscle in the bronchioles.
Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the
nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his
lips are dusty
, blue. Vital signs reveal heart rate of 112, respiratory rate of 36, and pulse oximeter
reading of 81%. He starts coughing up frothy pink sputum. The priority intervention is
to
A) have medical supply department bring up suction equipment.
B) apply oxygen via nasal cannula at 3 lpm.
C) page the respiratory therapist to come give him a breathing treatment.
D) call for emergency assistance utilizing hospital protocol.
Give this one a try later!
Ans: D
Feedback: Mr. V. is experiencing acute pulmonary edema. This is a life-
threatening condition. The person is seen sitting and gasping for air. The
pulse is rapid, the skin is moist, and the lips/nail beds are cyanotic. Dyspnea
and air hunger are accompanied by productive cough with frothy and
often blood-tinged sputum (pink). The patient needs the emergency
responder team (including ICU nurses, physicians, respiratory therapist,
etc.) to intervene. Applying O2 by mask will not increase his oxygen level
fast enough, and he is probably mouth breathing (gasping for air). Suction
equipment may be needed, but getting a physician to give orders for
diuretics and inotropic medications is the priority. Of course respiratory
therapist will arrive with the emergency assistance team.
A client has many residual health problems related to compromised circulation
following recovery from septic shock. The nurse knows that which of the following
complications listed below are a result of being diagnosed with septic shock and
therefore should be assessed frequently? Select all that apply.
A) Profound dyspnea due to acute respiratory distress syndrome
B) Atelectasis resulting in injury to the endothelial lining of pulmonary vessels, which
allows fluid/plasma to build up in alveolar spaces
C) Formation of plaque within vessels supplying blood to the heart causing muscle
damage and chest pain
D) Acute renal failure due to decreased/impaired renal perfusion as a result of low
BPE) Flushed skin and pounding headache that coincides with each heart beat
