LATEST 2025 UPDATED PCCN EXAM QUESTIONS WITH CORRECT ANSWERS GRADED 100%

LATEST 2025 UPDATED PCCN EXAM QUESTIONS WITH CORRECT ANSWERS GRADED 100% A frail, elderly pt recovering from an exploratory laparotomy was extubated following a prolonged period of mechanical ventilation and IV sedation. She continues to receive PRN opioids for pain. Today, the nurse notes occasional combativeness, fluctuating lethargy and poor short-term memory. Data are as follows BP 104/60 HR 87 RR 24 O2 sat 95% on 2L via NC The nurse should recognize that A. mobilization should be limited to prevent injury B. the RASS scale should guide medication administration C. the use of Haldol is associated with lethal dysrhythmias D. moving the pt to a room with a window is a useful distraction technique - RIGHT ANSWER -C. The most current guidelines advise cautious use of antipsychotic meds to manage delirium, as risk versus benefits data remain unclear. Another choice may be a short-term trial of an atypical antipsychotic such as Quetiapine (Seroquel) A nurse caring for a 76 year old patient in the PCU. Which of the ff age related cardiac changes should the nurse anticipate. A. decreased response to catecholamines B. increased myocardial complaince C. decreased audibility of S1 D. increased resting heart rate - RIGHT ANSWER -A. Aging is associated with a decreased response to catecholamines. It is also associated with decrease in myocardial compliance. It is also associated with an increased audibility of S1 because of increased rigidity of the ventricular wall. It is associated with a decrease in resting HR. A nurse overhears a student recommending a popular high-protein weight loss program to a patient admitted with an exacerbation of heart failure. When the nurse asks the student why the recommendation was made, the student replies, "The patient is obese." The nurse should explain that A. this is an appropriate recommendation, since heart failure patients are often obese because of lack of energy B. heart failure patients may appear to be obese are often nutritionally challenged because of poor appetite. C. the pt should be cautioned instead to decreased protein intake to avoid azotemia D. nutritional counseling should be done by the physician - RIGHT ANSWER -B. The pt with heart failure may be volume overloaded by 5 to 50 pounds over dry weight. A patient admitted following an episode of new onset sepsis. assessment reveals new onset dyspnea, intercostal retractions and crackles in all lung fields, pt is placed on oxygen via NC at 4Lpm which criteria ABG results should the nurse anticipate. pH pCO2 pO2 O2sat HCO3 A. 7. B. 7. C. 7. D. 7. - RIGHT ANSWER -A. As the pt is dyspneic, the initial change in arterial blood gases will be respiratory alkalosis. This will be reflected in a decrease in CO2 and corresponding increase in pH. A patient develops chest pain, shortness of breath and coughing 3 days after STEMI. The nurse should suspect A. Pneumothorax B. aortic dissection C. Pulmonary embolism D. Pericarditis - RIGHT ANSWER -C. This pt is exhibiting symptoms of PE A patient reports severe nonradiating substernal chest pain. ECG reveals a 2 mm ST segment elevation in the precordial leads. After pain relief is achieved with nitroglycerin, the ECG returns to normal. Which of the following data is most useful in the acute management of this patient. A. troponin I B. serum electrolytes C. coagulation studies D. lipid profile - RIGHT ANSWER -A. This pt is demonstrating symptoms of ACS. In order to determine if cardiac damage has occurred, troponin levels are obtain. When myocardial cells become damaged, troponin levels will begin to rise in the bloodstream. Determination of the presence of myocardial damage will help guide pt care management. A cardiac pt with with DNR status is being managed medically. The nurse notes a new cough, thick yellow sputum and a temperature of 101.4 (38.4) Coarse crackles are present in the right upper field. The nurse should most immediately anticipate A. blood and sputum cultures followed by a broad spectrum abx B. mucolytics and judicious IV fluid administration C. an antyipyretic and conservative management D. NPO status and encouragement of frequent activity - RIGHT ANSWER -A. This pt symptoms are consistent with pneumonia. Management should include abx therapy, oxygen therapy for hypoxemia, mechanical ventilation if acute respiratory failure develops, fluid management for hydration, nutritional support, and treatment of associated medical problems and complications. A fellow employee confides to you about a personal addiction to narcotics. The colleague has not sought professional help but is considering the need to do so. Conversation further reveals she has been forging prescriptions to obtain drugs. When you ask her to report this to the supervisor, she refuses and asks you not to share what you spoke about. What is the nurse best course of action A. confidentially report the conversation to the EDA B. disregard the conversation and hope the situation resolves C. remove the prescription pads and limit her access to them D. speak with the nursing supervisor - RIGHT ANSWER -D. Nurses who divert drugs pose a significant threats to patient safety but also become a liability to healthcare organizations and the nursing department where the diversion occurred. Healthcare and nursing leaders have a responsibility to ensure that security systems are in place to prevent diversion and protect pt if nursing impairment is suspected as a result of drug diversion. Nursing leaders must consider legal, regulatory, ethical, humanistic and practical considerations in resolving this issue. The nursing supervisor must be notified immediately and in a private area. This is a very sensitve issue. A patient with dilated cardiomyopathy is admitted with dyspnea, cough, palpitations and decreased level of consciousness. The patient is in sinus tach with no ectopy. The nurse should anticipate management to include A. administration of captopril (Capoten) B. insertion of a temporary left ventricular assist device C. loading the pt with digoxin D. preparation for dynamic cardiomyopathy procedure - RIGHT ANSWER -A. This pt is showing symptoms of heart failure related to dilated cardiomyopathy. ACE inhibitors have been effective in improving both symptoms and survival in these pt. Most pt will tolerate ACE inhibitor therapy as well. A post op CABG pt questions why he is receiving an insulin drip. The nurse explains the rationale is A. prevent the development of DM B. reduce the risk of infection C. prevent the development of intestinal ischemia D. reduce the risk of acute renal failure - RIGHT ANSWER -B. Good glycemic control helps prevent the risk of postoperative infections A postoperative African-american pt with a history of heart failure is being prepared for discharge. The pt continues to report pain as 5 to 6 on a 0 to 10 scale. The physician wrote a prescription for ibuprofen to be taken 3 times a day. The pt expresses concern about the prescription. The physician states "opioids are inappropriate for her acute pain." Which of the following is indicated A. instruct the pt to fill the prescription and call the physician if pain goes unrelieved. B. realize women complain of pain more frequently than men do, and the prescription is realistic. C. explain to the pt that African-Americans are at greater risk for opioid abuse than Caucasians and that the prescription is appropriate. D. collaborate with the physician to determine if race impacted the pain management decision - RIGHT ANSWER -D. Racial and ethnic disparities in pain are well documented in the literature. As an advocate and moral agents for this pt and consistent with caring practices in the synergy model, collaboration with the physician prior to pt discharge is indicated to determine if any biases contributed to the pain regimen prescribed for this patient. A postoperative thoracic surgery pt has a chest tube in place. The nurse notes the water seal level is fluctuating and corresponding with the pt breathing. CXR earlier revealed an unresolved pneumothorax. The nurse should. A. continue to observe B. check the tubing for kinks C. milk/strip the chest tube D. clamp the chest tube, and call the surgeon immediately - RIGHT ANSWER -A. The observation described in the scenario is expected and is known as tidaling. The absence of fluctuations can indicate that the lung is re-expanded. No intervention is required for normal findings. A pt develops a rapid heart rate of 168 and BP if 82/48. The pt reports light headedness and shortness of breath. Which of the following is indicated A. diltiazem 5 mg IV bolus B. synchronized cardioversion C. amiodarone 300 mg IV bolus D overdrive pacing - RIGHT ANSWER -B. This patient has symptomatic SVT as evidenced by the presence of hypotension, lightheadedness and shortness of breath. Synchronized cardioversion is indicated at this time. A pt develops SVT hypotension and chest pain. The goal of therapy will be to A. reduce HR to increase diastolic filling time B. produce arteriolar constriction to increase perfusion pressure C. dilate coronary arteries to increase myocardial O2 delivery D. promote venous constriction to increase preload - RIGHT ANSWER -A. Rapid heart rates can lead to hemodynamic instability, because the fast rate prevents adequate ventricular filling during diastole and increases myocardial oxygen demand, while decreasing time available for coronary artery filling A pt family requests to stay beyond visiting hours. The nurse best response is to A. determine the pt wishes B. explain the need to adhere to the visiting policy C. allow a longer stay D. encourage the family to leave - RIGHT ANSWER -A. Evidence shows that the unrestricted presence and participation of a support person can enhance patient and family satisfaction, because it improves the safety of care. Unrestricted presence of a support person can improve communication, facilitate a better understanding of the pt, advance pt and family centered care, and enhance staff satisfaction. Determining what the pt prefers is the first step and is consistent with caring practices in the Synergy Model. A pt has undergone vascular surgery for PAD. To prevent future exacerbation, the nurse should include which of the ff discharge teaching A. modify diet to include low fat and high simple carbohydrates B. avoid all alcoholic beverages C. exercise no more than 30 minutes a day D. avoid secondhand smoke. - RIGHT ANSWER -D. PAD is associated with an increased risk for atherosclerotic adverse events. Modification or elimination of risk factors, especially smoking, is included in the treatment goals. A pt in the PCU who is a regular cocaine user develops non-radiating chest pain. The ECG reveals ST and T wave abnormalities. The pt CK is elevated, and CK-MB and troponin levels are pending. The nurse should anticipate adminsitration of which of the following A. beta-blocker B. calcium channel blocker C. thrombolytic D. benzodiazepine - RIGHT ANSWER -D. A benzodiazepine is indicated to control hyperactivity, hypertension, tachycardia, anxiety, hyperthermia, and seizures associated with cocaine use. A pt is admitted following mitral valve replacement. Which of the following should most likely be included in the patent's plan of care A. positive inotropic agent B. anticoagulant C. prophylactic antibiotic D. ACE inhibitor - RIGHT ANSWER -B. Anticoagulatn therapy recommendations are based on the valve apparatus and the pt risk factors (afib, LV dyfunction, previous thromboembolism, and hypercoagulable condition). Mechanical valve replacement require lifelong anticoagulant therapy, while most pt with bioprosthetic valve replacement require short term anti-coagulation (3 months). In pt with NSR and no risk factors for thrombus, only aspirin therapy is recommended after bioprosthetic valve replacement. A pt is admitted for evaluation of exercise intolerance, increasing short of breath and a new-onset mitral murmur. Assessment reveals a QT segment of 0.46 second. The nurse should recognize that the pt is at most risk for development of A. atrial fib B. 2nd degree HB II C. ventricular dysrhythmia D. paroxysmal atrial tachycardia - RIGHT ANSWER -C. Pt with QT prolongation are at risk for development of torsades de pointes or polymorphic vtach. This pt QT interval is prolonged. A pt is admitted with a history of end-stage renal disease (ESRD), diarrhea, nausea, vomiting, prolonged QT interval, hyperreflexia and paresthesia of the fingers. Which lab value should the nurse monitor A. calcium B. potassium C. magnesium D. sodium - RIGHT ANSWER -A. This pt is demonstrating signs of hypocalcemia. The kidneys reabsorb up to 98% of filtered calcium, with less than 25 excreted in the urine. Patients with ESRD are usually hypocalcemic, because of the inability to reabsorb filtered calcium, along with decreased production of vitamin D3 in the nonfunctioning kidney. A pt is admitted with a severe headache, nausea and vomiting. BP on arrival is 280/140 mm Hg. The nurse should anticipate immediate administration of A. atniemetics B. labetalol C. mannitol D. analgesics - RIGHT ANSWER -B. Hypertensive urgencies may be treated with rapid-acting oral antihypertensive agents. There are many drug categories available, including ACEIs, ARBs, calcium channel blockers and beta-blockers. Labetalol is an example of a beta-blocker that may be used in this situation. A pt is admitted with acute pancreatitis reporting severe abdominal pain. The most appropriate analgesic is A. acetaminophen (tylenol) B. ibuprofen (motrin) C. meperidine (demerol) D. morphine - RIGHT ANSWER -D. Although it has been previously thought that morphine was contraindicated in acute pancreatitis, a review of the literature shows no evidence of this. Data suggest that morphine may be of more benefit than meperidine by offering longer pain relief with less risk seizures. A pt is admitted with GI bleeding and a 3 day history of melena. The pt is unresponsive but is breathing spontaneously. Urine output is 15 ml in 8 hours, and skin is cool to the touch. Assessment data include BP 86/54, HR 138, RR 30, T 99.3 (37.3) CVP 3 The nurse should anticipate immediate administration of which of the following A. adenosine B. aggressive fluid resuscitation C. 3 units PRBCs D. dopamine (intropin) - RIGHT ANSWER -B. This pt has risk factors, signs and symptoms of hypovolemic shock. Aggressive fluid resuscita is indicated at this time. A pt is admitted with hematuria secondary to an overdose of warfarin (Coumaidn). Lab data include: INR 9.8, Hgb 13.5, Hct 35.6. The nurse should anticipate the administration of A. FFP B. cryoprecipitate C. platelets D. vitamin K - RIGHT ANSWER -D. This pt has an elevated INR. Choice of treatment for this pt depends on the degree of coagulopathy and on the clinical impact of potential blood loss if bleeding occurs. One option is to simply hold the warfarin until the INR is again within therapeutic range. Alternatively, vitamin K may be given as a more active management strategy. Vitamin K safely and effectively corrects the INR. A pt is admitted with hypertrophic cardiomyopathy. For which of the ff dysrhytmias is this patient at risk A. SB B. PAC C. SVT D. asystole - RIGHT ANSWER -C. Hypertrophic cardiomyopathy is distinguished by a hypertrophied, non-dilated left ventricle. A trial dilation results in atrial fibrillation and SVT A pt is admitted with respiratory infection. The pt has shortness of breath with a frequent productive cough and is expectorating light-green sputum. The nurse should initially anticipate which of the following ABG results A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis - RIGHT ANSWER -B. Pt who are hyperventilating for SOB will develop respiratory alkalosis. Pneumonia is a known etiology of hyperventilation and respiratory alkalosis A pt is admitted with sepsis. Pt does not desire intubation, vasopressors or resuscitation in the event of cardiac arrest but will accept conservative treatment, including IV fluids, antibiotics and blood products, if needed. In assessing this pt, the nurse notes 2 blood sugar readings are greater than 180 consecutively. The nurse should anticipate A. no treatment, and elevated blood sugar is expected in elderly patients with sepsis B. administration of insulin to maintain a blood sugar of less that or equal to 180 C. monitoring the blood sugar unless it increases to greater than 200 D. no treatment; to avoid increased mortality associated with rebound hyperglycemia - RIGHT ANSWER -B. Administration of insulin is consistent with the pt wishes. Tight glycemic control does not improve outcomes in critical care pt who are septic. A target range of less than or equal to 180 and avoidance of hypoglycemia and highly variable blood glucose values is the evidence-based approach to glycemic control in this population. A pt is being discharged and continuing on amiodarone therapy. pt teaching will include monitoring for which of the following long-term complications. A tachyarrhythmias B. renal insuff C. pulmonary fibrosis D. hyperkalemia - RIGHT ANSWER -C. A well-documented side effect of amiodarone after long-term use is pulmonary fibrosis A pt is being discharged is tearful and states, "Medication costs are overwhelming, and i have to come back to the hospital when my condition flares up when I have no medications. THe social workers give me phone numbers and websites, but i don't have a computer or know what to say to those people." This is the patient's third admission. The doctor has written 5 necessary prescriptions for the pt heart condition. THe next action for the nurse should be to A. perform medication reconciliation to determine generic equivalents for the prescriptions B. review previously provided information and assist the pt in contacting assistance programs before discharge C call the physician and request enough samples to fill the prescription D. help the pt prioritize which medications are necessary and which she could do without. - RIGHT ANSWER -B. Assisting the pt to contact assistance programs (e.g., from the pharmaceutical companies) may help the pt afford the prescribed medications A pt is confused about time and place, despite frequent reorientation. For the pt safety, the nurse should initially A. put a vest restraint on the pt B. ask a family member to stay with the pt C. administer a mild sedative D. increase the frequency of pt observation - RIGHT ANSWER -D. Pt have a right to receive safe care in a safe environment. However, the use of restraints is inherently risky. THe decision to use a restrain or seclusion is not driven by diagnosis, but by a comprehensive patient assessment. FOr a given pt at a particular point in time, this assessment determines whether the use of less restrictive measures poses a greater risk than the risk of using a restraint. Increasing the frequency of observation may be all that is required to keep this pt safe. The comprehensive assessment to identify medical problems that may be causing behavior changes in the pt. For example, temperature elevations, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions and adverse effects may cause confusion, agitation and combative behavior. Addressing these medical issues may eliminate or minimize the need for restraint. A pt is receiving milrinone therapy should be assessed for which of the following side effects A. hyperkalemia B. chest pain C. thrombocytopenia D. decreased urination - RIGHT ANSWER -B. Chest pain, ventricular dysrhthmias and hypotension are potential side effects of milrinone administration. Thrombocytopenia is a side effect of inamnirone, another PDI but not milrinone. A pt is transferred to the PCU following a CABG 3 days ago. The pt developed bleeding in the immediate postoperative period, which led to re-operation and infusion of 8 units of packed RBCs. The pt's lab data reveal a plt count of 48k. The nurse should suspect which of the ff etiologies A. PLT dysfunction from use of the pump during surgery B. bone marrow suppression. C diltiazem (Cardizem) used for postoperative atrial fibrillation D. HIT - RIGHT ANSWER -D. This pt has risk factors and laboratory data consistent with HIT. Thrombocytopenia is a well-recognized complication of heparin therapy usually occurring within the first 10 days after heparin treatment has started. HIT must be suspected when a pt receiving heparin has a decrease in PLT count particularly 50% of the baseline count, even if the platelet count nadir remains >150 A pt post heart transplant develops second degree heart block, type II. Vital signs are BP 86/40, HR 42, RR 24. Assessment reveals mild onset of chest pain rated 2 out of 10, warm and dry skin, and clear breath sounds. The pt denies SOB. The nurse should initially A. anticipate transcutaneous pacing B. administer 0.5 mg IV atropine C. draw blood to help determine if the pt is rejecting his organ D. reassure the patient that this rhythm is common following a heart transplant - RIGHT ANSWER -B. This pt has an unstable bradycardia. Current recommendations by AHA include administration of 0.5 mg of atropine, although this initial treatment may not be effective because the transplanted heart lacks vagal innervation A pt presents with a temperature of 105.6 F (40.9) and nuchal rigidity. A nurse obtains blood culture and administers antibiotics. The patient remains febrile, and the family questions the adequacy of the interventions. The nurse's best response should be to A. arrange a social service consult B. assure the family that everything will be explained later. C suggest that the family discuss their concerns with the physician D. acknowledge the family's concerns while explaining rationales for the interventions - RIGHT ANSWER -D. The nurse demonstrating high levels of caring practices and facilitation of learning will acknowledge and address the family's learning A pt presents with left-sided weakness, Physical exam reveals a left facial droop and decreased grip strength of the left arm. History identifies chronic atrial fibrillation treated with digoxin (Lanoxin) and warfarin (Coumadin) VS: BP 156/64, HR 110, irregular Lab values: Hgb 11, Hct 32.7%, BUN 14, Cr 2, PT 25, INR 2.3 Which of the above information excludes the pt from receiving thrombolytic therapy A. BP B. history of atrial arrhythmias C. INR D. renal function - RIGHT ANSWER -C. This pt has an elevated INR, which could precipitate bleeding. This an exclusion criterion for thromobolytic therapy. A pt reports chest pain that is sharp, constant, worse when lying down and alleviated with sitting up and leaning forward. The most likely cause of these findings is A. ACS B. pericarditis C. PE D. AAA - RIGHT ANSWER -B Pericarditis is inflammation of the pericardial sac. The damaged epicardium becomes rough and inflamed and irritates the pericardium lying adjacent to it, precipitating pericarditis. Pain is the most common symptom of pericarditis. THe pain is sharp, constant and is alleviated when sitting up and leaning forward. A pt reports of sudden pain and change in color of the leg. Assessment reveals one lower extremity is mottled and cold. Superficial veins are collapsed, and a pulse deficit is noted. The nurse should A. elevate the affected extremity B. instruct the pt that, if needed, to only take cold remedies with pseudephedirne C. anticipate initiation of aniplatelet therapy D. perform very gentle removal of calluses from feet - RIGHT ANSWER -C. This pt is exhibiting symptoms of PAD. Management includes administration of antiplatelet therapy to reduce the risk of MI and stroke A pt states that he works the night shift, is accustomed to taking his medications at night instead of in the morning and needs to get back on his regular schedule. The first dose is schedule. The first dose is scheduled for 0900. The most appropriate response would be to A. explain the importance of maintaining a routine administration time to the pt B. ask the pharmacist to provide education and information on BP medication to the pt C. remind the pt that he will not be working after his discharge, and recommend follow-up at hist first postoperative appointment D. contact the pharmacy and request that administration times be changed to meet thte pt individual needs - RIGHT ANSWER -D. Consistent with caring practices, participation in care and participation in decision making in the Synergy Model, his wishes should be granted. The pt medication schedule should not be modified accordingly, unless contraindicated A pt tells a nurse, "I don't know how I'm going to pay for this hospitalization." The nurse should A. arrange a meeting with hospital social services staff B. Notify the business office so a payment plan can be designed C. redirect the pt toward meeting psychologic needs D. give the pt applications for public assistance medical coverage - RIGHT ANSWER -A. Collaboration with a social worker is indicated in this case the social worker can assist the pt in identifying ways to address the financial implications of this hospitalization and help identify methods of payments. A pt w resp infection sustained blunt trauma in MVA. Pt is on O2 via face mask and is hemodynamically stable. The RN should anticipate which of the following interventions to prevent development of acute resp distress syndrome. A. Prophylactic mechanical ventilation w/ large tidal volumes B. minimizing transfusion of packed red blood cells C. measures to keep pt pH 7.25-7.35 D. withholding antibiotic therapy until definitive identification of the organism is made. - RIGHT ANSWER -B. Studies suggest that minimizing transfusions decreases the likelihood of developing ARDS A pt was recently diagnosed with hypertrophic cardiomyopathy. Nursing instructions to the pt should include A. avoidance of strenous exercise or extreme physical exertion B. no need for genetic testing C. the need for periodic used of a temporary pacemaker being likely in the future D. a low-sodium diet - RIGHT ANSWER -A. Pt with hypertrophic cardiomyopathy must abstain from highly strenous competitive activity and highly strenous physical exertion due to the high risk of arrhythmogenic sudden death. A pt who is extubated following 3 days of mechanical ventilation is noted to have hot and flushed skin and is expectorating thick yellow sputum. Auscultation reveals bilateral crackles halfway up posterior. Data are as follows BP 112/60 HR 138 RR 30 T 102 (38.9) o2 SAT 93% ON 2 l nc Which of the ff orders should the nurse anticipate A. lasix 40 mg ivp and increase 02 to 4 L/min B. albuterol inhaler and methylprednisolone 125 mg IVP C. serum BNP and HCTZ D. blood culture and IV antibiotics - RIGHT ANSWER -D. This pt is demonstrating symptoms of pneumonia. Rapid administration of antibiotics contributes to improved outcomes. Obtaining blood cultures will help the provider determine the appropriateness of selected antibiotics. A pt who is immediately post hemodialysis reports headache, nausea and vomiting. Which of the following is the best response A. "your symptoms are due to the removal of urea during your treatment B. "I will report this to the dialysis team so they can increase your treatment time in the future." C. "Have any of your visitors been exposed to the flu." D. "your treatment may be done less frequently since you are having side effects." - RIGHT ANSWER -A. Uremia must be corrected slowly to prevent disequilibrium syndrome, which is a set of signs and symptoms ranging from headache, nausea, restlessness and mild mental impairment to vomiting, confusion, agitation and seizures. This is thought to occur as the plasma concentration of solutes, such as urea nitrogen, is lowered A pt who is in initial DKA will present with A. increased potassium and decreased sodium B. decreased plasma osmolality and ketones in urine C. hyperphosphatemia and hyperglycemia D. hypophosphatemia and acidosis - RIGHT ANSWER -A. Initially, pt with DKA will have a sodium level that is normal or low. potassium levels are falsely elevated due to the presence of acidosis (loss of hydrogen ions). A pt who is newly admitted is hemodynamically stable, had sustained a stroke and had been on mechanical ventilation via tracheostomy tube, a continuous sedation infusion and enteral feedings in the ICU for several days. The pt is now off sedation and receiving O2 via a trach collar. Gastric residual volumes of 250 ml every 6 hours over the past 3 days have been noted. Upon collaborating with the nutritionist and physician, the nurse should anticipate which of the ff A. dilution of the enteral feeds by 50% with water B. administration of a prokinetic agent C. decreasing the rate of enteral feedings by 50% D. initiation of pernteral nutrition - RIGHT ANSWER -B. In a studr of 206 critically ill pt, 2 or more GRVs of at least 200 mL and 1 or more GRVs of at least 250 mL were found significantly more often in pt who experienced frequent aspiration. Prokinetics have been advocated to improve gastric emptying. A pt who is visually impaired is to be transferred to another unit. The nurse should prepare the pt for the transition by A. explaining the physical layout of the receiving unit to the pt B. advising the staff on the receiving unit to orient the pt C. providing written materials about the receiving unit to the pt family D. arranging for the pt family to tour the receiving unit - RIGHT ANSWER -A. Preparing the pt for transfer by providing information about the receiving unit may help alleviate transfer anxiety. A pt who sustained a fall reports a headache and, soon after, develops acute confusion. The nurse notes ST segment depression on the pt ECG. Which of the following should the nurse suspect is the most likely cause A. hypokalemia B. cerebral hemorrhage C. alcohol intoxication D. ischemia - RIGHT ANSWER -B. This pt has risk factors (fall) and symptoms of cerebral hemorrhage. Pt with a cerebral hemorrhage may have ST segment depression or QT prolongation. A pt who was in the ICU has been weaned after 2 weeks of mechanical ventilation and a continuous midazolam (versed) infusion. In the PCU, the pt is experiencing episodes of agitation and anxiety during the day and reports inability to sleep during the night. Which of the following interventions is indicated A. place the pt in a private room away from the nurses' station B collaborate with the physician to obtain an order for a sleeping aid C. perform all care for the pt until the episodes of agitation and anxiety decrease D. perform a delirium screen - RIGHT ANSWER -D. This patient has a risk factors (ICU admission and continuous infusion of midazolam) as well as symptoms of deliruim. Screening for delirium so that appropriate interventions can be initiated is indicated at this time. A pt with a history of ACS involving the anterior wall develops chest pain, dyspnea, wheezing, diaphoresis, and restlessness. The most likely cause of these findings is A. pulmonary embolism B. pulmonary edema C. severe asthma D. unstable angina - RIGHT ANSWER -B. The pt has risk factors (anterior wall MI) and symptoms of pulmonary edema. Obstruction of coronary blood flow produces myocardial ischemia causes myocardial wall dysfunction. During these episodes, pulmonary edema can develop. The nurse should watch for pulmonary edema after an anterior wall MI. A pt with a history of COPD is admitted. ABG results are: pH 7.24, pCO2 78, pO2 54, HCO3 30, O2 sat 82% These reuslts indicate hypoxemia and A. acute respiratory acidosis B. compensated metabolic acidosis C. compensated respiratory alkalosis D. acute metabolic alkalosis - RIGHT ANSWER -A. A low pH and elevated CO2 indicate respiratory acidosis. As the pH is not with normal range, compensation has not been reached at this point. A pt with a history of diabetes and hypertension reports onset of numbness in her hands, unusual fatigue, loss of appetite, indigestion and a cough. Which of the following response by the PCU nurse is indicated A. Your doctor will likely order a CT scan without contrast B. I will call the dietitian to review your meal selections and intake with you C. How have you been sleeping the last couple of nights D. I will call the physician to obtain an order for an electrocardiogram - RIGHT ANSWER -D. This pt has risk factors for and is demonstrating symptoms of possible ACS. An ECG will help diagnose this condition. A pt with a history of heroin and alcohol abuse is admitted for treatment of cellulitis. The pt has flushed, slightly moist skin and is slow to respond to verbal stimuli. The affected arm is edematous and hard to the touch, with yellow exudate noted from puncture wounds on the skin. Vital signs are BP 88/50 HR 120 RR 26 T 102 (38.9) The nurse should anticipate orders for which of the ff A. abx and crystalloid administration B. antipyretic and dopamine administration C. CT scan of the head and a drug screen D. colloid followed by norepineprhine administration - RIGHT ANSWER -A. This pt has risk factors and is exhibiting signs of sepsis. The main goals are to control infection and provide immediate resuscitation of the hypoperfused state. Early goal-directed therapy during the first 6 hours of resuscitation improves survival. This they includes aggressive fluid resuscitation to augment intravascular volume and increase preload until a CVP of 8 to 12 mm Hg. (12 to 15 mm Hg in mechanically ventilated pt). is acheived. Crystalloids or colloids may be used. A fluid challenge for hypovolemia should be initiated. A pt with a history of hyperlipidemia and alcohol abuse reports left upper quadrant abdominal pain. vital signs are BP 85/50 HR 110 RR 24 T 101 (38.3) Which of the following lab values should the nurse anticipate A. decreased sedimentation rate and elevated calcium level B. decreased serum amylase level and increased WBC count C. decreased LDH and increased SGOT (AST) D. decreased Hct and increased lipase level - RIGHT ANSWER -D. This pt is demonstrating signs, symptoms and risk factors of pancreatitis. A decrease in Hct and an increase in lipase levels are consistent with this condition. A pt with a history of IV drug abuse is admitted with a fever and a grade III/VI systolic murmur. The patient develops sudden dyspnea and anxiety. Chest auscultation reveals a loud holosystolic murmur and crackles. Which of the ff is the most likely cause A. Mitral valve insufficiency B. ventricular aneurysm formation C. Heart failure D. hemopericardium with tamponade - RIGHT ANSWER -A. This pt has a risk factor (IV drug abuse) and symptoms of endocarditis, which is common in IV drug abusers because of the nonsterile injection into the nervous system. While the tricuspid valve is most typically affected, involvement of the mitral and aortic valves can occur. A pt with a history of unstable angina is admitted following gastric bypass surgery. The pt reports sudden SOB and chest pain with inspiration and appears anxious and apprehensive. Data are as follows BP 106/64, HR 124. RR 24. O2 sat 86% on room air Which of the following is the most likely cause of the symptoms A. pulmonary embolism B. anastomatic leak C. NSTEMI D. cardiac tamponade - RIGHT ANSWER -A. This pt is at risk for a pulmonary embolism and is and is demonstrating symptoms of this primary complication of bariatric surgery. According to the international bariatric society registry, the primary cause of death after bariatric surgery is pulmonary embolism. Signs of PE include unexplained SOB, chest pain that worsens with a deep breath or cough, coughing up blood, anxiety or feelings of dread, lightheadedness, increased respiratory rate, tachycardia, decreased SpO2 and diaphoresis A pt with a tracheostomy requires frequent suctioning for thick sputum, A nurse finds a colleague instilling saline in the endotracheal tube prior to suctioning. The most appropriate response by the nurse would be to A. report the colleague to the charge nurse or manager B. noted the practice on the pt chart to ensure consistency of suctioning techniques C. ask the attending physician to review the suctioning policy. D. collaborate with the colleague to review the evidence about this practice. - RIGHT ANSWER -D. In addition to an unappreciable increase in sputum recovery, use of NS adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies, thus contributing to lower airway contamination. Other harmful pt outcomes have been reported in the nursing literature, including delays in return to baseline vital signs, Spo2 and intracranial pressure. Because no solid scientifically based benefits for routine use of normal saline have been shown, it is highly recommended that this potentially harmful practice be abandoned. Instead, treatment considerations should center on ways to prevent the development of thick tenacious secretions. A review of these data should take place with the colleague to help mitigate continuation of this dangerous practice A pt with ACS who has undergone cardiac surgery 2 days ago develops new onset of JVD, muffled heart tones, palpitations, difficulty breathing and chest pain that worsens with coughing. Decreased peripheral pulses are noted. Vital signs are as follows BP 110/60 to 90/50 HR 96 to 134 RR 20 to 28 Which of the following should the nurse anticipate A. needle decompression B. echocardiogram C. administration of dopamine D. spiral Ct - RIGHT ANSWER -B. This pt is at risk for and is demonstrating signs of cardiac tamponade. Cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart's ability to pump. Signs of tamponade include elevated and equalized filling pressures (CVP, PADP, PAOP), decreased cardiac output, respiratory rate, jugular venous distention, pulsus paradoxus, and muffled heart sounds. Transesophageal or transthoracic echocardiography may be used to diagnose or confirm cardiac tamponade. A pt with acute arterial occlusion is being prepared for discharge. Which of the following should be included in pt teaching A. walk 35 to 50 minutes on a treadmill or track 3 to 4 times/week B. keep the legs at heart level C. for pain relief at night, keep the head of bead flat D. initiate cold remedies upon early onset of cold symptoms - RIGHT ANSWER -A. This exercise is an important but underused treatment. It can increase symptoms-free walking distance and improve quality of life. Mechanisms probably include increased collateral circulation, improved endothelial function with microvascular vasodilation, decreased blood viscosity and decreased ischemia-induced inflammation. A pt with acute coronary syndrome/ unstable angina has received morphine with relief of symptoms. The nurse notes a sudden widening of the QRS complex, although the pt remains in sinus rhythm. A 12 lead ECG indicates the development of a new-onset left bundle branch block. Which of the following should the nurse anticipate A. electrophysiology study B. transeophageal echocardiogram with bubble study C. evaluation for contraindications of fibrinolytic therapy D. troponin I - RIGHT ANSWER -D. The LAD coronary artery is the primary source of blood supply to the bundle of His and bundle branches. Therefore, pt with an anterior wall MI caused by and LAD occlusion are at risk for ventricular conduction defects. Conduction defects such as a left bundle branch block may occur. Obtaining troponin levels will help diagnose whether this pt is experiencing an MI that is being manifested with a left bundle branch block. A pt with an elevated BMI is having fluctuations in BP, HR and oxygen saturation, and reports feeling sleepy and fatigued despite intershift report of the pt sleeping. The nurse noted periods of irritability and memory deficits. Which of the ff interventions is indicated A. monitoring for hypotension B. administering small doses of benzodiazepines C. performing a mini-mental status exam D. collaborating with the physician for use of a CPAP mask - RIGHT ANSWER -D. This pt has primary risk factor (obesity) and symptoms of obstructive sleep apnea. Continuous positive airway pressure (CPAP) may be initiated if the pt CO2 level is stable and acceptable. A pt with an extensive history of ACS is admitted with an acute exacerbation of heart failure. Data are as follows Bp 90/60, HR 120, O2 sat 90% on 4l via nasal cannula She has diffuse crackles throughot all lung fields. The physician has ordered diuretics and insertion of a central line for dobutamine administration. Her husband favors withdrawal of treatment but the pt has indicated she wants to continue treatment even if its painful and possibly futile. She is oriented to person and place but disoriented to time and year. The nurse should recognize A. the pt wishes should be supported under the ethical principle of autonomy B. the pt should be educated that comfort can be maintained for her even without further treatment C. the pt cognition may be impaired because of hypoxia and decreased blood pressure, and the husband should make medical decisions D. that the spiritual care should be consulted before healthcare d - RIGHT ANSWER -A. As an advocate and moral agent, the nurse must support the pt wishes as long as the pt has capacity, which is the case in this scenario. A pt with chronic alcohol abuse has lab data that reveal a phosphorous level of 0.8. Given the pt history and current condition, which of the following is the pt at risk of developing A. hyperventilation B. increase glucose production C. bacterial infection D. decreased deep tendon reflex - RIGHT ANSWER -C. Since phosphorous assists in cellular immunity (resistance to infectious diseases), the pt with low phosphorous levels is at increased risk of developing a bacterial infection. A pt with chronic alcohol abuse is admitted with altered mental status. The pt has periods of clear sensorium but has frequent episodes of agitation accompanied by diaphoresis, nausea and vomiting. The nurse notes increased muscle weakness and new onset of first-degree AV block. Which of the following is indicated at this time A. collaborate with the physician for a neuro consult B. check the pt magnesium level C. perform a 12 lead ECG D. institute seizure precautions - RIGHT ANSWER -B. This pt has a risk factor (chronic alcohol abuse) and symptoms of hypomagnesemia. A pt with end-stage renal disease asks the nurse why is anemic. The nurse explains the anemia is caused by A. blood loss in the urine B. renal insensitivity to vitamin A C. inadequate production of erythropoietin D. inability of the kidney to retain iron. - RIGHT ANSWER -C. As chronic kidney disease progresses to stage 2 and 3, erythropoietin production decreases and anemia may become clinically evident A pt with ESRD and HF is receiving HD through an AV graft. VS are BP 190/94, HR 104, RR 26. The pt has crackles bilaterally and is bleeding from the graft site. The nurse should A. asses for bruit and thrill every 30 min for 2 hours and reasses B. notify the interventional radiologist C. ask the nephrologist to insert a temp catheter into the contralateral arm D. collaborate with the nephrologists regarding not using heparin during dialysis treatment - RIGHT ANSWER -B. If the bleeding is not controlled following application of direct pressure to the site, repair by an interventional radiologist is indicated. A pt with hepatic failure and end stage renal disease is hemodynamically stable but disoriented. The family is trying to make end of life decisions but is expressing frustration, because "every doctor who comes in tells us something different." The most appropriate action for the nurse would be to A. review the physicians' progress note with the family members B. contact the physicians individually, explain the issue and ask them to speak once more with the family C. ask the clinical nurse specialist to help coordinate a family conference with as many physicians as possible D. request that an ethics committee intervene and review the case. - RIGHT ANSWER -C. Having all providers together will allow for sharing of perspectives and possibly consensus-building surrounding the pt's condition A pt with hepatic failure overhears on rounds that the phosphorous level is decreasing and inquires what that means. The best response is A. "your liver is regenerating." B. "your kidney function has not been affected." C. "we can now prepare you for a liver biopsy to help pick the best treatment." D. "you will start to feel like you have more energy within a day or two." - RIGHT ANSWER -C. Lower phosphorous levels and early phosphorous administration are associated with a good prognosis in pt with acute liver failure. Elevated phosphorous levels are associated with a poor recovery. A pt with hepatic failure related to hepatitis B is being admitted. Lab data include PT >50 seconds, aPTT 59 seconds, bilirubin 18 mg/dL. Which of the following interventions should be anticipated A. arterial blood gas monitoring BID and preparing pt for a CT of the head B. checking blood sugar TID and hourly mental status assessment C. assessing ammonia levels BID and phosphorous levels daily D. preparing pt for a liver biopsy and transfusing FFP BID - RIGHT ANSWER -B. This pt has a risk factor (hepatic failure) and symptoms of potential fulminant hepatic failure (FHF). Complication of FHF include encepalopathy, cerebral edema and hypoglycemia. Monitoring blood sugar and mental status are indicated for this pt. A pt with HF is on a diuretic and fluid restriction. Assessment indicated atrial tachycardia with a rate of 130, presence of crackles in all lung fields, an S3 at the left apex and BP of 90/40 (previously 130/60). The patient reports feeling SOB. The nurse should anticipate administration of A. a fluid bolus to enhace preload B. dopamine to support BP C. dobutamine to augment cardiac output D. adenosine to reverse tachycardia - RIGHT ANSWER -C. In pt with decompensated heart failure, use of intravenous inotropic agents such as dobutamine may be indicated to support cardiac function and cardiac output. A pt with history of COPD and anterior wall MI that occurred 1 year ago is now SOB and expectorating pink frothy sputum. The pt has a rapid, irregular heart-beat with an O2 sat of 89%. The most likely cause of these S/S is A. pulmonary edema B. cardiac tamponade C. pneumococcal pneumonia D. ARDS - RIGHT ANSWER -A. History and current symptoms are consistent for pulmonary edema A pt with history of COPD is receiving 28% oxygen via face mask and has the following ABG values. pH. 7.35 pCO2 48 pO2 62 HCO3 26 O2 sat 89 Which of the ff is indicated at this time A. continue ongoing therapy and monitoring B. increase the dead space of the oxygen tubing C. increase the FIO2 D. administer 1 meq/kg of sodium bicarbonate - RIGHT ANSWER -A. Pt with COPD usually present with very high levels of carbon dioxide and lower oxygen levels. The ABG results of the patient in this scenario are within acceptable ranges for a pt with COPD. No intervention is indicated at this time. A pt with history of taking gentamicin (Garamycin) is admitted with oliguria, confusion, lethargy, nausea and vomiting. Lab data are as follows BUN 26 Cr 1.6 Na 130 K 4.9 Calcium 7.8 Which of the following should the nurse suspect A. dehydration B. acute tubular necrosis C. GI infection D. chronic renal failure - RIGHT ANSWER -B. This pt has received a nephrotoxic agent, which puts the pt at risk for development of ATN. Lab data support this diagnosis with an elevated BUN, creatinine and potassium. Calcium and sodium levels will be decreased. A pt with HTN, dyslipidemia and CAD has leg pain and decreased skin temperature in the legs and feet. The pt legs have pallor and decreased pulses that become fainter when the legs are elevated. The nurse should suspect. A. DVT B. chronic venous insufficiency C. acute arterial occlusion D. PAD - RIGHT ANSWER -D. The symptoms described in this scenario are consistent with PAD. This pt also has risk factors for PAD. Risk factors for PAD include DM and impaired glucose tolerance, smoking, hypertension, hyperlipidemia and hyperhocysteinemia A pt with mitral stenosis is admitted. Which of the ff dysrhythmias should be of greatest concern to the nurse A. PVCs 4 per min B. junctional rhythm, rate 58 C. second degree AV block Type I D. afib rate 136 - RIGHT ANSWER -D. As forward flow from the left atrium to the left ventricle decreases with mitral stenosis, cardiac output decreases. Blood backed up behind the stenotic valve causes left atrial dilation and increased left atrial pressure. As a result, mitral stenosis and left atrial dilation causes atrial fibrillation A pt with multiple rib fractures sustained in a motor vehicle collision 4 days ago reports sudden chest pain and difficulty breathing. Chest xray reveals a right hemothorax. The pt appears anxious and has decreased breath sounds on the affected side. Which of the ff procedures should the nurse anticipate A. needle decompression, 2nd ICS at midclavicular line B. bronchoscopy with broncial lavage C. placement of a right-side chest tube in the 6th ICS at the posterior axillary line D. CT scan for further evaluation and diagnosis - RIGHT ANSWER -C. Blunt or penetrating thoracic trauma can cause bleeding into the pleural space, resulting in a hemothorax. This life-threatening condition must be treated immediately. Resuscitation with intravenous fluids is initiated to treat the hypovolemic shock. A chest tube is placed on the affected side to allow drainage of the affected side to allow drainage of blood. A pt with sepsis has the ff lab data PT 12.5 aPTT 58.2 Fibrinogen elevated Fibrin split products elevated Which of the ff is indicated A. PLT B. cryoprecitpitate C. Vitamin K D. FFP - RIGHT ANSWER -D. The pt aPTT is elevated, indicating an alteration with the intrinsic pathway or common pathway of the clotting cascade. FFP is needed to help correct this abnormality. A pt with suspected pulmonary hypertension should be prepared for which of the ff tests to confirm the diagnosis A. angiography B. echocardiography C. electrocardiography D. cardiac catheterization - RIGHT ANSWER -D. RIght heart catheterization is required to confirm a diagnosis of pulmonary hypertension, to assess the severity of the hemodynamic impairment and to test the vasoreactivity of the pulmonary circulation A pt with systolic heart failure has slight dyspnea at rest. The nurse should anticipate management to include A. metoprolol B. milrinone C. lisinopril D. diltiazem - RIGHT ANSWER -C. Use of an oral afterload reducer is indicated at this time to manage systolic heart failure. Decreasing heart workload may alleviate symptoms. A pt with type II diabetes and recent pneumonia is admitted with a serum glucose level of 590. The pt is alert and oriented, denies nausea or vomiting and reports being very thirsty with frequent urination. Data are as follows BP 112/58, HR 114, RR 18, T 100 (37.8), O2 sat 92% on 2 L via NC Which of the ff lab findings should the nruse anticipate Urine ketones Arterial pH A. negative 7.42 B. positive 7.24 C. negative 7.35 D. positive 7.50 - RIGHT ANSWER -B. This pt is demonstrating signs and symptoms of DKA. DKA is associated with an elevated blood sugar, ketonuria and decrease in pH associated with a metabolic acidosis. A pt with upper GI bleeding is admitted with a Hgb of 10.8. The ff day the pt has become obtunded and is having melena stools. Lab data reveal a Hgb of 6.1. Which of the ff should the nurse do first A. check the pt for orthostatic changes and hold medications that inhibit PLT function B. obtain intubation equipment and administer normal saline C. insert a NG tube to promote removal of bile, and transfuse 2 units of packed RBCs D. prepare the pt for upper endoscopy and collaborate with the pharmacist regarding a vasopressin infusion - RIGHT ANSWER -B. Because this pt in obtunded, airway patency is in question. Intubation is indicated for airway protection at this time. The mental status changes may be indicative of hypovolemia. Emergent fluid resuscitation is indicated A pt with which of the ff is at greatest risk for torsades de pointes A. depressed ST segment B. development of peaked T waves C. prolonged QT interval D. development of a U wave - RIGHT ANSWER -C. The normal QTc is less than 0.46 second (460 msec) in women and less than 0.45 second (450 msec) in men. A prolonged QT interval is significant because it can predispose the pt to the development of polymorphic VT, also known as torsades de pointes. When drugs associated with a high risk of torsades de pointes are started, it is important to record the QT and QTc interval and to continue to monitor the QT and QTc interval during treatment. Prolongation of the absolute QT interval beyond 0.5 second (500 msec) increases the risk of polymorphic VT. According to recommendations based on research findings, pain assessment should occur A. based on changes in vital signs B. only when the pt movements indicate the pt is seeking attention C. routinely, regardless of physical findings D. only when the presence of pain can be validated - RIGHT ANSWER -C. Pain is considered the fifth vital sign and must be assessed regularly. Presence of physical findings may be part of the comprehensive assessment of pain. However, physical findings may not be present in all patients with pain After a STEMI, a pt suddenly experiences a decreased level consciousness, a weak and thready pulse and posterior crackles in the lower half of the lung fields bilaterally. Data are as follows BP 76/43 HR 139 RR 24 UO 5 ml for the past hour O2 sat 88% on 2 L via nasal (from 97%) The nurse should suspect which of the ff causes A. CVA B. cardiogenic shock c. pulmonary embolus D. ARDS - RIGHT ANSWER -B. This pt has a primary risk factor (STEMI) and signs of cardiogenic shock. The hypotension is caused by a decrease in contractility of cardiac muscle. Compensatory mechanisms of tachycardia and tachypnea result. A decrease in urine output, decreased level of consciousness, crackles and a weak and thready pulse result from hypoperfusion associated with the condition. An adult pt is admitted with status asmaticus. ABGs are pH 7.45, pCO2 29, pO2 60, HCO3 24. She is given 02 at 6 l per nasal cannula, epinephrine and albuterol (ventolin) treatments. Which of the ff ABG results are most indicative her condition is worsening pH pCO2 pO2 HCO3 A. 7. B. 7. C. 7. D. 7. - RIGHT ANSWER -B. These arterial blood gases reveal a low pO2 and high pCO2 (stage 4 of blood gas progression in pt with status asmaticus, the most serious) which occurs with respiratory muscle insufficiency; this is an even more serious sign that stage 3, and mandates intubation and ventilatory support. Apatient is admitted with acute respiratory failure, left lobar pneumonia and COPD. Physical examination reveals severe fatigue, coarse inspiratory crackles and expiratory wheezing. Data also include HR 132, RR 35, T 102.6 (38.9), pH 7.28, pCO2 72, pO2 48, HCO3 36 Based on this information, the nurse should anticipate which of the following additional clinical findings A. purulent sputum B. mediastinal shift to the right C. bradypnea D. intermittent apneic periods - RIGHT ANSWER -A. Pneumonia is common in pt with COPD. Sputum becomes purulent over time in pt with pneumonia. ECG changes associated with STEMI affecting the inferior wall include changes in which of the ff leads A. II, III, aVF B. V4, V5, V6 C. II, III, aVR D. V1, V2, V3 - RIGHT ANSWER -A. The ECG changes with an inferior wall MI occur in leads II, III and aVF Emergency treatment of ventricular dysrhythmias for the pt who has an ICD pacemaker includes which of the following A. If a pt develops vfib, the nurse should not defibrillate with external paddles B. if the ICD is firing correctly and the pt does not have pulse, CPR is not indicated C. when preparing for external defibrillation, avoid placing the paddle directly over the ICD pulse generator D. when you need to turn off all functions of the ICD or pacemaker, apply a magnet - RIGHT ANSWER -C. Defibrillation has been known to cause malfunction of an ICD or pacemaker. Care should be taken to ensure the defibrillation paddle/ pads are applied at least 4-finger breaths away from the device. The anterior-lateral and anterior-posterior positions for paddle/pad placement are acceptable in a pt with a permanent ICD or pacemaker. The pads may also be placed safely away from the ICD with 1 pad at the apex left mid-axillary, 5th ICS., and the other pad right of the sternum just below the clavicle. Based on the device implanted and the manufacturer, application of a magnet may turn device off or reset to the default settings. Following CABG surgery, a pt lab data reveal a plt count of 51k. Lab results obtained 6 hours postoperatively revealed a plt count of 62k. Which of the ff identifies the best nursing action A. Continue to observe the pt, remembering that plt counts often decrease after bypass B. monitor closely for s/s of increased ICP and cerebral hemorrhage C. inform the pt that even though his pt count is a little low, you are going to administer daily aspirin D. notify the physician and anticipate administering a plt transfusion - RIGHT ANSWER -C. The success of CABG depends mainly on the patency of the graft vessels. Aortocoronary vein graft disease is composed of 3 distinct but interrelated pathological processes: thrombosis, intimal hyperplasia and atherosclorosis. In addition to positive blood cultures, which of the following are indicative of septic shock BP HR RR T WBC A. 108/.6 13 B. 92/.2 21 C. 85/ D. 126/.8 14 - RIGHT ANSWER -C. This pt has sign of septic shock: the pt is hypotensive, tachycardic, tachypneic, and has subnormal temperature and elevated WBC Pt w/ a hx of heart failure and ACS is admitted following episode of syncope. 2 hours later assessment reveals BP 134/64 (supine) 90/60 sitting HR 115 w weak thready pulse (supine) 130 (sitting RR 32 shallow BS clear UO 30 ml of past 2 hours The nurse should initiate A IV fluids B Nesiritide (natrecor) C. Mannitol (Osmitrol) D. Digoxin (Lanoxin) - RIGHT ANSWER -A. Although this pt has a history of heart failure, data suggest orthostatic hypotension and hypovolemia, which should initially be treated with fluids. While heart failure may be of concern, this pt breath sounds are clear at present. The authority of a surrogate speak for a pt should be based on which of the ff conditions A. the surrogate is a family member and has recently lived with the pt B. the family has designated the surrogate as the most knowledgeable person regarding the pt wishes C. the pt has specifically conveyed wishes to the surrogate regarding current or similar circumstances D. the pt indicates to the nursing staff that the surrogate should speak on the pt behalf - RIGHT ANSWER -C. The main difference between a medical power of attorney and a healthcare surrogate is that pt appoint a medical POA to make healthcare decisions for them when they become unable to make them for themselves. Pt can specify what healthcare decisions they want their medical power of attorney to make. A healthcare surrogate, on the other hand, is appointed to make healthcare decisions for pt if they become unable to make them themselves. pt have no say in who becomes their healthcare surrogate. They can avoid having a healthcare surrogate appointed if they have appointed a medical power of attorney representative and that representative is still willing and able to serve. The condition of a pt who opted to receive no further treatment is deteriorating rapidly. The pt is receiving a morphine drip titrated to maintain comfort and is now poorly responsive with a wide-complex bradycardia. Respirations are labored and BP is 80/40. A student nurse suggests that the morphine should be stopped. The preceptor should explain that morphine A. is a form of benign euthanasia related to the pt discomfort. B. is decreasing cardiac preload and may increase cardiac output and blood pressure C. is a comfort measure, but the pt disease process is ultimately responsible for his death D. may indeed hasten death and should be discontinued - RIGHT ANSWER -C. Consistent with caring practices in the Synergy Model, morphine is indicated at this time. its administration is also consistent with the pt's wishes. The dysrhythmia most commonly associated with mitral stenosis is A. 2nd degree AB block type II B. idioventricular rhythm C. sinus bradycardia D. afib - RIGHT ANSWER -D. Mitral stenosis increases the risk of developing atrial fibrillation because of high pressures in the left atrium that will stimulate left atrial remodeling and enlargement. The nurse needs to perform a physical and gather history data on a pt who speaks only mandarin. The pt is accompanied by a visitor representing herself as the daughter, who offers to interpret. When the nurse responds that there will be an interpreter, the visitor become upset and wants to know why that is necessary. The nurse's best response is A. "Since the pt doesn't speak english, I can't be sure you are really her daughter, and the interpreter can tell me that." B. "Our policy states that an interpreter must be used at all times in this hospital when communicating with a person who does not speak english." C. "In discussing medical medical issues, a professional interpreter can help to ensure complete understanding of all information. You may also participate, with permission from the pt." D. "I'm not sure that you will understand the medical terminology well enough to translate it correctly into mandarin." - RIGHT ANSWER -C. This response is consistent with caring practices in the synergy model. In order to maintain confidentiality, ensure accurate communication and support patient- and family- centered care principles, family members, friends or other unqualified interpreters should not be used as interpreters except in emergent situations. As an advocate and moral agent for the pt, staff should use qualified interpreters to ensure effective communication The oliguric phase of ATN is characterized by which of the ff A. decreased UO, hypokalemia, alkalosis, elevated creatinine B. decreased UO, hyperphosphatemia, acidosis, hyponatremia C. hypotension, acidosis, elevated BUN, hypernatremia D. HT, alkalosis, elevated creatinine, hypercalcemia - RIGHT ANSWER -B. Pt with ATN will present wit a decrease in UO, hyperphosphatemia, acidosis (secondary to hyperkalemia) and hyponatremia (there is an elevated fractional excretion of sodium with ATN) The physician gave metoprolol (Lopressor) to a patient with rapid afib 5 minutes ago without effect for rate control and is currently administering IV diltiazem (Cardizem); BP is 94/60. Which of the following should the nurse anticipate. A. calcium chloride B. synchronized cardioversion C. digoxin D. transcutaneous pacing - RIGHT ANSWER -D. A beta-blocker and calcium channel blocker combination should be used with caution. When drugs from these 2 classes are given together, the additive effect is the potent suppression of the AV node. Having transcutaneous pacing nearby can help the pt be treated early if this complication develops. The primary goal of thrombolytic therapy for ACS is A. troponin release B. chest pain relief C. myocardial reperfusion D. ectopy prevention - RIGHT ANSWER -C. Thrombolytic therapy is administered to establish and maintain the patency of coronary arteries, thus improving myocardial perfusion. Three days following STEMI and cardiac catheterization with stent insertion, a pt develops sudden-onset diffuse crackles and a new loud murmur heard most prominently at the 5th ICS mid-clavicular line. The nurse should recognize that this may represent A. mitral regurgitation B left sided heart failure C. stent occlusion D. cardiogenic shock - RIGHT ANSWER -A. The pt has a risk factor (STEMI) and symptoms of mitral regurgitation. The murmur is located at the 5th intercostal space mid-clavicular line Twelve hours after sustaining a pelvic fracture, a pt reports chest pain, hemoptysis and severe shortness of breath. Respiratory rate is 34. ABG on 02 at 4l via NC are: pH 7.48, pCO2 28, p02 68. The nurse should suspect that the patient has developed