NUR-213 Final EXAM PRACTICE QUESTIONS & ANSWERS CORRECT

NUR-213 Final EXAM PRACTICE QUESTIONS & ANSWERS CORRECT Which patient should the nurse assess first? a. 2nd degree Mobitz 1 b. 1st degree AV block c. occasional PVCs d. ST elevation d. ST elevation This indicates the pt is having a STEMI now The patient is in V-fib and code blue has been activated. What setting with the nurse use on the defibrillator? a. cardiovert b. pace c. defibrillate c. defibrillate The patient's BP is 80/50 and has a 1+ brachial pulse. What drug is now indicated? a. amiodarone b. metoprolol c. amlodipine d. atropine e. nitroglycerine d. atropine This is a cholinergic drug that increase HR and BP A client diagnosed with shock is prescribed dobutamine. Which finding indicates this medication is effective? a. BP decreases from 160/120 to 140/88 b. urine output increases from 20 mL/hour to 40 mL/hour c. peripheral pulses decrease in strength from 2+ to 1+ bilaterally d. respirations increase from 10 bpm to 18 bpm b. urine output increases from 20 mL/hour to 40 mL/hour Dobutmaine is prescribed to increase cardiac output, which increases perfusion. When their is increases renal perfusion, urine output will increase as well. A client is suffering from pericarditis after an MI. What assessment finding will confirm this medical diagnosis? a. distended neck veins b. chest pain is relieved by nitroglycerin c. chest pain with exertion d. audible friction rub over left sternal border d. audible friction rub over left sternal border A client is about to received a thrombolytic after an EKG shows changes consistent with an MI. What information is most important for the nurses to obtain from the client's family? a. the client takes amlodipine daily b. the client takes levothyroxine 100 mcg daily c. the client is allergic to shellfish d. the client takes clopidogrel 75 mg daily d. the client takes clopidogrel 75 mg daily Clopidogrel is an anti platelet that could interact with a thombolytic and increase the chances of the pt bleeding out. Which assignment should the LPN take? a. 100% capture b. STEMI c. complete heart block d. asystole a. 100% capture it has predictable outcomes The EKG rhythm strip on telemetry notes 2nd degree Mobitz 1. What will be the priority action of the nurse? a. notify the HCP b. call a rapid response c. assess the client's pulse oximetry reading d. assess the client's BP d. assess the client's BP The nurse is caring for a client admitted with a purulent draining pressure injury. What client assessment(s) will alert the nurse that the client could be developing sepsis? a. BP 148/78 b. O2 93% on RA c. RR 28 bpm d. HR 118 bpm E. lethargy b. O2 93% on RA c. RR 28 bpm d. HR 118 bpm E. lethargy A client with cardiomypathy has an invasive pulmonary artery catheter inserted. The pulmonary capillary wedge pressure is 18 mmHg and the central venous pressure is 15 mmHg. What medication/parenteral therapy will the nurse anticipate administering? a. warfarin PO b. furosemide IV c. hetastarch d. albumin b. furosemide IV An elevated PCWP and CVP indicates hypervolemia and signs of CHF. What interventions can be assigned that could decrease the chance of a client becoming septic? a. empty indwelling catheter bag every 12 hrs b. ambulate the client once a day around the nursing station c. catheter care q2h d. mouth care once per shift c. catheter care q2h The nurse suspects that a client diagnosed with an MI is developing cardiogenic shock. What assessment finding led the nurse to conclude the client is developing cariogenic shock? a. petechiae over trunk, arms, and legs b. JVD c. fever 102.6 F d. laryngospasm b. JVD With cardiogenic shock, the pump is ineffective leading to s/sx of CHF A client who developed septic shock secondary to a UTI is now at risk for what life-threatening complications? SELECT ALL THAT APPLY. a. Disseminated intravascular coagulation (DIC) b. metabolic alkalosis c. hypoglycemia d. acute kidney injury e. thyroid storm a. Disseminated intravascular coagulation (DIC) d. acute kidney injury - due to decreased perfusion to the kidneys A client with diabetes is prescribed metoprolol for a heart disorder and a student nurse is providing medication instruction. Which instruction will require the nursing instructor to intervene? a. "Sometimes this drug causes SOB, it should get better after about 2 weeks" b. Rise slowly from a sitting or lying position c. check your finger stick blood sugars closely and notify the HCP for elevated glucose levels d. check your radial pulse a. "Sometimes this drug causes SOB, it should get better after about 2 weeks" Metoprolol decreases the workload of the heart, which can lead to heart failure What fluid orders would the nurse question for a pt experiencing Hypovolemic shock? SELECT ALL THAT APPLY. a. LR b. 0.9% NaCl c. 0.45% NaCl d. 0.25% NaCl e. dextrose 5% in water c. 0.45% NaCl d. 0.25% NaCl e. dextrose 5% in water isotonic and hypertonic fluids are indicated to replace volume What EKG change would validate that a client is experiencing an acute MI? a. loss of atrial (P) waves b. ST-segment elevation c. Sinus bradycardia d. atrial flutter b. ST-segment elevation A nurse is caring for a client in CCU and sees a rhythm that shows an elevated ST segment. What will be the nurse's priority action? a. administer O2 at 2-3 lpm b. prepare to defibrillate c. notify the HCP d. administer a bolus of amiodarone a. administer O2 at 2-3 lpm STEMI indicates myocardial injury, applying oxygen will increase oxygenation to the myocardium Which medication will the nurse administer first receiving evening report? a. the loading dose of antibiotic to the client diagnosed with endocarditis, possible sepsis b. the anti platelet medication to the client who had a MI c. the coronary vasodilator patch to the client diagnosed with coronary artery disease d. the statin medication to the client with atherosclerosis a. the loading dose of antibiotic to the client diagnosed with endocarditis, possible sepsis its a loading (1st) dose The client on telemetry is having what appears to be Vtach. What will the RN on the floor delegate to the UAP? a. have the UAP to activate the code blue b. ask the UAP to answer call lights on the unit c. send the UAP to the client's room to start basic life support d. ask the UAP to notify the client's HCP b. ask the UAP to answer call lights on the unit The nurse sees the rhythm strip of Vtach at the nursing desk. What will be the first action of the nurse? a. defibrillate the client b. start CPR c. assess for a pulse d. cardiovert the client c. assess for a pulse A client admitted with chest pain is on amlodipine and atorvastatin at home. What items on the food tray will the nurse remove? a. apple juice b. orange juice c. cranberry juice d. grapefruit juice d. grapefruit juice The nurse is caring for clients on a cardiac unit. Which client will the nurse see first? a. the client with angina who is reporting chest pain 3 out of 10 b. the client with CHF who has 3+ bilateral pedal edema c. the client with endocarditis who has a temperature of 100 F d. the client diagnosed with aortic valve stenosis who is complaining of being light-headed a. the client with angina who is reporting chest pain 3 out of 10 A child has been admitted to the ICU after being diagnosed with a ventricular septal defect. What assessment finding will confirm this medical diagnosis? a. heart murmur b. weight gain c. breath sounds equal and clear d. clubbed nails a. heart murmur Which statement by a client on aspirin every day would require further assessment by the nurse? a. I have foul smelling urine b. My gums have been bleeding when I brush my teeth c. I have stomach pains whenever I need to eat d. My joints have not been hurting as bad lately b. My gums have been bleeding when I brush my teeth The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? a. confusion and bradycardia b. uncontrolled diuresis and tachycardia c. numbness and tingling in the extremities d. chest pain and SOB a. confusion and bradycardia Digitalis toxicity symptoms include nausea, visual disturbances, confusion, anorexia The nurse is caring for a 68-year-old pt, the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment data? a. skin turgor b. potassium level c. white blood cell count d. peripheral pulses b. potassium level The nurse is planning care for a patient who is mechanically ventilated. How often will the nurse anticipate endotracheal tube suctioning? a. every 2-4 hours b. as soon after intubation as possible c. at least four times per shift d. only when the patient's condition requires suctioning d. only when the patient's condition requires suctioning A nurse is caring for a patient who is mechanically ventilated, sedated, and requires frequent suctioning to maintain airway patency. Prior to suctioning, what intervention should the nurse perform first? a. apply suction immediately after the suction catheter is fully withdrawn b. administer a bolus of IV fluid c. hyperoxygenate with 100% oxygen d. place the patient into supine position e. document the patient's ABGs c. hyperoxygenate with 100% oxygen The nurse is screening the unit's patient population for those who are at highest risk for the development of ARDS. Which patient(s) does this include? SELECT ALL THAT APPLY. a. the to admitted for smoke inhalation b. the pt who has been a stable diabetic for 10+ years c. the pt who developed a fat embolism following a femur fracture d. the pt who is developing septic shock e. the pt admitted for tx of pancreatitis a. the to admitted for smoke inhalation c. the pt who developed a fat embolism following a femur fracture d. the pt who is developing septic shock e. the pt admitted for tx of pancreatitis The nurse is assessing a pt who is in the initial stage of ARDS. What physical finding is the nurse most likely to note? a. bradycardia b. increased urine output c. hypertension d. tachypnea d. tachypnea hypoxemia triggers tachypnea as the pt attempts to restore homeostasis The RN is planning care for a pt who is being mechanically ventilated for the tx of ARDS. What nursing intervention should be included in this plan of care? SELECT ALL THAT APPLY. a. provide for sedation as needed and as ordered b. ambulate the to q4h c. change pt positions frequently d. ensure that the ventilator alarms are set correctly e. keep the HOB elevated at least 30 degrees a. provide for sedation as needed and as ordered c. change pt positions frequently d. ensure that the ventilator alarms are set correctly e. keep the HOB elevated at least 30 degrees The RN is caring for a pt who is mechanically ventilated. What intervention is most important to prevent ventilator associated pneumonia (VAP)? a. trendelenburg positioning b. early and frequent ambulation c. frequent oral care d. scheduled endotracheal suctioning c. frequent oral care