NRS 440 Final Exam 100% Correct Answers

A nurse is caring for a patient admitted to the ICU. The patients vital signs are heart rate of 28 per minute, blood pressure of 78/48mm/Hg, respiratory rate of 34/min, and temperature of 38.6 (101.4F). The client is becoming unresponsive. Which of the following interventions should the nurse perform first? - Apply transcutaneous pacing pads A patient is taking a beta1 adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that this drug acts by increasing: - myocardial contractility An older adult patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? - Skin integrity An older adult is admitted to the emergency department after being the restrained front seat passenger in a motor vehicle accident. The nurse assessing this patient should consider that which physiological response to hypovolemia is not as likely in an older adult? - tachycardia A 75 year old patient has been admitted to the intensive care unit for respiratory failure. When caring for this patient, the nurse will give increased attention to skin integrity because of the: - increased fragility from loss of protective subcutaneous layers When measuring pulmonary artery pressure, what information do you obtain when the balloon is wedged in a branch of the pulmonary artery? - left sided heart pressures Cardiac output is calculated by: - heart rate x stroke volume A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mmHg and a PAWP of 17mmHg. Which of the following findings should the nurse expect? (select all that apply) - bilateral crackles in the lungs hepatomegaly jugular vein distension A 68 year old patient has been admitted to the coronary care unit after an inferior myocardial infarction. Age-related changes in myocardial pumping ability may be evidenced by: - decreased contractility A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? - A chest x-ray is needed to verify placement after the procedure What is the mean arterial pressure (MAP) of a patient with a blood pressure of 140/60? - 87 Which action should the nurse take when preparing for cardioversion of a patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mmHg - administer a sedative before cardioversion is implemented The blood pressure of an adult patient admitted with pneumonia is 160/70 mmHg. What is an age-related change that contributes to this finding? - Loss of elasticity adrenergic sensitivity The nurse is working on the night shift when s/he notices sinus bradycardia on the patient's cardiac monitor. The nurse should: - assess for hemodynamic instability When caring for a client who has atrial fibrillation, consider that he is at high risk for: - stroke The patient with ventricular fibrillation (VF) is: - pulseless Adenosine (adenocard) is an antidysrhythmic agent given primarily to: - to convert supraventricular tachycardia Identify the rhythm (picture) of a sawtooth rhythm with tall and thin p-waves: - atrial flutter Which intervention is appropriate for a patient in asystole? - CPR Normal CVP ranges between: - 2-8 mmHg While assessing a patient with a central venous catheter, the nurse notes the catheter insertion site is red and tender and the patient's temperature is 101.8F. The nurse will plan to: - get an order to discontinue the catheter and culture the tip change the flush system and monitor the side A twenty-year old client has received a gunshot wound of the chest and is admitted to the intensive care unit (ICU) in hypovolemic shock. A central venous pressure (CVP) line is inserted, and the nurse measures the pressures. Which rationale is most appropriate for this nursing action? - CVP determines fluid status and blood volume A patient with cardiogenic shock has the following vital signs BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medications? - furosemide (Lasix) IV A trend that has reduced the number of 'codes' initiated in the hospital is the emergence of: - rapid response teams Which laboratory result for a patient whose cardiac monitor shows multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? - serum potassium 2.8 mEq/L The mean arterial pressure (MAP) is calculated by: - adding the systolic blood pressure and two diastolic blood pressures and then divide by 3 A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? - atropine A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (select all that apply) - decreased cough reflex