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N434 Exam 1 Questions

Terms in this set (81)

When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse?

a. The PR interval is 0.21 seconds.

b. The QRS duration is 0.13 seconds.

c. There is a right bundle-branch block.

d. The heart rate (HR) is 42 beats/minute.
d. The heart rate (HR) is 42 beats/minute.
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that

a. it will be important to lie completely still during the procedure.

b. a flushed feeling may be noted when the contrast dye is injected.

c. monitored anesthesia care will be provided during the procedure.

d. arterial pressure monitoring will be required for 24 hours after the test.
b. a flushed feeling may be noted when the contrast dye is injected.
While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?

a. Document this finding in the patient's record.

b. Obtain vital signs, including oxygen saturation.

c. Have the patient perform the Valsalva maneuver.

d. Observe for JVD with the patient upright at 45 degrees.
d. Observe for JVD with the patient upright at 45 degrees.
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

a. connect the recorder to a computer once daily.

b. exercise more than usual while the monitor is in place.

c. remove the electrodes when taking a shower or tub bath.

d. keep a diary of daily activities while the monitor is worn.
d. keep a diary of daily activities while the monitor is worn.
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be

a. myoglobin.

b. low-density lipoprotein (LDL) cholesterol.

c. troponins T and I.

d. creatine kinase-MB (CK-MB).
c. troponins T and I.
When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse?

a. Patient complaint of feeling tired

b. Pulse change from 87 to 101 beats/minute

c. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg

d. Newly inverted T waves on the electrocardiogram
d. Newly inverted T waves on the electrocardiogram
The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the

a. postoperative patient with a BP of 116/42.

b. newly admitted patient with a BP of 150/87.

c. patient with left ventricular failure who has a BP of 110/70.

d. patient with a myocardial infarction who has a BP of 140/86.
a. postoperative patient with a BP of 116/42.
--> MAP = (SBP + 2DBP)/3
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider?

a. The patient's pedal pulses are +1.

b. The patient is allergic to shellfish.

c. The patient had a heart attack a year ago.

d. The patient has not eaten anything today.
b. The patient is allergic to shellfish.
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first?

a. Start an IV line.

b. Place the patient on NPO status.

c. Administer O2 per nasal cannula.

d. Give lorazepam (Ativan) 1 mg IV.
b. Place the patient on NPO status.
A P wave on an ECG represents an impulse arising at the

a. SA node and repolarizing the atria.

b. SA node and depolarizing the atria.

c. AV node and depolarizing the atria.

d. AV node and spreading to the bundle of His.
b. SA node and depolarizing the atria.
Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)?

a. Monitoring vital signs and ECG

b. Checking the catheter insertion site and distal pulses

c. Assisting the patient to ambulate to the bathroom to void

d. Informing the patient that he will be sleepy from the general anesthesia

e. Instructing the patient about the risks of the radioactive isotope injection
A, B

a. Monitoring vital signs and ECG

b. Checking the catheter insertion site and distal pulses
When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the

a. family history of coronary artery disease.

b. increased risk associated with the patient's gender.

c. increased risk of cardiovascular disease as people age.

d. elevation of the patient's low-density lipoprotein (LDL) level.
d. elevation of the patient's low-density lipoprotein (LDL) level.
Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes?

a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.

b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes.

c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible.

d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.
c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible.
Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)?

a. The pain increases with deep breathing.

b. The pain has lasted longer than 30 minutes.

c. The pain is relieved after the patient takes nitroglycerin.

d. The pain is reproducible when the patient raises the arms.
b. The pain has lasted longer than 30 minutes.
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?

a. The patient states that the pain "wakes me up at night."

b. The patient rates the pain at a level 3 to 5 (0 to 10 scale).

c. The patient states that the pain has increased in frequency over the last week.

d. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.
d. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.
After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?

a. "I can expect some nausea as a side effect of nitroglycerin."

b. "I should only take the nitroglycerin if I start to have chest pain."

c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart."

d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."
c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart."
Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will

a. reduce heart palpitations.

b. decrease spasm of the coronary arteries.

c. increase the force of the heart contractions.

d. help prevent plaque from forming in the coronary arteries.
b. decrease spasm of the coronary arteries.
Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased?

a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

b. Oxygen saturation drops from 99% to 95%.

c. Heart rate increases from 66 to 92 beats/minute.

d. Respiratory rate goes from 14 to 20 breaths/minute.
c. Heart rate increases from 66 to 92 beats/minute.
A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next?

a. Assess the feet for pedal edema.

b. Palpate the radial pulses bilaterally.

c. Auscultate for a pericardial friction rub.

d. Check the heart monitor for dysrhythmias.
c. Auscultate for a pericardial friction rub.
--> Symptoms suggest pericarditis
When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following?

a. "They will circulate my blood with a machine during the surgery."

b. "I will have small incisions in my leg where they will remove the vein."

c. "They will use an artery near my heart to go around the area that is blocked."

d. "I will need to take an aspirin every day after the surgery to keep the graft open."
b. "I will have small incisions in my leg where they will remove the vein."
--> internal mammary artery was used -- no need for saphenous vein removal from leg
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best?

a. "Most patients are able to enjoy intercourse without any complications."

b. "Sexual activity uses about as much energy as climbing two flights of stairs."

c. "The doctor will provide sexual guidelines when your heart is strong enough."

d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."
b. "Sexual activity uses about as much energy as climbing two flights of stairs."
A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider?

a. Generalized muscle aches and pains

b. Dizziness when changing positions quickly

c. Nausea when taking the drugs before eating

d. Flushing and pruritus after taking the medications
a. Generalized muscle aches and pains
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider?

a. Complaints of incisional chest pain

b. Pallor and weakness of the right hand

c. Fine crackles heard at both lung bases

d. Redness on both sides of the sternal incision
b. Pallor and weakness of the right hand
When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first?

a. Obtain the blood pressure.

b. Attach the cardiac monitor.

c. Assess the peripheral pulses.

d. Auscultate the breath sounds.
b. Attach the cardiac monitor.
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?

a. The troponin level is elevated.

b. The patient denies ever having a heart attack.

c. Bilateral crackles are auscultated in the mid-lower lobes.

d. The patient has occasional premature atrial contractions (PACs).
c. Bilateral crackles are auscultated in the mid-lower lobes.
A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first?

a. Chest x-ray

b. Troponin level

c. Electrocardiogram (ECG)

d. Insertion of a peripheral IV
c. Electrocardiogram (ECG)
Which patient at the cardiovascular clinic requires the most immediate action by the nurse?

a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL

b. Patient with stable angina whose chest pain has recently increased in frequency

c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL

d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
b. Patient with stable angina whose chest pain has recently increased in frequency
--> may have unstable angina
In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include (select all that apply)

a. diffuse involvement of plaque formation in coronary veins.

b. abnormal levels of cholesterol, especially low-density lipoproteins.

c. accumulation of lipid and fibrous tissue within the coronary arteries.

d. development of angina due to a decreased blood supply to the heart muscle.

e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm.
B, C, D

b. abnormal levels of cholesterol, especially low-density lipoproteins.

c. accumulation of lipid and fibrous tissue within the coronary arteries.

d. development of angina due to a decreased blood supply to the heart muscle.
After teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says

a. "I would like to add weight lifting to my exercise program."

b. "I can only keep my blood pressure normal with medication."

c. "I can change my diet to decrease my intake of saturated fats."

d. "I will change my lifestyle to reduce activities that increase my stress.
a. "I would like to add weight lifting to my exercise program."
A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia

a. will always progress to myocardial infarction.

b. will be relieved by rest, nitroglycerin, or both.

c. indicates that irreversible myocardial damage is occurring.

d. is frequently associated with vomiting and extreme fatigue.
b. will be relieved by rest, nitroglycerin, or both.
The nurse is caring for a patient who is 2 days post MI. The patient reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which action would be a priority?

a. Notify the physician STAT and obtain a 12-lead ECG.

b. Obtain vital signs and auscultate for a pericardial friction rub.

c. Apply high-flow O2 by face mask and auscultate breath sounds.

d. Medicate the patient with PRN analgesic and reevaluate in 30 minutes.
b. Obtain vital signs and auscultate for a pericardial friction rub.
A patient is admitted to the ICU with a diagnosis of unstable angina. Which drugs(s) would the nurse expect the patient to receive (select all that apply)?

a. ACE inhibitor

b. Antiplatelet therapy

c. Thrombolytic therapy

d. Prophylactic antibiotics

e. Intravenous nitroglycerin
A, B, E

a. ACE inhibitor

b. Antiplatelet therapy

e. Intravenous nitroglycerin
A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan?

a. Refrain from sexual activity for a minimum of 3 weeks.

b. Plan a diet program that aims for a 1- to 2-pound weight loss per week.

c. Begin an exercise program that aims for at least five 30-minute sessions per week.

d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity.
c. Begin an exercise program that aims for at least five 30-minute sessions per week.
The most common finding in individuals at risk for sudden cardiac death is

a. aortic valve disease.

b. mitral valve disease.

c. left ventricular dysfunction.

d. atherosclerotic heart disease.
c. left ventricular dysfunction.
A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of

a. echocardiography.

b. daily blood cultures.

c. cardiac catheterization.

d. 24-hour Holter monitor.
a. echocardiography.
--> can detect pericardial effusions associated with pericarditis
To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should

a. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.

b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.

c. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub.

d. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.
b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.
The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should

a. note when Korotkoff sounds are auscultated during both inspiration and expiration.

b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).

c. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle.

d. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.
a. note when Korotkoff sounds are auscultated during both inspiration and expiration.
--> gap of >10 mmHg between when Korotkoff sounds can be heard only during expiration & when they can be heard throughout the respiratory cycle
The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to

a. teach the patient to take deep, slow breaths to control the pain.

b. force fluids to 3000 mL/day to decrease fever and inflammation.

c. remind the patient to request opioid pain medication every 4 hours.

d. place the patient in Fowler's position, leaning forward on the overbed table.
d. place the patient in Fowler's position, leaning forward on the overbed table.
A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give?

a. Fentanyl 1 mg IV

b. IV morphine sulfate 4 mg

c. Oral ibuprofen (Motrin) 600 mg

d. Oral acetaminophen (Tylenol) 650 mg
c. Oral ibuprofen (Motrin) 600 mg
Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?

a. Pulsus paradoxus 8 mm Hg

b. Blood pressure (BP) of 168/94

c. Jugular venous distention (JVD) to jaw level

d. Level 6 (0 to 10 scale) chest pain with a deep breath
c. Jugular venous distention (JVD) to jaw level
--> indicates potential cardiac tamponade
Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first?

a. Auscultate the heart sounds.

b. Check the patient's temperature.

c. Notify the patient's health care provider.

d. Give the PRN acetaminophen (Tylenol).
a. Auscultate the heart sounds.
--> consistent with pericarditis
The nurse is caring for a patient with chronic constrictive pericarditis. Which assessment finding reflects a more serious complication of this condition?

a. Fatigue

b. Peripheral edema

c. Jugular venous distention

d. Thickened pericardium on echocardiography
c. Jugular venous distention
The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use?

a. Count the number of large squares in the R-R interval and divide by 300.

b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes.

c. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next?

a. Immediately notify the health care provider.

b. Document the rhythm and continue to monitor the patient.

c. Perform synchronized cardioversion per agency dysrhythmia protocol.

d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.
d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.
After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states

a. "I will avoid cooking with a microwave oven or being near one in use."

b. "It will be 1 month before I can take a bath or return to my usual activities."

c. "I will notify the airlines when I make a reservation that I have a pacemaker."

d. "I won't lift the arm on the pacemaker side up very high until I see the doctor."
d. "I won't lift the arm on the pacemaker side up very high until I see the doctor."
Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg?

a. Turn the synchronizer switch to the "off" position.

b. Give a sedative before cardioversion is implemented.

c. Set the defibrillator/cardioverter energy to 360 joules.

d. Provide assisted ventilations with a bag-valve-mask device.
b. Give a sedative before cardioversion is implemented.
A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first?

a. Perform immediate defibrillation.

b. Give epinephrine (Adrenalin) IV.

c. Prepare for endotracheal intubation.

d. Give ventilations with a bag-valve-mask device.
a. Perform immediate defibrillation.
--> v-fib
A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next?

a. Recheck the heart rhythm and BP in 5 minutes.

b. Have the patient perform the Valsalva maneuver.

c. Give the scheduled dose of diltiazem (Cardizem).

d. Apply the transcutaneous pacemaker (TCP) pads.
d. Apply the transcutaneous pacemaker (TCP) pads.
--> symptomatic bradycardia
The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first?

a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago

b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due

c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating

d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first?

a. Obtain a 12-lead electrocardiogram (ECG).

b. Notify the health care provider of the change in rhythm.

c. Give supplemental O2 at 2 to 3 L/min via nasal cannula.

d. Assess the patient's vital signs including oxygen saturation.
c. Give supplemental O2 at 2 to 3 L/min via nasal cannula.
Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias?

a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole

c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation

d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia
A patient admitted with ACS has continuous ECG monitoring. An examination of the rhythm strip reveals the following characteristics: atrial rate 74 beats/min and regular; ventricular rate 62 beats/min and irregular; P wave normal shape; PR interval lengthens progressively until a P wave is not conducted; QRS normal shape. The priority nursing intervention would be to

a. perform synchronized cardioversion.

b. administer epinephrine 1 mg IV push.

c. observe for symptoms of hypotension or angina.

d. apply transcutaneous pacemaker pads on the patient.
c. observe for symptoms of hypotension or angina.
The nurse is monitoring the ECG of a patient admitted with ACS. Which ECG characteristics would be most suggestive of myocardial ischemia?

a. Sinus rhythm with a pathologic Q wave

b. Sinus rhythm with an elevated ST segment

c. Sinus rhythm with a depressed ST segment

d. Sinus rhythm with premature atrial contractions
c. Sinus rhythm with a depressed ST segment
The nurse prepares a patient for synchronized cardioversion knowing that cardioversion differs from defibrillation in that

a. defibrillation requires a lower dose of electrical energy.

b. cardioversion is indicated to treat atrial bradydysrhythmias.

c. defibrillation is synchronized to deliver a shock during the QRS complex.

d. patients should be sedated if cardioversion is done on a nonemergency basis.
d. patients should be sedated if cardioversion is done on a nonemergency basis.
Which patient teaching points should the nurse include when providing discharge instructions to a patient with a new permanent pacemaker and the caregiver (select all that apply)?

a. Avoid or limit air travel.

b. Take and record a daily pulse rate.

c. Obtain and wear a Medic Alert ID device at all times.

d. Avoid lifting arm on the side of the pacemaker above shoulder.

e. Avoid microwave ovens because they interfere with pacemaker function.
B, C, D

b. Take and record a daily pulse rate.

c. Obtain and wear a Medic Alert ID device at all times.

d. Avoid lifting arm on the side of the pacemaker above shoulder.
A male patient with hemophilia asks the nurse if his children will be hemophiliacs. Which response by the nurse is appropriate?

a. "All of your children will be at risk for hemophilia."

b. "Hemophilia is a multifactorial inherited condition."

c. "Only your male children are at risk for hemophilia."

d. "Your female children will be carriers for hemophilia."
d. "Your female children will be carriers for hemophilia."
Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload?

a. Mean arterial pressure (MAP)

b. Systemic vascular resistance (SVR)

c. Pulmonary vascular resistance (PVR)

d. Pulmonary artery wedge pressure (PAWP)
b. Systemic vascular resistance (SVR)
Following surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?

a. Administer IV diuretic medications.

b. Increase the IV fluid infusion per protocol.

c. Document the CVP and continue to monitor.

d. Elevate the head of the patient's bed to 45 degrees.
b. Increase the IV fluid infusion per protocol.
--> low CVP indicates hypovolemia
When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment?

a. Central venous pressure (CVP)

b. Systemic vascular resistance (SVR)

c. Pulmonary vascular resistance (PVR)

d. Pulmonary artery wedge pressure (PAWP)
c. Pulmonary vascular resistance (PVR)
The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse

a. balances and calibrates the monitoring equipment every 2 hours.

b. positions the zero-reference stopcock line level with the phlebostatic axis.

c. ensures that the patient is supine with the head of the bed flat for all readings.

d. rechecks the location of the phlebostatic axis when changing the patient's position.
b. positions the zero-reference stopcock line level with the phlebostatic axis.
When monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is

a. central venous pressure (CVP).

b. systemic vascular resistance (SVR).

c. pulmonary vascular resistance (PVR).

d. pulmonary artery wedge pressure (PAWP).
d. pulmonary artery wedge pressure (PAWP).
Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?

a. Fast flush the arterial line.

b. Check the left hand for pallor.

c. Assess for cardiac dysrhythmias.

d. Rezero the monitoring equipment.
c. Assess for cardiac dysrhythmias.
--> indicates drop in BP which may be caused by dysrhythmias
When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a

a. typical PA pressure waveform.

b. tracing of the systemic arterial pressure.

c. tracing of the systemic vascular resistance.

d. typical PA wedge pressure (PAWP) tracing.
d. typical PA wedge pressure (PAWP) tracing.
--> purpose of PA catheter is to measure PAWP
Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?

a. The right hand is cooler than the left hand.

b. The mean arterial pressure (MAP) is 77 mm Hg.

c. The system is delivering 3 mL of flush solution per hour.

d. The flush bag and tubing were last changed 3 days previously.
a. The right hand is cooler than the left hand.
To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to

a. auscultate for the presence of bilateral breath sounds.

b. obtain a portable chest x-ray to check tube placement.

c. observe the chest for symmetric chest movement with ventilation.

d. use an end-tidal CO2 monitor to check for placement in the trachea.
d. use an end-tidal CO2 monitor to check for placement in the trachea.
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should

a. inflate the cuff with a minimum of 10 mL of air.

b. inflate the cuff until the pilot balloon is firm on palpation.

c. inject air into the cuff until a manometer shows 15 mm Hg pressure.

d. inject air into the cuff until a slight leak is heard only at peak inflation.
d. inject air into the cuff until a slight leak is heard only at peak inflation.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

a. The patient's oxygen saturation is 93%.

b. The patient was last suctioned 6 hours ago.

c. The patient's respiratory rate is 32 breaths/minute.

d. The patient has occasional audible expiratory wheezes.
c. The patient's respiratory rate is 32 breaths/minute.
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to

a. increase the FIO2.

b. increase the tidal volume.

c. increase the respiratory rate.

d. decrease the respiratory rate.
d. decrease the respiratory rate.
--> respiratory alkalosis from too high of an RR
A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required?

a. The arterial pressure is 90/46.

b. The heart rate is 58 beats/minute.

c. The stroke volume is increased.

d. The stroke volume variation is 12%.
a. The arterial pressure is 90/46.
--> high pressure caused by PEEP may be decreasing venous return & CO
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?

a. The patient's heart rate is 97 beats/min.

b. The patient's oxygen saturation is 93%.

c. The patient respiratory rate is 32 breaths/min.

d. The patient's spontaneous tidal volume is 450 mL.
c. The patient respiratory rate is 32 breaths/min.
--> patient's work of breathing is too high to allow weaning to proceed
When caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health care provider?

a. The patient has a positive Allen test.

b. There is redness at the catheter insertion site.

c. The mean arterial pressure (MAP) is 86 mm Hg.

d. The dicrotic notch is visible in the arterial waveform.
b. There is redness at the catheter insertion site.
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?

a. Activate the rapid response team.

b. Provide reassurance to the patient.

c. Call the health care provider to reinsert the tube.

d. Manually ventilate the patient with 100% oxygen.
d. Manually ventilate the patient with 100% oxygen.
The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse take next?

a. Offer reassurance to the patient.

b. Bag the patient at an FIO2 of 100%.

c. Listen to the patient's breath sounds.

d. Notify the patient's health care provider.
c. Listen to the patient's breath sounds.
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?

a. The RN increases the FIO2 to 100% before suctioning.

b. The RN secures a bite block in place using adhesive tape.

c. The RN asks for assistance to reposition the endotracheal tube.

d. The RN positions the patient with the head of bed at 10 degrees.
d. The RN positions the patient with the head of bed at 10 degrees.
A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next?

a. Verbally coach the patient to breathe with the ventilator.

b. Sedate the patient with the ordered PRN lorazepam (Ativan).

c. Manually ventilate the patient with a bag-valve-mask device.

d. Increase the rate for the ordered propofol (Diprivan) infusion.
a. Verbally coach the patient to breathe with the ventilator.
The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?

a. The RN plans to suction the patient every 1 to 2 hours.

b. The RN uses a closed-suction technique to suction the patient.

c. The RN tapes connection between the ventilator tubing and the ET.

d. The RN changes the ventilator circuit tubing routinely every 48 hours.
b. The RN uses a closed-suction technique to suction the patient.
What are the appropriate nursing interventions for the patient with delirium in the ICU (select all that apply)?

a. Use clocks and calendars to maintain orientation.

b. Encourage round-the-clock presence of caregivers at the bedside.

c. Silence all alarms, reduce overhead paging, and avoid conversations around the patient.

d. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors.

e. Identify physiologic factors that may be contributing to the patient's confusion and irritability.
A, D, E

a. Use clocks and calendars to maintain orientation.

d. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors.

e. Identify physiologic factors that may be contributing to the patient's confusion and irritability.
The hemodynamic changes the nurse expects to find after successful initiation of intraaortic balloon pump therapy in a patient with cardiogenic shock include (select all that apply)

a. decreased SV.

b. decreased SVR.

c. decreased PAWP.

d. increased diastolic BP.

e. decreased myocardial O2 consumption.
B, C, D, E

b. decreased SVR.

c. decreased PAWP.

d. increased diastolic BP.

e. decreased myocardial O2 consumption.
The purpose of adding PEEP to positive pressure ventilation is to

a. increase functional residual capacity and improve oxygenation.

b. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity.

c. determine if the patient is in synchrony with the ventilator or needs to be paralyzed.

d. determine if the patient is able to be weaned and avoid the risk of pneumomediastinum.
a. increase functional residual capacity and improve oxygenation.
The nursing management of a patient with an artificial airway includes

a. maintaining ET tube cuff pressure at 30 cm H2O.

b. routine suctioning of the tube at least every 2 hours.

c. observing for cardiac dysrhythmias during suctioning.

d. preventing tube dislodgment by limiting mouth care to lubrication of the lips.
c. observing for cardiac dysrhythmias during suctioning.
The nurse monitors the patient with positive pressure mechanical ventilation for

a. paralytic ileus because pressure on the abdominal contents affects bowel motility.

b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide.

c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return.

d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels.
c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return.
Sets found in the same folder