Nursing Interventions for Common Medical Conditions, Exams of Nursing

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A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7. B. HCO3 above 26 mEq/L C. PaO2 below 70 mmHg D. PaCO2 above 45 mmHg - A. pH below 7. A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect? A. Hypoactive deep tendon reflexes B. Shortened QT intervals C. Tingling of the extremities D. Constipation - C. Tingling of the extremities A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission? A. 16.5 mg/dL B. 3.1 mg/dL C. 35 mg/dL D. 10 mg/dL - C. 35 mg/dL A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect? A. Hypercalcemia B. Elevated BUN C. Metabolic alkalosis D. Hypokalemia - B. Elevated BUN

A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. Respiratory rate 24/min B. Heart rate 130/min C. Urine specific gravity 1. D. Capillary refill greater than 3 seconds - C. Urine specific gravity 1. When evaluating the therapeutic response for a client receiving a heparin infusion which laboratory results should the nurse monitor? A. Complete blood count (CBC) B. Activated partial thromboplastin time (aPTT) C. International normalized ratio (INR) D. Prothrombin time (PT) - B. Activated partial thromboplastin time (aPTT) A nurse is caring for a client who has the following arterial blood gas results: HCO3: 18 mEq, PaCO2: 28 mmHg, and pH: 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis - D. Metabolic acidosis A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Continue routine care because the results are within the expected reference range. B. Evaluate urine for amount and for specific gravity C. Decrease the IV fluid infusion rate and limit oral fluid intake

B. Cellular hypoxia C. Fluid retention D. Prolonged bleeding - B. Cellular hypoxia A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? A. Dry, sticky mucous membranes B. Negative Chvostek's sign C. Polyuria D. Muscle tremors - B. Negative Chvostek's sign A nurse is assessing a client who has Graves disease. The nurse should expect which of the following laboratory results? A. Decreased triiodothyronine (T3) level B. Decreased thyroxine (T4) level C. Decreased thyroid-stimulating hormone (TSH) level D. Decreased thyroid-stimulating immunoglobulins (TSI) percentage - C. Decreased thyroid- stimulating hormone (TSH) level A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate? A. Administering sodium polystyrene sulfonate B. Administering a potassium-sparing diuretic C. Encouraging the client to eat bananas D. Initiating an IV potassium infusion - A. Administering sodium polystyrene sulfonate A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Weak, irregular pulse

B. Extreme thirst C. Hyperactive bowel sounds D. Hyperactive reflexes - C. Hyperactive bowel sounds A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? A. Flushed skin B. Nausea and vomiting C. Fever D. Extreme thirst - D. Extreme thirst A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following laboratory values indicates the client needs a change in the formula? A. Hematocrit 42% B. Sodium 142 mEq/L C. Urine specific gravity 1. D. BUN 28 mg/dL - D. BUN 28 mg/dL A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2500 mL in the past 16 hrs. Which of the following electrolyte imbalances should the nurse monitor the client for? A. Decreased calcium level B. Elevated magnesium level C. Elevated sodium level D. Decreased potassium level - D. Decreased potassium level A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16000/mm3 with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results?

B. initiate a dopamine IV infusion for the client C. Elevate the clients feet D. Administer a unit of packed RBC's - A. Increase the clients IV fluid rate The nurse prepares a patient for insertion of a pulmonary artery catheter. Preprocedural teaching for this client will include which of the following statements? A. the catheter will assist in directly monitoring your arterial pressure B. The catheter will provide information about your left ventricular function C. the catheter will provide information about your cardiac output D. the catheter will provide information about your cardiac index - B. the catheter will provide information about your left ventricular function The patient is taking a beta1- adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows the drug acts by increasing: A. cardiac preload B. cardiac afterload C. myocardial contractility D. venous return - C. myocardial contractility Which of the following measures preload? (Select all that apply) A. PAWP (PAOP) B. SVR C. RAP D. CVP - C. RAP D. CVP Which of the following patients would typically have a low cardiac output? A. a patient with anemia B. A patient receiving vasopressin C. a patient with SVT at 142 D. A patient with hyperthyroidism - C. A patient with SVT at 142

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP80/50 mmHg, HR 135 beats/min, respirations 36 breaths/ min, CO of 2L/min, systemic vascular resistance of 3000 dynes/sec/cm-5 and a hematocrit of 20%. The nurse anticipates administration of which of the following therapies or medications? A. dopamine hydrochloride (dopamine) infusion B. Dobutamine (Dobutrex) infusion C. Blood transfusion D. Furosemide (Lasix) - C. blood transfusion Which of the following can cause an elevated right arterial pressure? (select all that apply) A. left ventricular failure B. decreased ventricular compliance C. cardiac tamponade D. third- degree heart block - B. decreased ventricular compliance C. cardiac tamponade Which nursing actions are most important for a patient with right radial arterial line? (Select all that apply) A. restraining all four extremities with soft limb restraints B. Maintaining a pressurized flush solution to the arterial line setup C. checking the circulation to the right hand every 2 hours D. monitoring the waveform on the monitor for dampening - B. maintaining a pressurized flush solution to the arterial line setup C. checking the circulation to the right hand every 2 hours D. monitoring the waveform on the monitor for dampening The nurse is caring for a 100 kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60mm Hg, HR 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. cardiac index (CI) of 1.2 L/min/m B. Cardiac output (CO) of 4 L/min C. Pulmonary vascular resistance (PVR) of 80 dynes/ sec/ cm- D. Systemic vascular resistance (SV)of 1800 dynes/sec/cm-5 - A. Cardiac index (CI) of 1.2 L/min/m

D. a patient with a pulmonary artery pressure of 25/10 mmHg and an oxygen saturation of 94% on 2L of oxygen via nasal cannula - A. a patient with a pulmonary artery occlusion pressure of 25 mmHg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula During hemodynamic monitoring, the nurse finds that the patient has a decreased CO with unchanged pulmonary artery wedge pressure (PAWP), HR, and SVR. The nurse identifies that the patient has a decrease in a. preload B. afterload C. stroke volume D. contractility - D. Contractility A nurse is caring for a client receiving dopamine. Which of the following potential nursing diagnosis is appropriate for this client? A. fluid volume excess B. increased cardiac output C. ineffective tissue perfusion D. disturbed sensory perception - C. innefective tissue perfusion The beside RN has just completed hemodynamic numbers. He reports the following: CO 5, CVP 6, PAWP 9, SVR 900, PVR 200, LVSWI 50. Based on the clinical findings, what is the anticipated clinical interventions to be completed? A. continue to monitor hemodynamics B. give fluid boluses C. give lasix D. start dopamine - A. Continue to monitor hemodynamics A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to? A. an increase in cardiac preload B. an increase in stroke volume C. a decrease in cardiac preload D. a decrease in cardiac contractility - C. a decrease in cardiac preload

The primary purpose of afterload reducing medications is to: A. restrict blood flow to internal organs B. produce vasodilation and improve stroke volume C. produce vasoconstriction and increase myocardial oxygen consumption D. increase blood pressure and CO - B. produce vasodilation and improve stroke volume Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply) A. exercise B. shock C. hypovolemia D. myocardial infarction - B. shock C. hypovolemia D. myocardial infarction The nurse is caring for a patient with pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mmHg, heart rate of 125 beats/min, respiratory rate 35 breaths/ min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0L/min, central venous pressure (CVP) of 1 mmHg, and a pulmonary artery occlusion pressure (PAOP) of 3 mmHg. The nurse questions which of the following physicians orders? A. administer furosemide (Lasix) 20 mg intravenously B. Titrate supplemental oxygen to achieve a SpO2 --> 94% C. Infuse 500mL of 0.9% normal saline over 1 hour D. obtain arterial blood gas and serum electrolytes - A. administer furosemide (Lasix) 20 mg intravenously Which of the following measures left ventricular preload? A. CVP B. Wedge (PAOP) C. LVSWI D. SVR - B. Wedge (PAOP)

C. Valsalva maneuver D. Precordial thump - True or False: All Acute Myocardial Infarctions are caused by thrombotic events. True or False - False The emergency nurse initiates the prescribed treatment for a patient with a dissecting aortic aneurysm. Which condition indicates that this intervention is having the desired effect? A. Dysrhythmias have subsided. B. External bleeding is stopped. C. The patient is able to speak. D. Blood pressure is controlled. - D. blood pressure is controlled A client is receiving thrombolytic therapy with a continuous infusion of streptokinase (Streptase). The client suddenly becomes anxious and complains of itching. The nurse hears stridor and on examination of the client notes generalized urticaria and hypotension. Which of the following should be the priority action of the nurse? A. Cut the infusion rate in half and sit the client up in bed. B. Stop the infusion and call the physician. C. Administer oxygen and protamine sulfate. D. Administer diphenhydramine (Benadryl) and continue the infusion. - B. stop the infusion and call the physican The patient is brought to the ED with an anterior ST-elevation myocardial infarction (STEMI). You are assessing him for possible administration of fibrinolytics. An absolute contraindication for this treatment is: A. The patient has received aspirin in the last 2 hours. B. The patient had a previous MI 6 years ago. C. Symptoms began 36 hours before arrival. D. The patient's pain is not relieved by medications. - A. the patient has received aspirin in the last 2 hours

You are working in the Emergency Department when a 32-year-old female is brought in by personal vehicle complaining of "feeling her heart beating in her chest and head." Her color is good. She is alert and oriented. Her BP is 138/84. Her pulse is 180. Respirations are 22 and the Pulse Ox is 98% on room air. She states that she was sitting watching television when suddenly it felt like her heart was pounding out of her chest. The patient is placed on the cardiac monitor (this rhythm strip). You immediately recognize this rhythm as: A. Supraventricular Tachycardia B. Atrial Fibrillation C. Ventricular Tachycardia D. Ventricular Fibrillation - A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which of the following observations would indicate that the procedure was unsuccessful? A. Rising blood pressure B. Rising central venous pressure C. Clearly audible heart sounds D. Client expressions of relief - B. rising central venous pressure On average, less than ___ of patients who receive CPR survive to leave the hospital. A. 20% B. 5% C. 15% D. 10% - C. 15% You are responding on an ambulance to a wedding where the elderly father of the bride has collapsed while dancing. Bystanders say he was complaining of chest pain earlier but didn't want to mess up the celebration by going to the hospital. He was dancing when he suddenly lost consciousness and fell to the ground. Bystanders have started CPR. You arrived and placed the patient on the monitor. It shows sinus bradycardia but the patient has no palpable pulse. CPR continues with high quality compressions and ventilation. You have established IV access. The only drug appropriate in this scenario would be: A. Epinephrine B. Amiodarone C. Atropine

A. Tension Pneumothorax B. Hypokalemia C. Hypervolemia D. Hypoxia - C. hypervolemia Serious adverse effects of Adenosine (Adenocard) are: A. bradycardia, bronchospasm, and ventricular standstill B. tachyarrhythmias, hypotension, prolonged effect C. coma, respiratory distress, and erratic behavior D. Nausea, vomiting, and diarrhea - A lethal cardiac arrhythmia that is cause by Magnesium deficiency is: A. Supraventricular Tachycardia B. Ventricular Fibrillation C. Tosades de Pointes D. Complete Heart Block - You are working in an emergency department. Your patient is a 69-year-old male who is being treated for chest pain. He has an IV in place and is on a bedside monitor. Diagnostic tests are complete and he is awaiting the arrival of the cardiac catheterization team. You go into his room to check on him and he suddenly loses consciousness. You look up at the monitor and see ventricular fibrillation. You are not sure whether you feel a pulse or not. You should immediately: A. Ventilate using a Bag Valve Mask B. Have another nurse double check for the presence of a pulse C. Defibrillate at 200J or manufacturer guidelines. D. Perform a Precordial thump - Which of the following EKG changes are abnormal findings that may indicate ischemia or injury to the cardiac muscle found on a 12-lead EKG? SELECT-ALL-THAT-APPLY: A. T-wave inversion B. QT interval narrowing C. ST-segment depression D. ST-segment elevation

E. Tall t-waves F. Lengthening p-waves - A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse suspects pulmonary edema and immediately asks another nurse to contact the physician. The nurse should be prepared to implement which priority interventions? Select all that apply: A. Administer furosemide (Lasix) B. Administer oxygen C.Insert a urinary catheter D. Place the client in a low Fowler's side-lying position E. Administer Morphine sulfate IV F. Transport the client to the coronary care unit - Therapeutic hypothermia is initiated for a patient with return of spontaneous circulation after cardiac arrest. The nurse should expect to maintain the hypothermic state for how long after the resuscitation? A. Until the patient is weaned from the ventilator B. Twelve to twenty-four hours C. Until the pupils react normally D. Up to three days - B. twelve to twenty- four hours A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce T- wave inversion. You obtain the patient's vital signs and find the following: Blood pressure 190/98, HR 110, oxygen saturation 96% on room air, and respiratory rate 20. Select-all-that-apply in regards to the MOST IMPORTANT nursing interventions you will provide based on the patient's current status: A. Assess urinary output B. Administer Morphine IV as ordered per protocol C. Administer Nitroglycerin sublingual as ordered per protocol D. No interventions are needed at this time E. Collect cardiac enzymes as ordered per protocol F. Encourage patient to cough and deep breath G. Place patient on oxygen via nasal cannula

A. Client has an NG tube to gastric suction. B. Client is currently prescribed spironolactone. C. Client reports drinking 3.5 to 4 L of water each day. D. Client has a history of alcohol abuse disorder. - A. client has an NG tube to gastric suction A nurse is reviewing a client's laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings? A. Decreased pH and metabolic acidosis B. Elevated pH and respiratory alkalosis C. Decreased pH and respiratory acidosis D. Elevated pH and metabolic alkalosis - A. decreased pH and metabolic acidosis A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following laboratory values indicates the client needs a change in the formula? A. BUN 28 mg/dL B. Hematocrit 42% C. Urine specific gravity 1. D. Sodium 142 mEq/L - A. BUN 28 mg/dl A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results? A. Decreased thyroid-stimulating hormone (TSH) level B. Decreased thyroxine (T4) level C. Decreased thyroid-stimulating immunoglobulins (TSI) percentage D. Decreased triiodothyronine (T3) level - A. Decreased thyroid-stimulating hormone (TSH) level A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect? A. Elevated BUN B. Metabolic alkalosis C. Hypercalcemia D. Hypokalemia - A. elevated BUN

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.) A. Circumoral paresthesia B. Flushing C. Kussmaul's respirations D. Lethargy E. Bicarbonate excess - C. Kussmaul's respirations D. Lethargy E. Bicarbonate excess A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³ with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? A. Neutropenia B. An acute infectious process C. Allergic reaction D. A resolving inflammatory process - B. an acute infectious process A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. PaCO2 above 45 mm Hg B. HCO3 above 26 mEq/L C. pH below 7. D. PaO2 below 70 mm Hg - C. pH below 7. A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis - B. metabolic acidosis