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Fluids - Gas
1.
 
The client has had an acute myocardial infarction and is on a cardiac monitor. She is beginning to havepremature ventricular contractions (PVCs) at 10/minute. According to ICU protocol, you will administer:a.
 
Atropine.b.
 
Nitroglycerin.c.
 
Propranolol (Inderal).d.
 
Lidocaine.
Lidocaine decreases cardiac irritability and is the first line drug for treatment of PVCs. Option #l, Atropine, is ananticholinergic drug used to treat bradycardia and heart block effect. Option #2, nitroglycerin, is primarily given for anginalpain. Option #3, Inderal, is used (primarily) to treat supraven-tricular dysrhythmias
 
2.
 
Your client has returned from having a bowel resection; and as you make rounds at the beginning of your shift,you notice that he is becoming restless. Your first action will be to:a.
 
administer pain medication as ordered.b.
 
order stat labs for electrolytes and blood gasses.c.
 
ask his family if he has a history of drug or alcohol abuse.d.
 
assess vital signs and urine output.
Post-operative restlessness should create a high degree of suspicion of hypoxemia (for instance due to bleeding). Vital signsand urine output will give information regarding intravascular volume. Option #1 calls for further assessment to rule outhypoxemia as the cause of the restlessness. Option #2 might be the second priority. Option #3 may indicate an erroneousassumption.
 
3.
 
The nurse is caring for a thoracotomy client, one day postoperative, on 40% humidified oxygen. Arterial bloodgas (ABG) results are:
• p0290mmHg• oC02 49 mmHg f 
 
•
pH7.30
• HC0326mEq/l
 Based on this information, which nursing action would be best?a.
 
Position in high-Fowlers and encourage coughing and deep breathing. Evaluate airway patency.b.
 
Place in prone position. Request respiratory therapy to perform postural drainage and percussion therapy.c.
 
Call the physician, and advise him of the arterial blood gas report. Anticipate increase in oxygenpercentage.d.
 
Administer antianxiety agent, and assist the client with a rebreathing device to increase oxygen levels.
The client is experiencing respiratory acidosis from decreased ventilation. Increasing the quality of ventilation by removingsecretions may resolve the problem. Option #2 is used for chronic airway problems. Option #3 is incorrect because the oxygenlevels are within the normal range. Action needs to be taken before notifying the physician. Option #4 is for respiratoryalkalosis.
 
4.
 
The nurse is caring for a client who has a 5-year history of chronic lung disease. The nursing assessment reveals aseverely dyspneic client, pulse at 140, respirations labored, and slightly cyanotic. An appropriate nursing actionto relieve the clients dyspnea would include:a.
 
administer oxygen at 40% heated mist.b.
 
assist the client to cough and deep breathe.c.
 
elevate the head of the bed, low flow oxygen.d.
 
position the client prone and assess breath sounds.
The client is dyspneic, but administering too much oxygen may increase his dyspnea by decreasing his respiratory drive.Position him in high-Fowlers to improve quality of ventilation, and begin oxygen at low liter flow. Option #1 is too high a levelof oxygen. Option #2 is not a priority for this client. Option #4 does not address the problem.
5.
 
For a client taking hydrochlorothiazide (Hydrodiuril), home medication instructions should include:a.
 
operation of heavy machinery and cars should be avoided.b.
 
limit intake of fluids to 1500-2000 cc daily.c.
 
this medication may cause discolored urine.d.
 
eat a banana or dried apricots each day.
Continued use of this diuretic may cause a loss of potassium. Dietary intake of foods such as bananas or dried apricots, whichare high in potassium, should be encouraged. Option #1 is incorrect because this medication does not cause drowsiness. Option#2 is incorrect because restrictions on fluid at this time could be detrimental. Option #3 does not occur.
6.
 
A client recovering from Streptococcal pneumonia has a chest x-ray which reveals a higher degree of atelectasisin the right lower lobe. Which nursing intervention would be most appropriate?a.
 
Instruct the client to take deep breaths more frequently.
 
 
b.
 
Reposition client every hour to the right side.c.
 
Increase frequency of incentive spirometry.d.
 
Change respiratory treatment to every 2 hours.
Incentive spirometry is a quantifiable method to assess respiratory effort with deep breathing exercises. Increasing thefrequency would be a sound nursing decision in an effort to improve the clients pulmonary status. Option #1 would beeffective, however, not as much as Option #3. Option #2 would actually decrease the thoracic expansion of the chest wall on theright side. Option #4 is incorrect because there is no basis to make a judgment about the type of treatment.
7.
 
Which nursing assessment would support the complication of right-sided heart failure?a.
 
Increasing respiratory difficulty with exertion.b.
 
Cough productive of a large amount of thick yellow mucus.c.
 
Peripheral edema and anorexia.d.
 
Twitching of extremities.
Right-sided heart failure is manifested by a congestion of the venous system resulting in peripheral edema as well ascongestion of the gastric veins resulting in anorexia and the eventual development of ascites. Option #1 is a commonassessment finding of the chronic lung client. Option #2 is describing a complication of pneumonia. Option #4 is notappropriate to this client.
8.
 
Which observation would alert the nurse to the possible development of pneumonia in a client with cysticfibrosis?a.
 
Coughing up thick yellow mucus.b.
 
Increased mucus production with postural drainage.c.
 
Exertional dyspnea increasing over the day.d.
 
Complaints of difficulty breathing
This response is specific to pneumonia in any client. Option #2 is incorrect because increased mucous drainage is the purposeof postural drainage. Options #3 and #4 are not unusual for this client.
 
9.
 
A 72-year-old client has an order for digoxin(Lanoxin) 0.25 ing PO in the morning. The nurse reviews thefollowing information:
• apical pulse 68
 
• respirations 16
 
• plasma digoxin level 2.2 ng/ml
Based on this assessment, which nursing action is appropriate?a.
 
Give the medication on time.b.
 
Withhold the medication: notify the physician.c.
 
Administer epinephrine 1:1000 stat.d.
 
Check the clients blood pressure.
Withhold the medication and notify the physician because the therapeutic plasma level ofdigoxin is 0.5-2.0 ng/ml. Option #1 isincorrect because the medication should be withheld. Option #3 is not a correct statement. Option #4 is inappropriate becauseit ignores the blood level of digoxin.
 
10.
 
Which instruction would be important for the nurse to include in discharge teaching of a hypertensive client?a.
 
If you begin to have a headache, double your medication for the next dose.b.
 
Do not decrease or discontinue your medications, even if your blood pressure feels normal.c.
 
If you begin to feel fatigued, decrease your medication for 2 days and call the physician.d.
 
Increase your intake of dairy products to replace the calcium you will be losing
Compliance with medication administration is a serious problem with hypertensive clients. Options #1 and 3 are incorrectbecause clients must continue their medication, and notify the physician of excessive fatigue or consistent headaches. Theyshould not alter their medication without notifying the physician. Option #4 is incorrect because calcium is not a problem withthis client.
 
11.
 
A client is 3 days postoperative mitral valve replacement. Which recommendation would the nurse include inthe nursing care plan to prevent postoperative complications?a.
 
Maintain in supine position to prevent tension on the mediastinal suture line.b.
 
Encourage deep breathing, but discourage coughing because of increased central venous pressure.c.
 
Decrease fluids to prevent fluid retention and development of congestive heart failure.d.
 
Encourage early activity to promote ventilation and improve quality of circulation.
Postoperative open-heart clients should be encouraged to be out of bed and ambulate as soon as possible. Option # 1 isincorrect because the client is maintained in semi-Fowlers position. Option #2 is incorrect because coughing and deepbreathing should be encouraged. Option #3 is incorrect as fluids are encouraged unless there is evidence of cardiac failure.
12.
 
The nurse is caring for a client in ICU. Hemody-namic monitoring is accomplished via a Swan-Ganz catheter. Thistype of monitoring will provide which piece of information?a.
 
Measures the circulatory volume in the coronary arteries.b.
 
Indirectly measures the pressure in the ventricles.
 
 
c.
 
Analyzes the adequacy of pulmonary circulationd.
 
Directly measures the adequacy of C02 exchange.
The CVP readings measure the pressure of the right ventricle; and the pulmonary artery wedge pressure reading is anindirect pressure of the left ventricle. Options #1, #3, and #4 are not functions of this catheter and do not reflect hemodynamicmonitoring.
13.
 
A permanent demand pacemaker set at a rate of 72 is implanted in a client for persistent third degree block.Which nursing assessment would indicate a pacemaker dysfunction?a.
 
Pulse rate of 88 and irregular.b.
 
Apical pulse rate regular at 68.c.
 
Blood pressure of 110/88, pulse at 78.d.
 
Tenderness at site of pacemaker implant.
Anytime the pulse rate drops below the preset rate on the pacemaker, then the pacer is malfunctioning. The pulse should bemaintained at a minimal rate set on the pacemaker. Options #1 and #3 do not indicate malfunction of the pacemaker. Option#4 may be an early sign of infection at the site.
 
14.
 
The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure. Whatinformation in the clients history would have a direct correlation with her current
problem?
 a.
 
History of rheumatic fever four years ago.b.
 
Presence of ventricular septal defect as an infant.c.
 
Heart disease in both the maternal and paternal families.d.
 
Persistent ear infections and mastoiditis as a child.
By far the most common cause of mitral valve problems is a history of rheumatic fever with subsequent complication of carditis that affect the valve. Options #2, #3, and #4 do not contribute to mitral valve disease.
 
15.
 
A client is 2 days postoperative aortic aneurysm resection. A complete blood count reveals a decreased redblood cell count. Which symptoms is the nursing assessment most likely to reveal?a.
 
Fatigue, pallor, and exertional dyspnea.b.
 
Nausea, vomiting, and diarrhea.c.
 
Vertigo, dizziness, and shortness of breath.d.
 
Malaise, flushing, and tachycardia.
These constitutional symptoms are characteristic of most types of anemia and are predominantly the result of tissue hypoxiasecondary to inadequate red blood cells. Options #2, #3, and #4 are not as indicative of the loss of red blood cells.
 
16.
 
A client has tested positive for tuberculosis and is started on isoniazid (INH) for 6 months. What informationwould the nurse plan to include in the clients teaching plan?a.
 
The color of the urine will change.b.
 
Subsequent TB tests will be negative after drug administration.c.
 
Other medications should be withheld during therapy.d.
 
Alcohol consumption is contraindicated.
Alcohol consumption while on INH therapy has been reported to increase isoniazid-related hepatitis. Therefore, clients shouldbe cautioned to restrict consumption of alcohol. Options #1, #2, and #3 are untrue.
 
17.
 
Which finding would the nurse identify as interfering with the effective functioning of chest tubes?a.
 
15 cm. water suction on chest tube system.b.
 
An air leak in water seal chamber.c.
 
Leaking blood around chest tube site.d.
 
Clots of blood in the chest tube.
An air leak would not allow negative pressure to be reestablished and would hinder complete resolution of the pneumothorax.Therefore, partial atelectasis could be noted. Option #1 is an appropriate order for chest tubes. Option #3 does not hinder thechest tube functioning. Option #4 would be an expected finding. It would be important for the nurse to ensure tube patency.
 
18.
 
A client is scheduled for a left lower lobe lobectomy. Which nursing observation would most indicate the needfor an antianxiety agent?a.
 
Agitation and decreased level of consciousness.b.
 
Lethargy and decreased respiratory rate.c.
 
Restlessness and increased heart rate.d.
 
Hostility and increased blood pressure.
The most indicative observation for antianxiety drugs is restlessness and increase in heart rate due to circulatingcatecholamines (fight or flight syndrome). Options #1 and #2 are more indicative of preoperative complications and should bereported before medications are given. Option #4 may be best treated by ventilating feelings.
 
19.
 
A 36-year-old client tested positive for the tuberculosis antibody and was placed on isoniazid (INH) 4 weeks ago.Which assessment finding might indicate hepatic impairment secondary to this medication?a.
 
Fatigue and dark urine.
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