AH III EXAMS 1-3 TESTBANKS VERIFIED

Exam 1 1. Testbank Ch38#8: A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the clients stress levels. d. Tell the client that anxiety is common and that you can help. ANS: D. Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client’s anxiety. Pre-op before emergency CABG & pt is yelling. Nurse to: 2. HTN patient on enalapril x 3 weeks needs to call HCP if a. Coughs a lot b. Complains of occasional dizziness c. Other choices 3. Testbank Ch34 #11: A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client’s concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client. ANS: C. Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities. 4. A patient with Ventricular Tachycardia has which problem as the frequently most concerning? a. Produces increased cardiac output leading to ischemia b. Uncomfortable sensation of impending doom c. Other choices Rationale: there is decreased cardiac output (not increased). See Action Alert pg. 673: For patients with sinus tachycardia, assess for fatigue, weakness, SOB, orthopnea, ↓oxygen saturation, ↑pulse rate, and ↓blood pressure. Also assess for restlessness and anxiety from ↓cerebral perfusion and for ↓urine output from impaired renal perfusion. The patient may also have anginal pain and palpitations. See “Tachydysrhythmias” bullet point & chart 34-1, both on pg. 672. 5. Propranolol potential serious complication? a. Complains of wheezing b. Other choices Rationale: beta blockers may fuck with the heart on accident if they are nonselective. Any kind of lung problem from a heart medication is undesirable, and we should always watch for that. See chart 34-4 on P.677 6. Testbank Ch38 # 22: A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours ANS: C. Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal. 7. Mitral stenosis patient teaching completed effectively if pt say, “___.” a. Left atrium to the left ventricle has narrowing which leads to decreased blood flow b. Other choices 8. Testbank Ch38 #10: A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider. ANS: C. Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the providers prescription and the client’s current medications. 9. Jugular vein distention, 2+ edema in feet and ankles, crackles in lungs, swollen hands/fingers, distended abdomen, pink sputum coughed up. What problem does pt have? a. Right sided HF b. Lt sided HF c. Class IV HF d. Both L & R sided HF 10. A pt who already has cardiac disease has developed AFIB. His ventricular HR is 150 bpm. What’s the next assessment finding will be? a. Digoxin toxicity b. Increased cardiac enzymes c. Decreased blood pressure (Decreased cardiac output) d. Jugular vein distention 11. Testbank Ch38 # 3: A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan. ANS: B This client’s physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. The patient’s v/s before going to the bathroom are pulse 88, RR 16, and oxygen saturation 95%. Nurse to 12. Testbank Ch34 # 14: A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave ANS: A. Chest pain, possibly angina, indicates that tachycardia may be increasing the client’s myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death. 13. Cardiogenic shock symptoms; select all that apply.  Increased HR  Cold, clammy skin  Decreased BP  Febrile  Urine output greater than 30 mL/hr 14. Testbank Ch 34 #7: 7. A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability ANS: C. A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client’s level of consciousness is the priority. 15. Repeat of #7 above 16. Testbank Ch38 #11: An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor. ANS: A. Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed. 17. Testbank Ch35#5: Rt sided Heart Failure patients need to be weighed daily, why? a. Weight is best indicator of fluid retention b. Other choices 18. A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip? [image of EKG strip included on test] a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs) ANS: D. Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization. 19. Left anterior chest pain with SOB. a. Get full cardiac history b. Increase position to high Fowlers Melfi rationale: Position change will help FIRST. Getting a full cardiac hx is futile if pt can’t breathe enough to talk to you. 20. Testbank Ch38 #14: A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking ANS: B. Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for. Who to see first? 21. [image of EKG strip] – what will nurse do first? a. Give meds b. Assess peripheral pulse c. Other choices See chart 34-2 pg. 672 “care of patient with dysrhythmias” 22. Abnormal MI symptoms in women include a. Indigestion, intrascapular pain, choking sensation b. Other choices 23. Pacing is used for ____ a. Continuous electrical reading b. Continuous reading of BP for drug titration c. Measure pressures in heart chambers d. Other choice See bottom of pg 665 & top of p. 666 24. Testbank Ch 34 Multiple Response #1: A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output ANS: A, D, E. Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall. 25. Heart Failure Core Measures. Immediately report _____ to HCP. (select all that apply) a. Decreased exercise tolerance b. Rapid weight increase c. Excess nocturia/polyuria d. Other choices See Action Alert on pg 704 26. Dose calc 27. Testbank Ch 35 #11: A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the client’s respiratory status. b. Draw blood to assess the client’s serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications. ANS: A. Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status. 28. Dose calc 29. What is the antidote to heparin? a. Protamine sulfate b. Other choices 30. Dose calc 31. A patient is having a stress test. Which finding would need immediate action? a. Oxygen saturation of 91% b. Pt reports Chest pain of 3 c. Other choices Rationale: “No level of chest pain is acceptable. Stop the test for any chest pain. The oxygen may have been that low to begin the exam (the answer choice doesn’t say it decreased). 32. Testbank Ch38 Multiple Response #3: A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause ANS: A, B, D, E. The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion. See Table 33-1 pg 650 33. Testbank Ch34 # 19: A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: [ekg strip shows v-tac]. Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR). ANS: A. Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action 34. Testbank Ch35 #7: After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia. ANS: B. Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure. 35. A patient having an MI has tachycardia & air hunger with frothy pink sputum. The nurse will find which of the following on assessment? a. Crackles in the lungs b. Other choices 36. In an EKG strip showing no p-waves, which is the accurate nurse documentation: a. V FIB b. A FIB c. Other choices See bottom of pg 678 37. The location of the crackles heard on auscultation is important why? a. If it ascends, the situation is worsening b. Other choices 38. Testbank Ch38 #24: The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. It constricts vessels, improving blood flow. b. It dilates vessels, which lessens the work of the heart. c. It increases the force of the heart’s contractions. d. It slows the heart rate down for better filling. ANS: C. A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct. (long sentence involving the word inotropic). “D” is the definition for “chronotropic.” 39. Testbank Ch 35, #14: After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client’s understanding. Which client statement indicates a need for additional teaching? a. “I’ll be able to carry heavy loads after 6 months of rest.” b. “I will have my teeth cleaned by my dentist in 2 weeks.” c. “I must avoid eating foods high in vitamin K, like spinach.” d. “I must use an electric razor instead of a straight razor to shave.” ANS: B. Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy should be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal. 40. A patient has an EKG showing normal sinus rhythm with fatigue SOB ventricular rate of 46. What’s probably causing the decreased heart rate? a. Other Med choices b. Amlodipine 41. Why is the BNP drawn? a. Assess heart failure b. Other choices See pg. 697 42. Testbank Ch38 Multiple Response #5: A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking ANS: A, B, C, E. Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not. 43. Testbank Ch35 #4: While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit. ANS: A. The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted. 44. The EKG strip shows no P wave but a wide QRS complex with ventricular rate of 140 bpm. How documented? a. V TAC b. Other choices See pg. 684 45. Testbank Ch38 #17: A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L ANS: B. The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable. 46. A patient had an AMI. Joint Commission core measures indicate: a. Begin fibrinolytics within 30 minutes b. Other choices This question is similar but not identical to Ch38 Testbank #16: A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics. ANS: B. The Joint Commissions Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed. 47. Testbank Ch35 #2: A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. “I have been drinking more water than usual.” b. “I am awakened by the need to urinate at night.” c. “I must stop halfway up the stairs to catch my breath.” d. “I have experienced blurred vision on several occasions.” ANS: C. Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure. 48. Testbank Ch35 MultipleResponse #1: A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night ANS: A, B, E. Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema. 49. Testbank Ch34 #4: 4. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity ANS: B. Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance 50. ST elevation or depression in a patient may be indicative of a. Myocardial injury VTAC can lead to VFIB (not the other way around). All dysrhythmias lead to DECREASED cardiac output. Afib has NO p waves. V tac usually doesn’t either. VTAC vs VFIB: VTAC is rhythmic; vfib is irregular & crazy Cardiac problems ALWAYS NEED OXYGEN Respiratory problems ALWAYS NEED TO BE SAT UP IN HIGH FOWLERS Don’t reassess another area if the question said you assessed already. Don’t call the doc on one S3 heard once. Basically, any abnormal potassium needs EMERGENCY ADJUSTMENT EXAM 2 1. Appropriate pt teaching has occurred if a patient reports back what regarding taking guaifenesin? a. I’ll take this drug with a full glass of water every time 2. Why do patients with asthma wheeze? a. That’s the sound of air moving through a narrow airway 3. Tube obstruction in a trach patient could cause a. Quiet respirations b. Thick/wet secretions c. Difficulty breathing d. High PEEP 4. Complications of tracheostomy include ___. Select all that apply. a. Pneumothorax b. subQ emphysema c. bleeding d. inability to eat e. other choice “Inability to eat” is not expected – they may have DIFFICULTY but no unable. 5. Chronic xerostomia related to radiation can be improved by a. Increase fluids, use of artificial saliva 6. Testbank: A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin) ANS: A. Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting. 7. Difference between wet and dry chest tubes is a. Water seal chamber b. Suction chamber c. Other choice 8. PE most common s/s is a. Sudden chill/fever b. Chest pain suddenly c. Hot/flushed sensation d. Dyspnea with deep breaths 9. Testbank Ch12 #15: A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 85 mm Hg Blood pressure = 135/45 PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min HCO3– = 26 mEq/L O2 saturation = 88% Which action should the nurse take first? a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowler’s position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess. ANS: A. The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the client’s respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a mask does nothing to improve the client’s hypoxic drive, nor would it address the client’s most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety. 10. Similar to Testbank Ch 32 Multiple Response #4: The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule ANS: A, B, C, D. The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed. 11. Testbank Ch 31 #21: 21.A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr. ANS: A. All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics. 12. Testbank Ch 32 #3: A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome. c. The blood clot interferes with perfusion in the lungs. d. The client needs immediate intubation and mechanical ventilation. ANS: C. A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment. 13. Dose calc 14. Why to deflate the trach cuff? a. Allow ease in swallowing b. Other choices 15. Testbank Ch31 #8: A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity ANS: A. The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority. 16. Fully compensated respiratory acidosis will have what expected lab values? a. pH 7.38 CO2 35 HCO3- 22 PaO2 97 b. other choice c. other choice d. pH 7.35 CO2 65 HCO3- 36 PaO2 78 the pH will need to be normal; resp acidosis means the CO2 is acidotic, & if fully compensated (as given in original question), then HCO3 is alkaline 17. Excessive NG suctioning will result in a. Metabolic alkalosis Suctioning out too much stomach ACID into the sputum container leaves NOT ENOUGH acid in the body 18. Most common test to diagnose PE a. CT or CT-PA b. Chest xray c. 12 lead EKG d. Coronary angiogram 19. Chest tube assessment need nurse intervention (Select All That Apply) a. Bubbling only with cough b. Constant bubbling in water chamber c. No tidaling d. Constant bubbling in suction chamber e. Bloody drainage in a patient with a hemothorax 20. Seizure patient has pH 6.88, PaO2 50, paCO2 60, HCO3- 22. What is the nurse’s next action? a. Apply oxygen b. Have patient breathe into a brown bag The patient has respiratory acidosis. There’s too much CO2 right now, so brown bag breathing is NOT the desired goal. Look at the Pa O2 – it’s low and needs to be increased, so give oxygen. 21. If a patient with a tracheostomy has a disposable inner cannula, teaching for family includes a. Remove the inner cannula and replace it with a new one 22. Trach tube and warming humidified oxygen combination therapy is used why? a. Prevent drying out of secretions b. Prevent risk for hypoxia 23. Partially compensated metabolic acidosis will have which of the following lab values: a. pH 7. b. other choice c. pH 7. d. Other choice Metabolic acidosis means kidneys are working for this issue; the pH will be low in acidosis. If partially compensated, then the lungs will START TO HELP. Metabolic acidosis leads to CO2 being 35. 24. Pneumonia order of skills: a. 5,4,1,2,3 (skills were listed out per number). All ended in 3 though, so don’t use that to ID it. b. Other order choices 25. COPD’s main pulmonary infection risk is due to a. Pooling respiratory secretions b. Decreased A-P diameter c. Decreased fluid intake and weight loss d. Fluid imbalance and pitting edema 26. Most effective way to clear thick secretions a. Increase fluids b. Other choices 27. Rt side empyema patient needs thoracentesis will have what symptom? a. Patient sitting in tripod position 28. Non-reliable patient receiving anti-Tuberculosis drug therapy. How will nurse proceed? a. DOT 29. Dose calc 30. Immediate nursing intervention if ___. Select all that apply a. RR of 8 b. Sternal retraction c. Stridor d. SpO2 of 95% e. Occasional wheeze 31. Pneumovax and flu vaccine same year vaccination is okay. I have no idea what the question was. 32. Prevent an obstruction of the tracheostomy by being alert to or performing which of the following a. Trach with noisy respirations b. Suction regularly and PRN with Yankuer 33. Testbank Ch 32 #6: A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3 ANS: B. This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender. 34. Dose calc 35. Testbank Ch 31 #10: A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough. ANS: C. Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it. 36. Hemothorax and chest tube needs emergency intervention if a. Crackling is heard at the site of chest tube 37. Testbank Ch32 #4: A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin). ANS: B. For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation. 38. Why skin test is performed for TB a. Exposure to TB **Does not test for ACTIVE TB though, just exposure. 39. BCG vaccine given for TB in patient’s past. What’s next step to test for TB? a. Chest xray or Interferon Gold 40. TestbankCh12 #10: A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3– 22 mEq/L. Which client condition should the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema ANS: B. The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis. 41. Testbank Ch 30 #10: While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique. ANS: B. Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options. 42. Testbank Ch30 #13: A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client’s anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths. ANS: D. A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client’s discomfort and need to take deep breaths to prevent complications. 43. [Interpret ABGs] 44. Accidental decannulation education: a. Secure it 45. High risk PE measures to instate. Select all that apply a. Elevate legs and provide passive ROM b. Turn & reposition every 2 hours c. Use SCDs d. Other choice e. Other choice 46. A patient had a thoracentesis. Which symptom requires immediate action by the nurse? a. Change in LOC b. Tachycardia Thoracentesis is an in-and-out procedure. Complication of thoracentesis is an accidental lung puncture, which causes tachycardia. This is the most important thing we watch for after the procedure. 47. Movement of the tube into a false passage a. Possible within the first 72 hours after tracheostomy is placed 48. Most common pneumonia symptom? a. Weak b. Fever c. Cough d. confused 49. Prevent aspiration in a tracheostomy patient by a. Thickening the liquids 50. D-dimer test is done in a patient with suspected PE, why? a. If low or negative, DVT/PE may still be present b. If high, other diagnostic tests will be ordered c. Value determines PT/INR for patient d. If positive, heparin bolus and drip ordered See p. 618-619 and p.743 Exam3 1. Notify the HCP if a PTU patient has dark colored urine 2. TB Bradycardia/hypothyroidism  levothyroxine 3. PCKD & HTN on diuretic needs further teaching a. Weight same time each day b. Avoid NSAID c. I will avoid ASA & ASA-containing product d. Limit daily fluids to 1L/day 4. BUN 35 (normal 12-20) & Creatinine is 1.0. nurse to ask for a. Fluid restriction b. Urine c/s c. Serum eGFR d. IV fluids 5. Thyroid storm select all that apply a. Fever b. Increased systolic BP c. Tachycardia d. Hypothermia e. Decreased HR 6. TB Graves patient has a 1 degree fever elevation. 7. TB teach early PCKD 8. TB hypothyroidism secondary to HT 9. Acute DKA nurse action a. Correct acidosis b. Administer D5 ½ IV c. Insulin IV d. EKG 10. TB Acute glomerulernephritis issue to address 11. TB GFR 40 (normal 100-120) fluid overload 12. Which often misdiagnosed in older patient with acute glomerulernephritis a. CHF b. CVA c. AA d. TIA 13. Dose calc 14. TB levothyroxine effective if HR is 70 15. DM only respond to sternal rub BG 33, IV infiltrated. What to do a. Admin glucagon 16. Post-op subtotal thyroidectomy with laryngeal stridor r/t tetany. Nurse to first a. Give calcium gluconate 17. Prednisone DM on NPH, which Rx anticipate a. Increase NPH 18. Which nurse assessment in acute glomerulernephritis & periorbital edema a. Test urine for protein b. Auscultate breath sounds 19. Priority problem hypothyroid a. Obesity b. Water retention c. Heat intolerance 20. TB? DKA and Kussmaul respirations a. Give IV insulin 21. TB ABG DKA 22. TB delay DM onset  tight BG control 23. TB? BG 82, a1c 5.9% a. Good 24. PACU report to HCP? a. Weak, hoarse b. Increased swelling at neck c. HR 112 d. 7/10 pain 25. TB confused, diaphoretic 2 day s/p hysterectomy and PICC. First – dextrose 26. TB CT – metformin 27. Dose calc 28. Acute glomerulernephritis, nurse to ask a. Have you had a recent infection 29. TB DKA SATA 30. Why Kussmaul respirations in DKA? a. pH low, compensatory 31. dose calc 32. TB hyperpara – lift sheet 33. TB? PKD not normal a. Periorbital edema b. Bloody, cloudy urine 34. Potassium IV in DKA nurse needs to know a. Urine output 35. Oliguria acute glomerulernephritis diet a. Decreased sodium, decreased potassium b. Increased sodium, increased potassium c. Decreased protein, decreased potassium d. Increased calcium & phosphorus 36. A nurse is monitoring a client newly diagnosed with DM for signs of complications. Which s/s indicates client is a risk for complications associated with DM a. Polyuria b. Diaphoresis 37. Dose calc 38. Rapid acting insulin a. Lispro b. Regular c. NPH d. Glargine 39. NPH 0700, sleeping at 1500 a. Feel for dampness 40. DKA 950 BG then short-acting insulin and rehydration. Next action? a. Ampule of 50% dextrose b. IV fluid with dextrose c. NPA subQ d. Phenytoin 41. Graves I 131 a. Destroys tissues 42. Neck surgery a. Hypoparathyroidism needs calcium supplement 43. TB? HHS tx needs changing if a. Same LOC 44. How DKA occurs a. Fat is broken down into ketones, which produce acid 45. HHS expected finding a. Dry mucous membranes b. Ketone breath odor c. Kussmaul respiration d. Diarrhea/epigastric pain 46. Similar TB: frequent BG 300. Teach a. Check ketones 47. Before giving potassium, check a. Urine output 30 48. Same as 36 above. 49. Dose calc 50. Nurse admit client on PTU. Continues to collect data suspecting client has ___ hx. a. Hashimoto’s b. Thyroiditis c. Myxedema d. Grave’s