Question: The nurse provides care to a patient with a central line. Which clinical manifestations does the nurse report to the health-care provider? Select all that apply.
Answer Choices:
A. The patient’s pulse rate is 88 bpm.
B. The patient’s blood pressure is 110/70 mm Hg.
C. The patient’s respiratory rate is 32 bpm.
D. The patient’s dressing appears soaked in serosanguineous drainage.
E. The patient’s cardiac rhythm that indicates ventricular tachycardia.
Answer: C, D, E
Question: Which clinical manifestations does the nurse anticipate when providing care to a patient who is diagnosed with a pulmonary embolism (PE)? Select all that apply.
Answer Choices:
A. Tachypnea
B. Bradycardia
C. Shortness of breath
D. Bilateral lower extremity edema
E. Use of accessory muscles to breathe
Answer: A, C, E
Question: While awaiting cardiac transplantation, a patient with severe heart failure has a portable, long-term ventricular assist device (VAD) implanted. What should the nurse include in the plan of care?
Answer Choices:
A. Administration of immunosuppressant medications
B. Monitor the surgical site for signs of infection
C. Maintain the patient on continual bed rest
D. Keep the patient NPO until cardiac transplantation
Answer: B. Monitor the surgical site for signs of infection
Question: A nurse is assessing a patient with a new-onset cardiac dysrhythmia. The telemetry monitor shows an irregular rhythm with a heart rate of 38 bpm. Which combination of assessment findings would indicate the patient is symptomatic and experiencing decreased cardiac output?
Answer Choices:
A. Blood pressure 128/76, warm extremities, alert and oriented, no complaints of discomfort
B. Heart rate 38, blood pressure 86/50, cool extremities, delayed capillary refill, dizziness
C. Heart rate 38, regular rhythm, potassium 3.5 mEq/L, no reported symptoms
D. Blood pressure 112/68, respiratory rate 18, ECG with peaked T waves, no change in mental status
Answer: B. Heart rate 38, blood pressure 86/50, cool extremities, delayed capillary refill, dizziness
Question: A patient’s telemetry monitor shows a regular rhythm at 48 beats per minute with no visible P waves and narrow QRS complexes. Which cardiac structure is most likely responsible for this rhythm?
Answer Choices:
A. Purkinje fibers
B. Sinoatrial node
C. Atrioventricular node
D. Bundle of His
Answer: C. Atrioventricular node
Question: The nurse provides care to a patient who is prescribed intravenous (IV) adenosine (Adenocard). Which is the priority nursing action before administering the medication?
Answer Choices:
A. Monitoring respirations
B. Palpating the patient’s pulse
C. Teaching the patient to avoid caffeine intake
D. Ensuring a transcutaneous pacemaker is available
Answer: D. Ensuring a transcutaneous pacemaker is available
Question: The nurse provides discharge instructions to a patient who is admitted for angina. Which patient statement indicates a need for additional teaching?
Answer Choices:
A. I will continue to keep my SL nitroglycerin with me at all times
B. I will take my blood pressure regularly at home, reporting any extreme change
C. I will take an aspirin a day as prescribed by my HCP
D. If my chest pain will not cease, I will wait 4–6 hours before notifying my provider
Answer: D. If my chest pain will not cease, I will wait 4–6 hours before notifying my provider
Question: Which patient statement indicates to the nurse a need for additional teaching regarding the prevention of pulmonary embolism (PE)?
Answer Choices:
A. “I will decrease my intake of saturated fats.”
B. “I joined a gym so that I can take an aerobic exercise class.”
C. “I will continue to try to quit smoking by using a nicotine gum.”
D. “I won’t need any blood work since I am being discharged with warfarin.”
Answer: D. “I won’t need any blood work since I am being discharged with warfarin.”
Question: The nurse is reviewing the manifestations of an acute myocardial infarction with a patient diagnosed with type 2 diabetes mellitus. What should the nurse emphasize as being an atypical manifestation of this cardiac disorder?
Answer Choices:
A. Fatigue
B. Dyspnea
C. Tachycardia
D. Hypertension
Answer: A. Fatigue
Question: The nurse hears crackles when auscultating the lung sounds of a patient with cardiomyopathy. What should this finding indicate to the nurse?
Answer Choices:
A. Atelectasis
B. Pneumothorax
C. Stasis pneumonia
D. Pulmonary edema
Answer: D. Pulmonary edema
Question: A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing assessment for this patient?
Answer Choices:
A. Breathing and ventilation
B. Circulation with hemorrhage control
C. Airway maintenance with cervical spine protection
D. Disability and neurological assessment
Answer: C. Airway maintenance with cervical spine protection
Question: The nurse suspects that a patient with cardiomyopathy is experiencing heart failure. What finding did the nurse use to make this clinical decision?
Answer Choices:
A. Dizziness
B. Chest pain
C. Palpitations
D. Dyspnea when supine
Answer: D. Dyspnea when supine
Question: The nurse suspects that a patient is experiencing a complication from a pulmonary artery catheter. What findings did the nurse use to make this clinical determination? Select all that apply.
Answer Choices:
A. Bleeding
B. Increased urine output
C. Elevated body temperature
D. Acute onset of shortness of breath
E. Development of a cardiac dysrhythmia
Answer: A, C, D, E