216 Test

Front 1

* You may delegate which action to a nursing assistant?
- Place the client on a cardiac telemetry monitor
- Draw cardiac enzymes and send to laboratory
- Obtain a 12-lead electrocardiogram
- Monitor and record client's intake and output

Back 1

- Monitor and record client's intake and output.
- Monitoring and recording intake and output are within the scope of practice for a nursing assistant

Front 2

* Which of they physician's orders takes first priority at this time?
- Check vital signs every 2 hours.
- Obtain 12-lead ECG every 6 hours.
- Place client on cardiac monitor.
- Check cardiac enzymes every 6 hours.

Back 2

- Place client on cardiac monitor.
- Cardiac monitoring is the highest priority because the client's heart rate is rapid and irregular, and the client is experiencing chest pressure

Front 3

What is the cardiac isoenzyme that rises early and is most specific in detecting early acute heart attack?

Back 3

- CK-MB
- Myoglobin is the first marker to rise, but is not specific to myocardial damage. CK-MB is specific and diagnostic for myocardial damage.

Front 4

* The client's telemetry cardiac monitor shows a rhythm of sinus tachycardia with frequent premature ventricular contractions (PVCs). Which drug should you administer first?
- Amiodarone (Cordarone) IV push
- Nitroglycerine SubQ
- Morphine sulfate IV push
- Atenolog (Tenormin) IV push

Back 4

- Amiodarone (Cordarone) IV push
- With frequent PVCs the client is at risk for life-threatening dysrhythmias such as ventricular tachycardia or ventricular fibrillation. Amiodarone is an antidysrhythmic drug used to control ventricular dysrhythmias.

Front 5

* All of the following laboratory values were obtained in the ED. Which value has immediate implications for the care of this client?
- Potassium 3.4
- CK 329/CK-MB 7%
- Glucose 123
- Slight elevation of WBCs

Back 5

- CK 329/CK-MB 7%
- CK and CK-MB are elevated and diagnostic for acute MI. Even though all the other lab values are normal, none of them is life threatening.

Front 6

* Ms. S. complains of worsening chest discomfort. The cardiac monitor shows ST segment elevation and you notify the physician. Which of the following orders takes priority?
- Administer morphine sulfate 2 mg IV push.
- Schedule an ecocardiogram.
- Draw serum coagulation studies.
- Give ranitidine 75 mg orally every 12 hours.

Back 6

- Administer morphine sulfate 2 mg IV push.
- Morphine sulfate has been ordered to relieve the chest discomfort that is common in the setting of acute MI

Front 7

* Because Ms.S continues to experience chest pain and has elevated cardiac enzymes, the following interventions have been ordered. What interventions can you assign to an experienced nursing assistant? (Choose all that apply.)
- Take vital signs every 2 hours.
- Maintain accurate intake and output.
- Administer tenecteplase IV push.
- Conduct serum coagulation studies.
- Read cardiac monitor every 4 hours.
- Assist her to the beside commode.

Back 7

- Take vital signs every 2 hours.
- Maintain accurate intake and ouput.
- Assist her to the bedside commode.

Front 8

* You delegate to the nursing assistant the task of taking the client's vital signs every 2 hours and recording the vital signs in the electronic chart. Later you check the client's chart and discover that the vital signs have not been recorded. What is your best action?
- Take the vital signs because it is not within the nursing assistant's scope of practice.
- Notify the nurse manager immediately.
- Call the nursing assistant to the nurses' station to reprimand.
- Speak to the nursing assistant privately to determine why the vital signs were not recorded.

Back 8

- Speak to the nursing assistant privately to determine why the vital signs were not recorded.
- Supervision should be done in a supportive rather than confrontational manner

Front 9

* Ms. S. is stable and has been transferred to the cardiac step-down unit. Which of the following should you instruct the nursing assistant to report immediately?
- Temp elevation to 99, with morning vital signs.
- Chest pain episode occurring during morning care.
- Blood pressure increase of 10 mm Hg after morning care.
Heart rate increase, 10 beats per minute after ambulation

Back 9

- Chest pain episode occurring during morning care.
- Chest pain can be an indicator of additional myocardial muscle damage. Additional episodes of chest pain significantly affect the client's plan of care.

Front 10

* The physician orders captopril 12.5 mg PO twice daily and HCTZ 25 mg PO every day. Which of the following would you be sure to include when teaching the client about these drugs?
- Take your HCTZ in the morning
- If you miss a dose of cptopril, take 2 tablets next time.
- Avoid foods that are rich in potassium.
- You should expect an increase in blood pressure

Back 10

- Take your HCTZ in the morning.
- HCTZ is a thiazide diuretic used to correct edema and lower BP.

Front 11

* Based on the information you have been given during change-of-shift report, what is your greatest concern for Mr E.?
- Purulent abdominal drainage
- Sinus tachycardia
- Decreased O2 sat
- Elevated temp

Back 11

- Decreased O2 sat

Front 12

You review Mr. E's med and note that he has a dose of gentamicin scheduled at 10AM. When will you ask the lab to draw blood for the gent trough level?
- 9 AM
- 9:45 AM
- 11:30 AM
- 2 PM

Back 12

- 9:45 AM

Front 13

What action will you take next?
- Assist him back to bed.
- Increase the O2 rate to 6L/min
- Administer morphine IV
- Finish the rest of his head-to-toe assessment

Back 13

- Increase the O2 flow rate to 6L/min

Front 14

Which change in therapy do you anticipate based on the ABGs?
- Place Mr. E on a non-rebreather mask at 15 L/min
- Admin sodium bicarbonate 50 mEq IV
- Administer morphine to slow the respiratory rate.
- The ABG results do not support the need for any change

Back 14

- Place Mr. E> on a non-rebreather mask at 15 L/min

Front 15

* The CBC results are also available. Which of the results are you most concerned about?
- Hemoglobin 10.5
- Hematocrit 37%
- WBC 24,000
- Platelets 120,000

Back 15

- WBCs 24,000

Front 16

* Which of these staff members is best to assign to care for Ms. O?
- An RN who has 10 years of experience on the pediatric unit and has floated to the step-down unit for the day.
- A new graduate RN who has finished a 3-month orientation and is scheduled for the first day without a preceptor.
- An on-call RN with 5 ears of experience on the step-down unit who will be able to arrive in about 1 hour.
- An experienced RN from a staffing agency who is orienting to the unit today in preparation for a 6-month assignment

Back 16

- An RN who has 10 years of experience on the peds unit and has floated to the step-down unit for the day.

Front 17

* Fifteen min. after use of the non-rebreather mask of O2 admin is implemented, Mr. E's pulse oximeter still indicates that the O2 sat is 88% to 89%. What complication is most likely based on your ongoing assessments of this client?
- Aspiration pneumonia
- Pulmonary embolism
- Spontaneous tension pneumothorax
- Acute respiratory distress syndrome

Back 17

- Acute respiratory distress syndrome

Front 18

* Mr. E's surgeion arrives and asks the hospital intensivist to consult. The intensivist gives these orders after assessing MMr. E. Which one will you implement first?
- Transport pt to the intensive care unit.
- Prepare for intubation and ventilation.
- Administer nebulized albuterol every 4 hours
- Obtain blood, urine, and abdominal drainage cultures.

Back 18

- Prepare for intubation and ventilation
- Improving Mr. E's oxygenation is the priority goal.

Front 19

* The intensivist proceeds tointubate Mr. E. After intubation, which of these actions is the most accurate way to confirm correct placement of the ET tube?
- Chest x-ray study
- Lung auscultation
- CO2 detector
- O2 sat

Back 19

- Chest x-ray study

Front 20

* Which ventilator change do you anticipate based on your analysis of these ABGs?
- Increase the FIO2 to 70%
- Change the rate on the ventilator to 20 breaths/min
- Increase the Vt to 1000 mL
- Change to continuous mandatory ventilation mode

Back 20

- Change the rate on the ventilator to 20 breaths/minute
- The pH and Pa CO2 indicate that Mr E is retaining CO2, and increasing the respiratory rate will improve the rate at which the lungs can "blow off" CO2

Front 21

* Based on these data, which collaborative interventions will you anticipate for Mr E?
- Increase IV rate to 150 mL/hr
- Administer Lasix 40 mg IV
- Start norepinephrine infusion
- Give diltiazem 5 mg IV
- Infuse total parenteral nutrition at 70 mL/hr
- Run Ensure enteral feeding at 50 mL/hr
- Give vancomycin 1000 mg IV

Back 21

- Increase IV rate to 150 mL/hr
- Run ensure enteral feeding at 50 mL/hr
- Give vancomycin 1000 mg IV

Front 22

* Although his O2 sat remains at 90%, Mr E. continues to be restless and needs frequent reminders to not pull at the Et tube. Which of these methods to reduce his anxiety and decrease the risk for accidental extubation will you try first?
- Obtain an order to restrain his hands, and apply soft wrist restraints.
- Administer neuromuscular blockade meds and sedatives.
-Have a family member stay at Mr. E's bedside and reassure him.
- Remind Mr. E. frequently that he needs the ET tube to breathe

Back 22

- Have a family member stay at Mr E's bedside and reassure him

Front 23

* You are working with a student who is preparing to suction Mr E. Which action by the student requires that you intervene immediately?
- The student increase the FIO2 to 100% for 1 minute before suctioning.
- The student uses an open-suction technique to perform the suctioning.
- The student administers morphine 2 mg IV prior to starting to suction.
- The student applies suction to the catheter while inserting it into the ET tube

Back 23

- The student applies suction to the catheter while inserting it into the ET tube.
- Application of suction causes hypoxemia and trauma to the tracheal mucosa. Suction should only be applied to the catheter while it is being withdrawn to minimize these problems

Front 24

* All of the following activities are included in the standard plan of care for a client with ARDS. Which activities can you delegate to an experienced LPN/LVN whom you are working with in the ICU?
- Provide oral care every 2 hours
- Place the pt in the prone position for 4 hours every shift
- Check residuals for enteral feedings every 4 hours
- Assess breath sounds every 4 hours
- Check rectal temp every 4 hours
- Suction endotracheal tube as needed.
- Educate the pt and family about routine nursing care
- Check PAWP every 2 hours
- Obtain arterial pressures from arterial line every hour.

Back 24

- Provide oral care every 2 hours.
- Check residuals for enteral feedings every 4 hours
- Check rectal temp every 4 hours

Front 25

* What action will you accomplish first?
- Listen to Mr E's breath sounds and assess chest movement
- Use a bag-valve-mask system to manually ventilate Mr. E
- Check the ventilator settings and readouts.
- Suction Mr E after hyperoxygenating him

Back 25

- Listen to Mr E's breath sounds and assess chest movement.
- When an alarm sounds, assessment should take place in a systematic fashion, starting with the client.

Front 26

* You do not hear hear any breath sounds over Mr E's right side, and the right side does not expand much with inspiration. When you check the location of the ET tube at the pt's teeth, you find that it is still at the 23 cm mark. What complication of intubation and mechanical ventilation do you suspect?
- Inadvertent extubation
- Tension pneumothorax
- ET tube displacement
- Aspiration pneumonia

Back 26

- Tension pneumothorax
-

Front 27

* The intensivist arrives quickly and inserts a chest tube into the right anterior chest at the second intercostal space. Ou assess Mr. E after the chest tube insertion. Which of these assessment data is of most concern?
- A large number of air bubbles appear in the water seal chamber during expiration.
- Continuous bubbling occurs throughout the respiratory cycle in the suction control chamber.
- 100 mL of blood drains into the collection chamber immediately after the chest tube insertion.
- The pt indicates that he has pain with every ventilator-assisted inspiration

Back 27

- 100 mL of blood drains into the collection chamber immediately after the chest tube insertion.
- With a pneumothorax, there are usually only a few milliliters of blood in the collection chamber. There may have been trauma to the lung during the chest tube insertion.

Front 28

* Just before you prepare to give a change-of-shift report to the oncoming RN, you review Mr E's other lab test for today. Which of these is most impt to communicate to the physician?
- BG 140 mg/dL
- K 5.1
- Na 134
- BUN 52

Back 28

- BUN 52
- Renal failure is one of the common complications of ARDS

Front 29

* what is the priority nursing diagnosis for Mr. S?
- Risk of aspiration related to active bleeding
- Anxiety related to uncertainty of health status
- Deficient fluid volume related to vomiting blood and gastric secretions.
- Non compliance related to alcohol consumption and medication

Back 29

- Deficient fluid volume related to vomiting blood and gastric secretions.
- Vomiting bright red blood is a sign of active bleeding

Front 30

* What actions are appropriate in the care of this patient?
- Start of peripheral IV using a 22-gauge catheter
- Initiate I&O with hourly urine output measurements
- Check emesis and stool for occult blood
- Monitor hemoglobin and hematocrit every 4 hours
- Maintain the pt in a semi- of high-Fowler's position
- Prepare the pt for surgery.

Back 30

- Initiate I&O with hourly urine output measurements
- Check emesis and stool for occult blood
- Monitor hemoglobin and hematocrit every 4 hours
- Maintain the pt in a semi- of high-Fowler's position
- Mr. S. is at risk for hypovolemic shock

Front 31

* Which task is appropriate to assign to the nursing assistant?
- Obtain repeat vital signs every 2 hours
- Gather equipment for nasogastric lavage
- Check the BG level every 2 hours
- Notify the family

Back 31

- Obtain repeat vital signs every 2 hours

Front 32

* Which staff member under the supervision of an RN will you delegate to perform each task?
1) Place an automatic BP cuff
2) Establish 2 peripheral IVs with 16 gauge catheters
3) Place an NG tube and initiate saline lavage
4) Insert a Foley catheter attached to a urinometer
5) Set up blood transfusion equipment
6) Liaison with family members in the waiting room
7) Assess baseline breath and bowel sounds

Back 32

1) NA
2) Paramedic and RN
3) RN
4) LPN/LVN
5) RN
6) Clergy
7) RN

Front 33

* You are performing additional assessment and history on Mr S. which finding should you immediately report to the physician?
- Melena stools
- History of NSAID use
- Tense rigid abdomen
- Probably HIV status

Back 33

- Tense rigid abdomen
- Could signal perforation, peritonitis, and/or a worsening hemorrhage

Front 34

* Despite your best efforts at therapeutic communication, Mr. S. refuses to cooperate with the NG tube insertion. He threatens to leave "if you stick that tube down my nose again." What should you do first?
- Physically restrain him and insert the tube.
- Explain the AMA form
- Notify the nursing supervisor and pt advocate.
- Page the physician and document the attempt.

Back 34

- Page the physician and Document the attempt.

Front 35

* You discover that the phlebotomist drew the STAT blood work from another pt, not Mr. S. What should you do first?
- Call the phlebotomist to come back.
- Draw the blood sample yourself.
- Report the phlebotomist to his supervisor.
- Ask the phlebotomist to explain what happened.

Back 35

- Draw the blood sample yourself.
- This expediates the STAT order. The other options will only delay the STAT order.

Front 36

* The physician orders a STAT blood transfusion. In the event of an emergency, for a pt such as Mr. S., a type-specific un-cross-matched blood could be used. What do you anticipate as the blood product in this case?

Back 36

- O negative

Front 37

* What meds is the physician most likely to order for emergency treatment of acute and severe bleeding of Mr S's ulcer?
- Antacid
- Histamine H2 -receptor antagonist
- Vasopressin
- Proton pump inhibitor

Back 37

- Vasopressin is used to control acute and severe bleeding.

Front 38

* Which additional assessment is most important to obtain at this time?
- Temp
- Breath sounds
- Pedal pulses
- O2 sat

Back 38

- O2 sat
- Ms. A's slow and irregular RR is a risk factor for hypoxemia, which would decrease O2 delivery to the brain as well as other vitalorgans and tissues

Front 39

* What is the best way to clearly document Ms A's LOC?
- Client has a decreased LOC
- Client is unresponsive
- Client Glasgow Coma Scale = 4
- Client is comatose

Back 39

- Client Glosgow Coma Scale = 4
- The other responses do not provide objective data that can be readily used to determine changes in the pt's neurologic status

Front 40

* Based on Ms. A's vital signs, she appears to be in shock. Which type(s) of shock are you most concerned about for this client?
- Cardiogenic
- Hypovolemis
- Neurogenic
- Septic
- Anaphylactic

Back 40

- Hypovolemic
- Neurogenic

Front 41

* YOu are working with Dr. G, a new medical resident whose first day in the ED rotation is today. Which action by Dr. G. will require you to intervene immediately?
- Dr G. assesses for Babinski's sign
- Dr G. increases the IV rate to 200 mL/hr
- Dr. G. orders a STAT electrocardiogram
- Dr G. prepares to do a lumbar puncture

Back 41

- Dr. G. prepares to do a lumbar puncture.
- Lumbar puncture is contraindicated in a client who may have increased intracranial pressure because it increases the risk for herniation of the brain stem through the tentorial notch

Front 42

* After triaging Ms A., you need to assign one of your ED staff members to care for her. Which of these staff members will be most appropriate to assign to take primary responsibility for Ms. A's ongoing care?
- A temp agency RN with extensive previous ED experience, who has been in your ED for 3 days.
- An LPN with 10 years of experience in your ED, who is in the last semester of an RN program
- An RN who has worked in your ED for the last 5 years after transferring from the mother-baby unit
- An RN who has 12 years experience in the ICU and has been floated to the ED today

Back 42

- An RN who has worked in your ED for the last 5 years after transferringfrom the mother-baby unit

Front 43

* Ms A suddenly being to vomit. Which action should the nurse take first?
- Utilize the backboard to logroll Ms A. to her side.
- Suction Ms. A's airway with a Yankauer suction device
- Hyperoxygeate Ms A with a bag-valve mask system
- Insert NG tube and connect to low suction

Back 43

- Utilize the backboard to log roll Ms A to her side.
- This prevents aspiration the best

Front 44

* The ED physician writes these additional orders. Which one will you implement first?
- Administer metoclopramide 10 mg IV
- Obtain head, chest, and abdomen CT scan, spine and leg x-rays
- Clean occipital laceration and apply antibiotic ointment
- Administer cefuroxime 1.5g IV

Back 44

- Obtain head, hcest and abdomen CT scan, spine and leg x-rays.
- These are necessary to determine the collaborative interventions needed for this pt who may have other trauma that will require surgery in addition to her head injury.

Front 45

* Which complication are you most concerned about at present?
- Brain stem herniation
- Respiratory acidosis
- Hemorrhage
- Hypothermia

Back 45

- Brain stem herniation
- This can result in death, and is the most life threatening complication and needs immediate surgical intervention

Front 46

* Which of the assessment data requires the most immediate nursing action?
- Cardiac rhythm
- BP
- O2 sat
- Intracranial pressure

Back 46

- Intracranial pressure

Front 47

* The post-craniotomy care plan for the first post-operative day includes all of these nursing actions. Which are best delegated to an experienced LPN/LVN working with you in ICU?
- Check gastric pH every 4 hours
- Perform neurologic status examination every 2 hours
- Assess breath sounds every 4 hours
- Check endotracheal tube cuff pressure each shift
- Turn client side to side every 2 hours
- Monitor intake and output hourly
- Send urine specimen for specific gravity daily
- Admin Tylenol elixir 625 mg per OG tube PRN if temp > 101

Back 47

- Check gastric pH every 4 hours
- Monitor intake and output hourly
- Send urine specimen for specific gravity daily
- Admin Tylenol elixir 625 mg per OG tube PRN if temp > 101

Front 48

* At 10:00 the LPN/LVN tells you that Ms A's output for the last hour was 1200 mL and that her urine is very pale yellow. Which action is best to take next?
- Instruct the LPN/LVN to continue to monitor the urine output hourly
- Have the LPN/LVN send a urine specimen for specific gravity to the lab
- Notify the physician and obtain an order to increase the IV rate
- Assess the neurologic status for signs of increased irritabilty

Back 48

- Notify the physician and obtain an order to increase the IV rate
- This urine output suggest that she has developed DI, aa common complication of intracranial surgery

Front 49

* Ms. A's mother who has been staying at the bedside, asks you why her daughter is receiving Pepcid since she has no history of peptic ulcers. Which of these answer is best?
- It will lower the chance that she will aspirate
- It decreases the incidence of gastric stress ulcers
- It will reduce the risk for gastroesophagel reflux
- It prevents gastric irritation caused by the orogastric tube.

Back 49

- It decreases the incidence of gastric stress ulcers

Front 50

* About 20 min after you assist the LPN/LVN ins repositioning Ms A onto her right side, ou notice that her ICP has incerased to 30 mm HG. Ms A's BP is 120/55. The cardiac monitor shows sinus bradycardia, rate 42. Which is the most appropriate nursing action to accomplish next?
- Admin the PRN mannitol 100 mg IV
- Assess the alignment of Ms A's head and neck
- Elevate the head of the bed to 45 degrees
- Check Ms A's pupil size and response to light

Back 50

- Assess the alignment of Ms A;s head and neck
- Neck flexion can cause venou obstruction and an increase in ICP

Front 51

* As your shift ends, you are preparing Ms. A to transfer to surgery for an emergency fasciotomy. What is your best choice for obtaining informed consent for the fasciotomy?
- Informed consent is not needed for emergency sugery.
- Permission for surgery can be given by Ms. A's mother
- consent for surgery is not required for unconscious pts
- Authorization can be given by the nursing supervisor.

Back 51

- Permission for surgery can be given by Ms A's mother
- Permission from the family can be given after discussing the benefits and risks of the surgery

Front 52

* What is your priority concern at this time/
- Spinal immobilization to prevent additional injuries to the pt
- Airway status due to interruption of spinal innervations to the respiratory muscles
- Potential for injuries related to the pt's decreased perception of sensation
- Dysrhythmias due to disruption of the autonomic nervous system

Back 52

- Airway status due to interruption of spinal innervation to respiratory muscles

Front 53

* Mr M is stabilized and moved to the neurologic ICU with a diagnosis of spinal cord injury at level C4-5. You are the admitting nurse and are working with an experienced nursing assistant. When performing frequent respiratory assessments, which actions can you delegate to the nursing assistant?
- Auscultate breath sounds every hour for decreased or absent ventilation.
- Ensure that oxygen is flowing at 5L/min via nasal cannula
- teach the pt to breathe slowly and deeply and use incentive spirometry
- Check the pt's O2 sat by pulse oximetry every 2 hours

Back 53

- Ensure that oxygen is flowing at 5 L/min via nasal cannula
- Check the pt's O2 sat by pulse oximetry every 2 hours

Front 54

* An hour later, Mr M's O2 sat drops to 88%, while his respirations are rapid and shallow. ON auscultation, he has decreased breath sounds bilaterally. What is your best action at this time?
- Increase the O2 flow to 10 L/min
- Suction the pt for oral secretions
- Notify the physicain immediately
- call respiratory therapy for a non-rebreather mask

Back 54

- Notify the physician immediately
- symptoms indicate the strong possibility of impneding respiratory arrest

Front 55

* The pt's cervical injury has been immobilized with cervical tongs and traction to realign the vertebrae, facilitate bone healing, and prevent further injury. Which occurrence necessitates your immediate intervention?
- The traction weights are resting on the floor after the pt is repositioned.
- The traction ropes are located within the pulley and hanging freely.
- The insertion sites for the cervical tongs are cleaned with hydrogen peroxide.
- The pt is repositioned every 2 hours by using the log rolling technique

Back 55

- The traction weights are resting on the floor after the pt is repostioned.

Front 56

* Mr M has a nursing diagnosis of ineffective tissue perfusion. What nursing actions should you delegate to the nursing student/
- Admin dantrolene 25 mg orally to control muscle spasticity.
- Monitor traction ropes and weights while the pt is repositioned.
- Check the pt's neurologic status for changes in movement and strength.
- Provide pin site care with hydrogen peroxide and normal saline.

Back 56

- Admin dantrolene
- Provide pin site care

Front 57

* Another diagnosis in Mr M's nursing care plan is impaired physical mobility. To prevent complications associated with this nursing diagnosis, which should you delegate to the experienced nursing assistant?
- Turn and reposition the pt in bed every 2 hours
- Inspect the pt's skin for reddened areas
- Perform ROM exercises every 8 hours
- Admin Lovenox subQ every 12 hours

Back 57

- Turn and reposition the pt in bed every 2 hours

Front 58

* The nursing student asks how best to assess Mr M's motor function. What is you best response?
- Apply resistance while the pt plantar flexes his feet.
- Apply resistance while the pt lifts his legs from the bed
- Apply downward pressure while the pt shrugs his shoulders upward
- Make sure the pt is able to grasp objects firmly and forms a fist.

Back 58

- Apply downward pressure while the pt shrugs his shoulders upwards

Front 59

* Mr. M's condition has stabilized and he has been removed from the ventilator. His cervical injury is now immobilized with halo fixation device and jacket. He has regained use of his arms and partial movement of his legs. Which instruction should you give to the nursing assistant providing assistance with ADS's
- Feed, bathe, and dress the pt so that he does not become fatigues.
- Encourage the pt to perform all of his own self-care
- Allow the pt to do what he can, then assist with what he can't
- Let the pt's wife perform bathing and dressing actions

Back 59

- Allow the pt to do what he can, then assist with what he can't

Front 60

* Mr. M is to be transferred to a rehabilitation facility. Which statment indicates that the pt needs additional teaching?
- After rehabilitation I may be able to achieve control of my bladder
- with rehabilitation I will regain all of my motor function
- Rehabilitation will help me become as independent as possible.
- After rehabilitation I hope to return to gainful employment

Back 60

- With rehabilitation I will regain all of my motor functions.

Front 61

* What action should you take first?
- Listen to her breath sounds.
- Ask when the dyspnea started.
- Increase her oxygen flow rate to 6 L/min
- Raise the hear of the bed to 75-85 degrees

Back 61

- Increase her oxygen flow rate to 6 L/min
- The pt's symptoms indicate acute hypoxemia, so improving oxygen delivery is the priority action.

Front 62

* Which one of these complications are you most concerned about, based on your assessment?
- Pulmonary edema
- Cor pulmonale
- MI
- Pulmoary embolus

Back 62

- Pulmonary Edema
- The pt's symptoms of hypoxemia and pink frothy sputum and her history of increasing shortness of breath and mitral valve regurgitation point toward pulmonary edema

Front 63

* Which action will you take next?
- Call the physician about the pt's condition
- Place the pt on a non-rebreather mask with FIO2 at 95%
- Assist the pt to cough and deep breathe
- Admin the ordered morphine sulfate 2 mg IV the the pt

Back 63

- Place the pt on a non-rebreather mask with FIO2 at 95%
-The pt is hypoxemic, so giving O2 at the highest level possible is the priority. Calling the physician and admin of morphine are also appropriate actions.

Front 64

* What additional assessment data are most important to obtain at this time?
- Skin color and capillaryrefill
Orientation and pupil reaction to light
- Heart sounds and point of maximum impulse
- BP and apical pulse

Back 64

- BP and apical pulse
- The best clinical indicators of sudden hcanges in cardiac output are vital signs such as BP, pulse, and RR. The otehr data may also be useful in determining how well the pt is perfusing, but they are not as impot as the PB and pulse rates.

Front 65

* Ms C's BP is 98/52 and her apical pulse is 116 and irregular. The cardiac monitor shows sinus tachycardia, rate 110-120, with frequent multifocal PVCs. You call Ms. C's physician and receive these orders. Which one will you implement first?
- Obtain serum digoxin level.
- Give Lasix 100 mg IV
- Check blood potassium level.
- Insert #16 French Foley Cath

Back 65

- Check blood potassium level
-Before the lasix can be admin, it is essential to know the potassium level

Front 66

*Which of these orders is best delegated to the experienced LPN/LVN who is assisting you?
- Obtain serum digoxin level.
- Give Lasix 100 mg IV
- Check blood potassium level.
- Insert #16 French Foley Cath

Back 66

- Insert #16 French Foley catheter

Front 67

* While you are waiting for the K level to be processed, you admin morphine sulfate 2 mg to Ms C. A new graduate RN who has just started in CCU asks why you are giving the morphine. What is the best resonse?
- It will help prevent any chest discomfort from occurring.
- It will decrease MS C/s RR
- It will make MS C more comfortable if she has to be intubated.
- It will decrease venous return to the heart

Back 67

- It will decrease venous return to the heart.

Front 68

* Ms C's K level, faxed to the CCU, is 3.1 mEq/L. You call the physician and receive orders to admin KCl 20 mE1 IV before admin the lasix. How will you administer the KCl?
- Utilze a syringe pump to infuse the KCl over 10 min.
- Diulte the KCl in 100 mL of D5W and infuse over 1 hour.
- Use a 5 mL syringe and push the KCl over at least 1 min
- Add the KCl to 1 liter of D5W and admin over 8 hours

Back 68

- Dilute the KCl in 100 mL of D5W and infuse over 1 hour.
- The administration of KCl at a rate no faster than 20 mEq/hr is recommended. To quickly could lead to cardiac arrest. Too slowly would delay the admin of the lasix

Front 69

* After you have infused the KCl, you admin the lasix to Ms C. Which of these nursing actions will be most useful in evaluating whether the lasix is having the desired effect?
- Obtain the pt's daily weight
- measure the hourly urine output
- Monitor BP
- Assess the lung sounds

Back 69

- Assess the lung sounds

Front 70

* Ms. C's physician arrives and, after assessing her status, leaves an order for Natrecor 100 mcg IV bolus, followed by a continuous IV infusion of .5 mcg/min. Which pt assessment is most impt to monitor during the nesiritide infusion?
- lung sounds
- Heart rate
- BP
- Peripheral edema

Back 70

- Blood pressure
- It causes vasoddilation and diuresis so hypotension is the most common adverse effect.

Front 71

* You are preparing to leave at the end of your shift. Which of these nurses is the best to assign to care for Ms. C?
- A float RN who has worked on the coronary step-down unit for 9 years and has floated before to CCU
- An RN from a staffing agency who has 5 year of CCU experience and is orienting to your CCU today.
- A CCU RN who is already assigned to care for a newly admitted pt with chest trauma
- The new graduate RN who needs more experience in caring for pts with left ventricular failure.

Back 71

- A float RN who has worked on the coronary step-down unit for 9 years and has floated before to CCU

Front 72

* Which info in your assessment is most impt to report to the physician?
- Crackles and O2 sat
- Atrial fibrillation and fuzzy vision
- Apical mumur and pulse rate
- Peripheral edema and weight

Back 72

- Atrial fibrillation and fuzzy vision
- These are signs and symptoms of digoxin toxicity which can lead to fatal dysrhythmias

Front 73

* All of Ms C's ordered meds are scheduled for 9 AM. Which ones will you hold until you have discussed them with her physician?
- lasix
- ASA
- Potassium chloride
- Captopril
- Digoxin

Back 73

- Lasix and digoxin

Front 74

* which info will you include when completing ms C's discharge teaching?
- Weight yourself first thing in the morning
- Call the doctor if your weight increases more than 5 pounds in one day
- Call the doctor if you feel more short of breath or get tired more easily.
- Do not take the digoxin if your radial pulse is less than 60
- Take the lasix first thing in the morning and again at bedtime
- Drink at least 2500 mL of fluids daily
- Move slowly when changing from a lying to a standing position

Back 74

- Weight yourself first thing in the morning
- Call the doctor if you feel more short of breath or get tired more easily
- Move slowly when changing from a lying to a standing position

Front 75

* What nursing action is indicated for Ms C?
- Teach her about the expected effects of carvedilol.
- Place her on a 1000 mL/daily fluid restriction
- Transport her to the ED for treatment.
- Encourage her to go to bed earlier in the evening.

Back 75

- Teach her about the expected effects of carvedilol
- It's impt that pts with heart failure be taught that when therapy with beta-blockers is started, symptoms such as weight gain and fatigue may get worse.