Flashcards

Front 1

When obtaining a radial pulse rate, the nurse understands that it reflects the function of the
1. arteries
2. veins
3. blood
4. heart

Back 1

4. heart

Front 2

Older adults tend to have higher blood pressure because they have:
1. aging hearts
2. thicker blood
3. lifestyle stressors
4. less elastic vessels

Back 2

4. less elastic vessels

Front 3

When taking the resting pulse rate of an older adult, the nurse recognizes which pulse as within the expected range?
1. 50 beats per minute and irregular
2. 90 beats per minute and regular
3. 105 beats per minute and irregular
4. 120 beats per minute and regular

Back 3

2. 90 beats per minute and regular

Front 4

A pt has a history of heart disease. After walking to the lounge, the pt sits in a chair, places a fist against the chest, and c/o severe upset stomach. The nurse should first:
1. take the pt's vital signs
2. walk the pt back to bed
3. administer an antacid to the pt
4. listen to the c/o the pt

Back 4

1. take the pt's vital signs

Front 5

Which statement regarding BP is true?
1. a BP differs 5 to 10 mm Hg between arms
2. a BP remains consistent regardless of the pt's position
3. the arm must be kep at the level of the clavicles to obtain a correct BP
4. the arm must be kept below the apex of the heart to obtain an accurate BP

Back 5

1. a BP differs 5 to 10 mm Hg between arms

Front 6

Which BP reading would be considered the most hypertensive?
1. 90/70
2. 130/86
3. 160/90
4. 150/115

Back 6

4. 150/115

Front 7

To determine the presence of orthostatic hypotension, when is the most significant time for a pt's BP to be assessed?
1. after standing
2. between meals
3. during activity
4. before standing

Back 7

1. after standing

Front 8

A pt's urine specific gravity is 1.035, indicating a need for:
1. fluids
2. protein
3. glucose
4. antibiotics

Back 8

1. fluids

Front 9

Which physiologic action is reflected by the diastolic BP?
1. contraction of the ventricles
2. Volume of cardiac output
3. resting arterial pressure
4. pulse pressure

Back 9

3. resting arterial pressure

Front 10

When obtaining pedal pulses, the nurse is assessing the function of the pt's:
1. veins
2. heart
3. blood
4. arteries

Back 10

4. arteries

Front 11

When assessing cardiac function, the nurse should recognize which principle of BP physiology?
1. a trough pressure occurs during systole
2. the pulse pressure occurs during diastole
3. a peak pressure occurs when the ventricles relax
4. the BP reaches a peak followed by a trough

Back 11

4. the BP reaches a peak followed by a trough

Front 12

When the physician orders that a pt be kept NPO, the MOST important action by the nurse should be to:
1. allow the pt to sip clear fluids with medication
2. give the pt mouth care q 4 hrs
3. measure the pt's I&O
4. permit the pt to suck on ice chips

Back 12

2. give the pt mouth care q 4 hrs

Front 13

A pt who had a heart attack because of atherosclerotic plaques should obtain protein by primarily ingesting:
1. white meats
2. legumes
3. shrimp
4. milk

Back 13

2. legumes

Front 14

A pt with a deficiency in vitamin K should be assessed for:
1. muscle cramps
2. signs of infection
3. cardiac dysrhythmias
4. bleeding irregularities

Back 14

4. bleeding irregularities

Front 15

The nurse should encourage a pt on a low-sodium diet to ingest:
1. milk
2. fruit
3. bread
4. vegetables

Back 15

2. fruit

Front 16

What interventions by the nurse is most important when feeding a patient with hemiparesis?
1. ensure that food is pureed
2. provide foods that require chewing
3. offer fluids with each mouthful of food
4. allow time to empty the mouth between spoonfuls

Back 16

4. allow time to empty the mouth between spoonfuls

Front 17

A pt walking in the hall complains of sudden chest pain. The initial intervention by the nurse should be to:
1. take the pt's vital signs
2. perform a detailed pain assessment
3. walk the pt back to bed slowly
4. get a chair so the pt can sit and rest

Back 17

4. get a chair so the pt can sit and rest

Front 18

What is the MOST important intervention by the nurse to increase both circulation and respiration of a pt?
1. encourage the use of a spirometer
2. reposition the pt every 2 hrs
3. massage bony prominences with lotion
4. teach the pt to cough and breathe deeply

Back 18

2. reposition the pt q 2 hrs

Front 19

While eating, a pt clutches the upper chest with the hands, appears unable to breathe, and has a frightened facial expression. The most appropriate initial intervention by the nurse is to:
1. perform the abdominal thrust maneuver
2. slap the pt 3 times on the back
3. ask the pt to attempt to speak
4. start artificial respirations

Back 19

3. ask the pt to attempt to speak

Front 20

To reduce anxiety r/t the use of oxygen via a nasal cannula, the nurse should say to the pt:
1. "Keep calme and everything will be OK"
2. "This is oxygen; it will help your breathing"
3. "This is a treatment that was ordered by your doctor"
4. "The oxygen will be discontinued asap"

Back 20

2. "This is oxygen; it will help your breathing"

Front 21

When a pt c/o being SOB, the nurse's initial action should be to:
1. obtain the vital signs
2. raise the head of bed
3. administer emergency oxygen
4. encourage pursed-lip breathing

Back 21

2. raise the head of the bed

Front 22

When a pt has moderate chronic impaired peripheral arterial circulation, the nurse should assess for:
1. yellow toenails and cool extremities
2. cyanosis of the feet and yellow toenails
3. cool extremities and continuous leg discomfort
4. continuous leg discomfort and cyanosis of the feet

Back 22

1. yellow toenails and cool extremities

Front 23

To BEST evalutate peripheral circulation in the lower extremities, the nurse should assess teh:
1. pedal pulses and presence of hair on the toes
2. capillary refill in the toenails and pedal pulses
3. presence of hair on the toes and BP
4. BP and capillary refill in the toenails

Back 23

2. capillary refill in the toenails and pedal pulses

Front 24

A common local adaptation to pressure is specifically referred to as:
1. edema
2. ischemia
3. orthopnea
4. hypovolemia

Back 24

2. ischemia

Front 25

The adequacy of tissue oxygenation is most accurately measured by:
1. hematocrit values
2. hemoglobin levels
3. arterial blood gases
4. pulmonary function tests

Back 25

3. arterial blood gases

Front 26

The nurse recognizes that a pt's fever can result in tachypnea because of the:
1. increase in the metabolic rate
2. need to retain carbon dioxide
3. decrease in carbon dioxide levels
4. attempt to compensate for respiratory alkalosis

Back 26

1. increase in the metabolic rate

Front 27

Postoperatively a pt c/o pain in the calf. What would be the most appropriate intervention by the nurse?
1. inform the physician
2. implement warm soaks
3. administer cool compresses
4. apply antiembolism stockings

Back 27

1. inform the physician - if the pain is due to thrombolphlebitis, the pt is at risk for a pulmonary embolus and the physician should be notified immediately

Front 28

Which assessment is most significant when assessing a postoperative pt with a history of heart disease?
1. pain at the site of the incision
2. alterations in fluid balance
3. an irregular pulse rhythm
4. dependent edema

Back 28

3. an irregular pulse rhythm - this could indicate a life-threatening dysrhythmia

Front 29

A pt has an order for morphine sulfate 10 mg SQ q 4 h for pain after abdominal surgery. The nurse would know that the morphine was effective when the pt:
1. does not ask for another injection for pain
2. is able to cough with minimal discomfort
3. requests another injection in 3 h
4. has a decreases in the respiratory rate

Back 29

2. is able to cough with minimal discomfort

Front 30

Which is an age-related alteration in the older adult that may affect the absorption of an oral hypoglycemic agent?
1. an increase in hydrochloric acid production
2. an increase in mesenteric blood flow
3. a decrease in abdominal body fat
4. an increase in cardiac output

Back 30

2. an increase in mesenteric blood flow - as the body ages, there is a decrease in fat in the extremities and an increase of fat in the abdominal area

Front 31

Which drug would be most effective in the immediate treatment of anaphylaxis?
1. Prednisone
2. Solu-Cortef
3. Epinephrine
4. Solu-Medrol

Back 31

3. Epinephrine

Front 32

A pt receiving a cardiac glycoside is "digitalized." The nurse recognizes that digitalization means:
1. large does of the drug were administered to quickly reach the therapeutic window
2. an excessive amount of the drug was given and acceptable side effects occurred
3. blood levels of the drug have been maintained at acceptable levels over time
4. the therapeutic window was exceeded and toxicity has occurred.

Back 32

1. large doses of the drug were administered to quickly reach the therapeutic window

Front 33

Which group of medications has a high risk for a drug interaction with digoxin (Lanoxin)?
1. glucocorticoids
2. sulfonamides
3. antibiotics
4. antacids

Back 33

1. glucocorticoids - prednisone, a glucocorticoid with mineralocorticoid activity, can precipitate hypokalemia. Hypokalemia increases the sensitivity of the myocardium to digitalis. Hypokalemia can precipitate digitalis toxicty, even if digoxin serum levels are in the therapeutic range of 0.4 to 2.0 ng/mL

Front 34

Which undesirable clinical response would indicate the need to discontinue heparin therapy?
1. international normalized ratio (INR) of 2.5
2. platelet count of 100,000/mm3
3. hematuria
4. gastritis

Back 34

1. hematuria (blood in the urine) is a seriuos side effect of heparin therapy that requires the temporary termination of therapy. If severe bleeding is identified, protamine sulfate is administered as an antidote

Front 35

Which statement by the patient receiving digoxin (Lanoxin) 0.25 mg every day would indicate that futher teaching is necessary.
1. "I should not take antacids with digoxin"
2. "I should call the doctor if I have N/V or weakness"
3. "If I forget to take my digoxin, I should take 2 pills the next day"
4. "I should not take the digoxin if my apical pulse is below 60 bpm

Back 35

3. "If I forget to take my digoxin, I should take 2 pills the next day" - this action is unsafe and could lead to toxicity. If a dose is missed, it should be taken within 12 hours of the scheduled dose.

Front 36

Postural hypotension is a common side effect of most of the medications in which classification of drugs?
1. antibiotics
2. antiemetics
3. antihistamines
4. antihypertensives

Back 36

4. antihypertensives

Front 37

When collecting a health history for a pt who will be receiving IV heparin therapy, which statement by the pt needs further exploration?
1. "I stopped taking my daily aspirin table about 5 days ago"
2. "I always experience heavy menstrual periods"
3. "I eat a lot of green leafy vegetables"
4. "I may be pregnant"

Back 37

2. "I always experience heavy menstrual periods" - this could be a contraindication for the use of heparin because of an increased risk of prolonged bleeding during menstruation

Front 38

Which is most important to have readily available on the unit when a pt is receiving heparin IV?
1. potassium chloride
2. protamine sulfate
3. prothrombin
4. plasma

Back 38

2. protamine sulfate

Front 39

Antipsychotics potentiate the effects of:
1. amphetamines
2. anticoagulants
3. opioid analgesics
4. oral hypoglycemic agents

Back 39

3. opioid analgesics - antipsychotics decrease the effectiveness of drugs in this classification

Front 40

Which pt response would require a dose of digoxin to be withheld?
1. respiratory rate of 30
2. apical heart rate of 56
3. irregular pulse rhythm
4. BP of 110/60

Back 40

2. apical heart rate of 56 - digoxin causes a negative chronotropic effect. This drug must be held if the apical heart rate taken over a full minute falls below 60. Take the pt's apical pulse rate in 1 hour and if it is still below 60, notify physician