A nurse is caring for a client who is experiencing supraventricular
tachycardia. Upon assessing the client, the nurse observes the
following findings: heart rate 200/min, blood pressure 78/40 mm Hg,
and respiratory rate 30/min. Which of the following actions should the
nurse take?
a. Defibrillate the client's heart.
b. Perform synchronized cardioversion.
c. Begin cardiopulmonary resuscitation.
d. Administer lidocaine IV bolus. - CORRECT ANSWER b. perform
synchronized cardioversion
A nurse is teaching a young adult client how to perform testicular self-
exam.
-use one or both hands? examine at same time?
-roll each testicle how?
-perform when?
-how often? - CORRECT ANSWER -use both hands to examine one
testicle at a time
-roll each testicle horizontally between the thumb and the fingers to
feel for any deep lumps in the center
-during or after warm bath/shower
-once a month
A nurse is assessing a client following the administration of
magnesium sulfate 1 g IV bolus. For which of the following adverse
effects should the nurse monitor?
-reflexes?
,-BP?
-breathing?
-cardiac - CORRECT ANSWER -depressed or absent reflexes
-decreased BP
-respiratory paralysis
-depressed cardiac function/heart block
Magnesium sulfate can be used to treat what cardiac conditions?
What is an adverse cardiac effect? - CORRECT ANSWER treats
cardiac dysrhythmias such as torsades de pointes and refractory
ventricular fibrillation
AE: depressed cardiac function including heart block
A nurse is planning care to decrease psychosocial health issues for a
client who is starting dialysis treatments for chronic kidney disease.
Which of the following interventions should the nurse include in the
plan?
a. Remind the client that dialysis treatments are not difficult to
incorporate into daily life.
b. Inform the client that dialysis will result in a cure.
c. Tell the client that it is possible to return to similar previous levels
of activity.
d. Begin health promotion teaching during the first dialysis treatment. -
CORRECT ANSWER c. Tell the client that it is possible to return to
similar previous levels of activity.
The nurse should help the client develop realistic goals and activities
to have a productive life
T/F: Before starting dialysis, the nurse should inform the client of the
difficulty of incorporating dialysis into daily life to allow the client to
develop realistic expectations. - CORRECT ANSWER True.
T/F: Dialysis is a cure for CKD. - CORRECT ANSWER False, it is a life-
long management.
,For a client starting dialysis, when should the nurse begin health and
lifestyle teaching? - CORRECT ANSWER In the first weeks after
starting the dialysis treatment once the client feels better physically
and emotionally.
effect of hypokalemia on EKG - CORRECT ANSWER -flatted T wave
-presence of U wave
effect of hypocalcemia on EKG - CORRECT ANSWER prolonged ST
interval and prolonged QT interval
The nurse should review the client's (what lab value?) after the
administration of FFP. What is the desired effect of fresh frozen
plasma on the lab value? - CORRECT ANSWER prothrombin time
the desired effect is a decrease in prothrombin time
What blood product is rich in clotting factors? - CORRECT ANSWER
Fresh frozen plasma. FFP is administered to treat acute clotting
disorders. The desired effect is a decrease in the prothrombin time.
The nurse should teach that the maximum effect of epoetin alfa will
occur in how long? - CORRECT ANSWER 2-3 months
The client who has what condition will have a plethoric (dark, flushed)
manifestation of the facial skin and mucous membranes? - CORRECT
ANSWER polycythemia vera
The client who has what type of anemia will have manifestation of
glossitis (smooth, beefy-red tongue) and weight loss? - CORRECT
ANSWER pernicious anemia
The client who has what type of anemia will have manifestations of
jaundice with an enlarged liver and spleen? - CORRECT ANSWER
sickle cell anemia
In aplastic anemia, what blood components are absent/reduced? What
is this called? Is it sudden or gradual? - CORRECT ANSWER All three
major blood components (red blood cells, white blood cells, and
, platelets) are reduced or absent, which is known as pancytopenia.
Manifestations usually develop gradually.
cardiac tamponade findings
-BP
-special BP thing
-heart sounds - CORRECT ANSWER -hyoptension
-pulses paradoxus
-muffled heart sounds
What is pulses paradoxus? - CORRECT ANSWER When the systolic
BP is at least 10 mmhg higher on expiration than on inspiration.
pericarditis findings
-HR
-EKG abnormality
-3 symptoms
-what relieves the chest pain - CORRECT ANSWER -tachycardia
-ST-T spiking (elevation)
-dyspnea, hiccups, nonproductive cough
-chest pain relieved by sitting upright or leaning forward
The nurse should increase the intake of food containing what for a
client who has megaloblastic anemia? - CORRECT ANSWER folic acid
Which adventitious breath sound? "high-pitched musical squeak on
inspiration or expiration through a narrow or obstructed airway." -
CORRECT ANSWER wheezes
Which adventitious breath sound? "coarse, loud, low-pitched sounds
during inspiration or expiration. Coughing often clears the airway and
stops the sound." - CORRECT ANSWER rhonchi
Which adventitious breath sound? "loud, dry, rubbing or grating sounds
over the lower lateral anterior chest surface during inspiration or
expiration." - CORRECT ANSWER friction rub
tachycardia. Upon assessing the client, the nurse observes the
following findings: heart rate 200/min, blood pressure 78/40 mm Hg,
and respiratory rate 30/min. Which of the following actions should the
nurse take?
a. Defibrillate the client's heart.
b. Perform synchronized cardioversion.
c. Begin cardiopulmonary resuscitation.
d. Administer lidocaine IV bolus. - CORRECT ANSWER b. perform
synchronized cardioversion
A nurse is teaching a young adult client how to perform testicular self-
exam.
-use one or both hands? examine at same time?
-roll each testicle how?
-perform when?
-how often? - CORRECT ANSWER -use both hands to examine one
testicle at a time
-roll each testicle horizontally between the thumb and the fingers to
feel for any deep lumps in the center
-during or after warm bath/shower
-once a month
A nurse is assessing a client following the administration of
magnesium sulfate 1 g IV bolus. For which of the following adverse
effects should the nurse monitor?
-reflexes?
,-BP?
-breathing?
-cardiac - CORRECT ANSWER -depressed or absent reflexes
-decreased BP
-respiratory paralysis
-depressed cardiac function/heart block
Magnesium sulfate can be used to treat what cardiac conditions?
What is an adverse cardiac effect? - CORRECT ANSWER treats
cardiac dysrhythmias such as torsades de pointes and refractory
ventricular fibrillation
AE: depressed cardiac function including heart block
A nurse is planning care to decrease psychosocial health issues for a
client who is starting dialysis treatments for chronic kidney disease.
Which of the following interventions should the nurse include in the
plan?
a. Remind the client that dialysis treatments are not difficult to
incorporate into daily life.
b. Inform the client that dialysis will result in a cure.
c. Tell the client that it is possible to return to similar previous levels
of activity.
d. Begin health promotion teaching during the first dialysis treatment. -
CORRECT ANSWER c. Tell the client that it is possible to return to
similar previous levels of activity.
The nurse should help the client develop realistic goals and activities
to have a productive life
T/F: Before starting dialysis, the nurse should inform the client of the
difficulty of incorporating dialysis into daily life to allow the client to
develop realistic expectations. - CORRECT ANSWER True.
T/F: Dialysis is a cure for CKD. - CORRECT ANSWER False, it is a life-
long management.
,For a client starting dialysis, when should the nurse begin health and
lifestyle teaching? - CORRECT ANSWER In the first weeks after
starting the dialysis treatment once the client feels better physically
and emotionally.
effect of hypokalemia on EKG - CORRECT ANSWER -flatted T wave
-presence of U wave
effect of hypocalcemia on EKG - CORRECT ANSWER prolonged ST
interval and prolonged QT interval
The nurse should review the client's (what lab value?) after the
administration of FFP. What is the desired effect of fresh frozen
plasma on the lab value? - CORRECT ANSWER prothrombin time
the desired effect is a decrease in prothrombin time
What blood product is rich in clotting factors? - CORRECT ANSWER
Fresh frozen plasma. FFP is administered to treat acute clotting
disorders. The desired effect is a decrease in the prothrombin time.
The nurse should teach that the maximum effect of epoetin alfa will
occur in how long? - CORRECT ANSWER 2-3 months
The client who has what condition will have a plethoric (dark, flushed)
manifestation of the facial skin and mucous membranes? - CORRECT
ANSWER polycythemia vera
The client who has what type of anemia will have manifestation of
glossitis (smooth, beefy-red tongue) and weight loss? - CORRECT
ANSWER pernicious anemia
The client who has what type of anemia will have manifestations of
jaundice with an enlarged liver and spleen? - CORRECT ANSWER
sickle cell anemia
In aplastic anemia, what blood components are absent/reduced? What
is this called? Is it sudden or gradual? - CORRECT ANSWER All three
major blood components (red blood cells, white blood cells, and
, platelets) are reduced or absent, which is known as pancytopenia.
Manifestations usually develop gradually.
cardiac tamponade findings
-BP
-special BP thing
-heart sounds - CORRECT ANSWER -hyoptension
-pulses paradoxus
-muffled heart sounds
What is pulses paradoxus? - CORRECT ANSWER When the systolic
BP is at least 10 mmhg higher on expiration than on inspiration.
pericarditis findings
-HR
-EKG abnormality
-3 symptoms
-what relieves the chest pain - CORRECT ANSWER -tachycardia
-ST-T spiking (elevation)
-dyspnea, hiccups, nonproductive cough
-chest pain relieved by sitting upright or leaning forward
The nurse should increase the intake of food containing what for a
client who has megaloblastic anemia? - CORRECT ANSWER folic acid
Which adventitious breath sound? "high-pitched musical squeak on
inspiration or expiration through a narrow or obstructed airway." -
CORRECT ANSWER wheezes
Which adventitious breath sound? "coarse, loud, low-pitched sounds
during inspiration or expiration. Coughing often clears the airway and
stops the sound." - CORRECT ANSWER rhonchi
Which adventitious breath sound? "loud, dry, rubbing or grating sounds
over the lower lateral anterior chest surface during inspiration or
expiration." - CORRECT ANSWER friction rub
