NUR 2790 Exam2 PN3 1. A client who is being mechanically ventilated has positive end respiratory pressure (PEEP) set at 20 cm of water. Which of the following should the nurse assess for the client? 2. A nurse is completing discharge teaching with a client who has a pacemaker. Which of the following statements by the client is correct? 3. In order to reduce afterload in a client with HTN and HF, the nurse will administer which IV medication? 4. A client diagnosed with a-fib will most likely be placed on which two long term medications? 5. A client is complaining of dizziness and near syncope. The nurse’s assessment reveals the following: VS: B/P 80/40, HR: 36 RR: 12. Cardiac monitor shows this: strip. the nurse anticipates giving which one of the following medications? PAGE 674. 6. The nurse suspects a client is in left-sided HF when which of the following are assessed? 7. A client is receiving an infusion of tissue plasminogen activator (t-PA). the client becomes disoriented to person, place, and time. What is the first action the nurse should take? INDICATOR FOR A MASSIVE MI 8. Which of the following interventions are for a client diagnosed with a pneumothorax? SATA. 9. The nurse is caring for a client is caring for a client diagnosed with a STEMI. Select the interventions a nurse will expect to give. SATA. 10. a client is getting weaned from the ventilator. Which setting will give partial support (continue to give ventilations and allow spontaneous breathing) and is used during the weaning process? 11. which lab value is most important to monitor for a client receiving a heparin infusion for tx of a PE? 12. a client in the critical care unit has an arterial line. The nurse is aware that an advantage to having an arterial line includes which one of following? 13. respiratory distress caused by a wide spread inflammatory response, damaged alveoli, and decreased O2 saturations even with 100% is called? 14. which of the following rhythms will require immediate application of an external pacemaker? 15. a client with fluid volume excess will exhibit which of the following s/s? 16. which of the following s/s and labs indicate a client has COPD? SATA 17. Following a Motor vehicle collision, a client is diagnosed with a flail chest. The nurse will anticipate which interventions? SATA 18. A client is admitted to the ICU with a flail chest and placed on mechanical ventilator. Breath sounds are clear bilaterally. The nurse should monitor which of the following? 19. Following a myocardial infarction, a client begins to feel lightheaded. The cardiac monitor shows a third-degree heart block. The nurse administers oxygen and anticipates which next treatment? 20. When caring for a client with a head injury, the nurse suspects increased intracranial pressure when the vital signs indicate Cushing’s triad. Which vitals did the nurse observe? 21. a nurse is assessing a client with DVT during the assessment the nurse will also assess for wotf side effects or complication of a DVT? 22. The nurse is caring for a client with a blood pressure of 70/30. Which medication does the nurse anticipate will be ordered? 23. STRIP: During an assessment of a client (on a cardiac monitor), the nurse observes a change in the client’s rhythm. Identify this rhythm and the appropriate initial treatment. 24. MATH: Mr. M is admitted to the hospital with a GI bleed and his physician orders a blood transfusion of PRBCs. Order: 1 unit PRBCs (520 ml) IV to infuse over 4 hours. Drop Factor: 10 gtt/ml. What is the infusion rate in gtt/min? 25. Critically ill clients are in a hypermetabolic state. Which intervention will address this issue? 26. A client is learning about cholesterol. The nurse explains that the “good cholesterol” transports plasma cholesterol away from plaques and to the liver for metabolism. This type of cholesterol is called: 27. During report, a nurse states the client has an ejection fraction of 60%. Based on this percentage, which of the following next statements made by the nurse is correct? 28. Post-operative complications after pacemaker insertion will include which of the following? SATA 29. A practioner has just intubated a client who was in respiratory arrest. The nurse assess breath sounds for tube placement and can only hear breath sounds over the right lung. What is the most…. 30. Which of the following nursing interventions would be appropriate for a client who just had an endotracheal tube removed? 31. A client presents with a glucose level of 700 mg/dL. An arterial blood gas (ABG) shows the following results: pH 7.30, pcCO2 28 mm Hg, HC03 18 mm… 32. STRIP: A client with a history of dysrhythmias is placed on a cardiac monitor. The following rhythm is observed. The nurse correctly documents which rhythm? 33. During an assessment of a client diagnosed with a STEMI, the nurse realizes fibrinolytic therapy cannot be given when the client makes which statement? Current vital signs are BP 150/90, HR 100, RR 34. Core measures for myocardial infarction include which of the following interventions? 35. A client is complaining of recurrent chest pain that occurs during both exercise and rest. This pain is relieved after several nitroglycerine. The nurse realizes that this client is experiencing which type of angina? 36. The ICU nurse is caring for a client on a ventilator when the low pressure alarm goes off. The nurse’s next step is to assess for which of the following? 37. Prevention of a thromboembolism includes which one of the following interventions? 38. In triage, a client presents with not feeling well. An ECG shows the following rhythm below. Assume this is a 6 second strip. Which of the following does the nurse document? 39. A one-day post operative client Is experiencing a sudden onset of chest pain, SOB, and hemolysis. Based on history and presenting symptom, which condition does the nurse suspect? 40. A client with COPD is compelling of severe shortness of breaths and a productive cough. An atrterial blood gas (ABG) shows pH 7.27, PaCO2 53 mmgHg, HCO3 24 mmo/L, and PaO2 60 mmHg. How would you interpret this? 41. A client is recently diagnosed with a myocardial infarction and admitted to the progressive care unit. The client begins to have frequent dysrhythmias. What action does the nurse do first? 42. 43. A client has a 90% blockage of the left anterior descending artery. Which of the following interventions is NOT appropriate to treat coronary artery? 44. The nurse assess a client and finds the following breathe sounds reveal crackers and rale posteriorly, 3 pitting edema to lower extremities. Which intervention does the nurse anticipate will be given? 45. A client is unresponsive and has a weak pulse. The nurse notes that the electrocardiogram tracing shows continuous large and bizarre QRS complexes measured greater than 0.12. this rhythm is identified as ____. The next treatments is? 46. Which of the following signs and symptoms would indicate a client may have active tuberculosis (SATA). 47. A client has been diagnosed with a pulmonary embolism. Which diagnostics and treatments does the nurse anticipate will be ordered (SATA). 48. Asystole 49. While caring for a patient with respiratory disease, the nurse observes that the client’s SpO2 drops from 94% to 85% when ambulating in the hall. Which of the following is the best plan the nurse should follow? 50. A client is being discharged following a CABG. When giving discharge instructions, which statement made by the nurse is correct?