392

TEST 1
A patient with a non-ST-segment-elevation mycocardial infarction (NSTEMI) is receiving heparin. What is
the purpose of the heparin?
-Heparin will prevent the development of new clots in the coronary arteries.
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after
having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need
for immediate intervention by the nurse?
-Chest pain level 8 on a 10-point scale
A patient who has chest pain is admitted to the emergency department (ED), and all the following
diagnostic tests are ordered. Which on e will the nurse arrange to be completed first?
-Electocardiogram (ECG)
During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD)
with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
-elevated right atrial pressure
Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. during
the first hours of administration, the nurse will need to adjust the nitroprusside rate if the patient develops
-a systolic BP < 90 mm Hg
A patient who has chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the
middle of the night feeling like I was suffocating!" The nurse will document this assessment information as
-Paroxysmal nocturnal dyspnea
The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly
diagnosed heart failure has been effective when the patient
-calls the clinic when the weight increases from 124 to 130 pounds in a week
Following an acute myocardial infarction, a perviously healthy 67-year-old develops clinical manifestations
of heart failure. The nurse anticipates discharge teaching will include information about
-angiotensin-converting enzyme (ACE) inhibitors
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute
shortness of breath has heart failure.
-B-type natriuretic peptide (BNP)
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires
the most rapid action by the nurse?
-Oxygen saturation of 88%
the nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of
acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient response to
the medications, the best indicator that the treatment has been effective is
-decreased dyspnea with the head of bed at 30 degrees
Which topic will the nurse plan to include in discharge teaching for a patient with systolic hear failure and
an ejection fraction of 38%?
-Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to
be restricted include
-milk, yogurt, and other milk products

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin
(Lanoxin) and hydrochlorothiazide (HydroDiuril). Appropriate instructions for the patient include
-notify the health care provider about any nausea
(NEVER take digoxin if pulse is below 60)
A patient who has just been admitted with pulmonary edema is scheduled to receive these medications.
Which medication should the nurse question?
-carvedilol (Coreg) 3.125 mg
A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a lowsodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's first
action will be to
-assess the patient for clinical manifestations of acute heart failure
After receiving change-of-shift report, which of these patients admitted with heart failure should the nurse
assess first?
-A patient who is cool and clammy, with new-onset confusion and restlessness
An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with carvedilol (Coreg).
which of these assessment findings is most important for the nurse to report to the health care provider?
-BP of 88/42 mm Hg
A patient who is receiving dobutamine (Dobutrex) fro the treatment of acute decompensated heart failure
(ADHF) has the following nursing actions included in the plan of care. Which action will be best for the
RN to delegate to an experienced LPN/LVN?
-Monitor the patient's BP and heart rate every hour
when admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action should
the nurse carry out first?
-Attach the cardiac monitor
TEST 2
To determine whether there is delay in impulse conduction through the atria, the nurse will measure the
length of the patients
-P Wave
The nurse needs to estimate quickly the heart rate for a patient with a regular heart rhythm. Which method
will be best to use?
-Use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10
P wave not apparent, ventricular rate 162, r-r interval regular, p-r not measurable, QRS wide and distorted,
QRS duration 0.18 seconds
-Ventricular tachycardia
Atropine effective
-Increase pts heart rate
Pace maker for a-fib
-stimulates heart beat if its too low
Pacemaker teaching effective
-wont lift arm on side of the pacemaker
Cardioversion

-Administer sedative before cardioverting

Athlete with sinus bradycardia, swim team
-allow him to participate
Potassium normal level
Unconscious and pulseless
-Defibrilate
EKG PVCs
-Stress level and coffee use
Atrial flutter
-12 lead EKG
No pulses, sinus tach, rate 102, apneic
-CPR
Infective endocarditis
-dentist visits
IE expect
-New regurgitant murmur
Pericarditis
-echocardiogram
Pericardial friction rub
-listen with stethoscope diaphragm lower left sternal border
Acute pain pericarditis
-Position in Fowlers leaning on over bed table
Rheumatic fever
-recent sore throat
Decrease risk of rheumatic fever by
-getting treatment for strep
Mitral valve stenosis
-assess for shortness of breath
Mitral valve replacement
-need for labs for blood tests
IE
-blood cultures from 2 sites
IE
-sudden onset of left flank pain
MI chest pain with breathing
-auscultate heart sounds
TEST 3
Balloon pump

-Masure output hourly

Left radial arterial line take action when
-left hand is cooler than the right hand
Hemodynamic monitoring teaching effective when
-positions the zero reference stopcock line level with the phlebo axis
Disturbed sensory perception and disturbed sleep pattern
-cluster nursing activities and uninterrupted rest periods
Not a treatment for cardiogenic shock
-administration of blood product
Shock, check for perfusion by
-LOC, urinary output, and BP
Stung by bee, respiratory distress
-epinepherine
Shock is caused from
-impaired tissue perfusion
Fluid recussitation with
-normal saline
Intubated and making sounds
-check cuff inflation on ETT
Pilot balloon is deflated with ventilator
-nothing required for ventilation
Peep immediate intervention needed when
-BP drops
Vent client becomes restless
-check O2 sat
Suspect distributive shock in
-MVA accident with severe head injury
Risk for acidosis
-increase serum lactic acid
Bleeding internally, assess for shock by
-asking what their normal HR is
Dopamine effective when
-increase cardiac output
Distributive shock assess
-are you normally this swollen
Suspect MODS when
-creatinite level is high

Ventilator, notify MD if
-JVD
Nipride effective
-skin is warm, dry, and pink
MVA client otw
-prep for 2 14 gauge IV catheters
Vasopressin, notify MD if
-pt c/o chest pain
Fluid recussitation successful when
-UO is 60 mL over one hour
Septic shock, 20 mL/ 3 hr UO, pulse 120
-question Lasix
TEST 4
ICP 20 and CPP 85
-ICP high and CPP normal
Clear nasal drainage
-test it for glucose
Cerebral tissue swelling
-elevate HOB 30 degrees
GCS
-11
15 GCS drops to 13
-notify MD of change
Seizures need to be treated beacause
-Increase metabolic rate and ICP
Mannitol or furosemide
-decreases ICP and increase UO
Decrease ICP
-Mannitol
Basilar skull fracture
-risk for meningitis
ICP through intracatheter
-aseptic technique to prevent infection
When increase ICP
-monitor fluid and electrolytes
Increase ICP
-bradycardia

ARDS, inspiratory pressure alarm

-assess airway
ARDS risk
-older adult aspirated tube feeding
Intubated, ARDS, assess oxygenation and
-consult with dietician
Encephalitis symptom
-pain on flexion of neck
Meningitis
-do you live in a crowded residence
Meningitis gloves and
-surgical mask
Mannitol
-I&O closely
Ventilation perfusion mismatch or hypoxemic respiratory failure
-not caused by PE
Tripod position
-decreases anterior posterior chest expansion
Mobilize secretions by
-chest PT
Does not decrease work of breathing
-NG tube
Common cause of cerebral edema
-vasogenic
TEST 5
Hepatic encephalopathy
-irritable and lethargic
Impending coma with encephalopathy
-extend arm and hand
Lactulose with cirrhosis
-improve nervous system function
Ascites most important diagnosis
-ineffective breathing
Esophageal varices
-maintenance of the airway
Shunts increase the risk for
-hepatic encephalopathy
Esophageal varices

-Vasopressin infusion, balloon tamponade, ligation, shunting

Hepatitis refer for IG injection
-caregiver who lives in household
Jaundice, liver function
-Do you take any OTC drugs
Gullian Barre
-immune system destroys myelin sheath
Clinical manifestations of GB
-progressive ascending weakness and parathesia
GB
-take things slowly for several months after leaving the hospital
Bells palsy and herpes
-call MD if pain of herpes lesion occurs near the ear
Puncture wound, tetanus booster 7 year ago
-tetanus booster
Trigeminal neuralgia
-controllable facial twitching
Peripheral nerve repair postop priority
-assess skin surrounding cast
Trigeminal neuralgia surgery
-a small artery compressing the nerve will be relocated
Cirrhosis and vomiting worry about
-bleeding esophageal varices
Mild liver disease, to assess for ascites
-palpate abdomen for fluid wave
Asterixis
-extend your arm, flex wrist up, extend fingers
Cirrhosis
-Increase serum ammonia level
Decreased fecal urobilogen concentration
-clay colored stools
Hepatitis A
-May have been exposed when we ate shrimp last week
Sensory
-discriminate between touch and pinprick stimuli
Halo traction
-keep a wrench taped to halo incase CPR is needed

TEST 6
Electrical burns risk for
-cardiac dysrhythmias
Intubated for singed nasal hairs because
-inhalation injury causes edema can cause breathing problems
Chemical burn priority
-neutralize chemical
Skin integrity, most important thing to worry about is
-infection
Inhalation injury, priority
-100% humidified O2
Pulmonary tests for inhalation injury
-ABGs and bronchoscopy
Deep partial thickness
-red, shiny, fluid filled blisters
Circumferential burn on extremity
-monitor distal pulses
Hypovolemia
-capillary permeability, fluid into interstitium
Fluid assessment
-hourly UO
Restless
-check O2 sat
Infection control with burn
-PPE
Zantac with burn for
-stress or curlings ulcer
Kidney transplant, teaching neeed when
-after a few years, I can stop taking medication
Burn, pain meds
-drug and alcohol increase dose, increase dose b/c of metabolic rate, give before debridement
RN instruct LPN to
-wash hands
Postrenal
-renal calculi
Lasix AE
-monitor I&O
Prevent kidney damage
-no NSAIDS

Missed hemodialysis
-acceptance of disease
Creatinine 2, UO 2000 mL/day
-nonoliguric
HTN not controlled
-Creatinine 1.9
Fluid restriction
-abscense of crackles
AV fistula right arm
-Take BP in left arm