EXAM 1 - MED SURG - #3 - NCLEX style questions based on Blueprint for Exam 1 Med Surg II

The nurse is caring for a client with acute arterial occlusion of the left lower extremity. To prevent further tissue damage, it is important for the nurse to observe for which of the following? Blood pressure and heart rate changes. Gradual or acute loss of sensory and motor function. Metabolic Acidosis Swelling in the left lower extremity 3. RATIONALE udden interruption of blood flow. sult of complete or partial obstruction. nd motor function, and a pale, mottled, numb extremity are the most dramatic and observable changes that indicate a life-threatening i changes may be associated with the acute pain episode. Metabolic acidosis is a complication of irreversible ischemia. also indicate venous stasis or artenal insufficiency Some text here about the topic of discussion Subject | Subject 4. The nurse is caring for a patient presenting to the ED complaining of chest pain. Which of the following ECG findings would be most concerning to the nurse? ST Elevations Sinus Tachycardia Frequent Premature Atrial Contractions (PACs) Isolated Premature Ventricular Contractions (PVCs) 5. RATIONALE 6. The nurse is caring for a patient experiencing an acute MI (STEMI). The nurse anticipates the physician will prescribe alteplase (Activase). Prior to administering the medication, which of the following questions is most important for the nurse to ask the patient? "How many sublingual nitroglycerin tabs did you take?" "What is your pain level on a scale of 1 to 10?" "Do your parents have a history of heart disease?" "What time did you chest pain start today?" 7. RATIONALE The patient may be a candidate for thrombolytic (fibrolytic) therapy. onger than 20 minutes, unrelieved by nitroglycerin, ST-segment elevation in the least two leads that f Some text here about the topic of discussion Subject | Subject 8. A patient presents to the emergency room complaining of chest pain. The patient's orders include the following elements. Which order should the nurse complete first? Oxygen 2 liters nasal cannula 12-lead ECG Troponin Level Aspirin 325 mg orally 9. RATIONALE 10. The nurse is caring for a patient who was admitted to the telemetry unit with a diagnosis of rule/out acute MI. The patient's chest pain begain 3 hours ago. Which of the following lab tests would be most helpful in confirming the diagnosis of a current MI 11. CK-MM Troponin C Level Myoglobin Level Creatinine Kinase-Myoglobin (CK-MB) Level RATIONALE CK-MB levels begin to increase within a few hours, and peak within 24 hours. Troponin T & I are specific for cardiac muscle, not C. in is not very specific in indicating an acute cardiac event - however negative results are an excellent CK-MM is related to skeletal muscle and is not an indicator of cardiac muscle damage Some text here about the topic of discussion Subject | Subject 12. A nurse is caring for a patient who experienced an MI. The patient is ordered metoprolol (Lopressor). The nurse understands that the therapeutic effect of this medication is which of the following? Decreases resting HR Increases cardiac output 13. Decreases platelet aggression Decreases cholesterol levels RATIONALE he result is a reduced HR, slowed conduction of impulses through the conduction system, decrease B Some text here about the topic of discussion Subject | Subject 14. A patient has had a 12-lead ECG completed as part of an annual physical examination. The nurse notes an abnormal Q wave on an otherwise unremarkable ECG. The nurse recognizes this finding indicates which of the following? A past MI An evolving MI A cardiac dysrhythmia Variant Angina 15. RATIONALE 16. When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply. Immobilize the affected arm for 4-6 weeks Avoid lifting anything over 3 lbs Take and record daily pulse rate Avoid air travel 17. Avoid using a microwave oven RATIONALE t how to take and record his pulse daily. to avoid lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to hea fting until approved by the physician. emaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. ve ovens are safe to use and do not alter pacemaker function. Some text here about the topic of discussion Subject | Subject Answer Key 1. 2.b 3. 4.a 5. 6.d 7. 8.b 9. 10.d 11. 12.a 13. 14.a 15. 16. 17.