Complex Perfusion NCLEX Practice Questions

Complex Perfusion NCLEX Practice Questions Leave the first rating Students also studied Terms in this set (15) Science MedicineNursing Save HESI A2 Critical Thinking Questions 124 terms ChoznPreview HESI A2 Critical Thinking Teacher 617 terms Hope_Ramos-Uribe Preview PCCIV exam 1 NCLEX questions 17 terms karlee_christensen1 Preview STEMI

• terms

koo A nurse is teaching a student nurse about the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the student indicates an understanding of the teaching?

• "Air should be instilled into the monitoring system prior

to the procedure"

• " The client should be positioned on the left side

during the procedure"

• "The transducer should be level with the second

intercoastal space after the line is placed"

• "A chest x-ray is needed to verify placement after the

procedure"

a) INCORRECT: the nurse should purge air from the monitoring system

b) INCORRECT: the nurse should place the pt in supine or Trendelenburg

c) INCORRECT: the nurse should place the transducer level with the 4th

intercoastal space, at the base of the right atrium

d) CORRECT: The nurse should insure that the chest x-ray is obtained to confirm

proper placement of lines A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.)

• A client who has

metabolic alkalosis

• A client who has a serum

potassium level of 4.3 mEq/L

• A client who has an

SaO2 of 96%

• A client who has COPD
• A client who underwent stent

placement in a coronary artery

a) CORRECT: a client who has an acid base imbalance is at risk for dysthymias

b) INCORRECT: potassium is within normal range

c) INCORRECT: SaO2 is within range and does not increase the risk of

dysrhythmia

d) CORRECT: a client who has lung disease such as COPD is at risk for

dysrhythmias

e) CORRECT: a client who has cardiac disease and underwent a stent placement is

at risk for dysrhythmias

A nurse on a cardiac unit is reviewing the lab findings of a client who has a diagnosis of myocardial infarction (MI) and reports that dyspnea began two weeks ago. Which of the following cardiac enzymes would confirm that MI occurred 14 days ago?

a) CK-MB

b)Troponin I

c) Troponin T

d)Myoglobin

a) INCORRECT: the creatinine kinase MB levels are no longer evident after 3 days

b) INCORRECT: Troponin I levels are no longer evident after 7-10 days

c) CORRECT: The troponin T levels will still be evident for 10-14 days following a

MI event

d) INCORRECT: Myoglobin levels are no longer evident after 24hrs

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2000 mg daily.Which of the following foods should the nurse recommend? (select all that apply)

• 1 slice cheddar cheese
• 1 medium beef hot dog
• 3 oz Atlantic salmon
• 3 oz roasted chicken breast
• 2 oz lean baked ham

a) CORRECT: 1 slice cheddar cheese contains 180 mg sodium

b) INCORRECT: 1 medium beef hot dog contains 557mg of sodium and foods

should be less than 300mg per serving on a sodium restricted diet

c) CORRECT: 3 oz Atlantic salmon contains 37 mg of sodium

d) CORRECT: 3 oz roasted chicken breast contains 62 mg of sodium

e) INCORRECT: 2 oz lean baked ham contains 782 mg of sodium and foods

should be less than 300mg per serving on a sodium restricted diet A nurse educator is reviewing expected findings in a client who has right sided valvular heart disease with a group of new nurses. Which of the following findings should the nurse include in this discussion?( select all that apply)

• dyspnea

b)client reports fatigue

• bradycardia

d)pleural friction rub

• peripheral edema

a) CORRECT: dyspnea is a manifestation of right sided valvular heart disease

b) CORRECT: fatigue is a manifestation of right sided valvular heart disease

c) INCORRECT: a normal or rapid pulse and an irregularly irregular rhythm are

manifestations of right sided valvular heart disease NOT bradycardia

d) INCORRECT: a pleural friction rub is a manifestation of pleurisy or pneumonia

e) CORRECT: Peripheral edema is a manifestation of right sided valvular heart

disease You witness the UAP placing a blood pressure cuff on your patient with an AV fistula, on the same arm of the AV fistula, what is your next action?

• Allow the UAP to complete the vital signs so they can

be charted

• Tell the UAP that the cuff must be placed above or

below the fistula so it doesn't touch it.

• Stop the UAP from taking the bp on that arm and

educate her on the importance of not conducting vital signs on the same arm as the AV fistula.

• Ensure there is a band on the affected arm stating no

vitals or blood draws/sticks are to be done on that arm.C what are you to do next? Immediately stop vitals from being taken on that arm, they will possibly damage the fistula. It doesn't matter if the cuff isn't directly over the fistula it could still cause damage.Your dialysis patient is about to go up for dialysis, the patient asks if they are supposed to take all of their cardiac scheduled medications prior to dialysis, what is your response?

• Yes, you will need to take them before dialysis.
• No, we will hold the medications, as they will be

filtered out of the body and wasted.

• No we will wait till after dialysis
• We will hold the medication and give pending vital

signs post dialysis.D, hold the medications as they will be filtered out of the body, and they are cardiac medications so vitals will be needed to assess if they will be given, after dialysis it is likely the patients BP will be low, many cardiac medications lower BP.

You're in the ED and your patient is presenting with an onset of cp, lft arm pain and jaw pain, after completing a 12 lead you see what appears as grave stones on many of the leads what is your next action?

• Immediately show a Physician and call a stemi, as this is

ST elevation

• Give prescribed Nitro to improve pain
• Call the cath lab in preparation for a stent
• This is normal, continue on with assessment

A, ST elevation appears to look like gravestones on an EKG, some standing up and some will also be upside down meaning there is reciprocation and this is likely a STEMI, the first action is calling a stemi then all other orders follow.Your patient has come back from the cath lab after a PCI cath procedure, you're assessing limbs distal to cath site, the extremities are cool and clammy, what is your next step?

• Obtain a doppler to assess perfusion to affected limps
• Have another nurse assess for pulses and then obtain a

doppler machine to assess for perfusion

• Call a rapid
• Chart findings and the patients doctor

B assess the pulses from a second nurse, obtain a doppler machine. Do not wait to call the doctor by the time they call back the limb may have no perfusion.Calling a rapid before gathering more of an assessment is not appropriate.

• A patient presents to the ED with fever, chills, night

sweats and malaise, she states she is an IV drug user and that she has also been losing weight lately. She has petechiae and Janeway lesions on her body and upon auscultation she has a cardiac murmur. Being that she presents all theses symptoms and is an iv drug user this puts her at risk for what perfusion illness?

• Infective endocarditis
• HIV
• Pericarditis
• Pneumonia

A infective endocarditis, she is an iv drug user which places her at higher risk for this infection, she has all the marking symptoms A patient is admitted with a medical diagnosis of acute arterial occlusion. What documentation does the nurse expect to see in the patient's medical record?

• Acute MI and/or atrial fibrillation within the previous

weeks.

• History of chronic venous stasis disease treated with

debridement and wound care.

• History of Marfan syndrome or Ehlers-Danlos

syndrome.

• Episode of blunt trauma that occurred several months

ago.

Answer: A

Rational: Patient's with a history of MI or A-fib have an increased risk of

developing a blood clot. Acute Arterial Occlusion is when a piece of a clot breaks free and travels to a new area. This could develop in the upper or lower extremities; however, it is more common in the lower extremities. Pg. 737

A nurse is preparing to discharge a patient who was recently diagnosed with a 4 cm abdominal aortic aneurysm (AAA). The patient is currently asymptomatic.What is the nurses goals for nonsurgical management for this patient?

• Teach lifestyle modifications that will minimize the

growth of the aneurysm.

• Monitor the growth of the aneurysm and follow the

antihypertensive medication regimen.

• Encourage compliance with anticoagulant drugs and

laboratory follow-up appointments.

• Stabilize the patient's condition and improve overall

health so surgery can be safely performed.

Answer: B

Rational: The desired outcome for nonsurgical management is to monitor the

aneurysm, control the patient's blood pressure at a normal level to decrease the risk of the aneurysm rupturing. Pg. 739 A nurse is teaching a patient who is at risk for developing a venous thromboembolism (VTE). The patient is currently asymptomatic and is living in the community. What interventions does the nurse instruct the patient to do to minimize the risk of VTE? Select All that apply

• Avoid oral contraceptives.
• Drink adequate fluids and avoid dehydration.
• Exercise the legs during long periods of bedrest or

sitting.

• Arise early in the morning for ambulation.
• Use a venous plexus foot pump.
• Avoid potential trauma such as contact sports.

Answer: A,B,C,F

Rational: Avoid things that can cause your blood to either pool in an area, thicken, or clot. Oral contraceptives have a side effect of blood clots and should be avoided if you have a history of blood clots or a clotting disorder. Keeping your body hydrated will help the blood circulate through the body. Exercising the legs will prevent blood from pooling in the lower extremity(ies). If injuries occur during playing contact sports then the patient could have down time in bed and put them at an increased risk of developing a VTE. Pg. 743 The medication ordered for unfractionated heparin (UFH) is for 80 units/kg of body weight. How does the nurse interpret this order?

• Appropriate dose for the continuous IV infusion.
• Higher than expected dose for the initial IV bolus.
• Appropriate dose for the initial IV bolus.
• Appropriate dose for maintenance therapy.

Answer: C

Rational: The initial IV bolus dose of UFH is 80-100 units/kg of body weight.

Following a initial bolus dose the patient is given IV heparin and then the patient's PTT is monitored at least daily and results are reported to the physician. Pg. 744 CitationsIgnatavicius, D.D, Workman, M.L, Rebar, C.R. (9th edition) Study Guide. Medical-

Surgical Nursing: Concepts for interprofessional Collaborative Care. Elsevier

Henry, Norma Jean, et al. RN Adult Medical Surgical Nursing. 10th ed., Assessment Technologies Institute, 2016.