#41 The nurse assesses a patient who has been hospitalized for 2…

Question Answered step-by-step #41 The nurse assesses a patient who has been hospitalized for 2… #41The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?o  Oral temperature of 100.1 OFo  Serum sodium level of 138 mEq/L (138 mmol/L)o  Gradually decreasing level of consciousness (LOC)o  Weight gain of 2 pounds (1 kg) over the admission weightQ#42Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?o  Flush a saline lock with normal salineo  Verify blood products prior to administrationo  Remove the patient’s central venous cathetero  Titrate the flow rate of vasoactive IV medicationsQ#43During the administration of the thrombolytic agent to a client with an acute myocardial infarction, the nurse should stop the drug infusion if the client experiences which abnormal cues?o  Bleeding from the gumso  A decrease in level of consciousnesso  Increase in blood pressureo  A non-sustained episode of ventricular tachycardiaQ#44Which electrocardiographic (ECG) change is most important for the nurse to report to the healthcare provider when caring for a client with chest pain?o  Inverted P waveo  Sinus tachycardiao  ST-segment elevationo  Sinus bradycardia Q#45Dopamine 4 mcg/kg/min is ordered for a client who weighs 175lbs. The solution available is 400mg of Dopamine in 250mL D5W. To infuse by infusion pump. How many mg/min will have infused? Write the number only (Do not round)   Q#46The nurse notes during the pre-operative assessment that her patient who has not had any prior surgeries says “for some reason my arm feel very itchy when you touched them wearing those gloves and it appears red over”. Which action is most important for the nurse to take?o  Notify the dietician about the specific food allergieso  Alert the physician about the possible latex allergyo  Reassure the patient that all allergies are noted on the health recordo  Ask whether the patient uses antihistamines to reduce allergic reactionsQ#47The nurse is caring for a client with a possible myocardial infarction. Which intervention should the nurse anticipate in the initial plan of care?o  12 lead ECG within 25 minutes of arrival.o  Cardiac catheterization within 90 minutes of arrival if STEMI is notedo  Administer beta blockers within 48 hours of admissionQ#48Which action should the nurse perform when preparing a client with supraventricular tachycardia for cardioversion who is alert and has blood pressure of 110/66mmHg?o  Give a sedative before cardioversion is implementedo  Turn the synchronizer switch to the “off” position.o  Set the defibrillator/cardioverter energy to 360 jouleso  Provide assisted ventilations with a bag-valve-mask deviceQ#49A client develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mmHg, and is complaining of feeling faint. Which action should the nurse take next?o  Apply the transcutaneous pacemaker (TCP) padso  Recheck the heart rhythm and BP in 5 minuteso  Have the client perform the Valsalva maneuver o  Give the scheduled dose of diltiazem Q#50A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?o  Sinus tachycardiao  Atrial fibrillationo  Sinus bradycardiao  First degree AV blockQ#51Identify the above rhythmo  Ventricular tachycardiao  Ventricular fibrillationo  Asystoleo  Torsade de pointesQ#52A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?o  Left ventricular failureo  Fluid overloado  Intra-cardial shunto  Hypovolemia Q#53A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditionso  Intracranial pressureo  Spinal cord perfusiono  Hemodynamic statuso  Renal functionQ#54A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client’s plan of care? (Select all that apply)o  Check peripheral pulses in the affected extremityo  Place the client in high-Fowler’s positiono  Measure the client’s vital signs every 4 hourso  Keep the client’s hip and leg extendedo  Have the client remain in bed up to 6 hours.Q#55The nurse notices the following rhythm on the cardiac monitor. What is the best nursing action?o  Start dopamine infusion to stimulate heart functiono  Begin transcutaneous pacing of the patiento  Give atropine to increase heart rateo  Assess for hemodynamic instabilityQ#56The nurse notices ventricular tachycardia on the heart monitor. When the client is assessed, the client is found to be unresponsive with no pulse. What is the best nursing action?o  Treat with intravenous amiodarone or lidocaineo  Begin cardiopulmonary resuscitation and advanced life supporto  Provide electrical cardioversiono  Ignore the rhythm because it is benignQ#57The nurses is assessing a client with left-sided heart failure. Which symptoms would the nurse expect to find?o  Dependent edemao  Distended neck veinso  Dyspnea and crackleso  Nausea and vomitingQ#581.    Which therapeutic interventions may be withdrawn or withheld from the terminally ill client? (Select all that apply)o  Antibioticso  Dialysiso  Nutritiono  Pain medicationso  Simple nursing interventions such as repositioning and hygieneQ#591.    The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient continues to “fight” the ventilator. What physician order does the nurse anticipate?o  Continuous lateral rotation therapyo  Guided imageryo  Neuromuscular blockadeo  Prone positioningQ#60The nurse in the ICU should recognize which ABG finding as associated with acute respiratory failure?o  PaO2 is 70mmHg and PaO2 is 48 mmHgo  PaO2 is 80mmHg and SaO2 is 96%o  PaO2 is 60mmHg and SaO2 is 90%o  PaO2 is 46mmHg and PaO2 is 67mmHgQ#61A nurse in the ICU suspects that a patient is developing hypoxia. Which assessment finding is one of the earliest findings as hypoxia develops?o  Restlessnesso  Tachycardiao  Intercostal muscle retractionso  Cyanosis Q#62A nurse in the ICU is caring for a patient who was just placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Which strategy is the most likely to prevent ventilator-induced lung injury (VILI)?o  Tidal volume (Vt) between 4 and 8 mL/kgo  PEEP greater than 25 cm H2Oo  Intravenous fluid rate greater than 200 mL/houro  Maintain PaCO2 less than 35 mmHgQ#63A nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient’s oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse’s priority action?o  Ask respiratory therapist to get a new ventilatoro  Call the rapid response team to assess the patient.o  Manually ventilate the patiento  Continue to find the cause of the alarm and fix itQ#64A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85mmHg, and HCO3 25mEq/L. The patient’s current ventilator settings are A/C mode, Vt 500, RR 18, PEEP 10, FiO2 60%. The nurse would anticipate an order for the change in:o  An inverse ration setting of 2:1o  The respiratory rate to 20 bpmo  The FiO2 to 100%o  The respiratory rate to 14 bpmQ#65Which is positive and expiratory pressure (PEEP) used when a patient is placed on mechanical ventilation?o  Permit smaller tidal volumes with permissive hypercapniao  Prevent alveolar collapse throughout the respiratory cycleo  Promote complete emptying of the lungs during exhalationo  Provide for delivery of 100% oxygen to the lungs under pressureQ#66The ICU nurse is attempting to wean a patient from the ventilator. The nurse would stop the weaning process if assessment findings indicated: [Select all that apply]o  Oxygen saturation ? 90%o  Respiratory rate of 25bpmo  Heart rate change 10% from baselineo  Agitation Q#67After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?o  Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilatoro  Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoringo  Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours.o  Patient with a central nervous O2 saturation (ScvO2) of 69% while on bi-level positive airways pressure (BiPAP)Q#68The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows a potentially lethal rhythm. The patient has no pulse. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?o  Contact the attending physician immediately to determine if CPR should be initiated.o  Contact the family immediately to determine if they want CPR to be started.o  Give emergency medications but withhold intubationo  Initiate CPR and call a code.Q#69A patient’s ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 0.6 to 0.7 and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient’s blood pressure drops from 120/76 mmHg to 90//60 mmHg. What is the most likely cause of this decrease in blood pressure?o  Decrease in cardiac outputo  Hypovolemiao  Increase in venous returno  Oxygen toxicityQ#70A patient’s endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is re-taped, the nurse auscultates the patient’s lungs and notes that the breath sounds over the left lungs fields are absent. The nurse suspects which of the following?o  The endotracheal tube is in the right mainstem bronchuso  The patient has a left pneumothoraxo  The patient has aspirated secretions during the procedureo  The stethoscope earpiece is clogged with wax     Health Science Science Nursing COMPLEX CR NR 341 Share QuestionEmailCopy link Comments (0)

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