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101 Cards in this Set
- Front
- Back
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When assessing the adult heart, which heart sounds does the nurse expect to hear? |
S1 & S2 (Lub Dub) |
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The S1 heart sound corresponds to which of the following physiological events? |
Closure of the AV valves. |
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The S2 heart sound corresponds to which of the following physiological events? |
Ejection of blood from the ventricle and results from aortic and pulmonic valve closure |
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How many beats per minute does the nurse expect to hear listening to adult heart sounds when a normal sinus rhythm is present?
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60-100 |
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The person is admitted to the hospital for evaluation and diagnosis of cardiovascular pathology. The person is scheduled for an ejection fraction study. What correct facts will guide teaching of the person? (Regarding CO and EF)?
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-An ejection fraction (EF) study will measure the percentage of total blood in the ventricle ejected from the heart with each beat. |
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Tachycardia occurs when the nurse assesses an apical heart rate of how many beats per minute in an adult?
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Greater than 100 |
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At which location will S2 be heard the loudest? |
Right sternal border at the second intercostal space. |
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At which location will S1 be heard the loudest? |
Left midclavicular line at the fifth intercostal space.
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The nurse prepares to auscultate heart sounds. Which nursing interventions would be most effective to assist with this procedure?
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Explain to the patient that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard.
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A patient is being assessed for his semi-annual examination and you hear crackles bilaterally in his lungs. Which of the following could be a cause of crackles in the bases of his lungs?
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Pulmonary congestion / oedema
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The nurse assesses the patient with a history of Myocardial Infarction, and records the data collected. What would lead the nurse to anticipate that the patient may experience a decrease in cardiac output?
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An increase in preload related to ambulation in the hall |
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In conducting a respiratory assessment on a patient recently admitted to your ward, you hear dullness on percussion of the left parasternal border between the 3rd and 5th intercostal spaces. This finding is: |
Normal, the dullness is due to normal anatomical structures underlying this area |
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Adventitious breath sounds include wheezes. Wheezing is not a commonly described sign of:
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Not a sign of : Chronic Obstructive Pulmonary Disease (COPD) (only in late stage COPD apparently)
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What may alter oximetry results?
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Diagnosis of peripheral vascular disease
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You perform a respiratory assessment on a patient experiencing shortness of breath, which reveals mild dyspnoea and productive cough, and the patient states he fatigues easily. The patient has a history of working in heavy industry for 35 years. Which of the following conditions would most likely explain the patient’s symptoms? |
Chronic Obstructive Pulmonary Disease |
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A patient is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?
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Impaired gas exchange related to airflow obstruction
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When performing a respiratory assessment, which finding requires immediate intervention?
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Respiratory rate of 44 breaths/minute |
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A nurse admits a patient to her unit with a presumptive diagnosis of pneumonia. When a sputum specimen is obtained, the nurse notes that the sputum is greenish and copious. The nurse notifies the patient's physician because these symptoms are indicative of what? |
Infection
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While auscultating the lungs of a patient with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?
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Wheezes
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A patient newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema:Select one:
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An abnormal distension of the air spaces with destruction of the alveolar walls This is correct!
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A nurse caring for a patient recently diagnosed with COPD encourages the patient not to smoke. What is the rationale behind this nursing action?
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Because smoking damages the ciliary cleansing mechanism of the respiratory tract
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While conducting the physical examination during assessment of the respiratory system, which of the following does a nurse assess by inspecting and palpating the trachea?
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Deviation from the midline
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A nurse assesses a patient's respiratory status. Which observation is the most obvious sign to indicate that the patient is having difficulty breathing?
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Use of accessory muscles
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For a patient with pleural effusion, what does chest percussion over the involved area reveal?
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Dullness over the involved area
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A nurse is preparing a patient with a pleural effusion for a Thoracentesis. The ideal position for the nurse to assist the patient into should be:
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Assisted to a sitting position on the edge of the bed, leaning over the bedside table
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You are the registered nurse caring for a patient with a haemothorax. What is the optimal position for the patient to assist with haemothorax drainage? |
High Fowler’s (Nearly 90 degrees) |
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A nurse is caring for a patient with chest trauma. Which nursing diagnosis takes the highest priority?
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Impaired gas exchange
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What is the primary purpose of a chest tube?
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To remove air
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For a patient who has a chest tube connected to an under water-seal drainage system, the nurse should include which action in the care plan?
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Measuring and documenting the drainage in the collection chamber
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You are the registered nurse caring for a patient on day 2 post- thoractomy/lung resection. The patient begins to cough, at which time you notice a sudden gush of dark blood into the chest drainage unit. The patient’s observations are stable. The most likely explanation for this occurrence is:
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Retained blood, not active bleeding
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The nurse suspects the patient has developed a mild pneumothorax. Assessment findings supporting the presence of a pneumothorax include:
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Diminished or absent breath sounds on the affected side
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Which criterion will determine when you will allow a post-operative patient to drink fluids? |
Presence of a cough and gag reflex |
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If concern exists about fluid accumulation in a patient's lungs, what area of the lungs will the nurse focus on during assessment? |
Bilateral lower lobes |
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You are caring for a patient admitted with chronic obstructive pulmonary disease who is experiencing a change in his respiratory and mental status. You are aware that the most accurate measurement of the concentration of oxygen in the patient's blood is what? |
An arterial blood gas |
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What patient would be most in need of an endotracheal tube? |
Unconscious patients |
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Which of the following interventions is not appropriate when planning a patient's care who has thick, tenacious secretions? |
Maintaining a cool room temperature |
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A critical care nurse is caring for a patient with a tracheostomy tube who is on a ventilator. What is the priority of care? |
Maintaining a patent airway |
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After the patient has settled post-suctioning a tracheostomy tube, which findings indicate that the airway is now patent? |
Effective breathing at a rate of 16 breaths/minute through the established airway |
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Which patient would the nurse prioritise as needing emergent treatment, assuming no other injuries are present except the ones outlined below? |
A patient with a blunt chest trauma with some difficulty breathing |
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A student nurse is developing a teaching plan for a patient with COPD. What should the student include as a major area of teaching? |
Setting and accepting realistic short-term and long-range goals |
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The primary aim of a COPD management plan is: |
To optimise function through symptom relief |
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An elderly person is admitted to the hospital with cardiac complications of diabetes. Which of the following concerns should the nurse have regarding this person’s medications?
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Is the person receiving too much medication because of impaired renal function?
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A person with chronic kidney disease is diagnosed with hypertension. Why does the person's blood pressure need to be controlled?
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Blood pressure control can slow the decline of kidney function
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An elderly person is scheduled for a CT scan with and without contrast dye. Which of the following should be done prior to this CT scan?
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Monitor renal function
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A person with acute kidney injury (AKI) is prescribed frusemide. Why is this medication helpful for this person? It:
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will reduce oedema
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A person is scheduled to have an arteriovenous (AV) fistula created for renal dialysis. Which of the following interventions are appropriate for this person?
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A functioning fistula has a thrill on palpation and bruit on auscultation.
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A person who is recovering from acute renal injury is being discharged. Which of the following should the nurse include in this person’s instructions?
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Avoid alcohol consumption
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A person is admitted with signs of chronic kidney disease. Which of the following is indicative of metabolic acidosis?Select one:
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Kussmaul's respirations
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Which of the following interventions would be appropriate for a person in renal failure with the diagnosis of imbalanced nutrition: less than body requirements?
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Schedule meals for three times each day.
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A person with diabetes and heart disease is diagnosed with chronic kidney disease. The nurse realises that extra care should be taken with this person if prescribing which of the following classifications of medications?
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Metformin
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A person with chronic kidney disease is trying to decide between haemodialysis and peritoneal dialysis. Which of the following are advantages of peritoneal dialysis for this person?
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Better self-management & Greater intake of fluids permitted.
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Which of the following should be assessed in an elderly person with age-related renal dysfunction? |
Evidence of medication or drug toxicity
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A person is diagnosed with postrenal acute kidney injury. The nurse realises that this type of renal failure can be caused by which of the following?
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Enlarged prostate
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A person is diagnosed with 45% of normal glomerular filtration. The nurse realises that this person is experiencing which of the following?
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Renal insufficiency
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A person who is prescribed to have a glycosylated haemoglobin (Hb A1C) level drawn asks the nurse about the purpose of the test. Which of the following would be an appropriate response for the nurse to make to this person?
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"It's to check for pancreas functioning."
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What is the recommended frequency of blood sugar monitoring of diabetic patients on insulin?
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Before meals and at bedtime
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A person says, "I'm glad I only have diabetes. Many of my friends have heart problems." Which of the following would be an appropriate response for the nurse to make to this person?
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"Diabetes can affect your heart if it is not properly controlled."
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A person tells the nurse, "I eat all the time but I'm losing weight and I can't stop urinating!" The nurse realises that this person is describing which symptoms?
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Polyphagia and polyuria
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A nurse is developing a teaching plan for a patient with diabetes mellitus. A patient with diabetes mellitus should:
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Wash and inspect the feet daily
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Which of the following would be included in the teaching plan for a patient diagnosed with diabetes mellitus?
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Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision
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A patient with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. The nurse evaluates the patient’s diabetes management regimen and learns: that the patient sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:
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Deficient knowledge (treatment regiment)
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An elderly person newly diagnosed with type 2 diabetes says, "I don't want to be using a needle for the rest of my life." Which of the following would be an appropriate response for the nurse to make to this person?
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You need it for now. There's a chance you won't need it after you get well.
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A person is scheduled for an oral glucose tolerance test. Diabetes mellitus is considered to have been diagnosed if the person’s plasma glucose level is greater than what value two hours after ingesting 75 g of glucose?
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11.1 mmol/L
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A person with type 2 diabetes says, "I was feeling really shaky yesterday so I drank a glass of orange juice and felt better." Which of the following should the nurse instruct this person?
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"If this happens again, check your blood glucose level with your monitor."
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Which of the following is an ultra fast-acting insulin?
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Insulin aspart. It is often known as Novolog.
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The nurse is instructing a person with type 1 diabetes about care during sick days. Which of the following should be included in these instructions?
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Administer insulin dose as prescribed and check insulin more often than they usually would due to decreased or altered oral intake therefore risk of hypoglycaemia.
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A person with type 2 diabetes wants to lose 10 kg and asks the nurse to help plan her meal pattern. Which of the following would be appropriate for this person to aid with weight loss and blood glucose level maintenance?
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Plan for three equal-sized meals with one or two snacks
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A postoperative person with type 2 diabetes says, "I was under better control before the operation. Now I'm on insulin." Which of the following could the nurse say to this person?
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"It's just until you are able to take your other medication and start to recover from the surgery."
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A person with type 1 diabetes comes into the emergency department with deep respirations, lethargy and extreme thirst. What is the person demonstrating?
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Possible diabetic ketoacidosis (DKA)
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The nurse is caring for a type 1 diabetic patient, assessing the patient's self-care skills to determine if further diabetes teaching is required. What is the best way to assess the patient's ability to prepare and give insulin?
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Direct observation of the self-care skill
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Which instruction about insulin administration should a nurse give to a patient?
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The correct answer is: Insulin is absorbed more rapidly at abdominal injection sites than at other sites.
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The following persons come to the outpatient clinic for a physical exam. Which person has signs and symptoms of hypertension that require further assessment?
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A 55-year-old indigenous Australian male with a blood pressure of 120/100
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Cardiovascular heart disease (CHD) is a large problem in Australia. Persons with which of the following may require closer evaluation for CHD?
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Low HDL cholesterol, Physical inactivity & Diabetes.
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A nurse is conducting teaching about risk factor management for cardiovascular heart disease at a senior citizens centre. What is the most important information for the nurse to include?
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Stop smoking
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Which of the following statements is true about medications used to treat hyperlipidaemia? They:
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include statins, which act by lowering LDL levels
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A person is commenced on a diet consisting of foods high in complex carbohydrates and fibre, low in cholesterol and low in fat. What else should the program also include?
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Walking 45 minutes most days of the week
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What should a person who is taking a statin medication be monitored for?
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Serum cholesterol and liver enzymes
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Which of the following is correct for a 52-year-old obese male who is admitted with elevated triglycerides and a history of smoking two packs of cigarettes a day for 20 years? He:
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is at high risk of coronary artery disease
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The nurse is caring for an adult who is admitted with chest pain that began four hours ago. Which of the following tests will be most specific in identifying acute heart damage?
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Troponin
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When a person’s ECG shows frequent premature ventricular contractions (PVCs), the nurse expects that the doctor will create an order for which of the following?
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To check serum potassium, check serum magnesium & check Troponin
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Decreased pulse pressure reflects:
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Reduced stroke volume
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What is a priority of care for a person with a junctional escape rhythm?
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Assess the person for symptoms associated with the rhythm
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Sinus bradycardia (rate 56) is identified in a sleeping person on telemetry. What is the nursing priority for this person?
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Compare HR with previously recorded HR & perform a BP to assess further
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A person is in sinus tachycardia. What are the appropriate nursing interventions?
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Observe the person for effects on cardiac function, increase frequency of HR, BP and conscious state assessment, administer two tablets of paracetamol per doctor's order if an elevated temperature is present, assess pulse for irregularities and strength including an apical pulse if irregular.
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The nurse notes an ECG rhythm with a rate of 80bpm, a regular rhythm, a 1:1 relationship of P:QRS, a PR interval of 0.16 and a QRS complex measurement of 0.8. The nurse realises that this rhythm is evidence of which condition?
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Normal sinus rhythm
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The nurse measures a person’s blood pressure as 144/88 mm Hg. Previous BP was 135/80mmHg. Which of the following interventions would be most appropriate for this person?
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Check other vital signs, if stable, wait several minutes and then repeat the blood pressure recording
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A person with diabetes mellitus is commencing treatment for hypertension. Which of the following is a desirable blood pressure goal for this person?
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130/80 mm Hg
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While obtaining subjective assessment data from a patient with hypertension, the nurse recognises that a modifiable risk factor for the development of hypertension is:
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excessive alcohol consumption
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A person is started on metoprolol. What is a possible adverse effect of this medication that the person could report?
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Bradycardia.
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A person’s blood pressure continues to be elevated despite being prescribed an ACE inhibitor for several weeks. Which of the following would be most appropriate for the nurse to do at this time?
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Ask the person if they are taking the prescribed medication as ordered
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The patient asks the nurse what his urine output has to do with his cardiac function. The best reply by the nurse is which of the following?
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"The urine output is an important indicator of cardiac function; poor urine output may indicate inadequate blood flow to the kidneys."
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There are several things you need to do when you encounter a person in need of assistance. What should you do first?
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check for danger
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'No signs of life' means:
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unconscious, unresponsive, not moving and not breathing normally
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Which of these terms means 'CPR'?
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the technique of rescue breathing combined with chest compressions
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True or false : It is not important to wait for the chest to come back to its original position after each compression ?
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False
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When you commence CPR, how many initial breaths would you give?
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2 |
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If the victim is breathing normally, but not responding you should:
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Turn the victim to the side and wait for emergency personnel
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What is the recommended rate of compression?
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100 compressions per minute
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What is the recommended ratio of compressions to breaths before insertion of an advanced airway?
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30 compressions to 2 breaths
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How can you tell if ventilations are going into a victim?
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Watch for chest rise
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The most common cause of airway obstruction is:
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The tongue
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