Nursing Concepts and Clinical Scenarios, Exams of Nursing

Download Nursing Concepts and Clinical Scenarios and more Exams Nursing in PDF only on Docsity! 1 | P a g e PCCN FINAL AND PRACTICE EXAM 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS|ALREADY GRADED A+|BRAND NEW!!!|GUARANTEED PASS|LATEST UPDATE The authority of a surrogate speak for a pt should be based on which of the ff conditions A. the surrogate is a family member and has recently lived with the pt B. the family has designated the surrogate as the most knowledgeable person regarding the pt wishes C. the pt has specifically conveyed wishes to the surrogate regarding current or similar circumstances D. the pt indicates to the nursing staff that the surrogate should speak on the pt behalf C. The main difference between a medical power of attorney and a healthcare surrogate is that pt appoint a medical POA to make healthcare decisions for them when they become unable to make them for themselves. Pt can specify what healthcare decisions they want their medical power of attorney to make. A healthcare surrogate, on the other hand, is appointed to make healthcare decisions for pt if they become unable to make them themselves. pt have no say in who becomes their healthcare surrogate. They can avoid having a healthcare surrogate appointed if they have appointed a medical power of attorney representative and that representative is still willing and able to serve. The nurse needs to perform a physical and gather history data on a pt who speaks only mandarin. The pt is accompanied by a visitor representing herself as the daughter, who offers to interpret. When the nurse responds that there will be an interpreter, the visitor become upset and wants to know why that is necessary. The nurse's best response is A. "Since the pt doesn't speak english, I can't be sure you are really her daughter, and the interpreter can tell me that." B. "Our policy states that an interpreter must be used at all times in this hospital when communicating with a person who does not speak english." C. "In discussing medical medical issues, a professional interpreter can help to ensure complete 2 | P a g e understanding of all information. You may also participate, with permission from the pt." D. "I'm not sure that you will understand the medical terminology well enough to translate it correctly into mandarin." C. This response is consistent with caring practices in the synergy model. In order to maintain confidentiality, ensure accurate communication and support patient- and family- centered care principles, family members, friends or other unqualified interpreters should not be used as interpreters except in emergent situations. As an advocate and moral agent for the pt, staff should use qualified interpreters to ensure effective communication A 16 year old is admitted following a syncopal episdoe while on a basketball court. The pt reports having had syncopal episodes in the past, generally while in the midst of sports events. The nurse notes the pt is in SB with a rate of 55, PR interval of 0.16, QRS of 0.10, QT interval of 0.50, and a slightly peaked T wave. The nurse should anticipate A. cardiac cath the following morning B. performance of an echo C. serum and urine toxicology screens D. CBC and trop levels B. This pt has signs and symptoms of long QT syndrome. This condiition is a congenital disorder characterized by a prolongation of the QT interval on ECG and propensity for ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest or sudden death, Imaging studies, such as echocardiography, may help to exclude other potential reasons for arrhythmic events or associated congenital heart diseases. ANy young person with syncope that occurs during exercise or in any other circumstance in which a surge of adrenaline levels was likely to have been present should have long QT syndrome specifically ruled out A pt who sustained a fall reports a headache and, soon after, develops acute confusion. The nurse notes ST segment depression on the pt ECG. Which of the following should the nurse suspect is the most likely cause A. hypokalemia B. cerebral hemorrhage C. alcohol intoxication D. ischemia B. This pt has risk factors (fall) and symptoms of cerebral hemorrhage. Pt with a cerebral hemorrhage may have ST segment depression or QT prolongation. In addition to positive blood cultures, which of the following are indicative of septic shock BP HR RR T WBC A. 108/86 94 26 100.6 13 B. 92/72 128 36 101.2 21 C. 85/58 136 36 96 38 D. 126/69 96 24 102.8 14 C. This pt has sign of septic shock: the pt is hypotensive, tachycardic, tachypneic, and has subnormal temperature and elevated WBC 5 | P a g e D. This patient has a risk factors (ICU admission and continuous infusion of midazolam) as well as symptoms of deliruim. Screening for delirium so that appropriate interventions can be initiated is indicated at this time. A pt with hepatic failure overhears on rounds that the phosphorous level is decreasing and inquires what that means. The best response is A. "your liver is regenerating." B. "your kidney function has not been affected." C. "we can now prepare you for a liver biopsy to help pick the best treatment." D. "you will start to feel like you have more energy within a day or two." C. Lower phosphorous levels and early phosphorous administration are associated with a good prognosis in pt with acute liver failure. Elevated phosphorous levels are associated with a poor recovery. A pt is admitted with respiratory infection. The pt has shortness of breath with a frequent productive cough and is expectorating light-green sputum. The nurse should initially anticipate which of the following ABG results A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis B. Pt who are hyperventilating for SOB will develop respiratory alkalosis. Pneumonia is a known etiology of hyperventilation and respiratory alkalosis A pt with acute coronary syndrome/ unstable angina has received morphine with relief of symptoms. The nurse notes a sudden widening of the QRS complex, although the pt remains in sinus rhythm. A 12 lead ECG indicates the development of a new-onset left bundle branch block. Which of the following should the nurse anticipate A. electrophysiology study B. transeophageal echocardiogram with bubble study C. evaluation for contraindications of fibrinolytic therapy D. troponin I D. The LAD coronary artery is the primary source of blood supply to the bundle of His and bundle branches. Therefore, pt with an anterior wall MI caused by and LAD occlusion are at risk for ventricular conduction defects. Conduction defects such as a left bundle branch block may occur. Obtaining troponin levels will help diagnose whether this pt is experiencing an MI that is being manifested with a left bundle branch block. A nurse overhears a student recommending a popular high-protein weight loss program to a patient admitted with an exacerbation of heart failure. When the nurse asks the student why the recommendation was made, the student replies, "The patient is obese." The nurse should explain that A. this is an appropriate recommendation, since heart failure patients are often obese because of lack of energy B. heart failure patients may appear to be obese are often nutritionally challenged because of poor 6 | P a g e appetite. C. the pt should be cautioned instead to decreased protein intake to avoid azotemia D. nutritional counseling should be done by the physician B. The pt with heart failure may be volume overloaded by 5 to 50 pounds over dry weight. A pt who is immediately post hemodialysis reports headache, nausea and vomiting. Which of the following is the best response A. "your symptoms are due to the removal of urea during your treatment B. "I will report this to the dialysis team so they can increase your treatment time in the future." C. "Have any of your visitors been exposed to the flu." D. "your treatment may be done less frequently since you are having side effects." A. Uremia must be corrected slowly to prevent disequilibrium syndrome, which is a set of signs and symptoms ranging from headache, nausea, restlessness and mild mental impairment to vomiting, confusion, agitation and seizures. This is thought to occur as the plasma concentration of solutes, such as urea nitrogen, is lowered A pt in the PCU who is a regular cocaine user develops non-radiating chest pain. The ECG reveals ST and T wave abnormalities. The pt CK is elevated, and CK-MB and troponin levels are pending. The nurse should anticipate adminsitration of which of the following A. beta-blocker B. calcium channel blocker C. thrombolytic D. benzodiazepine D. A benzodiazepine is indicated to control hyperactivity, hypertension, tachycardia, anxiety, hyperthermia, and seizures associated with cocaine use. Which of the following heart sounds is most suggestive of mitral regurgitation A. diastolic murmur B. extra heart sound heard late in diastole C. pansystolic murmur D. snap heard after S2 C. THe type of systolic murmur is holosystolic (also called pansystolic), because the amplitude is high throughout systole. This type of murmur is caused by mitral or tricuspid regurgitation. In pt with hemodynamically significant primary mitral regurgitation, the left ventricular pressure remains highger than the left atrial pressure throughout systole. This explains the onset of a pansystolic murmur with an S3 gallop. A postoperative thoracic surgery pt has a chest tube in place. The nurse notes the water seal level is fluctuating and corresponding with the pt breathing. CXR earlier revealed an unresolved pneumothorax. The nurse should. A. continue to observe B. check the tubing for kinks C. milk/strip the chest tube D. clamp the chest tube, and call the surgeon immediately 7 | P a g e A. The observation described in the scenario is expected and is known as tidaling. The absence of fluctuations can indicate that the lung is re-expanded. No intervention is required for normal findings. Two days following a near-drowning accident, a pt is dyspneic, using accessory muscles, expectorating large amounts of secretions and reporting feeling of impending death. Changes to the assessment data include RR- 24 TO 36 CXR clear to bilateral diffuse infiltrates ABG 40% face mask or 100% non-rebreather mask pO2 120 mm Hg to 56 mm Hg pCO2 33 mmHg to 56 mmHg pH 7.42 to 7.35 HCO3 24 meq/L to 27 mEq/L Which of the ff do these changes most likely represent A. aspiration pneumonia B. pulmonary embolism C. interstitial pneumonitis D. ARDS D. The onset of symptoms occured within 48 hours of the incident. THe bilateral diffuse infiltrates and ABG results indicating hypoxemia and CO2 retention are all consistent with ARDS. Aspiration pneumonia should include hypoxxemia, respiratory alkalosis. The CXR results would reveal an area of opacity with aspiration pneumonia rather than diffuse infiltrates. Interstitial lung disease invlolves an inflammation of supportive tissue between the air sacs rather than inflammation in the air sacs themselves. Symptoms would be SOB and a dry cough. A pt reports chest pain that is sharp, constant, worse when lying down and alleviated with sitting up and leaning forward. The most likely cause of these findings is A. ACS B. pericarditis C. PE D. AAA B Pericarditis is inflammation of the pericardial sac. The damaged epicardium becomes rough and inflamed and irritates the pericardium lying adjacent to it, precipitating pericarditis. Pain is the most common symptom of pericarditis. THe pain is sharp, constant and is alleviated when sitting up and leaning forward. A pt tells a nurse, "I don't know how I'm going to pay for this hospitalization." The nurse should A. arrange a meeting with hospital social services staff B. Notify the business office so a payment plan can be designed C. redirect the pt toward meeting psychologic needs D. give the pt applications for public assistance medical coverage 10 | P a g e A pt with multiple rib fractures sustained in a motor vehicle collision 4 days ago reports sudden chest pain and difficulty breathing. Chest xray reveals a right hemothorax. The pt appears anxious and has decreased breath sounds on the affected side. Which of the ff procedures should the nurse anticipate A. needle decompression, 2nd ICS at midclavicular line B. bronchoscopy with broncial lavage C. placement of a right-side chest tube in the 6th ICS at the posterior axillary line D. CT scan for further evaluation and diagnosis C. Blunt or penetrating thoracic trauma can cause bleeding into the pleural space, resulting in a hemothorax. This life-threatening condition must be treated immediately. Resuscitation with intravenous fluids is initiated to treat the hypovolemic shock. A chest tube is placed on the affected side to allow drainage of the affected side to allow drainage of blood. A pt with which of the ff is at greatest risk for torsades de pointes A. depressed ST segment B. development of peaked T waves C. prolonged QT interval D. development of a U wave C. The normal QTc is less than 0.46 second (460 msec) in women and less than 0.45 second (450 msec) in men. A prolonged QT interval is significant because it can predispose the pt to the development of polymorphic VT, also known as torsades de pointes. When drugs associated with a high risk of torsades de pointes are started, it is important to record the QT and QTc interval and to continue to monitor the QT and QTc interval during treatment. Prolongation of the absolute QT interval beyond 0.5 second (500 msec) increases the risk of polymorphic VT. A pt is confused about time and place, despite frequent reorientation. For the pt safety, the nurse should initially A. put a vest restraint on the pt B. ask a family member to stay with the pt C. administer a mild sedative D. increase the frequency of pt observation D. Pt have a right to receive safe care in a safe environment. However, the use of restraints is inherently risky. THe decision to use a restrain or seclusion is not driven by diagnosis, but by a comprehensive patient assessment. FOr a given pt at a particular point in time, this assessment determines whether the use of less restrictive measures poses a greater risk than the risk of using a restraint. Increasing the frequency of observation may be all that is required to keep this pt safe. The comprehensive assessment to identify medical problems that may be causing behavior changes in the pt. For example, temperature elevations, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions and adverse effects may cause confusion, agitation and combative behavior. Addressing these medical issues may eliminate or minimize the need for restraint. A pt with ACS who has undergone cardiac surgery 2 days ago develops new onset of JVD, muffled heart tones, palpitations, difficulty breathing and chest pain that worsens with coughing. Decreased peripheral pulses are noted. Vital signs are as follows BP 110/60 to 90/50 11 | P a g e HR 96 to 134 RR 20 to 28 Which of the following should the nurse anticipate A. needle decompression B. echocardiogram C. administration of dopamine D. spiral Ct B. This pt is at risk for and is demonstrating signs of cardiac tamponade. Cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart's ability to pump. Signs of tamponade include elevated and equalized filling pressures (CVP, PADP, PAOP), decreased cardiac output, respiratory rate, jugular venous distention, pulsus paradoxus, and muffled heart sounds. Transesophageal or transthoracic echocardiography may be used to diagnose or confirm cardiac tamponade. A pt is admitted with a severe headache, nausea and vomiting. BP on arrival is 280/140 mm Hg. The nurse should anticipate immediate administration of A. atniemetics B. labetalol C. mannitol D. analgesics B. Hypertensive urgencies may be treated with rapid-acting oral antihypertensive agents. There are many drug categories available, including ACEIs, ARBs, calcium channel blockers and beta-blockers. Labetalol is an example of a beta-blocker that may be used in this situation. A pt who is extubated following 3 days of mechanical ventilation is noted to have hot and flushed skin and is expectorating thick yellow sputum. Auscultation reveals bilateral crackles halfway up posterior. Data are as follows BP 112/60 HR 138 RR 30 T 102 (38.9) o2 SAT 93% ON 2 l nc Which of the ff orders should the nurse anticipate A. lasix 40 mg ivp and increase 02 to 4 L/min B. albuterol inhaler and methylprednisolone 125 mg IVP C. serum BNP and HCTZ D. blood culture and IV antibiotics D. This pt is demonstrating symptoms of pneumonia. Rapid administration of antibiotics contributes to improved outcomes. Obtaining blood cultures will help the provider determine the appropriateness of selected antibiotics. When caring for a 15 year old pt, The nurse should A. answer questions with simple and practical information B. dispel fantasies and encourage questions 12 | P a g e C. encourage pt to talk about life experiences D. allow the pt peers to visit D. Teens want to be with people their own age- their peers. Peers are often more accepting of the feelings, thoughts and actions associated with the teen's search for self-identity. The influence of peers- whether positive or negative- is critical importance in an adolescent's life. A pt with a history of heroin and alcohol abuse is admitted for treatment of cellulitis. The pt has flushed, slightly moist skin and is slow to respond to verbal stimuli. The affected arm is edematous and hard to the touch, with yellow exudate noted from puncture wounds on the skin. Vital signs are BP 88/50 HR 120 RR 26 T 102 (38.9) The nurse should anticipate orders for which of the ff A. abx and crystalloid administration B. antipyretic and dopamine administration C. CT scan of the head and a drug screen D. colloid followed by norepineprhine administration A. This pt has risk factors and is exhibiting signs of sepsis. The main goals are to control infection and provide immediate resuscitation of the hypoperfused state. Early goal-directed therapy during the first 6 hours of resuscitation improves survival. This they includes aggressive fluid resuscitation to augment intravascular volume and increase preload until a CVP of 8 to 12 mm Hg. (12 to 15 mm Hg in mechanically ventilated pt). is acheived. Crystalloids or colloids may be used. A fluid challenge for hypovolemia should be initiated. A pt with HTN, dyslipidemia and CAD has leg pain and decreased skin temperature in the legs and feet. The pt legs have pallor and decreased pulses that become fainter when the legs are elevated. The nurse should suspect. A. DVT B. chronic venous insufficiency C. acute arterial occlusion D. PAD D. The symptoms described in this scenario are consistent with PAD. This pt also has risk factors for PAD. Risk factors for PAD include DM and impaired glucose tolerance, smoking, hypertension, hyperlipidemia and hyperhocysteinemia A pt with history of COPD and anterior wall MI that occurred 1 year ago is now SOB and expectorating pink frothy sputum. The pt has a rapid, irregular heart-beat with an O2 sat of 89%. The most likely cause of these S/S is A. pulmonary edema B. cardiac tamponade C. pneumococcal pneumonia D. ARDS 15 | P a g e After a STEMI, a pt suddenly experiences a decreased level consciousness, a weak and thready pulse and posterior crackles in the lower half of the lung fields bilaterally. Data are as follows BP 76/43 HR 139 RR 24 UO 5 ml for the past hour O2 sat 88% on 2 L via nasal (from 97%) The nurse should suspect which of the ff causes A. CVA B. cardiogenic shock c. pulmonary embolus D. ARDS B. This pt has a primary risk factor (STEMI) and signs of cardiogenic shock. The hypotension is caused by a decrease in contractility of cardiac muscle. Compensatory mechanisms of tachycardia and tachypnea result. A decrease in urine output, decreased level of consciousness, crackles and a weak and thready pulse result from hypoperfusion associated with the condition. A frail, elderly pt recovering from an exploratory laparotomy was extubated following a prolonged period of mechanical ventilation and IV sedation. She continues to receive PRN opioids for pain. Today, the nurse notes occasional combativeness, fluctuating lethargy and poor short-term memory. Data are as follows BP 104/60 HR 87 RR 24 O2 sat 95% on 2L via NC The nurse should recognize that A. mobilization should be limited to prevent injury B. the RASS scale should guide medication administration C. the use of Haldol is associated with lethal dysrhythmias D. moving the pt to a room with a window is a useful distraction technique C. The most current guidelines advise cautious use of antipsychotic meds to manage delirium, as risk versus benefits data remain unclear. Another choice may be a short-term trial of an atypical antipsychotic such as Quetiapine (Seroquel) The physician gave metoprolol (Lopressor) to a patient with rapid afib 5 minutes ago without effect for rate control and is currently administering IV diltiazem (Cardizem); BP is 94/60. Which of the following should the nurse anticipate. A. calcium chloride B. synchronized cardioversion C. digoxin D. transcutaneous pacing D. A beta-blocker and calcium channel blocker combination should be used with caution. When drugs from these 2 classes are given together, the additive effect is the potent suppression of the AV node. Having transcutaneous pacing nearby can help the pt be treated early if this complication develops. 16 | P a g e A pt with HF is on a diuretic and fluid restriction. Assessment indicated atrial tachycardia with a rate of 130, presence of crackles in all lung fields, an S3 at the left apex and BP of 90/40 (previously 130/60). The patient reports feeling SOB. The nurse should anticipate administration of A. a fluid bolus to enhace preload B. dopamine to support BP C. dobutamine to augment cardiac output D. adenosine to reverse tachycardia C. In pt with decompensated heart failure, use of intravenous inotropic agents such as dobutamine may be indicated to support cardiac function and cardiac output. The dysrhythmia most commonly associated with mitral stenosis is A. 2nd degree AB block type II B. idioventricular rhythm C. sinus bradycardia D. afib D. Mitral stenosis increases the risk of developing atrial fibrillation because of high pressures in the left atrium that will stimulate left atrial remodeling and enlargement. A pt with an elevated BMI is having fluctuations in BP, HR and oxygen saturation, and reports feeling sleepy and fatigued despite intershift report of the pt sleeping. The nurse noted periods of irritability and memory deficits. Which of the ff interventions is indicated A. monitoring for hypotension B. administering small doses of benzodiazepines C. performing a mini-mental status exam D. collaborating with the physician for use of a CPAP mask D. This pt has primary risk factor (obesity) and symptoms of obstructive sleep apnea. Continuous positive airway pressure (CPAP) may be initiated if the pt CO2 level is stable and acceptable. A pt with suspected pulmonary hypertension should be prepared for which of the ff tests to confirm the diagnosis A. angiography B. echocardiography C. electrocardiography D. cardiac catheterization D. RIght heart catheterization is required to confirm a diagnosis of pulmonary hypertension, to assess the severity of the hemodynamic impairment and to test the vasoreactivity of the pulmonary circulation A pt with sepsis has the ff lab data PT 12.5 aPTT 58.2 Fibrinogen elevated Fibrin split products elevated Which of the ff is indicated A. PLT 17 | P a g e B. cryoprecitpitate C. Vitamin K D. FFP D. The pt aPTT is elevated, indicating an alteration with the intrinsic pathway or common pathway of the clotting cascade. FFP is needed to help correct this abnormality. What is the recommended initial position to improve oxygenation for a pt with unilateral pneumonia A. prone B. high-fowler's C. side-lying on unaffected side D. supine C. With the affected side uppermost, the lower lung is better ventilated and better pefused. Thise improves V/Q matching and gas exchange A pt with a history of diabetes and hypertension reports onset of numbness in her hands, unusual fatigue, loss of appetite, indigestion and a cough. Which of the following response by the PCU nurse is indicated A. Your doctor will likely order a CT scan without contrast B. I will call the dietitian to review your meal selections and intake with you C. How have you been sleeping the last couple of nights D. I will call the physician to obtain an order for an electrocardiogram D. This pt has risk factors for and is demonstrating symptoms of possible ACS. An ECG will help diagnose this condition. A pt with a history of IV drug abuse is admitted with a fever and a grade III/VI systolic murmur. The patient develops sudden dyspnea and anxiety. Chest auscultation reveals a loud holosystolic murmur and crackles. Which of the ff is the most likely cause A. Mitral valve insufficiency B. ventricular aneurysm formation C. Heart failure D. hemopericardium with tamponade A. This pt has a risk factor (IV drug abuse) and symptoms of endocarditis, which is common in IV drug abusers because of the nonsterile injection into the nervous system. While the tricuspid valve is most typically affected, involvement of the mitral and aortic valves can occur. A pt with history of COPD is receiving 28% oxygen via face mask and has the following ABG values. pH. 7.35 pCO2 48 pO2 62 HCO3 26 O2 sat 89 Which of the ff is indicated at this time A. continue ongoing therapy and monitoring B. increase the dead space of the oxygen tubing 20 | P a g e C. Thrombolytic therapy is administered to establish and maintain the patency of coronary arteries, thus improving myocardial perfusion. A patient with dilated cardiomyopathy is admitted with dyspnea, cough, palpitations and decreased level of consciousness. The patient is in sinus tach with no ectopy. The nurse should anticipate management to include A. administration of captopril (Capoten) B. insertion of a temporary left ventricular assist device C. loading the pt with digoxin D. preparation for dynamic cardiomyopathy procedure A. This pt is showing symptoms of heart failure related to dilated cardiomyopathy. ACE inhibitors have been effective in improving both symptoms and survival in these pt. Most pt will tolerate ACE inhibitor therapy as well. Apatient is admitted with acute respiratory failure, left lobar pneumonia and COPD. Physical examination reveals severe fatigue, coarse inspiratory crackles and expiratory wheezing. Data also include HR 132, RR 35, T 102.6 (38.9), pH 7.28, pCO2 72, pO2 48, HCO3 36 Based on this information, the nurse should anticipate which of the following additional clinical findings A. purulent sputum B. mediastinal shift to the right C. bradypnea D. intermittent apneic periods A. Pneumonia is common in pt with COPD. Sputum becomes purulent over time in pt with pneumonia. A pt with end-stage renal disease asks the nurse why is anemic. The nurse explains the anemia is caused by A. blood loss in the urine B. renal insensitivity to vitamin A C. inadequate production of erythropoietin D. inability of the kidney to retain iron. C. As chronic kidney disease progresses to stage 2 and 3, erythropoietin production decreases and anemia may become clinically evident A pt is receiving milrinone therapy should be assessed for which of the following side effects A. hyperkalemia B. chest pain C. thrombocytopenia D. decreased urination B. Chest pain, ventricular dysrhthmias and hypotension are potential side effects of milrinone administration. Thrombocytopenia is a side effect of inamnirone, another PDI but not milrinone. Which of the ff ABG results should the PCU nurse anticipate in caring for a pt. with chronic alcohol abuse pH pCO2HCO3 21 | P a g e A. 7.35 36 18 B. 7.30 50 23 C. 7.50 30 25 D. 7.48 47 32 A. Pt with chronic alcohol abuse are at risk for developing metabolic acidosis, which is reflected with these ABG. This condition has been termed alcoholic ketoacidosis (AKA) as a distinct syndrome. AKA is characterized by metabolic acidosis with an elevated anion gap, elevated serum ketone levels and a normal or low glucose concentration A patient reports severe nonradiating substernal chest pain. ECG reveals a 2 mm ST segment elevation in the precordial leads. After pain relief is achieved with nitroglycerin, the ECG returns to normal. Which of the following data is most useful in the acute management of this patient. A. troponin I B. serum electrolytes C. coagulation studies D. lipid profile A. This pt is demonstrating symptoms of ACS. In order to determine if cardiac damage has occurred, troponin levels are obtain. When myocardial cells become damaged, troponin levels will begin to rise in the bloodstream. Determination of the presence of myocardial damage will help guide pt care management. Which electrolyte imbalance most commonly accompanies acute tubular necrosis A. hyponatremia B. hypokalemia C. hypophosphatemia D. hypouricemia A. ATN is characterized by the kidneys' inability to conserve sodium, so pt will be hyponatremic A pt is admitted for evaluation of exercise intolerance, increasing short of breath and a new-onset mitral murmur. Assessment reveals a QT segment of 0.46 second. The nurse should recognize that the pt is at most risk for development of A. atrial fib B. 2nd degree HB II C. ventricular dysrhythmia D. paroxysmal atrial tachycardia C. Pt with QT prolongation are at risk for development of torsades de pointes or polymorphic vtach. This pt QT interval is prolonged. A patient develops chest pain, shortness of breath and coughing 3 days after STEMI. The nurse should suspect A. Pneumothorax B. aortic dissection C. Pulmonary embolism D. Pericarditis 22 | P a g e C. This pt is exhibiting symptoms of PE A patient admitted following an episode of new onset sepsis. assessment reveals new onset dyspnea, intercostal retractions and crackles in all lung fields, pt is placed on oxygen via NC at 4Lpm which criteria ABG results should the nurse anticipate. pH pCO2 pO2 O2sat HCO3 A. 7.5 30 59 89 23 B. 7.3 51 49 81 18 C. 7.26 32 63 91 14 D. 7.48 46 52 85 28 A. As the pt is dyspneic, the initial change in arterial blood gases will be respiratory alkalosis. This will be reflected in a decrease in CO2 and corresponding increase in pH. Pt w/ a hx of heart failure and ACS is admitted following episode of syncope. 2 hours later assessment reveals BP 134/64 (supine) 90/60 sitting HR 115 w weak thready pulse (supine) 130 (sitting RR 32 shallow BS clear UO 30 ml of past 2 hours The nurse should initiate A IV fluids B Nesiritide (natrecor) C. Mannitol (Osmitrol) D. Digoxin (Lanoxin) A. Although this pt has a history of heart failure, data suggest orthostatic hypotension and hypovolemia, which should initially be treated with fluids. While heart failure may be of concern, this pt breath sounds are clear at present. A pt is being discharged and continuing on amiodarone therapy. pt teaching will include monitoring for which of the following long-term complications. A tachyarrhythmias B. renal insuff C. pulmonary fibrosis D. hyperkalemia C. A well-documented side effect of amiodarone after long-term use is pulmonary fibrosis Which of the following dysrhythmias should the RN watch for in a patient following lung resection surgery? A S.V.T. B Sinus bradycardia C V.Fib D P.V.C. 25 | P a g e C. Having all providers together will allow for sharing of perspectives and possibly consensus-building surrounding the pt's condition Twelve hours after sustaining a pelvic fracture, a pt reports chest pain, hemoptysis and severe shortness of breath. Respiratory rate is 34. ABG on 02 at 4l via NC are: pH 7.48, pCO2 28, p02 68. The nurse should suspect that the patient has developed. A. tension pneumothorax B. a pulmonary embolism C. post-intubation laryngeal edema D. respiratory failure B. This pt is at risk for developing a PE (postoperative status) and has symptoms of this condition A pt is admitted with hypertrophic cardiomyopathy. For which of the ff dysrhytmias is this patient at risk A. SB B. PAC C. SVT D. asystole C. Hypertrophic cardiomyopathy is distinguished by a hypertrophied, non-dilated left ventricle. A trial dilation results in atrial fibrillation and SVT A nurse caring for a 76 year old patient in the PCU. Which of the ff age related cardiac changes should the nurse anticipate. A. decreased response to catecholamines B. increased myocardial complaince C. decreased audibility of S1 D. increased resting heart rate A. Aging is associated with a decreased response to catecholamines. It is also associated with decrease in myocardial compliance. It is also associated with an increased audibility of S1 because of increased rigidity of the ventricular wall. It is associated with a decrease in resting HR. A pt with type II diabetes and recent pneumonia is admitted with a serum glucose level of 590. The pt is alert and oriented, denies nausea or vomiting and reports being very thirsty with frequent urination. Data are as follows BP 112/58, HR 114, RR 18, T 100 (37.8), O2 sat 92% on 2 L via NC Which of the ff lab findings should the nruse anticipate Urine ketones Arterial pH A. negative 7.42 B. positive 7.24 C. negative 7.35 D. positive 7.50 B. This pt is demonstrating signs and symptoms of DKA. DKA is associated with an elevated blood sugar, ketonuria and decrease in pH associated with a metabolic acidosis. 26 | P a g e Which of the ff is initially indicated for a pt diagnosed with an ischemic stroke 2 hours prior to admission to the PCU A. clopidogrel (Plavix) B. heparin C. argatroban (Acova) D. TPA (activase) D. TPA are used to dissolve clots. TPA dissolves the clots and permits reperfusion of the brain tissue. It should be used as soon as possible after onset of symptoms. The maximum time has been expanded to 4.5 hours or less from the onset of symptoms Three days following STEMI and cardiac catheterization with stent insertion, a pt develops sudden-onset diffuse crackles and a new loud murmur heard most prominently at the 5th ICS mid-clavicular line. The nurse should recognize that this may represent A. mitral regurgitation B left sided heart failure C. stent occlusion D. cardiogenic shock A. The pt has a risk factor (STEMI) and symptoms of mitral regurgitation. The murmur is located at the 5th intercostal space mid-clavicular line A pt with a history of ACS involving the anterior wall develops chest pain, dyspnea, wheezing, diaphoresis, and restlessness. The most likely cause of these findings is A. pulmonary embolism B. pulmonary edema C. severe asthma D. unstable angina B. The pt has risk factors (anterior wall MI) and symptoms of pulmonary edema. Obstruction of coronary blood flow produces myocardial ischemia causes myocardial wall dysfunction. During these episodes, pulmonary edema can develop. The nurse should watch for pulmonary edema after an anterior wall MI. A pt is admitted with hematuria secondary to an overdose of warfarin (Coumaidn). Lab data include: INR 9.8, Hgb 13.5, Hct 35.6. The nurse should anticipate the administration of A. FFP B. cryoprecipitate C. platelets D. vitamin K D. This pt has an elevated INR. Choice of treatment for this pt depends on the degree of coagulopathy and on the clinical impact of potential blood loss if bleeding occurs. One option is to simply hold the warfarin until the INR is again within therapeutic range. Alternatively, vitamin K may be given as a more active management strategy. Vitamin K safely and effectively corrects the INR. Which of the ff conditions is a risk factor for development of delirium during a PCU admission A. hypotension B. immobility 27 | P a g e C. limited range of motion D. alcoholism D. History of alcoholism is a documented risk factor for development of delirium A pt with upper GI bleeding is admitted with a Hgb of 10.8. The ff day the pt has become obtunded and is having melena stools. Lab data reveal a Hgb of 6.1. Which of the ff should the nurse do first A. check the pt for orthostatic changes and hold medications that inhibit PLT function B. obtain intubation equipment and administer normal saline C. insert a NG tube to promote removal of bile, and transfuse 2 units of packed RBCs D. prepare the pt for upper endoscopy and collaborate with the pharmacist regarding a vasopressin infusion B. Because this pt in obtunded, airway patency is in question. Intubation is indicated for airway protection at this time. The mental status changes may be indicative of hypovolemia. Emergent fluid resuscitation is indicated The oliguric phase of ATN is characterized by which of the ff A. decreased UO, hypokalemia, alkalosis, elevated creatinine B. decreased UO, hyperphosphatemia, acidosis, hyponatremia C. hypotension, acidosis, elevated BUN, hypernatremia D. HT, alkalosis, elevated creatinine, hypercalcemia B. Pt with ATN will present wit a decrease in UO, hyperphosphatemia, acidosis (secondary to hyperkalemia) and hyponatremia (there is an elevated fractional excretion of sodium with ATN) A pt is transferred to the PCU following a CABG 3 days ago. The pt developed bleeding in the immediate postoperative period, which led to re-operation and infusion of 8 units of packed RBCs. The pt's lab data reveal a plt count of 48k. The nurse should suspect which of the ff etiologies A. PLT dysfunction from use of the pump during surgery B. bone marrow suppression. C diltiazem (Cardizem) used for postoperative atrial fibrillation D. HIT D. This pt has risk factors and laboratory data consistent with HIT. Thrombocytopenia is a well- recognized complication of heparin therapy usually occurring within the first 10 days after heparin treatment has started. HIT must be suspected when a pt receiving heparin has a decrease in PLT count particularly 50% of the baseline count, even if the platelet count nadir remains >150 A pt with mitral stenosis is admitted. Which of the ff dysrhythmias should be of greatest concern to the nurse A. PVCs 4 per min B. junctional rhythm, rate 58 C. second degree AV block Type I D. afib rate 136 30 | P a g e A pt family requests to stay beyond visiting hours. The nurse best response is to A. determine the pt wishes B. explain the need to adhere to the visiting policy C. allow a longer stay D. encourage the family to leave A. Evidence shows that the unrestricted presence and participation of a support person can enhance patient and family satisfaction, because it improves the safety of care. Unrestricted presence of a support person can improve communication, facilitate a better understanding of the pt, advance pt and family centered care, and enhance staff satisfaction. Determining what the pt prefers is the first step and is consistent with caring practices in the Synergy Model. A pt states that he works the night shift, is accustomed to taking his medications at night instead of in the morning and needs to get back on his regular schedule. The first dose is schedule. The first dose is scheduled for 0900. The most appropriate response would be to A. explain the importance of maintaining a routine administration time to the pt B. ask the pharmacist to provide education and information on BP medication to the pt C. remind the pt that he will not be working after his discharge, and recommend follow-up at hist first postoperative appointment D. contact the pharmacy and request that administration times be changed to meet thte pt individual needs D. Consistent with caring practices, participation in care and participation in decision making in the Synergy Model, his wishes should be granted. The pt medication schedule should not be modified accordingly, unless contraindicated A fellow employee confides to you about a personal addiction to narcotics. The colleague has not sought professional help but is considering the need to do so. Conversation further reveals she has been forging prescriptions to obtain drugs. When you ask her to report this to the supervisor, she refuses and asks you not to share what you spoke about. What is the nurse best course of action A. confidentially report the conversation to the EDA B. disregard the conversation and hope the situation resolves C. remove the prescription pads and limit her access to them D. speak with the nursing supervisor D. Nurses who divert drugs pose a significant threats to patient safety but also become a liability to healthcare organizations and the nursing department where the diversion occurred. Healthcare and nursing leaders have a responsibility to ensure that security systems are in place to prevent diversion and protect pt if nursing impairment is suspected as a result of drug diversion. Nursing leaders must consider legal, regulatory, ethical, humanistic and practical considerations in resolving this issue. The nursing supervisor must be notified immediately and in a private area. This is a very sensitve issue. A pt with chronic alcohol abuse is admitted with altered mental status. The pt has periods of clear sensorium but has frequent episodes of agitation accompanied by diaphoresis, nausea and vomiting. The nurse notes increased muscle weakness and new onset of first-degree AV block. Which of the following is indicated at this time A. collaborate with the physician for a neuro consult 31 | P a g e B. check the pt magnesium level C. perform a 12 lead ECG D. institute seizure precautions B. This pt has a risk factor (chronic alcohol abuse) and symptoms of hypomagnesemia. A pt with an extensive history of ACS is admitted with an acute exacerbation of heart failure. Data are as follows Bp 90/60, HR 120, O2 sat 90% on 4l via nasal cannula She has diffuse crackles throughot all lung fields. The physician has ordered diuretics and insertion of a central line for dobutamine administration. Her husband favors withdrawal of treatment but the pt has indicated she wants to continue treatment even if its painful and possibly futile. She is oriented to person and place but disoriented to time and year. The nurse should recognize A. the pt wishes should be supported under the ethical principle of autonomy B. the pt should be educated that comfort can be maintained for her even without further treatment C. the pt cognition may be impaired because of hypoxia and decreased blood pressure, and the husband should make medical decisions D. that the spiritual care should be consulted before healthcare d A. As an advocate and moral agent, the nurse must support the pt wishes as long as the pt has capacity, which is the case in this scenario. A pt who is visually impaired is to be transferred to another unit. The nurse should prepare the pt for the transition by A. explaining the physical layout of the receiving unit to the pt B. advising the staff on the receiving unit to orient the pt C. providing written materials about the receiving unit to the pt family D. arranging for the pt family to tour the receiving unit A. Preparing the pt for transfer by providing information about the receiving unit may help alleviate transfer anxiety. Which of the following leads should be used for ST segment monitoring in a pt with suspected ACS A. III or V5 B. II or V1 C. I or aVL D. II or aVF A. For pt without definite ACS but suspected ACS, leads III and V5 should be monitored A 58-year-old male with a history of alcohol abuse is a heavy smoker. He complains of pain in his chest in the afternoons when he is sitting and watching TV. ECG shows elevation of ST segments. The most likely diagnosis is: a. Unstable angina. b. Variant/Prinzmetal's angina. c. Stable angina. d. Gastroesophageal reflux disease. 32 | P a g e B: Variant angina (also known as Prinzmetal's angina) results from spasms of the coronary arteries associated with or without atherosclerotic plaques; and is often related to smoking, alcohol, or illicit stimulants. Elevation of ST segments typically occurs with variant angina, which frequently occurs cyclically at the same time each day and often while the person is at rest. Stable angina occurs regularly with activity. Unstable angina occurs when there is a change in the pattern of stable angina. GERD pain may be mistaken for angina. Metabolic syndrome is characterized by: a. Abdominal obesity, decreased triglyceride level, increased HDL level, and hypertension. b. Hypertension, abdominal obesity, and increased HDL level. c. Abdominal obesity, increased triglyceride level, decreased HDL level, and increased fasting blood glucose level. d. Hypotension, decreased fasting blood glucose level, increased triglyceride level, and decreased HDL level. C: Metabolic syndrome (insulin resistance) puts people at risk for the development of diabetes mellitus and cardiovascular disease, and is characterized by abdominal obesity (>35 inches in women and >40 inches in men), increased triglycerides (150), decreased HDL level (<40 mm Hg in men and <50 mm Hg in women), elevation of blood pressure (130/ 85 mm Hg), and increased fasting glucose ( 110 mg/dL). Other indicators include elevation of C-reactive protein (evidence of a proinflammatory state) and high levels of fibrinogen (evidence of a prothrombotic state). Parenteral nutrition with a total nutrient admixture that includes lipids has been ordered for a burn patient for administration throughout a 24-hour period. When preparing to administer the solution, the nurse observes that the oil has separated, forming an obvious layer. Which of the following options is the correct action to take? a. Administer the solution, as oil separation is normal. b. Mix the solution by shaking the bag until no oil separation is noticeable. c. Discard the solution. d. Return the solution to the pharmacy for the addition of added emulsifier. C: The total nutrient admixture should be discarded if there is "cracking" of the lipid emulsion and the oil separates into a layer. With TNA, all the components of parenteral nutrition and lipids are admixed together in one container to create a 3-in-1 formula. Components of parenteral nutrition generally include proteins, carbohydrates, fats, electrolytes, vitamins, sterile water, and trace vitamins. While most postoperative patients need 1500 calories per day to prevent protein breakdown, those with fever, burns, major surgery, trauma, or hypermetabolic disease may need up to 10,000 more calories daily. A 30-year-old patient complains of post-operative pain at 8 on a 1-to-10 scale 12 hours after surgery, but is not moaning, grimacing, or exhibiting any standard physical signs of pain. The patient last received pain medication 6 hours earlier, and has orders for morphine every 4 hours as needed and ibuprofen every 6 hours as needed. Which is the most appropriate action? a. Administer ibuprofen. b. Administer morphine. 35 | P a g e Acquired immunodeficiency syndrome (AIDS) is diagnosed when the following criteria are met: a. HIV infection and AIDS-defining condition, such as cytomegalovirus. b. HIV infection and CD4 count 400 cells/mm. c. HIV infection, CD4 count <100 cells/mm, and AIDS-defining condition. d. HIV infection, CD4 count <200 cells/mm, and AIDS-defining condition. D: AIDS is diagnosed with HIV infection, CD4 count <200 cells/mm, and AIDS-defining condition, such as opportunistic infections (cytomegalovirus, tuberculosis), wasting syndrome, neoplasms (Kaposi's sarcoma) or AIDS dementia complex. Patients with AIDS may present with many types of symptoms, depending on the AIDS-defining condition, but more than half exhibit fever, lymphadenopathy, pharyngitis, rash, and myalgia/arthralgia. Upon physical examination a 23-year-old female complains of chest pain and faintness upon exertion, fatigue, and loss of appetite. She has tachycardia with a weak pulse. Auscultation identifies an ejection click, a brief high-pitched sound occurring immediately after SI. Which of the following cardiac disorders is the most likely diagnosis? a. Coronary artery disease b. Mitral valve stenosis c. Pericarditis d. Aortic valve stenosis D: These symptoms, including the abnormal heart sound (ejection click), are common to aortic valve stenosis. The aortic valve controlling the flow of blood from the left ventricle narrows, causing the left ventricular wall to thicken. Aortic stenosis may result from a birth defect or from damage caused by childhood rheumatic fever. Coronary artery disease is not directly associated with abnormal heart sounds although gallop rhythms can occur with related ventricular hypertrophy. Mitral valve stenosis may cause an opening snap, while pericarditis causes a friction rub. Which of the following rhythm disturbances is most common after cardiac surgery? a. Ventricular fibrillation b. Ventricular tachycardia c. Premature ventricular contractions (PVCs) d. Atrial fibrillation, flutter, and tachycardia D: Atrial arrhythmias, including fibrillation, flutter, and tachycardia, are very common after cardiac surgery, occurring in more than half of patients with valvular surgery. Arrhythmias occur usually in the first 2-3 postoperative days and are often transient but may recur. Arrhythmias are often related to surgical manipulation. Treatment includes digoxin, blockers, calcium channel blockers, and amiodarone (often given preoperatively for 7 days to reduce incidence of postoperative arrhythmias. Electrical cardioversion may be indicated after 24 hours if sinus rhythm remains abnormal. A 64 year-old male with chronic heart failure presents with dyspnea, cough, blood-tinged frothy sputum, cyanosis, wheezing, rhonchi, and diaphoresis. He is diagnosed with pulmonary edema, placed on oxygen by mask and given morphine and IV nitrate as well as inhaled aminophylline for bronchospasm. Which of the following diuretics is the most appropriate concomitant treatment option? a. Furosemide (Lasix) b. Spironolactone (Aldactone) 36 | P a g e c. Hydrochlorothiazide (Dyazide) d. Eplerenone (Inspra) A: A short-acting intravenous loop diuretic, such as furosemide (Lasix) or bumetanide (Bumex) is indicated to rapidly reduce fluid retention and decrease pulmonary edema. Spironolactone and eplerenone are potassium-spring diuretics that have weaker diuretic actions than loop diuretics. Hydrochlorothiazide is a long-acting thiazide diuretic given as a first line treatment for hypertension rather than for acute crises. Systemic inflammatory response syndrome (SIRS) is characterized by symptoms that may include: a. Bradycardia b. Dysrhythmia c. Leukocytosis (>12,000 mm) or leukopenia (<4000 mm) d. PaCO >32 mm Hg C: SIRS symptoms may include leukocytosis or leukopenia. SIRS is diagnosed with 2 of the following symptoms: Leukocytosis (>12,000 mm) or leukopenia (<4000 mm). Elevated (>38 C) or subnormal rectal temperature (<36 C). Tachypnea or PaCO <32 mm Hg. Tachycardia. SIRS, a generalized inflammatory response affecting many organ systems, may be caused by infectious or noninfectious agents, such as trauma, burns, adrenal insufficiency, pulmonary embolism, and drug overdose. If an infectious agent (such as Streptococcus pneumonia or Staphylococcus aureus) is identified or suspected, SIRS may be an aspect of sepsis. A patient has been receiving heparin for 5 days and develops type I heparin-induced thrombocytopenia and thrombosis syndrome (HITTS) with platelet count of 90,000 mm. Which of the following actions regarding heparin is most appropriate? a. Continue heparin, but monitor b. Stop heparin immediately c. Reduce dosage of heparin d. Switch to oral anticoagulants A: With type I HITTS, heparin is continued while monitoring platelet count. This condition is transient but typically resolves without intervention. Type II is an autoimmune reaction to heparin that occurs in 3% to 5% of those receiving unfractionated heparin and also occurs with low-molecular weight heparin. It is characterized by low platelets (<50,000 mm) that are 50% below baseline. Onset is 5 to14 days but can occur within hours of reheparinization. Heparin-antibody complexes form and release platelet factor 4 (PF4), which attracts heparin molecules and adheres to platelets and endothelial lining; stimulating thrombin and platelet clumping. When considering the use of a translator for a patient who does not speak English which of the following considerations is of the highest importance? a. The translator has training in medical vocabulary for both languages b. The translator speaks both languages well 37 | P a g e c. The translator knows the patient's history d. The translator is available onsite A: The translator should have training in medical vocabulary for both languages because just speaking the languages well does not mean that the translator will adequately translate specialized vocabulary. It is not necessary for the translator to know the patient's history as the translator's job is only to translate what is said, not add to it or interpret it based on prior knowledge. While on-site translators are ideal, translation can be done with a speakerphone at a distance. Which of the following aneurysms would likely require immediate surgical repair? a. A dissecting 6cm aneurysm in the ascending aorta b. A 3.5cm saccular abdominal aneurysm c. A 4cm bulging thoracic aneurysm in the ascending aorta in a patient with Marfan's syndrome d. A 5cm fusiform abdominal aneurysm A: A dissecting 6-cm aneurysm in the ascending aorta is a medical emergency and requires immediate repair. Abdominal aneurysm (saccular or fusiform) repair is often delayed until it reaches >5.5 cm unless an aneurysm is rapidly expanding in size. Thoracic aneurysm repair is also typically delayed until the aneurysm reaches >5.5 cm, but those with Marfan's syndrome may be advised to have surgery at 5 cm due to increased risk. A patient with a seizure disorder falls to the floor with a generalized (grand mal) seizure. Which of the following options is the most appropriate nursing action? a. Position the patient flat on his back and loosen his clothing b. Open the jaws and insert a padded tongue blade between the teeth c. Position the patient on one side with the head flexed forward d. Do not touch the patient until the seizure subsides C: If a patient is having a generalized (grand mal) seizure, the nurse should try to position the patient on one side with the head flexed forward to allow the tongue to fall forward so that it doesn't obstruct the airway to prevent aspiration of saliva and mucus. Padding should be placed under the head to prevent injury from contact with a hard surface. The patient should not be restrained as this can cause injury. Clothing should be loosened and furniture moved out of the way. If the patient is in bed, the pillow should be removed and side rails raised. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated with: a. Hypertension b. Diabetes mellitus c. Heart failure d. Renal failure. D: ACE inhibitors are contraindicated with renal failure, as one of the most serious side effects is renal impairment, especially in patients also taking diuretics and NSAIDs. ACE inhibitors are commonly used to treat hypertension and heart failure. They are often combined with diuretics, such as thiazide for hypertension or Lasix for heart failure. ACE inhibitors are sometimes given to those with diabetes mellitus to prevent diabetic neuropathy. 40 | P a g e c. Myoglobin d. Troponin and its isomers (C, I, and T) D: Troponin (protein in the myocardium) and its isomers (C, I, and T) regulate contractions, and levels increases as with CK-MB after an MI, but levels remain elevated for up to three weeks. An ECG is most helpful if taken immediately after an MI so heart changes over time can be monitored. Myoglobin levels increase in 1 to 3 hours after an MI and peak within 12 hours. CK-MB levels increase within a few hours and peak at about 24-27 hours (earlier with thrombolytic therapy or PTCA) for Q-wave MI and 12-13 hours for non-Q-wave MI. A patient is admitted to the unit after vomiting excessively for 4 days at home. The patient's serum pH is elevated, PCO is relatively normal, and the urine pH is >6. The patient is dizzy, confused and is exhibiting tremors, seizures, tingling, tachycardia, arrhythmias, and hypoventilation. The patient is most likely exhibiting symptoms of: a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis B: These symptoms are typical of metabolic alkalosis: Elevated serum pH, PCO relatively normal (if compensated) or increased (if uncompensated), and urine pH >6 (if compensated). The patient is dizzy, confused, and is exhibiting tremors, seizures, tingling, tachycardia, and arrhythmias. Metabolic alkalosis occurs with decreased strong acid or increased base, with compensatory COretention by the lungs associated with hypoventilation. Metabolic alkalosis is usually caused by excessive vomiting, gastric suctioning, diuretics, potassium deficit, excessive mineralocorticoids, and/or excessive NaHCO intake. A patient receiving chemotherapy for cancer has developed malnutrition and is receiving parenteral feedings, but the patient has developed abdominal discomfort, nausea, and diarrhea with resultant dehydration, hypotension, and tachycardia. What is the most appropriate action? a. Reduce the osmolality of the solution and then increase slowly b. Check tube placement c. Lower glucose content of solution d. Keep head of the bed elevated at all times A: The correct action is to reduce the osmolality of the solution to prevent dumping syndrome. A concentrated solution with high osmolality can draw fluid into the stomach and intestines from the surrounding tissues and the blood, causing abdominal discomfort and fullness, nausea, and diarrhea, leading to dehydration and a drop in blood pressure and increased heart rate. Patients who are weak are more prone to dumping syndrome. Reducing the osmolality and gradually increasing it allows the body to adjust and relieves symptoms. Janeway lesions, splinter hemorrhages, mucosal petechiae, and Roth's spots are most characteristic of which of the following cardiac disorders? a. Myocardial infarction b. Endocarditis c. Myocarditis d. Pericarditis 41 | P a g e B: Endocarditis is characterized by Janeway lesions (painless areas of hemorrhage on the palms of the hands and soles of the feet), splinter hemorrhages on the nails, petechiae on the oral mucosa, and Roth's spots (hemorrhagic lesions on the retina caused by emboli on nerve fibers). Other symptoms include slow onset with low-grade or intermittent fever, anorexia, weight loss, fatigue, anemia, splenomegaly, hepatomegaly, cyanosis and clubbing of fingers, CHF, heart murmur, and embolism to other body organs (brain, liver, bones). Oxygen concentration with nasal cannula delivery ranges from: a. 24% to 44% b. 50% to 64% c. 70% to 84% d. 90% to 100% A: Oxygen concentration with nasal cannula ranges from approximately 24% to 44% because it is not an airtight system; some ambient air is breathed in as well. While a nasal cannula can be used to deliver supplemental oxygen, it is only useful for flow rates6 L/min as higher rates are drying of the nasal passages. Which of the following is NOT a barrier to systems thinking? a. A holistic view of interrelationships within the organization b. Identification with role rather than purpose c. Reliance on past experience d. Feelings of victimization A: A holistic view of relationships within the organization facilitates problem-solving along with an understanding of how structures, patterns, and events affect outcomes. Those who identify with role rather than purpose may have difficulty understanding the needs of others. Those who rely too much on past experience may be resistant to change, and a feeling of victimization makes people feel that the organization or leadership is to blame for their own personal shortcomings, and they feel there is nothing they can do to make changes. Pulse oximetry is continually monitored after cardiac surgery. Arterial oxygen saturation (SPO) levels should be maintained at: a. 90% b. 92% c. 95% d. 98% C: Oxygen saturation should be maintained at >95% although some patients with chronic respiratory disorders, such as COPD may have lower SPO. Results may be compromised by impaired circulation, excessive light, poor positioning, and nail polish. If SPO falls, the oximeter should be repositioned, as incorrect positioning is a common cause of inaccurate readings. Oximetry is often used post surgically and when patients are on mechanical ventilation. An 80-year-old female presents with a small pneumothorax upon the administration of a chest radiograph, but is not in acute distress. Which of the following treatments is the most appropriate? a. Chest-tube thoracostomy with underwater seal drainage 42 | P a g e b. Immediate needle decompression and chest-tube thoracostomy c. Catheter aspiration d. Administration of oxygen at 3 to 4 L/min and observation for 3 to 6 hours and repeat chest x-ray to monitor change D: A small pneumothorax may resolve or stabilize, so the patient should receive oxygen and be observed for 3 to 6 hours. If there is no increase in size on a repeat x-ray, the patient may be discharged but asked to return for another x-ray in 24 to 48 hours. Chest-tube thoracostomy with underwater seal drainage is the most common treatment for all types of pneumothoraces. A tension pneumothorax requires immediate needle decompression followed by chest-tube thoracostomy When evaluating cardiac output in a normal heart, a decrease in heart rate should cause the stroke volume to: a. Increase b. Decrease c. Remain unchanged d. Vary A: The heart rate is controlled by the autonomic nervous system, and in a normal heart a decrease in heart rate is usually compensated for by an increase in stroke volume. However, with cardiomyopathy, this may not occur, and bradycardia may cause a decline in cardiac output. Normal cardiac output is about 5 L/min at rest for an adult although this may multiply 3 or 4 times with exercise and stress, with resultant changes in the heart rate and stroke volume. The nurse is teaching a patient to manage tracheostomy care. The nurse has prepared written directions and a video, but the patient ignores them and picks up the pieces of equipment and looks at each part, trying to figure it out. The patient's learning style is most likely: a. Auditory b. Visual c. Kinesthetic d. Mixed C: Kinesthetic learners learn best by handling, doing, practicing and should be allowed to handle supplies/equipment with minimal directions. They benefit from demonstrating their understanding by doing the procedure. Visual learners learn best by seeing and reading and benefit from written directions, videos, diagrams, pictures, and demonstrations, whereas auditory learners learn best by listening and talking, so procedures should be explained during demonstrations. Auditory learners benefit from audiotapes and extra time for questions. A 70-year-old male with chronic cirrhosis and hepatic failure has developed portal hypertension. Which of the following is the most common complication of portal hypertension? a. Jaundice b. Blockage of the bile duct c. Hemorrhage of esophageal varices d. Abdominal distention 45 | P a g e continue to gradually reduce the diastolic pressure to 85 mm Hg with oral antihypertensive medications D. Slowly lower the diastolic pressure to 85 mm C. Rapidly lower the diastolic pressure to 100 mm Hg with IV antihypertensive medications, then continue to gradually reduce the diastolic pressure to 85 mm Hg with oral antihypertensive medication 5. Which of the following labs must be closely monitored when administering Lisinopril to a patient with systolic heart failure? A. Sodium B. Phosphate C. Magnesium D Potassium D. Potassium Patients taking angiotensin converting enzyme inhibitors may experience hyperkalemia. ACE inhibitors block angiotensin II, which may lead to decreased aldosterone. Aldosterone is responsible forexcreting potassium from the kidneys. Therefore, ACE inhibitors can cause potassium retension and potassium levels should be monitored closely. In addition, renal labs such as BUN and creatinine should be monitored. If the patient develops more than a 20% increase in the creatinine, the medication should be discontinued. A 57-year-old man was admitted with an acute myocardial infarction and is rapidly deteriorating. He has a BP of 86/42 (57), heart rate of 110, weak, thready pulses, and mottled skin-especially at the knees. He has had minimal urine output the past 8 hours. A Rapid Response is activated. Which of the following medications would be the best option to increase the patient's cardiac output? A Dobutamine B Norepinephrine C Amiodarone D Phenylephrine A Dobutamine. Dobutamine is a positive inotropic medication used to improve myocardial dysfunction on patients with a low cardiac index and elevated afterload. It will improve contractility and reduce afterload. Milrinone, which is a phosphodiesterase inhibitor could also be used as an alternative to dobutamine, in the setting of decompensated heart failure. It is used cautiously in patients experiencing cardiogiogenic shock as one of the main side effects of Milrinone is hypotension. The half life of Milrinone is about 6 hours. Norepinephrine and Phenylephrine cause vasoconstriction, which would increase the SVR and may compromise cardiac output. You are caring for a patient post gastric bypass. Which of the following parameters should you closely monitor after surgery? A* HR, RR, temperature, WBC & MAP B* Protein levels and vitamin B12 C* Albumin and pre-albumin levels D* Signs of dumping syndrome 46 | P a g e A* HR, RR, temperature, WBC & MAP You are caring for a patient admitted after a ground level fall. The patient has decreased level of consciousness. On admission the patient is ordered to be a full code. The family arrives with advanced directives stating the patient wishes not to have CPR performed or life sustaining treatment continued. The nurse approaches the provider about this discrepancy and the provider states "I am aware of the advanced directive, but the daughter wants everything done." What is the appropriate next step by the nurse? A* Ask the daughter why she wants everything done B* Collaborate with the provider and social worker to schedule a family meeting C* Tell the doctor we have to follow the patient's wishes * Discuss the situation with the nurse manager B* Collaborate with the provider and social worker to schedule a family meeting Which is the best intervention to promote safety of the patient receiving hemodialysis? A* Direct visualization of the connection between the machine and the access device B* Strict intake and output monitoring C* Strict bedrest D* Electrolyte assessment q 4 hours A* Direct visualization of the connection between the machine and the access device The nurse must be able to visualize the junction of the central venous access and the dialysis unit at all times. Disconnection can result in exsanguination within minutes. Four hours after starting an insulin infusion in a patient admitted with diabetic ketoacidosis, the patient's blood glucose is 235 mg/dL. Which of the following fluids should be administered at this point? A Hypertonic solution to hydrate the cell B D5.45 or D NS with a glucose source C Isotonic saline bolus to maintain extracellular hydration D Hypotonic saline to provide cellular hydration B D5.45 or D NS with a glucose source Dextrose should be included in IV fluids since the glucose has dropped below 250. This is done to prevent hypoglycycemia. 11. A 45-year-old male is admitted to 1500m With Severe sepsis. You are administering lactated ringers 500 ml IV boluses. A central line has been placed. Which of the findings below indicate the fluid boluses are having its intended effect? A* MAP of 55 mm Hg 47 | P a g e B* ScvO, of 52% C* Initial lactate level 4.2 mmol/L, now 1.8 mmol/L D* Urine output of 15 ml/hour C* Initial lactate level 4.2 mmol/L, now 1.8 mmol/L Early goal directed therapy for sepsis include early fluid resuscitation at 30 mL/kg to maintain the MAP greater than 65 mm Hg, ScvO2 greater that 70%, and urine output greater than 0.5 mL/kg/hr. The goal is always to normalize the lactate level. The lactate clearance (lactate decreasing to 1.8 mmol/L) is a trend in the right direction and an indirect sign of increased perfusion. 12. A 72-year-old male patient has been in the PCU for 6 days for treatment of a COPD exacerbation. He has been receiving VTE prophylaxis with subcutaneous Heparin since admission. Today, his platelet count decreased significantly to 43,000 and he was found to have a new DVT on his right upper extremity. What do you suspect is the most likely cause of these new findings? A DIC B* ITP C* HIT D* TRALI C HIT The hallmark sign of Heparin Induced Thrombocytopenia (HIT) is a significant decrease in platelet count over a 24 hour period (>50% within 5-10 days of administering Heparin. The other hallmark sign is a new development of a DVT despite being on VTE prophylaxis. DIC and ITP can decrease platelet counts but with the specific scenario of a new DVT and precipitous drop in platelets the best answer is HIT. Transfusion related acute lung injury (TRALI) is a complication from a blood transfusion reaction, which causes acute lung injury typically within 6 hours of a blood transfusion. 20. Which laboratory values are consistent in a patient with acute pancreatitis? A. Elevated lipase, elevated amylase, hypocalcemia & hyperglycemia B• Elevated lipase, elevated amylase, hypercalcemia & hyperkalemia C• Decreased lipase, elevated amylase, hypocalcemia & hyperkalemia D. Decreased lipase, decreased amylase, hypercalcemia & hypokalemia A. Elevated lipase, elevated amylase, hypocalcemia & hyperglycemia 18. Several nurses on the unit are concerned with the accuracy of a new noninvasive device measuring stroke volume. The best way to initially address their concerns is to:• A. Research new devices to replace the existing equipment• B. Discuss concerns with the attending physician during rounds• C. Request an in-service from the device company• D. Take the issue to the unit nursing research council to investigate C. Request an in-service from the device company• 19. A 22-year-old female complains of palpitations. You see the following rhythm at the monitor: AAAAA You interpret the rhythm as: 50 | P a g e 31. A patient with bacterial endocarditis should be closely observed for which of the following clinical changes? A• Pulmonary edema B• Neurologic impairment C• Oliguria D• Rising liver enzymes B. • Neurologic impairment 32. The nurse assesses a small bore feeding tube at the beginning of the shift. The feeding tube is noted to be 35 cm at the nares. In review of the chart, the feeding tube placement was documented at 75 cm at the nares after insertion. Which is the nurse's most appropriate next step? A• Reinsert guide wire and advance the feeding tube B• Instill 60 ml air and auscultate placement C• Hold tube feedings and obtain abdominal radiograph D• Remove the feeding tube and reinsert C• Hold tube feedings and obtain abdominal radiograph 33. The nurse is caring for a patient status post bariatric surgery on post op day 2. The patient is anticipated to discharge home on post op day 3 if the patient remains without complications. The nurse is reviewing the anticipated discharge medications which includes 50 mg extended release metoprolol (Toprol XL) daily. Which is the appropriate response of the nurse when seeing this on the discharge medication list? • Review the medication with the patient and expected side effects, assessing if they have taken this before • Contact the provider verifying the medication is prescribed correctly • Handoff in report to the oncoming nurse to provide education at the time of discharge • Discuss the medication with the patient's spouse 34. A treatment strategy for a patient with worsening pulmonary arterial hypertension (PAH) is: A• Imdur B• Beta Blockers C• IV Calcium Channel Blockers D• IV Epoprostenol (Flolan) D• IV Epoprostenol (Flolan) 35. The kidneys release which glycoprotein hormone to increase RBC production in the bone marrow? A • Renin B • Aldosterone C• ADH D• Erythropoietin D• Erythropoietin 51 | P a g e 36. You are caring for a patient recovering from cardiac arrest who received Targeted Temperature Management (TTM). What is the clinical rationale for providing TTM to a patient after a cardiac arrest? A• Prevent sepsis from aspiration during the arrest B• Cardiac protection C• Stabilize shock D• Neurologic protection D• Neurologic protection 37. Chest pain is best described as pleuritic when it: A• Resolves with sublingual nitroglycerin B• Occurs only during sleep C• Increases with deep inspiration and decreases when the patient sits up and leans forward D• Resolves with a deep breath C• Increases with deep inspiration and decreases when the patient sits up and leans forward 38. A patient is being treated for nephrogenic diabetes insipidus with Chlorpropamide (Diabinese). The nurse should monitor closely for: A • Hyponatremia B• Hyperkalemia C• Hyperglycemia D• Hypoglycemia D• Hypoglycemia 39. A patient presents to your unit, post-op day 3 for a cardiac transplant. During the night the patient develops symptomatic bradycardia. Your best action to treat the bradycardia should include: A• Administer Atropine 1 mg IV and apply 100% 02 B• Connect epicardial pacing wires to a generator and pace the patient C• Give Atropine and start an Isuprel infusion D• Start a Dopamine infusion B• Connect epicardial pacing wires to a generator and pace the patient 40. which laboratory findings would you expect in a patient with SADH? A• Elevated urine osmolality; decreased serum osmolality; decreased serum sodium B • Decreased urine osmolality; elevated serum osmolality; elevated serum sodium C • Elevated urine osmolality; elevated serum osmolality; decreased serum sodium D• Decreased urine osmolality; decreased serum osmolality; elevated serum sodium A• Elevated urine osmolality; decreased serum osmolality; decreased serum sodium 41. Which of the following statements is inaccurate in regard to consent for clinical care? A• Consent can be waived if the patient refuses to sign a consent form B• In the absence of an advanced directive, consent can be obtained by the next of kin C• Expressed consent is given directly by written or verbal words D• Implied consent is presumed in emergency situations 52 | P a g e A• Consent can be waived if the patient refuses to sign a consent form 42. A patient is admitted with third degree burns over 10% of the total body surface area. On arrival to the PCU, volume fluid replacement is continued. The nurse understands volume replacement is a priority to prevent which specific type of renal failure? A • Intrarenal failure secondary to systemic inflammatory response B• Post renal failure due to calculi development C• Prerenal failure related to hypovolemia and decreased perfusion D• Intrarenal failure secondary to medication administration C• Prerenal failure related to hypovolemia and decreased perfusion 43. The charge nurse responds to a Rapid Response activation for a patient admitted with abdominal pain on the medical floor. The nurse finds the patient with the following data: BP 70/32 (44) HR 140 RR 26 T 102.3° F (39.0° C) SpO, 95% pH 7.23 / PaCO, 35 / PaO, 88 / HCO, 16 Lactate 4.6 mmol/L, Na* 140 The nurse should anticipate which of the following orders? A• Administer 100 mEq IV sodium bicarbonate B • Initiate Dopamine infusion at 3 mcg/kg/min C• BIPAP 50% FiO, IPAP +10/EPAP +5 D• Administer 1 liter of lactated ringers bolus IV D• Administer 1 liter of lactated ringers bolus IV 44. Medication management in a patient post subarachnoid hemorrhage (SAH) with signs of increased intracranial pressure (ICP) includes: A• Hypotonic saline, osmotic diuretics & loop diuretics B• Beta blockers, hypertonic saline & calcium channel blockers C• Osmotic diuretics, hypertonic saline & anti-hypertensives D• Calcium channel blockers, hypotonic saline & anticonvulsants C• Osmotic diuretics, hypertonic saline & anti-hypertensives 45. A 55-year-old female presents to the ED anxious and SOB. Her 12 Lead ECG reveals a STEMI. Which of following findings suggests an absolute contraindication for thrombolytic therapy? A• Dull chest pain, ST elevation in V, V, V new left bundle branch block B• History of cholecystectomy 2 weeks ago, ST elevation in V., V, Vs C• Sudden onset severe chest and back pain, uncontrolled BP 195/115, ST elevation II, III, aVF, and a new diastolic murmur over the left sternal border D• Left arm pain, BP 180/100 easily controlled on antihypertensive meds, ST elevation in V,, V,, V3° C• Sudden onset severe chest and back pain, uncontrolled BP 195/115, ST elevation II, III, aVF, and a new diastolic murmur over the left sternal border 46. You are assessing a patient who was involved in a motor vehicle collision. You notice bruising around her umbilicus. Which of the following clinical manifestations would be consistent with an injury to the liver? A• Epigastric pain, nausea and vomiting, ileus 55 | P a g e 58. A 65-year-old male is admitted to the PCU with syndrome of inappropriate antidiuretic hormone (SIADH) resultant from a brain tumor in his frontal lobe. The serum sodium is 115 mE/L. What is the priority of nursing care for the patient? A. Fluid restriction B. Sodium replacement to 140 mEg/L C. Administration of diuretics D.Maintaining a safe environment D.Maintaining a safe environment 59. You are caring for a patient with a resolving myocardial infarction in right-sided heart failure that now requires preload reduction. This can be accomplished using medications that cause: A. Arterial dilation B. Venous dilation C. Arterial constriction D. Venous constrictor B. Venous dilation Dilation of venous vasculature reducing filling pressures in the failing heart. The most common preload reducing medications are diuretics. Nitroglycerin and morphine are venous dilators often used in acute congestive heart failure. 60. Early signs of a proximal small bowel obstruction include: A. Diarrhea B. Fever C. Increased appetite D. Vomiting D. Vomiting 61. Which of the following patients requires emergent pacing? A. 2nd degree heart block Type II with 5 second pauses B. 82 year old with complete heart block with rate of 38 & BP 108/68 C. Sinus bradycardia with 1s degree AV block D. Junctional rhythm with a rate of 52 bpm A. 2nd degree heart block Type II with 5 second pauses 62. A patient s/p coronary artery bypass grafting (CABG) develops 2nd Degree Type Il heart block. The patient has epicardial pacing wires. After connecting the pacing wires to a pacing generator, you notice pacing spikes indiscriminately during all phases of the cardiac cycle. Your best action would be: A. Increase the sensitivity value (mV) B. Decrease the sensitivity value (mV) 56 | P a g e C. Increase the milliamps (mA) D. Decrease the milliamps (mA) B. Decrease the sensitivity value (mV) Indscriminant pacing spikes indicate that pace is not sensing, or seeing all the cardiac activity present, The sensitivity should be decreased so that the pacer is better able to see or "sense" the activity occuring. 63. A patient recently admitted with congestive heart failure is being treated with loop diuretics. What signs of hypokalemia would be evident on the ECG? A. Tachycardia B. Peaked T waves C. U waves D. Widened QRS C. U waves Hypokalemia secondary to diuresis can lead to impaired myocardial conduction and prolonged ventricular repolarization, This is evident by bradycardia, flattening of T waves, and prominent u waves. Peaked T waves and a widened QRS would be secondary to hyperkalemia 64. Peritoneal dialysis works on which of the following principles? A. Osmosis and diffusion B. Diffusion and convection C. Osmosis and convection D. Diffusion and diuresis A. Osmosis and diffusion 65. A patient presents with chest pain for 6 hours. Her 12 lead EC. is unchanged from 4 months ago. Which of the following would be the most appropriate for ruling out a MI? A. Cardiac catheterization B. Stress test C. Troponin I D. Transthoracic echocardiogram C. Troponin I 66. A 52-year-old female was started on Heparin 6 hours ago for suspicion of NSTE-ACS. Her troponin is 3.8 and VSS. She suddenly complains of aching pain in her left thigh and is having trouble moving her leg. Past history reveals previous heparin therapy for suspected MI. Ultrasound reveals a large DVT of the femoral vein. Which of the following do you anticipate? A. Immediately stop the Heparin infusion & draw aHeparin antibody panel B. Prepare for administration of TPA C. Continue the Heparin & draw a Heparin antibody panel D. Prepare for stat Coumadin 57 | P a g e A. Immediately stop the Heparin infusion & draw a Heparin antibody panel There are 2 types of heparin induced thrombocytopenia; one is a mild and temporary drop in platelet count several days after exposure, and the other can cause life threatening thrombosis, particularly with repeated exposure to heparin. If the latter is suspected due to clots, the patient should received no further heparin for any purpose. A heperin antibody panel can confirm the source of this patient's clot. 67. A patient with lung cancer has the following lab values:Serum osmo 256 mOsm/kgSerum Na 120 mEq/LUrine osmo 563 mOsm/kgUrine Na 24 mEq/L Initial treatment will include: A. Desmopressin (DDAVP) B. Carbamazepine (Tegretol) C. Hydrochlorothiazide (Hydrodiuril) D. Free water restriction D. Free water restriction SIADH involves excess secretion or activation of ADH, causing water retention, dilutional hyponatremia, and water intoxication. Treatment are focused on promoting excretion of water and correcting hyponatremia. DDAVP and Tegretol are used in diabetes insipidus to replace or enhance ADH. Loop diuretics such as furosemide (lasix) may be used in SIADH, but fluid restriction is the first intervention. 68. A patient who had a 3 vessel coronary artery bypass surgery 3 days ago, just transferred to your unit. Upon performing your assessment, you detect muffled heart sounds and jugular venous distention. At the bedside monitor, you notice electrical alternans- alternating heights of the R waves on the ECG. Lung sounds are clear bilaterally. What is the next appropriate action? A. Continue monitoring as these are normal findings B. Obtain a STAT chest CT scan C. Notify the cardiac surgeon immediately D. Gather supplies for chest tube placement C. Notify the cardiac surgeon immediately The signs and symptoms listed are associated with cardiac tamponade. The cardiac surgeon needs to know immediately to perform pericardialcentesis or take the patient back to the operating room for pericardial window. Cardiace tamponade is an emergent condition; if time allows, obtain a chest X-ray. Lung sounds are audible in both lung fields which rules out tension pneumothorax. 69. A 57-year-old male is admitted with a diagnosis of hyperosmolar hyperglycemic non-ketotic syndrome (HHNS), Which of the following should you expect as an initial treatment? A. IV of 40 mEq potassium in 100 ml normal saline over 4 hours B. Single IV bolus of 10 units of insulin C. Fluid replacement with dextrose 5% in half normal saline solution D. Fluid replacement with an isotonic solution 60 | P a g e C. Notify the provider immediately D. Administer ½ amp of D50 & recheck BG in 30 min & notify the provider 79. A patient is admitted to the PCU with severe sepsis. The patient has a central line and you are asked to draw a "mixed venous" (ScO,) sample from the distal port. Which of the following findings is of greatest concern? A. ScrO, of 74% B. Urine output of 400 cc the past 4 hours C. SevO, of 45% D. MAP of 66 mm Hg 80. A 62-year-old woman develops heart failure after having a STEMI. Her cardiac ECHO reveals an ejection fraction of 32%. Administering which class of drugs has been proven to decrease mortality & slow cardiac remodeling? A. Alpha blockers B. Calcium channel blockers C. ACE inhibitors D. Digoxin PCU after a fall at their skilled nursing facility. An emergent CT scan was performed, which revealed a large intraparenchymal hemorrhage. The patient has a known history of atrial fibrillation, for which she takes warfarin 5 mg PO daily. Her INR is currently 7.5. The nurse should anticipate initial orders for: Oral phytonadione x 3 doses Protamine 50 mg IV Vitamin K 10 mg IV slowly One unit of packed red blood cells 82. A patient arrives to the PCU for close observation, 4 hours after a high speed motor vehicle collision (MVC). The unrestrained driver struck the steering wheel on impact. Significant bruising is visible on the chest and the initial chest x-ray shows bilateral rib fractures 2-8 and a sternal fracture. The patient is on a 40% venti mask. Patient data is as follows: BP 120/92 HR 130 RR 28 sp0, 88% Which of the following is most likely contributing to the hypoxemia? Hidden bilateral pnemothoracies Aspiration pneumonia Pulmonary embolism Blossoming pulmonary contusions 83. A 78-year-old female has been hospitalized for 7 days with pneumonia and sepsis. She has now developed fine crackles in the bilateral lower lobes and a S3 heart sound (ventricular gallop). Patient data are as follows: BP 90/46 (60) HR 118 61 | P a g e + Jugular venous distention The nurse reports these findings to the medical provider and anticipates which of the following orders? Lactated ringers bolus 1 Liter IV Norepinephrine 2 mcg/min IV continuous Furosemide 40 mg IV x 1 now Nitroglycerin 2 inches paste to left chest every 6 hours 84. The nurse is working with a student nurse in the care of a patient post open heart surgery. Which of the statements by the student nurse demonstrates their understanding of the risk atrial fibrillation poses to the patient? "Lung collapse can occur because of a decreased pulmonary artery occlusive pressure" "They can develop refractory hypoxemia secondary to a rapid ventricular rate" "They may develop deep vein thrombus (DVT) due to a weak, thready pulse" "There is decreased cardiac output because of the loss of the atrial kick" 85. You receive a patient from the Cath lab s/p angiogram & PCI for an acute anterior wall MI. A stent was placed to the left anterior descending artery. The patient complains of dull chest pain and dyspnea, is tachypneic, and has crackles to the bilateral lung bases. The patient has a HR of 135, BP of 88/65, cool and clammy extremities, pulses are only audible by Doppler, and no urine output since admission. The Cardiologist has ordered the patient to be transferred to the CCU to place a pulmonary artery catheter for suspected cariogenic shock. Which of the following hemodynamic profiles would be consistent with cardiogenic shock? Low cardiac output & stroke volume, increased afterload, MAP 50 mm Hg Normal cardiac output & stroke volume, decreased afterload, MAP 55 mm Hg Increased cardiac output & stroke volume, increased afterload, MAP 60 mm Hg Low cardiac output & stroke volume, decreased afterload, MAP 55 mm Hg 86. A 73-year-old male is admitted with a diagnosis of pneumocystis carinii pneumonia. The patient is HIV positive. On admission, he brought in a notarized advanced directive that identifies his 57-year-old partner as healthcare agent and his desire not to have his life prolonged. The patient's biological children arrive and make request to transfer their father to another facility for aggressive management. Which is the next most appropriate nursing response? "I'm sorry. I'm afraid you don't have a say in the matter" "Certainly. I'll get the number of the appropriate Case Manager" "Let me call the doctor so you can talk with her" "Have you made your concerns known to your father and his partner" 87. You are managing a patient with a traumatic brain injury and signs of increased intracranial pressure (ICP) being treated with hyperosmolar therapy. Of the following parameters, which would you expect to hold the administration of Mannitol? Sodium level of less than 130 Serum osmolality greater than 320 mOsm/kg Serum potassium < 4 mEq/L. Urine Output greater than 250 ml/hour 88. Priorities when caring for a patient experiencing a seizure include: Safety & DVT prophylaxis 62 | P a g e Monitoring for SIRS & preventing aspiration pneumonia Safety & administration of an anti-convulsant medication Intracranial pressure monitoring & Cerebral perfusion pressure optimization 89. A patient from the psych unit was admitted for close monitoring after drinking 8 liters of water. You would expect which of the following: Hyponatremia Hypernatremia Hypokalemia Elevated serum osmolality 90. Which of the following signs would the patient report as left shoulder pain that is indicative of ruptured spleen? Brudzinski's sign Kehr's sign Grey-Turner's sign Cullen's sign 91. An 18-year-old patient on hospital day 5 was admitted with colitis from E. coli food poisoning. Pertinent patient lab data are as follows:WBC 23,000HCT 20%Hgb 6 g/dIPlatelet count 75,000K+ 5.9 mEq/LCreatinine 3.8 mg/dl The provider decided to begin hemodialysis. The nurse understands the complication from the infection is: Immune Thrombocytopenia Purpura (ITP) Thrombotic Thrombocytopenia Purpura (TTP) Heparin-Induced Thrombocytopenia (HIT) Hemolytic-Uremic Syndrome (HUS) 92. Ibutilide (Corvert) 1 mg IV is ordered to be administered over 10 minutes to a patient in rapid atrial fibrillation. You know you must discontinue the Ibutilide for which of the following reasons? Prolonged PR interval Development of PJCs Narrowing QRS Prolonged QT interval 93. The nurse is caring for a patient admitted for medical management of a dissecting abdominal aortic aneurysm (AAA). The patient describes sudden onset severe abdominal and back pain. Patient data is as follows: HR 120 BP 138/78 (98) RR 26 0, 94% on room air Which of the following interventions is a priority in care for the registered nurse? Administer PRN IV narcotic analgesia Provide oxygen via nasal cannula Administer PRN IV beta blocker Complete assessment of peripheral movement and sensation 65 | P a g e Liver failure Type Il diabetes 106. Which hemodynamic profile is consistent with early stages of septic shock? Decreased afterload, decreased cardiac output, decreased preload Increased afterload, decreased cardiac output, decreased preload Decreased afterload, increased cardiac output, decreased preload Increased afterload, decreased cardiac output, increased preload 107. A trauma patient with multiple comorbid issues has been in the progressive care unit for several weeks and has a large surgical wound with poor healing. Which lab value is most concerning? Hematocrit 28 mL/dL Calcium 7.0 mg/dL Albumin 2.2 mg/di. Glucose 135 mg/dL 108. You are assessing a patient 24 hours after an anterior-septal wall myocardial infarction. Findings include a new, harsh holosystolic murmur and a thrill, BP 88/56 (66), HR 108, RR 35 and 0, sat 86% on 2L NC. You should anticipate which of the following diagnostics to investigate the new murmur, hypotension, rapid breathing and desaturation? Lab work and re-administration of fibrinolytics Transesophageal echo and cardiac catheterization Intubation and mechanical ventilation Echocardiogram and cardiac surgery 109. A patient is prescribed to receive a transfusion of two units of PRBCs. The nurse verifies pre- transfusion vital signs, and consent. Patient identification and the unit of blood are also verified with another registered nurse before starting the transfusion. After fifteen minutes the vital signs are assessed and the patient is chilled, with hematuria noted in the urinary catheter. Vitals signs are as follows: Т 39.0° С HR 135 RR 34 BP 86/42 (56) The nurse stops the transfusion and begins infusing normal saline. The nurse anticipates the patient is experiencing what type of transfusion reaction? Delayed hemolytic reaction Febrile/non-hemolytic reaction Mild allergic reaction Acute hemolytic reaction 110. You are admitting a 56-year-old male patient with acute hypertensive crisis. As you are preparing to start IV access, you notice the patient repositioning himself frequently in bed and arching his back on occasion. What would be the next appropriate response? "Sir, please hold still while I start your IV" "How long have you had high blood pressure?" 66 | P a g e "These beds aren't comfortable at all" "I notice you are adjusting your position often. Are you in pain?" 111. A patient was transferred to the PCU after being in the ICU for 9 days. While in the ICU the patient required mechanical ventilation and was sedated on a Lorazepam infusion for the past 7 days for alcohol withdrawal. This morning's labs reveal a new anion-gap metabolic acidosis. Which of the following is most likely the cause of the metabolic acidosis? Lactic Acid Thiocyanate Ketones Propylene glycol 112. A 34-year-old patient with bacterial meningitis is admitted to your unit. The patient is extremely anxious with signs of increased intracranial pressure. The best initial intervention is to: Assess sedation and bolus as needed Open the Ventriculostomy to allow drainage Elevate the head of the bed to 45° Administer 1 g/kg of 20% Mannitol 113. A 9-year-old female is being assessed in the ED for an acute asthma exacerbation. Which of the following presentations would most likely warrant an admission to the PU for close monitoring and treatment? Presence of inspiratory wheezes Presence of expiratory wheezes Dyspnea that interferes with activities of daily living Inability to communicate in full sentences 114. Your patient is recovering from a myocardial infarction. and you now suspect he is experiencing acute mitral valve regurgitation. Which of the following findings on the echocardiogram are supportive of the diagnosis? Increase in right atrial diastolic pressure Decrease in left ventricular diastolic pressure Increase in left atrial diastolic pressure Increase in right ventricular diastolic pressure 115. A patient with severe dehydration is admitted and found to be in acute kidney injury (AKI). An arterial blood gas is performed revealing metabolic acidosis. Patient data is as follows:pH 7.30PaCO, 29PaO, 74HCO, 14 Which is a primary principle in management of metabolic acidosis? Sodium bicarbonate should be administered with caution to avoid overcorrection. B.Sodium bicarbonate should be replaced until serumHCO, returns to baseline. Respiratory compensation of the metabolic acidosis is the primary priority. No fluid should be given to minimize risk for pulmonary edema. 116. You are caring for a patient requiring Hemodialysis with ultrafiltration. Which of the following accurately describes ultrafiltration? Movement of water across a semipermeable membrane using a pressure gradient 67 | P a g e Movement of solutes from an area of higher concentration to an area of lower concentration Movement of water and solutes from an area of lower concentration to an area of higher concentration Movement of solutes across a semipermeable membrane using countercurrent pressure gradient 117. As a member of the education council, you are tasked to create a teaching pamphlet for patients and families regarding their post open-heart recovery time. You plan to include illustrations and written information. What is the appropriate reading level for this type of teaching material? High school graduate Eighth grade College graduate Fourth grade 118. A cardinal sign of hyperosmolar hyperglycemic syndrome (HHS) is: Ketones present in urine & increased serum osmolality Decreased serum osmolality & rapid shallow breathing Markedly elevated serum glucose & altered mental status Volume overload & hypokalemia 119. A patient experiencing ST segment elevations in leads V,-V likely has an occlusion in which coronary artery? Left Anterior Descending Artery Right Coronary Artery Circumflex Artery Posterior Descending Artery 120. In a patient with aortic stenosis, you can expect which of the following upon exam: Narrowed pulse pressure Diastolic murmur Systolic murmur Widened pulse pressure 121. A patient who sustained blunt chest injury is admitted to your unit. The patient develops dyspnea and confusion and has distant heart tones. Two hours post admission the BP has changed from 140/78 to 92/78. The patient now has visible jugular venous distention. The most likely cause is: Hypovolemia Cardiac tamponade Cardiogenic shock Pulmonary edema 122. A 58-year-old African-American male is being discharged from the hospital status post hypertensive crisis. What is the highest priority in his discharge education? Lifestyle modification Medication side effects Signs and symptoms of stroke Smoking cessation 70 | P a g e D. ST segment depression and T wave inversion Myocardial ischemia changes the repolarization of the ventricular muscle. That change is seen on the 12 lead ECG as ST-segment depression and T wave inversion, which demonstrate subendocardial ischemia - - the innermost layer of muscle in the myocardium. ST-segment elevation indicates acute injury or infarction, ST segment depression and T wave elevation may indicate an electrolyte abnormality, while Q wave formation indicates total infarction. Positive inotropic agents are used to: A. improve cardiac output and tissue perfusion B. decrease water loss through the kidneys C. increase heart rate D. vasodilate vessels A. improve cardiac output and tissue perfusion The term "inotropic" refers to affecting the force of myocardial contraction. Improvement of cardiac muscle contraction leads to improved cardiac output and tissue perfusion. A patient in the ED is now being admitted to telemetry bwith complaint of chest pain and has been judged to be a possible candidate for therapy with alteplase (Activase). Which of the following is not considered a contraindication for the use of this medication? A. current antibiotic use B. recent abdominal surgery C. recent gastrointestinal bleed D. recent intracranial bleed A. current antibiotic use Use of antibiotics is not a contraindication for the use of alteplase. All the other answers -- recent abdominal surgery, recent gastrointestinal bleeding and a recent intracranial bleed -- are contraindications for the use of any fibrinolytic. The two major components that determine blood pressure are: A. systemic vascular resistance (SVR) (afterload) and cardiac output B. contractility and SVR (afterload) C. preload and SVR (afterload) D. contractility and SVR (afterload) A. SVR (afterload) and cardiac output The equation for BP is: BP = SVR x cardiac output. BP is determined by resistance of the arterial bed and the cardiac output. If the SVR (afterload) is high and the cardiac output low, the patient may still have a normal BP. the pulse pressure will be lower, but this is a compensatory response by the heart to maintain BP. If the SVR (afterload) is low (as in early septic shock), the cardiac output is very high, thereby trying to support BP. The layer of the arterial vessel wall responsible for changes in the diameter of the artery is the: A. media B. intima 71 | P a g e C. externa D. adventitia A. media The media layer of the arterial wall contains vascular smooth muscle cells and is responsible for arterial tone. Vasoactive substances released in response to the sympathetic nervous system and/or the renin- angiotensin system determine arterial tone. Intima, externa and adventitia are incorrect. A patient presents in acute distress with rales halfway up bilaterally; cool and clammy extremities; elevated jugular venous distention (JVD); oxygen saturations at 95%, down from 99%; and complaints of shortness of breath. Which of the following findings correspond to the patient's cardiac status? A. no pulmonary congestion, normal perfusion B. no pulmonary congestion, low perfusion C. pulmonary congestion, normal perfusion D. pulmonary congestion, low perfusion D. pulmonary congestion, low perfusion Rales indicate fluid in the alveolar sacs, possibly secondary to pulmonary edema, causing pulmonary congestion. Pneumonia can also cause fluid in the alveolar sacs. The patient is complaining of shortness of breath, and the oxygen saturations are lowering, also indicating that the patient has pulmonary congestion. The patient's skin is cool and clammy, indicating that the skin is poorly perfused. Skin does not require oxygen and shunts blood away in decreased cardiac function; therefore, this patient has pulmonary congestion and low perfusion state. The other answers are incorrect. When listening to heart sounds, S1 signifies which of the following? A. the beginning of ventricular systole B. the beginning of ventricular diastole C. the propulsion of blood into a non-compliant ventricle D. the blood going in the wrong direction A. the beginning of ventricular systole The heart sound of S1 indicates the opening of the aortic and pulmonic valves and marks the beginning of ventricular systole or ejection. The beginning of diastole is after S2, propulsion of blood into a noncompliant chamber is S4, and blood going in the wrong direction will cause a murmur. A patient with pulmonary edema has impaired diffusion due to: A. increased thickness of the alveolar capillary membrane B. retaining CO2 C. an elevated body temperature associated with pulmonary edema D. low barometric pressure A. increased thickness of the alveolar capillary membrane With increasing left ventricular pressures, blood moves back into the left atrium, then to the pulmonary veins. When the pressure in the pulmonary veins increases, capillary function decreases, and fluid then shifts to the interstitial space, causing interstitial edema, thereby, increasing the thickness of the space oxygen must travel. When left ventricular pressures increase, the fluid then shifts to the alveolar space, causing pulmonary edema. This fluid acts as a deterrent to oxygen diffusion. Retention of CO2 does not 72 | P a g e impair diffusion. An elevated body temperature associated with pulmonary edema is not causing a diffusion abnormality; increased temperature shifts the oxyhemoglobin curve to the right, more quickly releasing oxygen to the tissues. Low barometric pressure has no effect on diffusion of gases in the lung. A patient with an anterior-wall STEMI is in cardiogenic shock. What would be the hemodynamic profile assessment? A. decreased cardiac index, increased preload, increased afterload B. decreased cardiac index, decreased preload, increased afterload C. decreased cardiac index, decreased preload, decreased afterload D. increased cardiac index, decreased preload, decreased afterload A. decreased cardiac index, increased preload, increased afterload In a patient with cardiogenic shock, both preload and afterload are increased due to severe vasoconstriction on both the venous and arterial side. Arterial vasoconstriction increases afterload and therefore lowers cardiac index. Because the ventricle is failing and contractility is also low, the left ventricular pressures increase and cause blood to increase in the pulmonary bed, resulting in increased right ventricular pressures and preload. In heart failure, there is an increase in preload and afterload with a decrease in cardiac index and contractility. The other answers are incorrect. A patient is discharged with the diagnosis of severe peripheral vascular disease (PVD). In addition to medication and a walking regime, if applicable, which of the following is essential education at time of discharge? A. nutritional counseling B. smoking cessation counseling C. social work consult D. speech therapy consult B. smoking cessation counseling Cessation of tobacco use is the most important non-pharmacological intervention that can be done to improve signs and symptoms of peripheral bvascular disease. Social work consult and speech therapy may not be indicated in this patient. All patients may benefit from nutrition counseling; however, this is not a primary concern for this patient. A medication that dilates both the venous and arterial beds will cause which of the following results? A. increased preload, decreased afterload B. increased preload, increased afterload C. decreased preload, decreased afterload D. decreased preload, increased afterload C. decreased preload, decreased afterload When both the venous and arterial beds are dilated, there will be less venous return, causing a decreased preload (ex. nitroglycerin). With arterial vasodilation, the afterload will decrease (ex nitroprusside, ACE-I). Afterload in this case is resistant to LV pumping. Stable angina is best defined as: A. pain that increases in severity B. pain that is new 75 | P a g e B. left ventricular hypertrophy C. left ventricular dilation D. right ventricular dysfunction B. left ventricular hypertrophy With chronic aortic stenosis, the left ventricle hypertrophies over time due to the increased workload of pumping blood through a narrowed opening. This leads to diastolic dysfunction as well as hypertrophy. The left atrium will enlarge over time, but the primary result is left ventricular hypertrophy, not dilation. The right ventricle remains normal for a period of time. Patients with pericardial effusions should be assessed for the development of which of the following complications: A. thrombocytopenia B. tamponade C. low hemoglobin and hematocrit D. endocarditis B. tamponade Any patient with a pericardial effusion should be assessed for cardiac tamponade physiology. Any accumulation of fluid in the pericardial sac can compress the myocardium, producing tamponade signs and symptoms. All patients are assessed for thrombocytopenia, low H+H and endocarditis; they are not the focus of complications with effusions but could be additional signs of tamponade (low H+H and thrombocytopenia). Nursing interventions in the patient with pericarditis include all the following except: A. providing comfort by administering pain medications and proper positioning B. auscultating heart sounds to assess for muffled heart sounds C. administering anticoagulants to prevent thrombus in the pericardium D. monitoring for jugular venous distention (JVD) and hypotension C. administering anticoagulants to prevent thrombus in the pericardium A patient with pericarditis should have pain-relief medication. The nurse should auscultate heart sounds and assess if they are muffled (a sign of possible tamponade), and monitor for JVD and hypotension (more signs of tamponade physiology). Do not give anticoagulants to the patient since they may cause bloody pericardial effusions and tamponade. Epinephrine is indicated as the first-line drug for any pulseless condition because it has the following actions: A. inotropic and selectively shunts blood to brain and heart B. converts ventricular fibrillation to sinus rhythm C. slows the heart rate and improves contractility D. causes decreased contractility, A. inotropic and selectively shunts blood to brain and heart Epinephrine is a pure catecholamine that increases contractility and causes vasoconstriction that shunts blood to the heart, brain, and diaphragm. According to ACLS, it is the drug of choice for any pulseless 76 | P a g e arrest. Epinephrine does not convert VF to any rhythm, slow heart rates or cause decreased contractility. The most common postoperative complication of coronary artery bypass (CABG) surgery is: A. bleeding B. stroke C. atrial fibrillation D. ventricular fibrillation C. atrial fibrillation The most common complication after CABG is the dysrhythmia atrial fibrillation. In approximately 33% of all patients who have atrial fibrillation, the mechanism is not completely understood. Postoperative myocardial edema may cause an atrial stretch, facilitating electrophysiological abnormalities. Other complications include bleeding, stroke, and ventricular fibrillation, but they are not the most common. An NSTEMI is differentiated from an unstable angina by: A. location of chest pain B. cardiac biomarker elevation C. ECG changes D. extent of cardiac history B. cardiac biomarker elevation In the NSTEMI vs unstable angina patient, the location of pain may be the same. Regarding ECG changes, both may have ST-Twave depression in the associated leads. The history of a patient with myocardial ischemia may not be pertinent. In an unstable angina, the patient may have ECG changes, but no cardiac enzyme changes. In NSTEMI, the patient will have cardiac enzyme elevation. The nurse auscultates an S3 on a patient just admitted with NSTEMI. What does that indicate? A. normal heart sounds B. mitral valve stenosis C. fluid overload D. increased afterload C. fluid overload The auscultation of an S3 is always abnormal in the adult patient. It indicates an overfilled left ventricle at the beginning of ventricular diastole and is a marker of poor ventricular function as well as fluid overload. S3 does not reflect mitral valve stenosis (diastolic murmur) or increased afterload The primary function of beta blocker therapy in heart failure is to: A. increase BP B. block compensatory vasoconstriction and increase heart rate C. increase urine output D. decrease preload B. block compensatory vasoconstriction and increase heart rate The treatment of heart failure is to reduce the actions of the sympathetic nervous system and the renin- angiotensin system. Beta blockers block the SNS and reduce afterload, slightly reduce contractility and improve heart rate regulation. These decrease the demands of oxygen for the patient with reduced 77 | P a g e ventricular function. Beta blockers do not increase heart rate, nor do they increase urine output or change preload in any way. Early symptoms of fluid overload and pulmonary edema are: A. rales and hypoxia B. S3 heart sound and tachycardia C. complaint of shortness of breath and orthopnea D. ST segment elevation in the chest leads C. complaint of shortness of breath and orthopnea Remember that symptoms are what the patient complains of, not signs that the nurse measures. Rales and hypoxia, S3 and tachycardia are signs that are measured at the bedside. ST segment elevation is a sign of cardiac injury/infarction. A complaint of shortness of breath and the inability to lie down are symptoms of early left-ventricular failure. An elderly patient is admitted and placed on warfarin (Coumadin) for arterial fibrillation. What is a therapeutic range for anticoagulation for this patient? A. international normalized ration (INR) less than 1.0 B. INR between 1.0 and 1.5 C. INR between 2.5 and 3.5 D. INR between 4.5 and 6.0 C. INR between 2.5 and 3.5 The therapeutic range of INR for any patient with atrial fibrillation is 2.5-3.5, no matter what their age. A normal INR is 1.0, and 4.5-6.0 is a high INR. After cardiac transplantation, the patient is placed on cyclosporine modified (Gengraf). In assessing this patient, the nurse should monitor: A. Blood glucose B. serum creatinine C. serum amylase D. serum magnesium B. serum creatinine When a patient is on cyclosporine for antirejection, serum creatinine should be followed closely. Cyclosporine is eliminated via the kidneys and can cause renal injury and failure. Of course, blood glucose should be monitored; however, this questions is looking for the consequence of a drug on renal function. Serum amylase is affected by liver disease or pancreatitis, and serum magnesium should always be monitored; however, it is not affected by cyclosporine. An elderly patient on warfarin (Coumadin) therapy has been admitted with an INR of 6.0. What is the antidote that can be used to counteract the effects of warfarin and decrease the risk of bleeding? A. vitamin A B. vitamin B12 C. vitamin C D. vitamin K 80 | P a g e C. metoprolol (Lopressor) Beta blockers are the best treatment for the prevention of an abdominal aortic aneurysm rupture. The other answers are all angiotensin-converting enzyme inhibitors and will decrease the patient's hypertension; it is the beta blocker that is suggested for this patient. Beta blockers, while decreasing blood pressure, also inhibit the force of ventricular contraction, which helps prevent tension on the aortic wall, thereby reducing stress and the possibility of rupture. During the treatment of supraventricular tachycardia, which medication is given rapidly intravenous (IV) push and may result in a brief sinus pause? A. lidocaine (Xylocaine) B. epinephrine (Adrenaclick) C. adenosine (Adenocard) D. procainamide C. adenosine (Adenocard) Adenosine is used for the treatment of supraventricular tachycardia. It is given as a rapid IV push with a large saline flush. It often results in a sinus pause, then the rhythm converts to sinus. None of the other medications are used for supraventricular tachycardia. You are caring for a patient recently admitted with an inferior wall MI. Which of the following 12-lead ECG findings would you anticipate? A. T wave inversion in leads I and aVL B. Q wave formation and ST segment elevation in leads II, III, and aVF C. QRS duration greater than 0.01 in all leads D. R wave taller in V6 B. Q wave formation and ST segment elevation in leads II, III, and aVF With STEMI, the patient will have ST segment elevation. The inferior leads are II, III, and aVF. T wave inversion in leads I and aVL indicate ischemia in the anterior leads. QRS duration that is prolonged may indicate an intraventricular conduction defect, and an R wave taller in V6 is a bundle branch block. A thoracic aortic aneurysm causes chest pain that: A. radiates to the left arm B. radiates through to the back C. is sharp and worse while reclining D. is associated with diminished breath sounds B. radiates through to the back Typically aortic aneurysms present with severe, acute onset of chest pain that radiates through to the back. Pain that radiates to the left arm may indicate myocardial ischemia. Sharp pain worsening with the reclined position may be pericarditis, and diminished breath sounds could be anything that is caused by decreased tidal volume. The most common ECG changes that occur during pulmonary embolus are: A. Q waves in AVR and Lead I B. tachycardia 81 | P a g e C. Bradycardia and ST segment depression D. high degree AV blocks B. tachycardia The most common ECG changes that occur with pulmonary embolism are tachycardia ( a good first clinical condition of almost anything) and atrial fibrillation due to increased pulmonary pressure, The other answers are incorrect. The anterior left ventricle receives blood via the: A. left circumflex artery B. right coronary artery C. posterior descending coronary artery D. left anterior descending coronary artery D. left anterior descending coronary artery The left anterior descending coronary artery perfuses the entire left anterior section of the left ventricle, two-thirds of the septum and the apex of the left ventricle. The right coronary artery perfuses the right ventricle. The left circumflex perfuses the left lateral ventricular wall, and the posterior descending coronary artery perfuses the inferior right and left ventricular wall. Patients with occlusion of the right coronary artery are at high risk for the development of Mobitz type I heart blocks. This is because 90% of the population use the right coronary artery to supply which part of the conduction system? A. sinoarterial (SA) node B. artrioventricular (AV) node C. bundle branches D. Purkinje fibers B. artrioventricular (AV) node Although the right coronary artery perfuses the SA node, it is the AV node ischemia that would cause a Mobitz Type 1 heart block. The bundle branches and the Purkinje fibers are perfused by the right and left circulation and if ischemic, would cause worse dysrhythmias such as complete heart block or idioventricular rhythm. The amount of oxygen delivered to the tissues is determined by what factor: A. cardiac output B. hemoglobin levels C. oxygen saturation D. all of the above D. all of the above Cardiac output, hemoglobin levels and oxygen saturation all contribute to the amount of oxygen delivered to the tissues When assessing myocardial chest pain, which of the following is not a common characteristic of angina: A. discomfort that is precipitated by exercise B. discomfort that is described as pressure or tightness 82 | P a g e C. discomfort that is relieved with rest or nitroglycerin D. pain that is intermittent and that comes and goes D. pain that is intermittent and that comes and goes Myocardial ischemia causing pain has the usual characteristics of precipitation by exercise or exertion, described as pressure or tightness, and relief by rest and/or nitroglycerin. Intermittent pain that comes and goes is not the usual presentation of myocardial ischemia. Signs of venous peripheral vascular disease in the legs include: A. brown pigmentation at the ankles, warm legs, open area over the lateral malleolus B. normal color, severe pain, open sore at the end of the great toe C. shiny skin with no hair, pale extremities, pain with ambulation D. pitting edema, absent pulses, thick toenails, feet becoming cyanotic when dependent A. brown pigmentation at the ankles, warm legs, open area over the lateral malleolus Arterial insufficiency Etiology: arteriosclerosis Risk factors: smoking, DM, HTN Pain: severe muscle ischemia, intermittent claudication, worse with exercise, pain at rest, muscle fatigue, cramping, numbness Vascular: decreased or absent pulses, pallor and rubor Skin changes: shiny, dry, nail changes, coolness Venous insufficiency Pain: minimal to moderate steady pain, aching Skin: thickening in tissues, dark, cyanotic, thickened and brown, with ulceration at sides of ankles (a medial malleolus classic), and legs are warm since there is normal arterial circulation A patient presents with pulmonary edema characterized by tachycardia, hypertension and cough with frothy sputum. What initial treatments are most common? A. oxygen, nitroglycerin, loop diuretics, and morphine B. oxygen, thiazide diuretics, and ACE inhibitors C. oxygen and thiazide diuretics D. oxygen, morphine, and calcium channel blockers A. oxygen, nitroglycerin, loop diuretics, and morphine The first line drugs of choice for acute pulmonary edema are oxygen, loop diuretics such as furosemide (Lasix), nitroglycerin (preload reducer and increased myocardial blood flow), and morphine (vasodilator to reduce preload, decrease pain and anxiety; pain and anxiety increase the oxygen needs of the myocardium). Thiazide diuretics, ACE inhibitors and calcium channel blockers are not used as first line drugs in treatment of pulmonary edema. A patient who experienced an episode of severe chest pain and weakness four days earlier is undergoing diagnostic tests. Which test would provide the most accurate information to diagnose a myocardial infarction after four days? A. an ECG B. creatine-kinase and isoenzyme (CK-MB) 85 | P a g e An atrial septal defect is characterized by: A. shunting of blood returning from the lungs through the left atrium back to the right atrium and then returns to the pulmonary circulation B. left to right shunt, increased pulmonary hypertension and right-sided heart failure C. right ventricular hypertrophy from increased pressure in the right ventricle and decreased pulmonary flow D. Left ventricular wall hypertrophy A. shunting of blood returning from the lungs through the left atrium back to the right atrium and then returns to the pulmonary circulation An arterial septal defect (ASD) allows blood from the left atrium (due to higher pressure gradient in the left atrium) to return to the right atrium and then the right ventricle before returning to the lungs. This causes a shunting of oxygenated blood to go through the pulmonary circulation again. This may cause pulmonary congestion. A ventricular septal defect (VSD) causes blood to cross from the left ventricle to the right ventricle, causing pulmonary hypertension and right ventricular failure. The other answers are incorrect. The jugular venous pulse is particularly valuable for assessing: A. right atrial function B. left atrial function C. right ventricular function D. left ventricular function A. right atrial function The jugular venous pulse is an excellent tool to assess the right ventricle. The right atrium is filled by the superior vena cava; the jugular comes off the SVC. The jugular vein will have increased pulsations when the right atrium is overloaded or overfilled. With acute right ventricular failure, the patient will have jugular venous distention. With prolonged right ventricular failure, the patient may exhibit JVD, but only when the right artria is involved. Which of the following vasodilators primarily dilates coronary arteries and is used to treat angina and supraventricular tachycardia? A. diltiazem (Cardizem) B. captopril (Capoten) C. nitroglycerin D. sodium nitroprusside (Nipride) A. diltiazem Diltiazem is an excellent vasodilator (classified as a non-dihydropyridine calcium channel blocker) with the property to dilate the coronary arteries and to treat supraventricular tachycardia. It is also a selective coronary vasodilator. It dilates coronary vessels better than it does systemic vascular beds. It is also used to decrease heart rate and treat supraventricular arrhythmias, inculding SVT. Captopril, an ACE-I, is also a vasodilator but has no affect on coronary circulation. Nitroglycerin, a well known coronary artery dilator, and nitroprusside, an excellent arterial and venous vasodilator, have no affect on SVT. 86 | P a g e A 70 year old female presents in cardiogenic shock secondary to myocardial infarction. Which of the following symptoms are consistent with cardiogenic shock? A. hypertension with systolic blood pressure greater than 90 mm Hg, bradycardia, chest pain and tachypnea B. hypotension with systolic blood pressure less than 90 mm Hg, tachycardia, dysrhythmias and tachypnea C. hypotension with systolic blood pressure less than 90 mm Hg, dysrhythmias and slow, labored breathing D. hypotension with systolic blood pressure less than 90 mm Hg, bradycardia and slow, labored breathing B. hypotension with systolic blood pressure less than 90 mm Hg, tachycardia, dysrhythmias and tachypnea Cardiogenic shock presents with low cardiac output syndrome: tachycardia, low systolic pressure, elevated diastolic pressure (decreased pulse pressure), tachypnea due to tissue hypoxia, and dysrhythmias due to myocardial ischemia. Hypertension does not fit with low cardiac output syndrome, nor does slow labored breathing. A patient is admitted 4 days postoperatively from an ascending aortic aneurysm repair. He acutely develops shortness of breath after his first time ambulating in the hall. The nurse should consider what possible problem? A. acute heart failure B. acute postoperative pneumonia C. pulmonary embolus D. routine postoperative pain C. pulmonary embolus At 4 days postoperative with acute shortness of breath after first time ambulation, the nurse should suspect pulmonary embolus. Acute heart failure is not a usual postoperative problem with this type of patient unless he or she had heart failure before surgery. Acute postoperative pneumonia may present with shortness of breath with activity, but the patient may have other signs and symptoms such as tachycardia, increased respiratory rate, fever, and cough. Routine postoperative pain does not occur acutely; this is a change in patient condition. The most common new-onset dysrhythmia seen in a patient with acute decompensated heart failure is: A. right bundle branch block B. ventricular tachycardia C. atrial fibrillation D. complete heart block C. atrial fibrillation Atrial fibrillation is the most common dysrhythmia in the heart failure patient. When interpreting an arterial blood gas, which of the following is one of the most important aspects for developing a treatment plan? A. pH B. arterial oxygenation 87 | P a g e C. venous oxygenation D. arterial bicarbonate A. pH The pH is most important since it establishes whether the patient is compensating. It also directs the action of the caregiver. If the pH is acidotic, that may be an indication for intubation. If the pH is alkalotic, the patient may require intubation or other means of support to improve oxygen delivery. Arterial oxygenation may be assessed using the pulse oximetry. Venous oxygenation is a good tool for the assessment of oxygen consumption, but not delivery. Arterial bicarbonate is a way to measure metabolic characteristics. A patient who is postoperative day 2 after a pancreatic resection for hemorrhagic pancreatitis is now complaining of acute shortness of breath with rales bilaterally and increasing oxygen requirements. This could be the beginning of: A. acute respiratory distress syndrome B. asthma C. postoperative pain syndrome D. gastric bleed A. acute respiratory distress syndrome Any patient with an inflammatory disorder (such as postoperative abdominal surgery) can develop acute respiratory distress syndrome approximately 24-36 hrs post event. The signs and symptoms include acute shortness of breath, rales bilaterally, diffuse bilateral ground-glass appearance, or white-out, on chest x-ray and increased requirements for oxygen. Asthma would include wheezing. Postoperative pain would not likely cause rales. A gastric bleed would not cause rales. A patient presents with acute decompensated heart failure and pulmonary edema. The patient has rales, dyspnea, tachycardia and cyanosis. Oxygen therapy is instituted. What other therapies will be started? A. oxygen therapy only B. diuretic therapy C. oxygen therapy and inotropic therapy D. fluid resuscitation will be required B. diuretic therapy The initial therapy for acute decompensated heart failure (pulmonary edema) is diuretic therapy and oxygen supplementation. The patient is fluid oveerloaded and requires diuresis with oxygen therapy for increased oxygen needs. Administering fluid will worsen the heart failure and increase the patient's work of breathing. A patient is admitted to your floor with the following arterial blood gas. pH 7.55 CO2 28 PaO2 88 HCO3 26 What is the interpretation? A. respiratory acidosis B. compensated metabolic alkalosis C. non-compensated respiratory alkalosis D. metabolic alkalosis 90 | P a g e Assessment of the patient with acute respiratory failure should include: A. mental status B. work of breathing C. oxygen saturations D. all of the above D. all of the above Again, be careful with these questions. Mental status changes occur with oxygenation problems or CO2 elevation and occur early in respiratory failure. Work of breathing and oxygen saturations are part of the basic respiratory assessments as well as respiratory rate. The patient goals for acute respiratory failure include: A. improve oxygenation greater than 60 mmHg B. allow for CO2 elevation greater than 60 mmHg C. allow respiratory rates greater than 35 to lower CO2 D. medicate the patient with anti-anxiety medications to lower respiratory rate A. improve oxygenation greater than 60 mmHg In most patients with acute respiratory failure, the goal is to maintain the most normal ABG possible; however, since many patients may not be able to attain that, the physician may ask for permissive hypoxia or allow for the PaO2 to be lower than normal or above 60 mm Hg. A goal for the patient would be to maintain or allow for slight increase in CO2; not to allow CO2 elevation above 60 mm Hg. An adult with a respiratory rate greater than 35 is in need of intubation and is working extremely hard to maintain gas exchange. This patient will not be able to tolerate this rate for long. The diaphragm requires more oxygen as the rate increases and will tire. The prevention of pulmonary emboli is geared toward prevention of: A. abdominal compartment syndrome B. deep vein thrombus formation C. hyperglycemia D. hyperthermia B. deep vein thrombus formation Over 90% of pulmonary emboli in the hospitalized patient originate from DVT, usually in the leg. Prevention of DVT has become of great importance and is an outcome goal. Abdominal compartment syndrome, hyperglycemia and hyperthermia are all complications that may occur in the postoperative patient, but do not have primary relationships to DVT and pulmonary emboli. One major complication of pulmonary embolus is: A. pulmonary infarction B. gastrointestinal infarction C. liver failure D. leg edema A. pulmonary infarction A pulmonary embolus is a venous embolus originating most commonly from a DVT from the leg. This travels into the pulmonary artery and occludes a small pulmonary artery. Distal to the occlusion, there 91 | P a g e will be no further circulation and infarction may occur in a segment of the lung; the size of infarct is dependent on the size of the embolus. Liver and gastrointestinal infarctions are not related to pulmonary emboli. Leg edema is not a complication of pulmonary emboli, but may result from DVT. The most common cardiac complication of post-thoracic (lung) surgery is: A. fluid overload B. pneumonia C. renal failure D. atrial fibrillation D. atrial fibrillation Because of the lung resection process, pulmonary pressure are elevated after lung surgery and may cause acute elevations in intrathoracic pressure, putting a stretch across the atria. This increase in pressure and stretch causes premature atrial complexes and the development of atrial fibrillation. Pneumonia is a complication of any surgery, but is not the most common in the postoperative lung surgery patient. Fluid overload is a complication of post lung surgery, but not the most common cardiac complication, nor is renal failure a cardiac complication. Which of the following parameters is used as an estimate of alveolar ventilation? A. PaO2 B. PaCO2 C. pH D. alveolar-arterial oxygen gradient B. PaCO2 A good estimate of alveolar ventilation is the patient's PaCO2 level. With good alveolar ventilation, the patient is washing out the CO2. With ventilatory failure, the PaCO2 increases. Remember: alveolar ventilation=tidal vol - dead space x frequency PaO2 reflects the oxygen in the blood, pH is the measure of acid/base of the blood and alveolar-arterial oxygen gradient is a measure of how much oxygen is transported from the alveolus to the arterial blood. The other answers are incorrect. At which level of FiO2 support is oxygen toxicity thought to develop? A. 30-40% for longer than 48 hrs B. 40-50% for longer than 2 hrs C. more than 50% for longer than 24-28 hrs D. FiO2 does not cause oxygen toxicity C. more than 50% for longer than 24-28 hrs Oxygen toxicity does occur in adults and is related to the amount of FiO2 over time. FiO2 at more than 50% for more than 24 hrs can cause toxicity. Toxicity is seen as increasing atelectasis due to decreased surfactant production. Inspired oxygen at levels less than 50% will not cause toxicity. Which of the following is a goal for positive end expiratory pressure (PEEP) therapy? A. to improve CO2 elimination B. to treat a metabolic acidosis 92 | P a g e C. to reduce postoperative abdominal bleeding D. to allow reduction in FiO2 support D. to allow reduction in FiO2 support PEEP therapy is used for improving oxygenation and for alveolar recruitment. Improving oxygenation would allow the practioner to decrease FiO2 support. PEEP does not help to eliminate CO2; increasing respiratory rate will lower CO2. Metabolic acidosis is corrected with treatment of the cause of acidosis such as: increased lactic acid, renal failure and/or diabetic ketoacidosis (DKA). For the postoperative cardiothoracic surgery patient who has chest bleeding, increasing the PEEP on the ventilator may reduce chest bleeding by tamponading the bleeder; this is not a common practice with other types of bleeding Which of the following is a complication of mechanical ventilation and positive end expiratory pressure (PEEP) therapy? A. atelectasis B. oxygen toxicity C. reduced cardiac output D. acute respiratory distress syndrome (ARDS) C. reduced cardiac output Because positive pressure ventilation increases intrathoracic pressures, this may cause a reduction in venous return and therefore a reduction in cardiac output. Reduced cardiac output is the most common complication of mechanical ventilation and the use of PEEP. PEEP therapy may reduce the FiO2 on the ventilator, and therefore decrease the complication of oxygen toxicity. Atelectasis and ARDS are treated mainly with increased PEEP; they are not complications of this treatment methodology. Pulmonary emboli produce all of the following physiologic changes except: A. pulmonary hypertension B. arterial hypoxemia C. hypocarbia D. left ventricular failure D. left ventricular failure With pulmonary emboli, the pulmonary pressures become elevated and may cause acute right ventricular failure. The left ventricle has no increase in afterload. A patient who becomes hypoxemic will increase his or her respiratory rate causing a lowered PaCO2 (hypocarbia). With pulmonary emboli, the patient typically has hypoxemia due to the decrease in alveolar perfusion. A patient just admitted to your floor from the PACU is agitated and has tingling of the fingers. ABG on room air reveals: pH 7.49 PaCO2 25 PaO2 95 HCO3 24 Which of the following is correct? A. normal acid-base balance B. compensated respiratory alkalosis C. uncompensated respiratory alkalosis D. uncompensated metabolic alkalosis 95 | P a g e A patient with a closed head injury has developed a fever of 104F (40C). The nurse understands that an increasing temperature: A. may cause improved intracranial pressure B. may cause increased oxygen requirements of the brain tissue C. may cause no change in neurologic functioning D. is easily lowered with acetaminophen (Tylenol) B. may cause increased oxygen requirements of the brain tissue Elevated systemic and brain temperature will increase the oxygen requirements of the brain tissue at a time when oxygen delivery may be in jeopardy. Increased temperature may actually increase ICP. If the temperature is secondary to the brain injury, acetaminophen will not decrease the hypothalamic mediated increased temperature. With increasing intracranial pressure (ICP), the patient's blood pressure will change. What is the blood pressure response to increasing ICP? A. only systolic blood pressure will increase B. only diastolic blood pressure will increase C. systolic blood pressure will increase with a decrease in diastolic blood pressure D. the pulse pressure will narrow C. systolic blood pressure will increase with a decrease in diastolic blood pressure With increasing ICP and brain stem edema, the systolic pressure elevates with a decrease in diastolic pressure, thereby widening the pulse pressure. This is a significant change that accompanies increasing ICP. There will also be a decreased heart rate. What are the signs of Cushing's triad, which indicates increasing intracranial pressure? A. lowered systolic blood pressure, decreased heart rate, lowered pulse pressure B. lowered systolic blood pressure, increased heart rate, lowered pulse pressure C. elevated systolic blood pressure, decreased heart rate, widened pulse pressure D. elevated systolic blood pressure, increased heart rate, widened pulse pressure C. elevated systolic blood pressure, decreased heart rate, widened pulse pressure An ICP increases, a variety of vital sign changes occur that is known as Cushing's triad. This includes: elevated systolic blood pressure, decreased diastolic blood pressure with a resultant widening pulse pressure. The heart rate also drops. This type of vital sign change does not occur with any other type of patient problem (such as volume depletion, heart failure or stress) After a spinal tap, the patient complains of severe headache, visual disturbances and nausea. An autologous blood patch may be injected near the puncture site in order to: A. prevent infection B. relieve local pain C. plug the puncture hole in the dura D. reduce edema at the puncture site C. plug the puncture hole in the dura After a spinal tap, the dura is penetrated and may stay open with a cerebrospinal fluid leak -- causing headache, visual disturbances and nausea and/or vomiting. A blood patch is injected epidurally near the 96 | P a g e puncture site to plug the puncture hole in the dura. The post-procedure headache results from loss of cerebrospinal fluid through the puncture hole, resulting in brain displacement and stress on supporting structures of the brain. Headache onset is usually 12 to 48 hours after puncture but may be delayed. Conservative treatment may include bed rest, fluids, and caffeine. The blood patch does not prevent infection, relieve local pain at the site or reduce edema, it only prevents further leak of cerebrospinal fluid. Two months after an ischemic stroke, a patient has difficulty understanding and producing language in speaking, reading and writing but can understand gestures, pictures and diagrams. This type of aphasia is: A. global B. transient C. Broca's D. Wernicke's A. global The term aphasia is the loss of the ability to use and/or understand written or spoken language. Global aphasia is characterized by difficulty understanding gestures, pictures and diagrams. transient aphasia is short-lasting, and often related to transient ischemic episodes. Broca's aphasia is characterized by the ability to understand, but difficult producing, language. Wernicke's aphasia is characterized by difficulty understanding language but with the ability to understand gestures and produce language. The most appropriate first-line drug for treatment of a seizure is: A. lorazepam (Ativan) B. midazolam (Versed) C. phenytoin (Dilantin) D. phenobarbital A. lorazepam (Ativan) According to ACLS, the first-line drug for the emergent treatment of seizure activity is lorazepam. Although midazolam is a sedative, it is not a first-line drug for seizure activity. Although phenytoin and phenobarbital are both frequently used in the suppression of seizures, they are not considered first-line drugs. The first 24 hours after stroke, the patient is at high risk for multiple complications. One complication that the nurse can protect the patient from is: A. bleeding B. decreased level of consciousness C. aspiration D. speech abnormality C. aspiration The post-stroke patient is most risk for aspiration since he or she may have swallow abnormalities. Patients who are poststroke should have a swallow evaluation before the reinstitution of feeding. Aspiration precautions should be initiated after stroke and continued until a complete swallow evaluation is done. The nurse cannot prevent bleeding, changes in consciousness or the presence of a speech abnormality; however, the nurse can assess and monitor these changes. 97 | P a g e A patient with a known seizure disorder falls to the floor having a generalized grand mal seizure. Which of the following options is most appropriate nursing action? A. position the patient flat on his or her back and loosen clothing B. place a tongue blade between his or her teeth C. do not touch the patient until the seizure subsides D. position the patient on his or her side with head flexed forward D. position the patient on his or her side with head flexed forward If a patient is having a generalized grand mal seizure, the priority is to first maintain an open airway. Placing the patient on his side with his head flexed forward will keep his tongue forward and prevent aspiration. Placing the patient flat on his back will not prevent aspiration. The patient should never be restrained or anything placed in his mouth. The answer to most medical-surgical questions should be the first priority care: airway, breathing, circulation and drugs. When plasma glucose falls to 250 mg/dL in acute diabetic ketoacidosis (DKA), IV fluids should be changed to D5 1/2NS to prevent which of the following? A. hyperglycemia B. hyperkalemia C. cerebral edema D. the Somogyl effect C. cerebral edema When lowering blood sugar in DKA, the patient is also fluid-depleted secondary to hyperosmolar diuresis. In that hypovolemic state with lowered blood sugar, the brain requiresfluid replacement. Dropping blood sufar too quickly without fluid replacement will cause severe cerebral edema. Hypotonic solutions will only cause cerebral edema to worsen because fluid moves from the vasculature to the interstitial space. Hyperglycemia doesnot occyur. The Somogyi effect is the rapid raise of blood sugar early in the morning after blood-sugar levels have dropped in the late evening because of too high of an insulin level during the late evening and early morning. In diabetic ketoacidosis (DKA), the patient has an increased serum osmolality. In the initial state of DKA, what are the other dangerous electrolyte abnormalities? A. hypernatremia B. hyponatremia C. hypocalcemia D. hyperkalemia D. hyperkalemia Initially, the patient has high serum potassium to the metabolic acidosis present from the ketones. This acidosis pulls potassium from the cell, making the patient hyperkalemic. As soon as insulin is given, however, potassium re-enters the cell and the ketosis stops. The initial sodium level in DKA is normal, as is calcium. Normal serum osmolality is within the range of: A. 145-155 mOsm/L B. 200-250 mOsm/L