Cardiovascular

The patient newly diagnosed with Cor pulmonale is found to have a hematocrit of 55%. Which statement is true regarding this information?

The patient with a history of hypertension and atherosclerosis presents to the emergency department (ED) complaining of severe lower back pain. Which question by the nurse is most important?

The patient with chronic obstructive pulmonary disorder has an oxygen saturation of 89% on room air. Which order does the nurse clarify with the provider?

The nurse planning care for the patient with left-sided heart failure understands that treatment centers around which treatment goal?

The patient in heart failure exhibits the following respiratory pattern. The nurse uses which term to document the patient’s respiratory effort?

The nurse reviews the provider note about a new patient and notes the patient’s skin is described as plethoric. Which assessment is consistent with this description?

The patient with Raynaud’s phenomenon presents with which characteristic during an exacerbation?

Which patients are at an increased risk for Raynaud’s phenomenon? Select all that apply.

The patient with Raynaud’s phenomenon has received teaching on how to manage the disorder. Which statement by the patient indicates a need for further teaching?

The nurse is providing education to the patient recently diagnosed with Raynaud’s phenomenon. Which information does the nurse include in teaching?

Which is the drug of choice for treatment of Raynaud syndrome?

The patient being treated for seizures has developed Raynaud’s phenomenon. The nurse anticipates the provider to order which medication for this patient?

Which test is used to diagnose conduction disorders of the heart?

Which pulse is assessed by palpating the lateral side of the wrist?

Which term is used to denote a weak, thready pulse?

The nurse has received an order to initiate nasogastric tube feedings for the patient with long-standing anorexia. After the tube feeding is initiated, the nurse is vigilant for which electrocardiogram changes which may indicate the patient is experiencing life-threatening complications of tube feeding? Select all that apply.

A mass casualty incident has occurred and the charge nurse must make beds available in the intensive care unit for incoming victims. Which patients can be safely downgraded to the floor? Select all that apply.

The nurse receives report on 4 patients by 0800. Which patient does the nurse assess first?

Which patient in the emergency department (ED) must be treated first?

Four patients have been ordered to receive a 12-lead electrocardiogram (ECG) but the floor only has one EKG machine. Which patient must receive the test first?

Which alarm does the nurse attend to first?

The nurse is a first responder after a gas explosion at an apartment complex. Which patient does the nurse mark to be treated first?

The nurse is first on the scene following a multivehicle accident. After activating emergency services and verifying the safety of the scene, the nurse begins the triage process. The first patient is unconscious and not breathing. Which action does the nurse take first?

The nurse is supervising the student nurse who is making a call to the provider about a patient who is decompensating. The student states, “Hello, Dr. Smith. This is Carly and I’m taking care of Alex Wright in room 433. He is in the hospital after surgery for a ruptured appendix. Over my shift his temperature has increased by 4 degrees and his heart rate is elevated. His blood pressure is decreased from the previous shift as well. Could you please come examine him?” Which additional comments are the priority for the nurse to add? Select all that apply.

After reviewing the patient’s chart, which order(s) require clarification? Review the patient’s chart, then select all that apply.

The patient who underwent a partial thyroidectomy 1 day ago complains of tingling in the lips and tongue. Upon assessment, the nurse notes increased deep tendon reflexes. Which order does the nurse question for this patient?

The nurse notes the patient’s nails appear to curl upwards like spoons. Which statement by the nurse is most appropriate?

The 2-day-old full term child has been rooming in with the mother who reports successful breastfeeding. Which information is most important to report to the provider?

The nurse monitors the patient with erysipelas for which symptoms that may indicate complications related to the condition? Select all that apply.

Following an explosion at a factory, the patient is brought by ambulance to the emergency department. The patient has soot on the face and around the mouth and is coughing up black sputum. He verbalizes severe pain in his leg and his voice is noted to be a hoarse whisper. Further assessment reveals full thickness burns to the arms and hands and partial thickness burns to the legs. Shrapnel appears to have been embedded in the patient’s thigh. While moving the leg to assess the inner thigh, a piece of shrapnel shifts and the patient begins bleeding profusely from the wound. The patient cries out in pain and requests pain relief. Which action does the nurse take first?

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

Several tenants from an apartment building are brought to the emergency department with concern for carbon monoxide poisoning. One patient presents with reddish-purple skin, a blood pressure of 94/48 mmHg, heart rate of 118 bpm, and altered consciousness (arouses when his name is shouted). The nurse anticipates testing will reveal which carbon monoxide level?

The nurse in the burn ICU is caring for a patient with third degree burns over 33% of the body. Which assessment best indicates that fluid resuscitation has been adequate?

The patient sustained third degree burns to the entirety of bilateral hands and forearms 96 hours ago. Which nursing intervention is most important to ensure the patient is able to keep the hands?

The patient with third degree burns to bilateral lower legs is undergoing hydrotherapy to debride eschar tissue from the wounds. Prior to the procedure, the patient received a bolus of intravenous morphine in addition to the continuous infusion for pain control. During the procedure, the patient’s level of consciousness decreases to only rousable by painful stimuli. The patient’s temperature is 36.4°C, respiratory rate is 14 breaths per minute, heart rate is 82 bpm, and oxygen saturation is 93% on room air. The nurse ends the hydrotherapy session and contacts the provider to request which intervention?

The nurse more closely assesses patients with which conditions for signs of pernicious anemia? Select all that apply.  

Four hours after a rectal resection for treatment of rectal cancer, the patient is noted to be pale and diaphoretic. Which assessments are the priority? Select all that apply.  

At 48 hours after a bowel resection surgery for colon cancer, the colostomy is noted to be moist and purple. Which additional assessment is most important?  

The nurse assesses the patient who has received continuous bladder irrigation (CBI) therapy since a transurethral resection of the prostate (TURP) 24 hours ago. Which assessment is the priority to report?  

The nurse is caring for the patient with prostate cancer and left-sided heart failure who underwent transurethral resection of the prostate (TURP) 12 hours ago. Clots are noted in the continuous bladder irrigation (CBI) outflow. Which action by the nurse is most appropriate?  

During a shift assessment 14 hours after a prostatectomy, the nurse notes bright red drainage in the continuous bladder irrigation (CBI) drainage bag. Which assessment is most important?  

The nurse is supervising a nursing student in the emergency department. Which actions by the nursing student indicate effective learning? Select all that apply.  

The patient is started on subcutaneous heparin injections 7500 units q12h for deep vein thrombosis prophylaxis at 0900. When does the nurse plan to obtain the activated partial thromboplastin time (aPTT) to determine effectiveness of therapy?  

The patient is receiving a continuous heparin infusion that started at 0000 for the treatment of a deep vein thrombosis in the leg. Prior to the initiation of therapy, the patient’s activated partial thromboplastin time (aPTT) level was 35 seconds. The aPTT level drawn at 0800 was found to be 70 seconds. The nurse reports this information to the provider and advocates for which intervention?  

The patient who was started on warfarin sodium for the treatment of atrial fibrillation has reached steady state with the current dose. Which instruction is most important to give the patient?

The patient’s platelet level is found to be 560,000 mm³. The nurse assesses the patient for which symptoms? Select all that apply.  

The patient is scheduled for a liver biopsy tomorrow. The nurse has difficulty obtaining blood specimens from the patient and can only send one lab. Which lab test does the nurse choose? 

The patient on bowel rest has been prescribed 10% dextrose total parenteral nutrition at 50 mL/h, intravenous lipids 3 grams/kg/day, and 10 mg intravenous famotidine every other day. Which information in the patient’s chart prompts the nurse to contact the provider? 

The 21-year-old patient with a body mass index of 10.1 undergoes placement of a peripherally inserted central catheter (PICC) at 1000 and total parenteral nutrition (TPN) is initiated at 1200. At 1600, 160 mL have infused and the patient is noted to be breathing shallowly, there is blood oozing from the PICC insertion site, and the patient is exhibiting confusion. Which action does the nurse perform first? 

The patient receiving total parenteral nutrition (TPN) is found to have received 24 hours’ worth of TPN in 4 hours. Which intervention does the nurse perform first?