UPDATED.
YouyareyreviewingytheychartyofyayPTywhoyisyreceivingyheparinytherapyyforyayDVT.yWh
ichyinterventionyshouldytheyRNyanticipateytakingyifytheyPTsyaPTTyisy96yseconds?
1.yIncreaseyheparinyinfusionyrateybyy2mL/hr
2.yContinueymonitorytheyheparinyinfusionyasyprescribed
3.yRequestyayprothrombinytimeyPT
4.yStopytheyheparinyinfusiony-yCORRECTyANSWER-4.yStopytheyheparinyinfusion-
yptyisyaboveytheytherapeuticyrangeyofy1-5-
2ytimesytheycontrol.yshouldydiscontinueytoypreventyharm
YouyareyprovidingyteachingytoyayPTywhoyisy2ydaysypostyopyfollowingyayheartytranspla
nt.yWhichyfollowingystatementsyshouldytheynurseyincludeyinytheyteaching?
1.yYouymayynoylongerybeyableytoyfeelychestypain
2.yYourylevelyofyactivityyintoleranceywillynotychange
3.yaftery6ymonthsyyouywillynoylongeryneedytoyrestrictyyouyNa
4.yYouywillybeyableytoystopytakingyimmunosuppressantsyaftery12ymonthsy-
yCORRECTyANSWER-1.yYouymayynoylongerybeyableytoyfeelychestypain-
ytransplantyPTsynoylongeryfeelychestypainydueytoydenervationyofytheyheart
ERynurseyisyassessingyPTywithybradydysrhythmia.yWhichyfindingyshouldyheyexpect?
1.yConfusion
2.yFrictionyRub
3.yHTN
4.yDryyskiny-yCORRECTyANSWER-1.yConfusion-
yasyayresultyofydecreasedytissueyperfusion
YouyareycaringyforyayPTywhoyhadyanyanterioryMI.yPTsyhxyshowsysheyisy1ywkypostyopyo
penycholecystectomyytheyRNyknowsythatywhichyinterventionyisycontraindicated?
1.yAdministeringyIVymorphine
2.ygivingyO2yaty2LyNC
3.yHelpingyclientytoyBSC
4.yAssistingyinythrombolyticytherapyy-yCORRECTyANSWER-
4.yAssistingyinythrombolyticytherapy-
yhavingysurgeryywithiny3ywksyisyaycontraindicationyforythrombolyticytherapy
YouyareycaringyforyayPTywhoyhasyendocarditis.yWhichyfindingyshouldyyouyrecognizeya
syaycomplication?
,1.yVentricularydepolarization
2.yGuillainyBarreySyndrome
3.yMyelodysplasticysyndrome
4.yValvularydiseasey-yCORRECTyANSWER-4.yValvularydisease-
ydamageywillyoccuryasyayresultyofyinflammationyoryinfectionyofytheyendocardium
YouyareycaringyforyPTywithyBPyofy254/139,yyouyrecognizeytheyPTyisyinyayhypertensiv
eycrisis.yWhichyactionyshouldyyouytakeyfirst?
1.yObtainybloodysamplesyforytesting
2.yTellytheyPTytoyreportyvisionychanges
3.yPlaceyHOByaty45ydegrees
4.yInitiateyIVyaccessy-yCORRECTyANSWER-3.yPlaceyHOByaty45ydegrees-
ABC'sythisywillypromoteyrespiratoryystatusyandypromoteyvenousyreturnyreducingywo
rkloadyonyheart
**InitiateyIVyaccess-ynotyfirstyaction
Whenyperformingyaycardiacyassessmentywhatyisytheypointyofymaximalyimpulse?
1.y2ndyintercostalyspaceyrightytoytheysternum
2.y2ndyintercostalyspaceyleftytoytheysternum
3.y5thyintercostalyspaceytoytheyleftyofythermalyborder
4.yLefty5thyintercostalyspaceyinytheymidclavicularyliney-yCORRECTyANSWER-
4.yLefty5thyintercostalyspaceyinytheymidclavicularyline-
thisyisybestytoyhearytheyapexyofytheyheartywhichyisyconsideredymaximalyimpulse
YouyareycaringyforyayPTywhoyisyexperiencingyAfib.yYouyshouldyreportywhatyfindingyto
ytheyprovider?
1.ySlurredyspeech
2.yIrregularypulse
3.yDependentyedema
4.yPersistantyfatiguey-yCORRECTyANSWER-1.ySlurredyspeech-
ygreatestyriskyisyanyembolusyandythisycanyindicateyembolus
YouyareyassessingyayPTywithyLeftysidedyheartyfailure.yWhatymanifestationyshouldyyou
yexpectytoyfind?
1.yIncreasedyabdominalygirth
2.yWeakyperipheralypulses
3.yJugularyvenousyneckydistention
4.yDependentyedemay-yCORRECTyANSWER-2.yWeakyperipheralypulses-
yr/tydecreasedyCOyfromyLSHF
, YouyareycaringyforyayPTywhoyisybeingytreatedyforyHFyandyhasyprescriptionsyforydigoxi
nyandyfurosemide.yYouyplanytoymonitoryforywhichyofytheyfollowingyasyanyadverseyeffe
ctyofytheseymeds?
1.ySOB
2.yLightheadedness
3.yDryycough
4.yMetallicytastey-yCORRECTyANSWER-2.yLightheadedness-
ycanycauseyaysuddenydropyinyBP=ylightheadedness
YouyareymonitoringyayPTyfollowingycoronaryybypassygraftysurgeryy(CABG).yWhichyfin
dingyindicatesycardiacytamponade?
1.ySternalyinstability
2.yIncreasedyWBCycount
3.yBPyofy140/82yonyinspirationyandy154/90yonyexpiration
4.ySinusyrhythmywithyoccasionalyprematureyatrialycontractionsyandyHRy88y-
yCORRECTyANSWER-
3.yBPyofy140/82yonyinspirationyandy154/90yonyexpiration=ypulsesyparadoxus
WhatyisyPulsusyParadoxus?y-yCORRECTyANSWER-
WhenytheysystolicyBPyisy10ypointsyhigheryonyexpirationythanyonyinspiration
**Thisyisyindicativeyofycardiacytamponade
YouyareypreparingyPTyforycoronaryyangiography.yYouyshouldyreportywhatyfindingytoy
theyproviderypriorytoyprocedure?
1.yHgby14.4
2.yHX:yPADyperipheralyarterialydisease
3.yUOPyofy200mlyiny4yhr
4.yPreviousyallergicyreactionytoyshellyfishy-yCORRECTyANSWER-
4.yPreviousyallergicyreactionytoyshellyfish-yshellfishyreactionywillyoftenyreactytoyiodine
YouyareycaringyforyayPTyfollowingyinsertionyofyaypermanentypacemaker.yWhichyPTyst
atementyindicatesyaypotentialycomplicationyofytheyinsertionyprocedure?
1.yIycan'tygetyridyofytheseyhiccups
2.yIyfeelydizzyywhenyiystand
3.yMyyincisionystings
4.yiyhaveyayheadachey-yCORRECTyANSWER-1.yIycan'tygetyridyofytheseyhiccups-
canyindicateytheypacemakeryisystimulatingytheychestywallyorydiaphragmyindicatingywi
reyleadyperforation
YouyareyprovidingydischargeyteachingytoyayPTywhoyhasyayprescriptionyforytheytransd
ermalynitroglycerinypatch.yWhichyinstructionywouldyyouyinclude?