AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+, Exams of Nursing

Download AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ and more Exams Nursing in PDF only on Docsity! AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ ) 1. A client who has been diagnosed with pneumonia is receiving Cipro 400 mg/100 mL normal sailing IV Q 8 hours to run over one hour. The drip factor is 60 (microdrops). Calculate the drops per minute a. 240 gtts/min b. 100 gtts/min c. 115 gtts/min d. 12 gtts/min Answer B 100mlx 60/60min= 100gtts/min 2. 2. A client who has diabetes insipidus is to receive potassium chloride 14.5 mEq by mouth. The pharmacy sent potassium chloride 40 mEq/20 cc. Calculate the amount of potassium the nurse will give to the client in cc. A. 7.45 cc B. 8.60 cc C.10 cc D. 7.25 cc Answer= D (14.5 *20)/ 40 = 7.25 cc 3. A heparin infusion at 1,500 units/hour is ordered for a 65-year-old client with a stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given? a. 15ml/hr b. 30ml/hr c. 45ml/hr AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ d. 50ml/hr Answer= B (1500 * 500)/25000 = 30 ml/hr 4.A client is admitted to the unit with meningitis. She is currently on D5W 1000 cc infusing at 125cc/hr. The nurse is ready to start clindamycin 600 mg in 200 cc D5W to infuse over 90 minutes via a pump. The pump delivers 1cc/ min. Calculate the pump rate for in cc/hr. ● 150 cc ● 136 cc ● 133 cc ● 40 cc Answer is 133 because 90minutes/60 minutes is 1.5 and 200cc/1.5 is 133 cc question is asking 1cc/min the first 2 sentences is just distraction. 5.A client has an order to receive 40 mg Laxis BID PO x 5 days. The client received 3 doses of Laxis 40 mg, when the physician changed the medication to Demadex. How many mg of Laxis did the client not receive from the original order? ● 280 mg ● 160 mg ● 120 mg ● 140 mg A is the answer .6. While in the hospital for cardiac surgery workup, a client has ECG changes dedicative of destruction of the conductive system. Which changes should the nurse anticipate? a. short R wave and S wave b. an elevated ST segment c. Complete heart block d. A prolonged QRS segment The answer is C . a complete heart block . During a cardiac surgery , we can expect some ECG changes such as elevated ST segment , prolonged QRS segment, short R wave or s wave or fibrillations. But a conduction failure may lead to complete heart block. That is so emergency and to be managed Quickly . So a nurse will expect a heart block from a conduction failure. AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ ● Thallium stress test ● Electrocardiogram (EKG) ● Intravenous thrombolytic Answer is D intravenous thrombolytic #12. A client is 4 hours post - PCI on the femoral region. Which nursing assessment receives the highest priority: ● Weak thready left pedal pulse ● Cold lower left extremity ● Drop of blood on the dressing ● Blood pressure of 160/92 A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurse's most appropriate action? A) Call for assistance and initiate cardiopulmonary resuscitation. B) Reposition the patient's leg in a nondependent position. C) Promptly remove the femoral sheath. D) Call for help and apply pressure to the access site. Ans: Call for help and apply pressure to the access site. Feedback: The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest. 13.Is completely missing Anwer: about milk 14.While assessing a lenient the nurse understand that the following complications is indicated by the third heart sounds ● Systermic HTN ● Aortic valve malfunction ● Increase Atrial contractions ● Ventricular dilation Answer is I think it is ventricular dilation but I need to verify. AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ S3 is ventricular gallops also indicate significant HF ( according to simulation with Dr. Smith) S4 is atrial gallops I did found that cardiomyopathy causes s3 heart sound. The right answer is c. An s3 heart sound is abnormal . Which can be an indication of congestive heart failure , cardiac myopathy. In these both cases, ventricular dilatation occurs. So the answer is ventricular dilatation. For systemic hypertension , se heart sound is very rare . So we can't choose , this option . For aortic valve dysfunction and atrial arrhythmia, s3 sound can't be heard. so the options a,b and d are wrong. 15.The nurse knows that an EKG support the diagnosis of atrial fibrillation when a client demonstrates: ● Prolonged P-R interval ● Premature atrial complexes ● Wide and bizarre ventricular complexes ● Irregular erratic, wavy baseline between ventricular complexes. Answer is D irregular erratic wavy baseline between ventricular complexes 16.Calcium channel blocker such as Nifedipine (procardia) are used to treat clients with angina pectoris because they act to : a) Reduce the workload of the left ventricle b) Cause contraction of the coronary arteries c) Increase systemic arteries pressure d) Promote arterial contractility For sure A reduce the workload of the left ventricle 17.The patient is complaining of chest pain. The nurse know that increase oxygen demand cause by: a. Hypovolemia b. Decreased hematocrit c. Coronary artery spasms d. Decrease heart rate Answer= C AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 18.A client who has infective bacterial endocarditis that spreads to the myocardium. The nurse notifies the physician recognizing that these may lead to A. Pump failure due to right sided acute heart failure B. hemolysis of red blood cells by hemolytic microorganism c. septicemia resulting in decreased glomerular blood flow d. colonization of microorganism in the lungs A the correct option is A. When an infective endocarditis affects myocardium, the first complications occurs for, cardiac pumping as the vegetations cause stenosis for cardiac valves and leads to heart failure. the other complications provided, are not related to myocardial infectivity. So b,c and d can't be taken as a right answer 19.A client has mitral stenosis. She asked the nurse what she hears upon heart auscultation. The nurse’s response is based on the understanding that in mitral stenosis the auscultation reveals: a) Holosystolic murmur b) Loud mid systolic murmur c) Low- pitched diastolic murmur d) Gallop and S3 heart sound Answer: C according to the book. 20.A client’s chart states that she had a myocardial infarction that progressed to cardiogenic shock. Which parameters would indicate that cardiogenic shock is developing? a) Decrease arterial blood pressure b) Slow respiratory rate c) Brady- arrhythmia d) A widening pulse pressure A 21.A client who is receiving intravenous Heparin has a partial thromboplastin time (PTT) of 78 seconds. What response would the nurse anticipate from the physician when this lab result is reported ? a) Add Coumadin to order AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ a) Sinus tachycardia b) Ventricular fibrillation c) Ventricular tachycardia d) Atrial fibrillation C Rationale: The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory P waves. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration 25.Which of these assessment data of a client with acute pericarditis should the nurse report immediately to the health care provider? a) Pulsus paradoxus 12 mm hg b) Chest pain with inspiration c) BP 166/90 d) Jugular vein distension ( JVD) Answeer D Rationale: The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis. 26.While caring for a client who has mitral valve prolapse with mild valvular regurgitation, the nurse determines that discharge teaching has been effective when the client tells the nurse she will: a) Limit physical activity to avoid stressing the heart valves b) Schedule an appointment with the doctor every 6 month c) Discuss the diagnosis of mitral prolapse with the dentist d) Take two to three liter of fluid daily to prevent embolization C is correct 27.While assessing a client with HF, the nurse notes that the client has jugular venous distention ( JVD) when lying flat. The nurse’s next action will be to: a) Palpate the JVD and compare the volume and pressure on both side b) Evaluate the client gradually to an upright position and example for continuous JVD c) Use a centimeter ruler to measure and document accurately the level of JVD d) Have the client take deep breaths and observe the JVD B 28.A client was admitted to the hospital with bilateral rales and rhonchi, distended the veins, respiratory rate 34, and labored and dependent edema. The symptoms he is experience demonstrate that he has: a) Both left and right side HF b) Left side HF AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ c) Cardiac tamponade and pulmonary emboli d) Cardiomyopathy with ARDS A is right AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 29.Premature ventricular contractions develop in a postoperative client following coronary bypass surgery (CABG). The nurse obtains a rhythm strip and closely monitors for progression of the rhythm to which more serious arrhythmia? a. Ventricular tachycardia b. First degree heart block c. Atrial fibrillation d. Paroxysmal supraventricular tachycardia Answer= A 30.The nurse is developing a plan of care for a newly admitted client with acute HF. It is most important for the nurse to include measures for which problem? a) Increase tissue perfusion b) Activity intolerance c) Fluid volume deficit d) Increase cardiac output B is right 31.The nurse is caring for a client with bacterial endocarditis. The nurse knows that the cardiac rhythm is consistent with bacteria colonizing around the heart valves is ( are ) select all that apply: a) Ventricular tachycardia b) Heart block c) Junctional tachycardia d) artial fibrillation 31.The nurse is caring for a client with bacterial endocarditis. The nurse knows that the cardiac rhythm(s) not consistent with bacteria colonizing around the heart valves is (are) a. Junctional tachycardia b. Atrial fibrillation c. Ventricular tachycardia d. Heart block Answer= ABC what I believe is but I will look up more. AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 35.The nurse instructing a family on the effect of fibrinolytic therapy. The nurse knows that further teaching is needed when the family member says that the fibrinolytic therapy will: a) Increase LV function preservation b) Reduce the area of infraction c) Decrease the likelihood of developing Q d) Contain the clot in a localized area. D or bleeding dressing if she happens to change the answer. 36.A client with septic shock has an urine output 180 ml for the past 8 hours. The central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? a) Increase normal saline infusion to 150 ml/hr b) Prepare to give drotrecogin alpha ( Xigris) 24 mcg/kg/hr c) Administer hydrocortisone 100 mg IV d) Give furosemide ( Laxis) 40 mg IV D 37.A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54 pulse 64 and an elevate pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will be concerning? a) Administer dobutamine to keep systolic BP > 90 mm Hg b) Infuse normal saline at 100 ml/hr c) Give nitroprusside unless systolic BP < 90 mm Hg d) Keep head of bed elevated to 30 degrees B 38.A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR) Which action will the nurse anticipate taking? a) Increase the rate for the prescribed dopamine infusion b) Increase the rate for the prescribed sodium nitroprusside infusion c) Decrease rate for the prescribed 5 % dextrose in water infusion d) Decrease the rate for the prescribed Ringers Lactate infusion. B Sodium Nitroprusside is vasodilator 39.After receiving 1000 ml of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of: a) Vasopressin b) Nitroglycerine c) Sodium nitroprusside d) AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ Norepinephrine D Norepinephrine: increase HR, increase BP AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 40)To the evaluate the effectiveness of the Omeprazole being administered to a patient with systemic inflammatory response ( SIRS) Which assessment will the nurse make? a) Monitor stools for occult blood I think is right Omeprazole is proton- pump inhibitor treat heartburn 41)The ED department received notification that a patient who has just been in an automobile accient is being transported to your facility with anticipated arrival in 1 minute. In preparation for the client’s arrival the nurse will obtain a) Normal saline solution b) Dopamine infusion c) 500ml of 5 % albumin d) 20 gauge IV catheter ACCORDING TO CHEGG: Bdopamine infusion(b) is the first step taken as in accident because it reduces pain in the body and reduction of pain plays main role in patient to be active normal saline infusion also given to patient immediately as there is blood loss BUT I DONT KNOW IT DID NOT MAKE SENSE TO ME I think is C but not sure tb says 14 gauge iv catheter The rational says A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. SO EASILY COULD BE A OR D. WE NEED MORE CRITICAL THINK FOR THIS. I think i would go with A because a patient with trauma might need blood transfusion and 20 guage needle would be small for that. TB QUESTION FOUND OVER EDITION 11 The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain a. hypothermia blanket. b. lactated Ringers solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion. ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool. 42)Which information obtain by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ b. the patient peripheral pulses are weak c. the patient heart rate is 108 beats/min d. the patient urine output is 15ml/hr AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ ANS:A Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy. DIF: Cognitive Level: Apply (application) REF: 1643 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 47)The health care provider prescribed these actions for a patient who has possible septic shock with BP 70/42 mm Hg and O2 sat of 90 %. What will the nurse implement first? a) Administer normal saline 1000 ml over 30 min b) GIve vancomycin 1g IV c) Infuse dopamine 10 mcg/kg/min d) Obtain blood and urine culture A LOW BP NEEDS NORMAL SALNINE TO INCREASE AND GIVE TISSUE PERFUSSION BUT I will look over the book Even if you need to obtain blood and urine culture for possible sepsis, you would want to give fluid first because of extremely low BP. 48)A client with sepsis being assessed by the nurse . Organ dysfunction is a) Polyuria b) A ratio of arterial oxygen tension c) Gradual and subtle change d) Metabolic acidosis D IS THE ANSWER D because is implicate as multiple organ dysfunction as like kidney and liver 49)The common manifestations of sepsis as explained by the nurse involves which systems ( select all that apply) a) Cardiovascular b) Skeletal c) Central nervous system d) Pulmonary A,C,A and if is asking which is not then is B 50) The nurse explain that which of the following would change a patient’s diagnosis from SIRS to Sepsis a) Heart rate greater than 90 beat per minute b) Difficult to breath AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ c) Decrease platelet count AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ clammy, QUIZLET AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ The patient is in the compensatory stage of shock. What manifestations indicate this to the nurse (select all that apply)? a. Pale and cool b. Unresponsive c. Lower BP than baseline d. Moist crackles in the lungs e. Hyperactive bowel sounds f. Tachypnea and tachycardia . a, c, f. In the compensatory stage of shock the patient's skin will be pale and cool (α- adrenergic stimulation). There may also be a change in level of consciousness but the person will be responsive, the BP will be lower than baseline, bowel sounds will be hypoactive (α-adrenergic stimulation), and tachypnea and tachycardia (β-adrenergic stimulation) will occur. Unresponsiveness and moist crackles in the lungs occur in the progressive stage of shock. Remember for progressive unresponsiveness and moist crackles in lungs AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ THIS CHARCT EXPLAIN ALL THE STAGE OVER DIFFERENCES SYSTEM 58.) The nurse on the medical floor is teaching a nursing student the importance of preventing and identify shock. What is the priority nursing responsibility in the prevention of shock? a) Teaching client’s health promotion activities to prevent shock AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 3.The nurse admitting a patient with an extensive burn injury develops a nursing diagnosis of risk for imbalanced nutrition: less than body requirements related to high caloric needs. The initial action a. encourage an oral intake of at least 5000 kcal per day. b. administer multiple vitamins and minerals in the IV solution. c. infuse total parenteral nutrition via a central catheter. d. insert a feeding tube and give 20 ml/hr enteral feedings. D. insert a feeding tube and give 20 ml/hr enteral feedings Correct Answer: D Rationale: Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients. 4. Which order by the health care provider for a chemical burn injury client with 36% total body surface area should the nurse be concerned about? a. Famotidine 20mg IV two times every day. b. Oxygen 2L/minute via nasal cannula AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ c. Lactated ringers at 50ml/hr AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ d. Morphine sulfate 2mg IV push every two hours. According to book, patient with burn greater than 30% , Fluid replacement is archived with Crystalloid solution (lactated Ringer’s), IV pain , ( not IM route) I REALLY DONT KNOW THIS ONE What is “ the nurse concerned about” mean? Does it mean the nurse should question about ? 5)Ranitidine is prescribed for a client who had extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication? a) Stool frequency b) Stools for occult blood c) Percent of meals eaten d) Bowel sounds ANSWER IS B EDITIONN 7 SAYS THAT WAS C BUT THE RATIONAL DID NOT MATCH HOWEVER EDITION 8 SAYS B AND THE RATIONAL MATCH. 7)A client who has deep partial- thickness facial and neck burns has a nursing diagnosis of disturbed body image. The nurse evaluates that the client outcome for this nursing diagnosis are met when the client: a) Refuses to look in the minor b) Express concern about the scar appearance c) Realizes that scaring is temporary d) Start to use makeup to cover the scars D 8)Client who has burns to the lower legs is assessed by the nurse in the emergency department. The nurse notes that the client's face is bright red. Which of these actions should the nurse take first a) Place client on 100% O2 using non- rebreather mask b) Assess for singed nasal hair and dark oral mucous membranes c) Insert 12 large- bore IV lines and administer lactated Ringer's solution d) Place the client on oxygen 2L per cannula/min A airway oxygenation comes first all time 9) Beta 2 agonist inhaler is prescribed for a client who had an extensive inhalation burn in 48 hour ago. Which information will the nurse report to the health care provide regarding the medication? A. Fever AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ c. Fractures d. Contusio n A is over tbs. 11)In planning nursing intervention the best between meal snack for a burn client who has been losing weight would be a) Crackers and cheese b) Almond and yogurt c) Grapes and nuts d) Bagels and nuts B 15. A client with severe burn injury involving 30% of total body surface area has fluid replacement ordered using the Parkland formula. He weights 115 pound. The nurse would expect that 10 hours after the burn occurred, the rate of the fluid administration should be 4x52x30=6272.4/2=31336.2/16= 196 EXTREMELY IMPORTANT TO KNOW WE MISS THIS POINT AND HALF FOR NOT KNOW THE FORMULA WHICH IS 4X KGX BODY PERCENT /2 AND THEN OVER 16 HOURS CORRECT ME IF I DID’T know HOW TO EXPLAIN ME . YOU ARE CORRECT 13 The burn patient is prescribed 4 mg or morphine sulfate by IV push. The nurse understand reason for administration the opioids analgesic to this client by the intravenous route is: a) The danger of an overdose during fluid remobilization is reduced b) The potential for medication addiction is reduced when this route is used c) The client had unpleasant experience while hospitalized at a young age d) The medication is less likely to interfere with the client’s breathing and oxygenation when this route is used A i got tricky by this question but I went to the ebook and and quizlet after the exam because this question could never come out outside my brain I knew that I choose the distraction answer!!!!! Lol A IS THE ANSWER 14) During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. Hypovolemia in a burn client occurs primarily because of a) Third spacing of fluid from the interstitial space into fluid- filled vesicles b) Evaporation of fluid form denuded body surfaces AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ c) Capillary permeability that causes fluid shift to the interstitium d) Major blood loss from injured tissue AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ A Rational: Emergent Phase The emergent (resuscitative) phase is the time needed to resolve the immediate, life-threatening problems resulting from the burn injury. This phase usually lasts up to 72 hours from the time the burn occurred. The main concerns are the onset of hypovolemic shock and edema formation. The emergent phase ends when fluid mobilization and diuresis begin.Fluid moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. 15)A nurse caring for smoke inhalation injury client with moderate level carbon monoxide poisoning would expect this finding during assessment: a. Seizures b. Tachypnea c. Hypertension d. Altered level of consciousness Answer D Unconsciousness or altered mental status in a burn patient usually results from hypoxia associated with smoke inhalation. Other possibilities include head trauma, substance use, or excess amounts of sedation or pain medication. A 72-year old male sustained burns 30% of this body and was in shock. The nurse notes his urine output has begun to increase at more 30cc/hr and his blood pressure is 140/90. One intervention to assist this clients circulatory function would be to: a. Stop diuretic therapy b. Send a urine specimen to the lab c. Decrease IV flow rate d. Monitor wound drainage C to decrease the high BP AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ A AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 25)Which information about the client who is receiving vasopressin ( Pitressin) to treat sepsis shock is most important for the nurse to communicate to the health care provider a) The client HR 112 b) The client urine output 15ml/hr c) The client complaining chest pain d) The client peripheral pulse are weak Answer is C Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy. DIF: Cognitive Level: Apply (application) REF: 1643 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 26)The health care provider prescribes these actions for a client who has possible sepsis shock with BP 70/42 mm Hg and oxygen Sat 90% what will the nurse implement first a) Administer normal saline 1000 ml over 30 min b) Obtain blood and urine culture c) Infuse vasopressin 0.01 unit/ min d) Give vancomycin 1g IV A low bp needs to be increased first and normal saline will help with that and the others are things that need to be done but they are not priority like the low bp that can be fatal and cause death. 27)The nurse explain thats which of the following would change a client’s diagnosis from SIRS to Sepsis: a) Infection document culture b) Decrease platelet count c) Difficult breathing d) HR greater than 90 bpm A 33)The nurse is providing discharge instruction to the client following cardiac surgery. Which instruction would not be included in the plan regarding a 1gm sodium diet? a) Read labels on foods and medications for sodium content b) Fresh fruit and vegetables have decreased sodium content c) Do not add salt at the table or when cooking foods d) You may have 2 to 3 glasses of milk per day D is over tb AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 34)The nurse is caring for a client with bacterial endocarditis. The nurse knows that the cardiac rhythm not consistent with bacteria colonizing around the heart valves is (are) select all that apply: a) Heart block b) Ventricular tachycardia c) Junctional tachycardia d) Atrial fibrillation A 35)The nurse is instructing the family of the effect of fibrinolytic therapy. The nurse knows that further teaching is needed when the family member says that the fibrinolytic therapy will: a) Decrease the area of infraction b) Decrease the chances of clot formation c) Decrease the likelihood of developing Q wave on the ECG d) Decrease the likelihood that IV function will be preserved B It just resolve the blood clot 36)The nurse is caring for ARDS client who is intubated and on mechanical ventilation. The oxygen concentration is set at 80% tidal volume 700 with PEEP of 12. The purpose of tidal volume is: a) To improve lung compliance and prevent pulmonary congestion b) To deliver a set amount of gas during each breath c) To decrease the amount of carbon dioxide present in arterial blood d) To keep the alveoli open so that oxygenation has a longer time to take place Answer= A the goal is applied PEEP in ARDS patients is to minimize and maintain alveolar recruitment thereby improving oxygenation and limiting oxygen toxicity. 37)A client is short of breath and restless. The nurse during her assessment observes that the early clinical manifestation of respiratory failure that the nurse may observe are a) Agitation and restless b) Cyanosis and apprehension c) Dyspnea and tachypnea d) Hypotension and tachycardia C 38)The nurse recognize that the primary pathological that initiates the pulmonary changes that occur in ARDS is: a) Disruption of the capillary endothelium b) Injury to the bronchial lining of the lungs c) Increased production of the surfactant d) Remodeling of the lung fibrous AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ with one or two words. option B -- is correct. closing the door to decrease the noise level in his room. the patient with anxiety is not stable emotionally,so avoid more noises to make him comfortable. For this patient also AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ trouble with respiratory failure , a nurse should help with inspiratory muscle training which helps to improve breathing pattern. option C -- is incorrect. Teaching him the pathophysiology of his disease process.The client may not take sound decisions or unable to take decisions or solve problems. in this situation, nurse should explain the pathophysiology of his disease to his family members. option D -- is incorrect. performing perineal care. The perineal carre is the washing of the genital and rectal areas of the body. It is done more often when the patient is incontinent means unable to control excretions. 50)Occasionally clients with acute respiratory distress syndrome (ARDS) are place in the prone position. How does this position help the client? a) It improves cardiac output b) It prevents skin breakdown c) It recruits more alveoli d) It makes the client more comfortable Answer:C 53)To verify the correct placement of an endotracheal tube after insertion the first action the nurse should take to: a) Mark the tube where it exits the nose or mouth b) Obtain an immediate x-ray to confirm placement of the tube c) Ask the client to take deep breath and watch for symmetrical chest movement d) Auscultate for the presence of bilateral breath sounds Answer: d 54)While suctioning the client with an endotracheal tube, the nurse notes the occurrence of premature ventricular contraction on the client’s cardiac monitor. The most appropriate action by the nurse upon this finding is to: a) Provide an explanation of the suctioning procedure to decrease the patient’s anxiety b) Ventilate the client with 100% oxygen with bag-valve mask c) Lower the suction pressure to 60 mm Hg d) Notify the physician of the need for anti- arrhythmic medications Answer:b 55)A client is being treated for acute respiratory distress syndrome with mechanical ventilator therapy. The nurse assessment reveals distended neck veins and the tracheal deviated to the left side. The client was diagnosed with tension pneumothorax. Which of the following statements will explain the nurse’s understanding of tracheal deviation: a) Increase intrathoracic secretion of pus, the lung collapses b) Pleural pressure leakage increase, the lung collapses c) Increase intrathoracic pressure, the lung collapses d) Accumulation of air in the pleural space, the lung AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ collapses. Answer:C AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ B. Place the client in high flower’s position C. Documented the respirations as cheyne-stokes D. Suction the client. Answer: C 4) A nurse who has been working full time as a hospice nurse providing care to terminal ill client for 2 years, begins to exhibit irritability, and mixed emotion when discussing sadness. She should look at her own: A. The number of hours she is working B. Patterns for dealing with death C. Beliefs toward death D. The workload with patient care. Answer: B 5) Client and families struggle with many decisions during the terminal illness and dying process. Which of the following are important for the nurse to provide information to the patient and family about legal and ethical issues affecting end-of-life care? Select all that apply A. Feeding tube placement B. Organ and tissue donations C. Advanced directives D. Mechanical ventilation Answer: LOOK ME A,C,D 6) The nurse is caring for a client receiving subcutaneous heparin injections for pulmonary emboli. Which assessment data is most important to communicate to the health care provider? A. Activated clotting time of 301 seconds B. The international normalized ration is 2-3 ( INR) AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ C. The BP of 90/52 AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ D. The activated partial thromboplastin time is 35 seconds. ( aPTT) Normal range of clotting time: 72-120 sec Normal INR: 0-1.1 Normal aPPT: 30-40 sec 7. The nurse is caring for a client who has ARDS who is intubated and on mechanical ventilation. The oxygen concentration is set at 80%, tidal volume 700 with a PEEP of 12. The purpose of these settings is to a. Keep the alveoli open so that oxygenation has a longer time to take place b. Decrease the amount of carbon dioxide present in arterial blood c. Prevent the formation of pulmonary emboli and improve circulation d. Improve lung compliance and prevent congestion Answer= D the goal is applied PEEP in ARDS patient is to minimize and maintain alveolar recutriment thereby improving oxygenation and limiting oxygen toxicity. 8. What general statement is true about hydrotherapy for the client with imparied skin integrity secondary to burns? a. In hemodynamically unstable client, hydrotherapy is used to thoroughly cleanse the burn injury and is a major contributor to prevention of infection b. In hemodynamically stable clients, hydrotherapy allows for wound debridement and assessment of wound appearance c. In hemodynamically stable clients, hydrotherapy is a painless way to cleanse the wound and allowed for precise estimation of the depth of the wound d. In hemodynamically stable clients, hydrotherapy offers the most efficient method of applying topical antibiotic therapy and preservation of fluid balance Answer= B 9. A client is in the early stage of burn injury. One nursing intervention AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ C. Osmolality 300mmol/kg D. WBC 0-5/ hpf Answer: A Find in a quizlet. the patient's renal failure has been caused by the prerenal problem of hypovolemia. Prerenal oliguria is characterized by the ability of the kidneys to concentrate urine, resulting in a high urine specific gravity. Normal Specific gravity 1.005- 1.030 High specific gravity mean urine concentrated 13. The health care provider orders intravenous sodium bicarbonate to be given to a client in Acute Kidney injury. To best evaluate the effectiveness of the medications, the nurse will a. Obtain serum calcium levels b. Monitor for dysrhythmias c. Check the sodium d. Assess BUN and creatinine levels You have to check Potassium level 14. The physician orders intravenous sodium bicarbonate to be given to a patient in acute renal failure whose serum potassium level is 6.3 mEq/L. The nurse recognizes that the expected effect of the sodium bicarbonate is a. increasing the release of insulin, which promotes movements of potassium into body cells, b. . promoting loss of body potassium by promoting the excretion of potassium in alkaline urine. c. c. promotion of the exchange of potassium ions for sodium ions in the renal tubules, AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ increasing potassium elimination. AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ d. d. an increase in blood pH, resulting in movement of potassium from the extracellular fluid into the cells in exchange for hydrogen ions. D If potassium level is at 9.0 so A will be answer 15. A patient is hospitalized with a severe myocardial infarction (MI) accompanied by cardiogenic shock. The day following his MI, his urine output falls to 380 ml/day, and his BUN and serum creatinine levels indicate that he is in acute renal failure. A clinical finding that the nurse would expect during this phase of the patient's renal failure is a. low urine specific gravity b. hypernatremia c. high urine specific gravity d. epithelial cell casts in the urine ANSWER: C 16. After the first dialysis treatment, a client with chronic kidney disease complains of nausea and a headache. The nurse notes mild jerking and twitching of the patient’s extremities. The nurse will anticipate the need to a. Slow the rate for the next dialysis to decrease the speed of solution removal. b. Switch to continuous renal replacement therapy to improve dialysis efficiency c. Increase the time for the next dialysis to remove waste more completely d. Administer medications to control these symptoms before the next dialysis. Answer: A AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ a. unlimited fluids are allowed since retained fluid is removed during dialysis b. increased calories are needed because glucose is lost during hemodialysis c. more protein will be allowed because of the removal of urea and creatinine by dialysis d. dietary sodium and potassium are unrestricted because these levels are normalized by dialysis Answer= C 19. . A client with hypertension and stage 2 chronic kidney disease is receiving captopril (Capoten) or Lisinopril . Before administration of the medication, the nurse will check the client's a. Creatinine b.glucose c. phosphate d. potassiu m answer: D 20. A client who has ESRD is on peritoneal dialysis. To prevent pulmonary problems the nurse should: a. Provide back rubs b. Increase the dwell time c. Encourage frequent repositioning d. Increase the outflow rate Answer: C 21.A client complains of leg cramps during hemodialysis. The nurse should a. Give acetaminophen Tylenol b. Infuse a bolus of three percent saline c. Reposition the client AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ d. Infuse a bolus of 10% dextrose in water. Answer: B Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps. 22.A client is admitted with acute kidney injury. What cost effective procedure can be performed to rule out urethral obstruction as the cause of acute kidney injury? Select one: a. Urine electrolytes b. Bladder catheterization c. Creatinine clearance d. Renal ultrasound. B 23. A client is in the oliguric phase of intrarenal acute kidney injury. Fluid is retained during this phase. Which of the findings below are indicated ? Select all that apply. a. sodium concentration of urine that would indicate injured tubules cannot respond to auto regulatory mechanisms b. bounding pulse and high blood pressure, indicating edema c. an S3 that would indicate fluid volume overload d. electrolyte abnormalities and uremia answer: ABD 24. A client needing vascular access for hemodialysis asks the nurse what the differences are between arteriovenous (AV) fistula and a graft. the nurse explains that one advantage of the fistula is that it can we use sooner after surgery increase has patient Mobility can accommodate larger needles is less likely to clot AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ This is over tb so yes that’s the answer AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ b. " b. “When the jaundice is gone, I have recovered from the illness and the infection is cured.” AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ c. c. " should use condom during sexual activity for the rest of d. d. "I should not drink alcohol for at least two weeks." Answer: A 31. In chronic hepatitis, the nurse would expect the client’s laboratory result to include: a. Decreased alanine aminotransferase b. Decrease urinary urobilinogen c. Increased indirect serum bilirubin d. Increase aspartate aminotransferase AST Answer: D Normal level of AST 5-40 unit 32. Clients with liver disease frequently exhibit fluid volume excess. The nurse knows that the best explanation for this alteration in fluid a. decreased colloid oncotic pressure b. reduce portal vein pressure and venous return c. high level of albumin and third spacing of fluid d. degeneration and destruction of the live Do you have rationale for this one 33.a client with cirrhosis has a PT of 51.4 seconds. Which of the nursing actions should the nurse be least concerned about? a. Monitor the blood pressure b. Hemoccult test the stool and urine every 8 hour. c. Observe the skin and mucus membrane for redness d. Monitor hematological level AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ Answer: D According to chegg Normal PT 11-12.5 34. A liver cirrhosis client has a high ammonia level. Which order by the physician will the nurse be concerned about? a. Neomycin b. Albumin c. Aspiring d. Lactulose Answer: D 35. A client scheduled to receive a liver transplant tells the nurse that her friend had two kidney transplants because of rejection, and that he is concerned about rejection. The nurse’s best response to the client is a. you are in good physical condition and rejection won’t be a problem for you b. the problem of rejection is not as common in liver transplants as in kidney transplants c. perhaps your friend did not have a good tissue match with the first kidney d. rejection is always a possibility but every day there are better immunosuppressive drug answer: B 36. The nurse is teaching a client with management of liver failure. Which of the following is not a component of quality nursing care for the client with liver failure? a. Measure the abdominal girth daily b. Administer the routine lactulose c. Recommend weekly abdominal tap d. Avoid IM injections C AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 44. . For collaborative management of a sepsis client the physician has an order for the client to receive vancomycin 1gm IV every 8 hours for seven days. What interventions do the nurse need to implement to safely minister vancomycin (select all that apply)? a. Monitor urine output, BUN, and creatinine levels b. Administer the infusion over a minimum of 1 hour c. Anticipate replacing the PICC line every 48 hours d. Hold the infusion if client complains of tinnitus answer: ABD 45.While taking the history of a client newly diagnosed with coronary heart disease, the nurse discusses risk factors and medication. Which of the following risk factors does the nurse recognize as most significant in the development of coronary artery disease? a. Obesity b. Sedentary lifestyle c. Stress d. Diabetes mellitus Answer= D 46.A client is prescribed Diltiazem (Cardizem) for a client who has chronic stable angina. Which statement made by the client indicates to the nurse that the client understands the specific side effect of the medication? Select one: a. "I may notice a drop in my blood pressure" b. "I should call the physician if I feel lightheaded" c. "I should call the physician if palpitation and irregular pulse occur” d. "I should report any weight gain of two pounds per month answer: C AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 47.A client admitted with sepsis and severe hypotension. Laboratory results indicate BUN 50 mg/dl (10.7 mmol/L) serum creatinine 2.0 mg/dl (177 mmol/L),urine sodium 70 mEq/L), intravenous fluid, which medication in low dose can act as a cardiac AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ urine specific gravity 1.010, and cellular casts and debris in the urine. The nurse knows these findings are consistent with a. chronic renal insufficiency b. pre kidney injury c. post-kidney injury d. acute tubular necrosis answer: D 48.A client with acute renal failure is hypotensive. In addition to the administration of renal arteries? a. Nitroprusside b. Nitroglycerine c. Amrinone. d. Dopamine D Nitroprusside - vasodilator → decrease BP Nitroglycerine also decrease BP Dopamine 49. In planning care for the client with acute pancreatitis with left upper quadrant abdominal pain, which of the following results does the nurse anticipate? a. Serum amylase of 100 U/L b. Glucose of 230 mg/dL or glucose 180mg/dl c. Serum lipase of 120 U/L AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ d. Extend both arms AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ Answer A,B,C 53.A client with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode. it is most important for the nurse to monitor a. prothrombin time. b. bilirubin levels c. ammonia levels. d. potassium levels answer: C 54. A portocaval shunt is considered for a patient with cirrhosis following an episode of bleeding esophageal varices. The nurse plans to teach the patient that this procedure a. is likely to improve the patient's life expectancy. b. will increase the risk of hepatic encephalopathy. c. will help to decrease the incidence of peritonitis. d. is a first-line therapy for portal hypertension B Rationale: The risk fo hepatic encephalopathy increases after shunt procedures because blood bypasses the portal system and ammonia is diverted past the liver and into the systemic circulation. Life expectancy is not improved. The risk for peritonitis is not decreased by a surgical procedure, which will increase infection risk. First-line procedures for portal hypertension are medications such as diuretics and albumin. 55. A client who has acute pancreatitis is complaining of numbness and tingling. What diagnostic test does the nurse expect the physician to order: a. Serum calcium AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ b. Serum ammonia c. Serum gluconate AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ d) increasing the release of insulin, which promotes movements of potassium into body cells. ANSWER: A It should be A. 3)A burn injury client is in the emergent phase. The nurse understand that life threatening measures are resolved during this phase and that hypovolemia occurs during the emergent phase of burn injury because of : (select all that apply ) A) b) increased vascular oncotic pressure c) d) fluid loss from denuded skin surfaces. A,C,D A burn injury client is in the emergent phase. The nurse understands that life threatening measures are resolved during this phase and that hypovolemia occurs during the emergent phase of burn injury as a result of? (select all that apply) Select one or more: a. Increased capillary permeability b. Loss of sodium to the interstitium c. Increased vascular oncotic pressured. d. Fluid loss from denuded skin surface A,B,D ACCORDING TO TB QUESTION IS A,B,D IDK this question PLEASE LOOK AT THIS QUESTION 4)Thirty-six (6 hours or 36 hours ? In the quizlet I see 6hours after a thermal burn injury involving the anterior and posterior chest and both arms, the nurse obtains all these data when assessing a client. Which information is most important to communicate to the health care provider? A) serous exudate is leaking from the burns increased capillary permeability. loss of sodium to the interstitium AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ b)blood pressure is 92/ 44 per arterial line AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ c) urine output is 30 to 35 ml per hour d) cardiac monitor shows a pulse rate of 106 C Found in quizlet Rationale : The urine output should be at least 30 to 50 ml/hour during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase. 5)Clients with liver disease frequently exhibit fluid volume excess. The best explanation for this alteration in fluid volume is : a) degeneration and destruction of the liver b)high levels of albumin and third-spacing of fluids c) reduce portal vein pressure and venous return d)decrease colloidal oncotic pressure. C FOR SURE 6) A client is receiving assist- control mechanical ventilation with peak end- expiratory pressure (PEEP) of 10 cm H2O and has an arterial line and pulmonary artery catheter in place. Which information indicates that a change In the ventilator settings may A) the pulmonary artery wedge pressure is (PAWP) is increased. b) the pulmonary artery pressure (PAP) is decreased c) the arterial line shows a blood pressure of 90/46 d) the cardiac monitor shows a heart rate of 58 beats/min C AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ D 12)A college student was brought to the emergency department with a sports related head injury. His teammates report loss of consciousness for a few minutes. He is conscious with a Glasgow Coma Score of 11. The nurse should interpret this score to mean that: A) injury such as this will require observation in case of further deterioration b) the coma score is adequate for observation at home by his parents c) a severe injury has occurred requiring immediate surgical intervention d) the clients neurological functioning has returned to normal A 13)Upon initial assessment of a client hospitalized following a stroke, the nurse finds the clients blood pressure to be 180/90. The nurse anticipates that : A) IV antihypertensive agents will be administered b) IV heparin will be administered c) IV fluids will be administered d) IV parenteral alimentation C for sure 14)Clients with basal skull structures require special consideration in nursing care. The nurse understands that basal skull fracture is generally associated with a) fracture of the brain stem b) rupture of the sella turcica c) perforation of the ventricles d) tear in the dura mater I cANSWER According to chegg f CORRECT OPTION IS D The most common symptoms associated with basal skull fracture is CSF damage. A tear in the dura mater is the primary cause of Csf leakage. In case of basal skull fracture, we need to monitor CSF leakage from the patient. AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ EXPLANATION FOR OTHER OPTIONS. Fracture of the brain stem. A basal skull fracture is caused by blunt force trauma, it involves the base of the skull. Basal skull fracture will damage the brain stem and blood vessels. b]Rupture of sella turcica It is most associated with frontal and maxillofacial trauma. It present in the bony nook at the base. It is not directly associated with a basal skull fracture. c]Perforation of ventricles has occurred as a result of fracture but it does not directly relate to a basal skull fracture. ompletely don’t know this may B or d? 15)The nurse identifies the nursing diagnosis of impaired verbal communication for a client with expressive aphasia. An appropriate nursing intervention to help support the clients communication is to : (select all that apply) a) ask questions that have one word response b)develop a list of simple words c) present one thought at a time d)allow the client to choose the questions to respond to I will say A AND C but idk 17) The following orders are received for a client who is unconscious after a head injury. Which one of the orders are appropriate? ( Select all that apply) a) do computed tomography (CT) scan b)prepare the client for lumbar puncture c) perform neurologic checks every 15 minutes d) obtain x-rays of the skull and spine A,c,d everything except B if they ask which is not or which is questioned the choose B 18). The nurse is assessing a client with as possible spinal cord lesion for sensation. Which action indicates an understanding about evaluation of a possible spinal cord injury? (select all that apply) AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ a. the new nurse tell the client,” you may feel a pinpick now.” b. the new nurse has the client close the eyes during testing. c. the new nurse tests for light touch before testing for pain. d. The new nurse uses an irregular pattern to test for intact touch. B,C,D if is except then is just A 19. The nurse would anticipate a client with a lesion at the lower midbrain level to demonstrate which breathing pattern? a. cluster breathing b. cheyne-stokes c. hyperventilation d. Apneustic breathing C 20. A client is scheduled for hemodialysis at 10:00 a.m. Which routine medication should be withheld at 9:00 a.m.? a. Ampicillin b. Amphogel c. Digoxin or Metoprolol or cardiazen d. Dextrose C for sure 21. After receiving a change-of-shift report about these four clients, which client should the nurse assess first? a. A 22-year-old admitted with SIADH who has a serum sodium level of 130 mEq/L b. A 31-year-old who has iatrogenic Cushing’s syndrome with a capillary blood glucose level of 295 mg/dl c. A 53-year-old who has Addison’s disease and is due for a scheduled dose of hydrocortisone (Solu- Cortef) AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 25. High doses of prednisone are used to control the symptom of an acute exacerbation of systemic Addison’s disease. Client education on the use of prednisone should include which most important information? a. monitor for any mood alteration b. check temperature daily c. weigh yourself daily d. avoid taking any vaccine C Corticosteroid excess causes pronounced changes in physical appearance (Fig. 49.10). Weight gain is the most common feature. It 26. A patient who uses every-other-day prednisone therapy for rheumatoid arthritis complains of not feeling as well on the non-prednisone days and asks the nurse about taking prednisone daily instead. The best response to the patient is that a. An every-other-day schedule mimics the normal pattern of cortisol secretion from the adrenal gland. b. Glucocorticoids are taken on a daily basis only when they are being used for replacement therapy. c. If it improves the symptoms, it would be acceptable to take half the usual dose every day. d. There is less effect on normal adrenal function when prednisone is taken every other day. D 15. A patient admitted to the hospital in an Addisonian crisis 1 month after a diagnosis of Addison's disease. Which statement by the client demonstrates understanding of the condition? a. "I double my dose of hydrocortisone in the days that I go for a run" b. “I had the stomach flu earlier this week and couldn't take the hydrocortisone" c. "I frequently eat at restaurants, and so my food has a lot of added salt" d. "I do yoga exercises almost every day to help me reduce stress and relax.” A understand AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 16. A client with cushing syndrome returns to the surgical unit following an adrenalectomy. During the initial postoperative period, the nurse gives the highest priority to a. Monitoring for infection b. Protecting the client’s skin c. Maintaining fluid and electrolytes status d. Preventing severe emotional disturbances C After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances. 17. A client with cushing syndrome is admitted to the hospital to have laparoscopic adrenalectomy. During the admission assessment, the client tell the nurse, “The worst thing about this disease is how terrible I look. Which response by the nurse is not therapeutic a. This must be difficult for you; would you like to talk about it? b. Your appearance is altered because of the Cushing’s disease c. “Most of the physical and mental changes caused by the disease will gradually improve after surgery.” d. “You really should not worry about how you look in the hospital. We see many worse things.” C 18. In a client diagnosed with hypothyroidism, when treatment with levothyroxine (Synthroid) is started, it is most important for the nurse to assess a. mental status. b. nutritional level. c. Cardiac function. d. fluid balance. C AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 19. . A client who has undergone a subtotal thyroidectomy develops laryngeal stridor and a cramp in the right hand. The nurse anticipates that intervention for this condition will be: a. administration of IV morphine b. . b. administration of IV calcium gluconate. c. c. endotracheal intubation with mechanical ventilation. d. d. immediate tracheostomy and manual ventilation B for sure is over tbs 20. While assessing a client who has just arrived in the post anesthesia recovery unit after a thyroidectomy, the nurse obtains these data. Which information is most important a. The client’s cardiac monitor shows a heart rate of 112 b. The client’s voice is weak and hoarse sounding c. The client is complaining of 9/10 incisional pain d. The client has increasing swelling of the neck D Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority 21. A client with symptoms of Diabetes insipidus is admitted to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the client is: a. Activity intolerance b. Risk for impaired skin integrity c. Excess fluid volume d. Altered sleep pattern D AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 27. When interviewing an acutely confused patient with a head injury, which of these questions will provide the most useful information? a. “Have you ever been hospitalized for a neurologic problem?” b. “Do you have any pain at the present time?” c. “What have you had to eat in the last 24 hours?” d. “Can you describe you usual pattern for coping with injury?” B is over the tbs of nursing assessment of neurology 28. When an elderly client who is being admitted to the hospital for minor surgery tell the nurse, “I haven’t slept through the night for several years now the nurse will plan to a. Teach the patient to drink a warm glass of milk at bedtime. b. Discuss changes in older people c. Request an order for sleep aid for the client d. Discuss normal in the reticular activating system. d 29. Spinal cord injury can be complicated by hypertension and bradycardia. These manifestations are primary a result of? A. Loss of sympathetic function and increased venous capacity B. Internal bleeding and hypovolemic shock C. Massive vasoconstriction in response to increased sympathetic input. D. Massive immediate cardiovascular reaction A EBOOK RATIONAL: neurogenic (vasogenic) shock can occur in cervical or high thoracic injury (T6 or higher). It occurs from unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation. It causes peripheral vasodilation, venous pooling, and decreased cardiac output. Manifestations include significant hypotension (< 90 mmHg), bradycardia, and temperature dysregulation. AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ 30. In planning a bladder program for the patient with a C8 spinal cord injury, the nurse realize that the patient: a. Will be able to control micturition b. Will require assistance in catheterizing c. Will not be able to tigger voiding d. Can sense bladder fullness. B C8), hyperactive deep tendon reflexes and bilaterally positive Babinski test (after resolution of spinal shock) Incomplete: Mixed loss of voluntary motor activity and sensation 31. Patient with cervical injuries have a high risk for developing the problem ineffective airway clearance. Because of this risk, the nurse should give priority to a. Monitoring arterial blood gas result b. Teaching assisted coughing techniques c. Document the quality of respirations d. Frequent assessment of vital signs According to chegg is D 32. When a client’s intracranial pressure is being monitored with an intraventricular catheter, the nurse plan care to. (select all that apply) a. Continuous monitoring of the waveform b. Observe the amount of cerebral spinal fluid c. Disconnected and change the bag every day d. Elevate the head pf the bed at 45 degrees. Answer: a,b Infection is a serious complication with ICP monitoring. Factors that contribute to infection include ICP monitoring more than 5 days, use of a ventriculostomy, a CSF leak, AHII FINAL EXAM:cardiac & sepsis QUESTIONS WITH ANSWERS 2023 SUCCESS ASSUREDA+ and a concurrent systemic infection. Routinely assess the insertion site, use aseptic technique, and monitor the CSF for a change in drainage color or clarity. 33. The nurse is caring for an unconscious patient who is neurological stable. Which action has the highest priority? a. Assess motor and sensory abilities b. Maintain a side lying position c. Hyperventilate the patient d. Evaluate skin integrity frequently B is over tb 34. A victim of an automobile accident was found unconscious at the scene of the accident but briefly regained consciousness during transport to the hospital. On admission, the Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse will anticipate the need to a. prepare the patient for immediate craniotomy. b. administer IV furosemide (Lasix). c. type and crossmatch for blood transfusion. d. initiate high-dose barbiturate therapy. A is over tb 35. In planning long term care for the patient following brain trauma, the nurse includes teaching and support for the family a. Most patients experience seizure disorders b. Patient will always have some residual deficit c. Families become dysfunctional and unable to cope d. Patient often have concentration problems D is on a quizlet. 36. The nurse administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?