Nursing Care for Patients with Respiratory and Cardiovascular Conditions, Exams of Nursing

Download Nursing Care for Patients with Respiratory and Cardiovascular Conditions and more Exams Nursing in PDF only on Docsity!

A college heath nurse interprets the peak expiratory flow rate for a student who has asthma and fluids that student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (select all that apply.)

a. The nurse should use his quick-relief inhaler b. The students asthma is not well controlled c. The students peek flow is 50% to 80% of his best peak flow d. The nurse should obtain a second expiratory flow rate

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?

a. 480 mL (The average tidal volume is 7-9 (60kg x 8ml/kg =480)

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

a. Movement of the ET into the right main bronchus. ( During intubation the staff can misplace the ET tube in the right stem bronchus. The nurse should identify absence of chest wall movement or breath sounds on a single sliding scale as indicating ET tube displacement, and should notify appropriate personnel to reposition the tube)

A nurse is assessing the respiratory pattern of an older adult client who is receiving end of life care. Which of the following assessment findings should the nurse identify as Cheyne-stokes respirations?

a. Breathing ranging from very deep to very shallow with periods of apnea. ( The Cheyne-stokes respirations is an indication that the client is approaching death.)

A nurse is caring for a client who is receiving mechanical ventilation via tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?

a. Stress ulcers (stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric

A nurse is assessing a client immedietaly after the provider removes the clients endotracheal tube. Which of the following findings should the nurse report to the provider?

a. Stridor

Alternating periods of hyperventilation and apnea is Cheyne-stokes breathing.

A nurse understands that there are three ways to decrease ventilator-assisted pneumonia called a “ventilator bundle”. Which of the following three nursing actions are included in the clients care bundle?

a. Hand hygiene, oral care, and HOB elevation

A nurse is caring for a client who has respiratory failure, is intubated, and is mechanically ventilated. The client pulls out the edotrachial tube. Which of the following is the priority action?

a. Ensure the airway is open

A nurse is assessing a clients wife how to take a blood pressure. Which of the following actions by the wife indicates a need for further instructions?

a. Place the clients arm above the level of the heart

A nurse is monitoring a post-operative client who is unable to respond to questions. Which of the following behviors should the nurse recognize as an indicator of pain? (select all)

a. Resltlessness b. Grimacing c. Clenching

A nurse is assisting with the discharge plan of a client who has a permanent tracheostomy. The nurse should verify the availability of which of the following equipment? (select all)

SBAR examples:

1. Gaslow coma scales falls under assessment
2. Intercranial pressure readings falls under assessment
3. Medication that is needed falls under recommendations

A nurse is monitoring the cardiac output of a client who has left sided heart failure using pulse pressure analysis. Which of the following findings can compromise the reading?

a. The client is experiencing premature atrial contractions.

A nurse in the ICU is providing teaching for a client proior to the removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

a. Avoid speaking for long periods

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the clients family about organ donation. The clients spouce states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?

a. What do you think your spouse would have wants?

A client is performing nasotrachial suctioning for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

a. Preoxygenate the clients with 100% oxygen for up to 3 min.

A charge nurse has access to the faciliteies electronic records. It is appropriate for the charge nurse to share her personal password with whom?

a. No one

A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?

a. Agitation A nurse is evaluating the CVP of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?

a. Hypovolemia (A low cvp indicates right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuressis)

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

a. Increased urinary output (Doubtamine is administered to clients who have heart failure to improve their hemodynamic status.)

A nurse in a ICU caring for a client who is post-op following a right pneumonectomy. After extubation from the ventilator. Which of the following positions should the client be placed?

a. Semi-fowlers

A nurse is preparing a client for transfer to the ICU for a placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

a. Hemodynamic status

A nurse is caring for a client who has a new diagnosis of CKD. Which of the following statements should the nurse identify as an indication of anticipatory grieving?

a. I just cant believe that this dialysis is going to ruin my whole life. (Anger and fear of the upcoming loss)

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (select all)

a. Elevate the hob 30

A. I have to choose a family member as my health proxy. (the client needs to choose someone they can trust for end of life care, should be a family member, but doesn’t have to be a family member.)

A nurse in the emergency department is caring for a client who has compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the clients family. Which of the following actions should the nurse anticipate the neurosurgeon taking?

a. Invoking implied consent

A nurse is admitted to the emergency room with a respiratory rate of 7/min. ABG reveals the following values. Which of the following is an appropriate analysis of the ABG’s?

a. Respiratory acidsis

A nurse is caring for a female client in the ER who reports SOB and pain in the lung area. She states that she started taking birth control 3 weeks ago and that she smokes. (the question too long to type)

a. Administer oxygen via face mask

A nurse is planning care for a client who as acute respiratory distress syndrome ARDS. Which of the following should the nurse include in the plan?

a. Place in prone position

A nurse in a dialysis center caring for a client who has a new diagnosis of ESKD. When he arrives he tells the nurse I decided to come today, but “I am not sure if I need to come back after today.” (too long to type)

a. Denial phase of grieving

A nurse enters a clients room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first?

a. Check for a carotid pulse

A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following should the nurse take?

a. Place the extremity in a dependent position

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicate that the medicine is effective?

a. Increased urine output (shows their hemodynamic status is improved)

A nurse enters an adult’s room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?

a. Summon the code team

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?

a. Administer the abdominal thrust

maneuver Life threatening emergency steps

1. Open airway using jaw maneuver
2. Determine effectiveness of ventilator
3. Establish IV access
4. Perform gaslows coma scale
5. Remove clothing for a thorough assessment

A nurse is assessing a client while suctioning the client tracheostomy tube. Which of the following indicates the client is experiencing hypoxia?

a. Increased heart rate

If patient has an extubation from the ventilator place the client in semi-fowlers position.

A nurse is receiving a transfer report from a client who has had a head injury. The client has a Gaslows Coma Scale score of 3 for opening eyes, 5 for best verbal response, and 5 for best motor response. Which of the following is a conclusion of this data?

a. The client opens his eyes when spoken to

A nurse is assessing a client who has a 8 gaslows coma scale to evaluate LOC. Which of the following statements accurately describes the score?

a. Indicates the need for total nursing care

A client with right ventricular has a central venous pressure monitoring catheter in place (CVP). The nurse should expect which of the CVP measurements?

a. 7 mm HG (a CVP above 6 indicates a reduced right ventricular preload, typically from hypovolemia)

A nurse is caring for a client who is immedietly postoperative following a thoracic surgery. The nurse administers a narcotic analgesic to the client frequently for pain. Which of the following should the nurse recognize as the primary reason for this action?

a. It facilitates the clients deep breathing