Arterial Blood Gas (ABG) Findings, Exercises of Nursing

Download Arterial Blood Gas (ABG) Findings and more Exercises Nursing in PDF only on Docsity!

NURS 1102 Passpoint-Cardiovascular {Revised}

Question 1 See full question Which statement would lead the nurse to determine that a client lacks understanding of her acute cardiac illness and the ability to make changes in her lifestyle? You Selected:

• "I talked with my husband yesterday about working on a new budget together." Correct response:
• "I already have my airline ticket, so I will not miss my meeting tomorrow." Explanation: Question 2 See full question What is the expected outcome of thrombolytic drug therapy for stroke? You Selected:
• dissolved emboli Correct response:
• dissolved emboli Explanation: Remediation: Question 3 See full question The client with peripheral vascular disease has been prescribed diltiazem. The nurse should determine the effectiveness of this medication by assessing the client for: You Selected:
• vasodilation. Correct response:
• vasodilation. Explanation: Remediation: Question 4 See full question Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: You Selected:
• reduce coronary artery vasospasm.

Correct response:

• revascularize the blocked coronary artery. Explanation: Remediation: Question 5 See full question A nurse is caring for a client with first-degree atrioventricular (AV) block. When instructing the spouse using a diagram, identify the area in the conduction cycle where this block occurs. You Selected:

Your selection and the correct area, market by the green box. Explanation:

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? You Selected:

• Arterial blood gas (ABG) findings Correct response:
• Arterial blood gas (ABG) findings Explanation: Remediation: Question 10 See full question Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome? You Selected:
• Column C Correct response:
• Column B Question 1 See full question A nurse is preparing to administer cardiac medications to two clients with the same last name. She checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes she didn't check the client's identification before administering the medication. Which action should the nurse take first? You Selected:
• Document the medication error and completion of the variance report in the client's chart and notify the physician. Correct response:
• Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. Explanation: Remediation: Question 2 See full question

The nurse is assessing a client with irreversible shock. The nurse should document which finding? You Selected:

• hypertension Correct response:
• circulatory collapse Explanation: Remediation: Question 3 See full question The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin. The client has had 2 previous episodes of coronary artery disease. At the onset of chest pain, what should the client do? You Selected:
• Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. Correct response:
• Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. Explanation: Remediation: Question 4 See full question A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? You Selected:
• Within 24 to 48 hours Correct response:
• Within 6 hours Explanation: Remediation: Question 5 See full question

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: You Selected:

• forget the names of foods. Correct response:
• eat food on only half of the plate. Explanation: Remediation: Question 9 See full question A client prescribed propranolol calls the clinic to report a weight gain of 3 lbs (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse’s best action? You Selected:
• Have the client come to the clinic in order to assess the lungs. Correct response:
• Have the client come to the clinic in order to assess the lungs. Explanation: Remediation: Question 10 See full question The nurse is preparing to administer oral digoxin to a child and notes that the child has nausea, has vomited, and has a pulse rate of 45 beats per minute. Which of the following is the appropriate nursing action? You Selected:
• Hold the digoxin and notify the physician of possible toxicity Correct response:
• Hold the digoxin and notify the physician of possible toxicity Question 1 See full question What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? You Selected:
• echocardiogram Correct response:

• pupil size and pupillary response Explanation: Remediation: Question 2 See full question When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in: You Selected:
• hypertension. Correct response:
• cardiac arrhythmias. Explanation: Remediation: Question 3 See full question In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? You Selected:
• Leg edema Correct response:
• Leg edema Explanation: Remediation: Question 4 See full question Which indicates hypovolemic shock in a client who has had a 15% blood loss? You Selected:
• systolic blood pressure less than 90 mm Hg Correct response:
• systolic blood pressure less than 90 mm Hg Explanation: Remediation: Question 5 See full question

often works outside in cold weather and also smokes two packs of cigarettes per day. Which directions should be included in the discharge plan for this client? Select all that apply. You Selected:

• Report signs of orthostatic hypotension.
• Stop smoking.
• Find employment that can be done in a warm environment. Correct response:
• Stop smoking.
• Wear a face covering and gloves in the winter.
• Report signs of orthostatic hypotension. Explanation: Remediation: Question 9 See full question A client hospitalized with a myocardial infarction (MI) has a blood glucose levels ranging from 12- 28 mmol/L (216- 504 mg/dL) asks the nurse why the readings are so high even though there are no added sweets on the diet tray. What is the best response by the nurse? You Selected:
• “The stress level in your body has increased with the MI, and more glucose is released during stressful times.” Correct response:
• “The stress level in your body has increased with the MI, and more glucose is released during stressful times.” Explanation: Remediation: Question 10 See full question A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time? You Selected:
• Ineffective tissue perfusion (cardiopulmonary) related to arrhythmia

Correct response:

• Ineffective tissue perfusion (cardiopulmonary) related to arrhythmia Question 1 See full question A client signed a consent form for participation in a clinical trial for implantable cardioverter- defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained? You Selected:
• "I wonder if there is any other way to prevent these bad rhythms." Correct response:
• "I wonder if there is any other way to prevent these bad rhythms." Explanation: Remediation: Question 2 See full question The client asks the nurse, “Why will the health care provider not tell me exactly how much of my leg he is going to take off? Do you not think I should know that?” On which information should the nurse base the response? You Selected:
• the adequacy of the blood supply to the tissues Correct response:
• the adequacy of the blood supply to the tissues Explanation: Remediation: Question 3 See full question When assessing a client with left-sided heart failure, the nurse expects to note: You Selected:
• pitting edema of the legs. Correct response:
• air hunger. Explanation: Remediation:

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission, what should the nurse assess first? You Selected:

• serum potassium level Correct response:
• blood pressure Explanation: Remediation: Question 8 See full question One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: You Selected:
• stop smoking. Correct response:
• stop smoking. Explanation: Remediation: Question 9 See full question When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum: You Selected:
• 1.5 inches (4 cm) Correct response:
• 2 inches (5 cm) Explanation: Remediation: Question 10 See full question A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member, the monitor exhibits the following. Which interventions would the nurse do first? You Selected:

• Assess the client’s airway, breathing, and circulation. Correct response:
• Assess the client’s airway, breathing, and circulation. Question 1 See full question A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? You Selected:
• pedal pulses Correct response:
• pedal pulses Explanation: Remediation: Question 2 See full question A client who has been experiencing angina has a new prescription for nitroglycerin. The nurse should instruct the client to report having which potential side effect of nitroglycerin? You Selected:
• hypertension Correct response:
• headache Explanation: Remediation: Question 3 See full question A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? You Selected:
• Pulse rate of 84 beats/minute Correct response:
• Blood pressure 84/52 mm Hg Explanation:

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best? You Selected:

• "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." Correct response:
• "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." Explanation: Remediation: Question 8 See full question A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention? You Selected:
• Control the pain and support breathing and oxygenation. Correct response:
• Control the pain and support breathing and oxygenation. Explanation: Remediation: Question 9 See full question The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram strip). The nurse should: You Selected:
• notify the health care provider (HCP). Correct response:
• assess the client for changes in the rhythm. Explanation: Remediation: Question 10 See full question

The nurse is caring for an elderly man who walks 2 miles every morning. The nurse notes that during his morning walk, he called his daughter and stated that he thought that he was having a heart attack. Which symptom, identified by the client, is the most common and consistent with that of a heart attack (myocardial infarction)? You Selected:

• Palpitations Correct response:
• Sternal pain

Question 1 See full question

A client with end-stage heart failure is preparing for discharge. The client and his

caregiver meet with the home care nurse and voice their concern that setting up a

hospital bed in the bedroom will leave him feeling isolated. Which suggestion by

the home care nurse best addresses this concern?

You Selected:

• Set up the hospital bed in the family room so the client can be part of household activities. Correct response:
• Set up the hospital bed in the family room so the client can be part of household activities. Explanation:

Question 2 See full question

The nurse observes that an older female has small to moderate, distended and

tortuous veins running along the inner aspect of her lower legs. The nurse should:

You Selected:

• encourage the client to avoid standing in one position for long periods of time. Correct response:
• encourage the client to avoid standing in one position for long periods of time.

You Selected:

• ventricular depolarization. Correct response:
• ventricular depolarization. Explanation: Remediation:

Question 6 See full question

A client who suffered blunt chest trauma in a motor vehicle accident complains of

chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse

detects a pericardial friction rub — a classic sign of acute pericarditis. The physician

confirms acute pericarditis and begins appropriate medical intervention. To relieve

chest pain associated with pericarditis, which position should the nurse encourage

the client to assume?

You Selected:

• Leaning forward while sitting Correct response:
• Leaning forward while sitting Explanation: Remediation:

Question 7 See full question

A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the

emergency department, the health care team obtains an electrocardiogram and

administers I.V. morphine. The physician also considers administering alteplase.

This thrombolytic agent must be administered how soon after onset of myocardial

infarction (MI) symptoms?

You Selected:

• Within 6 hours

Correct response:

• Within 6 hours Explanation: Remediation:

Question 8 See full question

A physician orders several drugs for a client with hemorrhagic stroke. Which drug

order should the nurse question?

You Selected:

• Phenytoin Correct response:
• Heparin sodium Explanation: Remediation:

Question 9 See full question

A client with left-sided heart failure complains of increasing shortness of breath and

is agitated and coughing up pink-tinged, foamy sputum. The nurse should

recognize these findings as signs and symptoms of:

You Selected:

• acute pulmonary edema. Correct response:
• acute pulmonary edema.