Cardiovascular

The patient with narrow QRS complex supraventricular tachycardia is found to be hemodynamically stable. Which initial intervention is appropriate? 

The nurse is notified the patient's heart monitor shows ventricular fibrillation. Initial assessment reveals strong peripheral pulses and even, unlabored respirations with an oxygen saturation of 98%. Which action does the nurse take first?

The unresponsive patient was pulled from a frozen lake. A regular heart rhythm is noted on the monitor with a rate of 28 bpm. Upon assessment, there is no palpable pulse. The first responders report which rhythm to the receiving hospital?

The unresponsive patient is found to have the following heart rhythm on electrocardiogram (ECG).  Which initial intervention is appropriate?

The patient is found to have the following rhythm on electrocardiogram (ECG): Pulses are noted on assessment. The nurse documents which rhythm in the patient's chart?

The patient is found to have the following rhythm on electrocardiogram (ECG): The nurse documents which rhythm in the patient's chart?

The nine-month-old infant appears to be in distress. For rapid assessment, which pulse does the nurse palpate?

Which is the correct ratio of crystalloid fluid administration to estimated blood loss to resuscitate the patient in hemorrhagic shock?

A school nurse is caring for an elementary school student who is gasping for breath after being stung by a bee. The child's airway is currently patent and heart rate is 100 bpm. No epinephrine or advanced airway is available. Which intervention is appropriate?

Which statement is true regarding the provision of cardiopulmonary resuscitation (CPR) in the community with an automated external defibrillator (AED)?

The nurse is examining the waveform produced by the patient's central venous pressure (CVP) catheter. Atrial contraction occurs at which point on the waveform?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. At which point on the waveform does atrial relaxation occur?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. Ventricular contraction occurs at which point of the waveform?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. Tricuspid valve opening is reflected at which point on the waveform?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. Passive filling of the atria occurs at which point on the waveform?

The patient with a central venous catheter develops substernal chest pain, hypotension, and cough. There is evidence of air in the line. Which action does the nurse take first​?

The child had a cast applied the previous day for a broken tibia. The mother returns the child to the provider to report swelling and significant pain. Upon assessment, the nurse notes pale, cool toes with a capillary refill time of 6 seconds. The child denies feeling the nurse's assessment but screams in pain when the leg is moved. The nurse anticipates which treatment for this patient? 

Which patient is seen first in the emergency department?

The nurse is preparing to discharge the patient following surgical creation of an arteriovenous fistula. For which complication is this patient most at risk?

The patient suddenly begins slurring. The nurse assesses the patient for additional symptoms of which condition?

An adult weighing 70 kg just arrived to the emergency department (ED) with burns on the front of both legs and the genital region. Using the Parkland formula, how much fluid is to be administered to the patient over the next 8 hours?

The nurse anticipates which laboratory results in the patient with end stage liver disease? Select all that apply.

The provider orders albumin for a patient with traumatic amputation and hemorrhage. Which patient characteristic prompts the nurse to clarify the order with the provider?

The patient's serum calcium quickly changed to 14 mg/dL (3.5 mmol/L). The nurse anticipates observing which symptoms? Select all that apply.

The patient has Stage I pressure ulcers on her heels bilaterally. The patient's husband asks the nurse if he can massage her feet. Which is the most appropriate response by the nurse?

Patients with which characteristics are at increased risk for infective endocarditis? Select all that apply.

The patient presents to the emergency department (ED) complaining of a severe headache that has not responded to nonsteroidal anti-inflammatory drugs, caffeine, hydration, or rest. The patient also reports transient syncope and weakness of the right side of the body. During the initial assessment, the patient becomes increasingly confused. The nurse prepares the patient for which test?

The patient has been diagnosed with an arteriovenous malformation (AVM) and is scheduled to undergo surgery in the morning. Which nursing intervention is the most important to promote safety in the patient?

The patient with arteriovenous malformation who takes a monoamine oxidase inhibitor for depression develops an upper respiratory infection. The nurse requests a prescription for which medication?

The patient with migraines undergoes an MRI and is found to have a cerebral aneurysm in the Circle of Willis. The nurse is vigilant for which symptoms that would indicate the patient is experiencing a life-threatening complication of the cerebral aneurysm? Select all that apply.

The triage nurse is assessing patients in the emergency department (ED). Which patient is seen first?

The community health nurse is developing an initiative to prevent long-term morbidity of cerebrovascular accidents by raising awareness of transient ischemic attacks. To which patient populations does the nurse direct these efforts? Select all that apply.

The patient is brought to the emergency department (ED) after being found on the floor in the garage by his wife. His right cheek balloons with each expiration and his right leg drags when he walks. While being assisted to the magnetic resonance imaging suite, the patient’s facial drooping resolves and he no longer walks with a limp. Which action does the nurse take first?

The patient is hospitalized following a cerebrovascular accident (CVA). The patient calls out to report a sudden, pounding headache. Which assessments are the priority? Select all that apply.

The nurse has received orders for the patient admitted following a hemorrhagic stroke and clarifies orders for which medications? Select all that apply.

The patient has been unconscious for 36 hours after a massive stroke. The nurse enters the room to see the unlicensed assistive personnel (UAP) cleaning the patient after an episode of fecal incontinence. The UAP states, “I can’t imagine not even being able to clean myself. What a sad existence.” Which response by the nurse is most appropriate?

Which order does the nurse clarify for the patient in the intensive care unit following a hemorrhagic stroke?

The nurse is supervising the care of the patient who suffered an embolic stroke of the right middle cerebral artery after a clot formed on the patient’s prosthetic mitral valve. Which instruction does the nurse provide to the unlicensed assistive personnel that will be most important to prevent bacterial endocarditis?

The nurse utilizes the ophthalmoscope to assess the patient’s retina and notes narrowing in the vessels where the arteries and veins cross. Which vital sign is consistent with this finding?

The nurse is preparing the patient for an ophthalmoscopic exam in which cyclopentolate drops must be instilled to allow for better visualization of the retina. Which characteristics, if present in the patient’s medical history, prompt the nurse to hold the drops and contact the provider for further instruction? Select all that apply.

Which instruction does the nurse give the patient prior to administering cyclopentolate eye drops?

The nurse is preparing the patient for a pneumotonometry test. Which instruction does the nurse give the patient?

Which test is used to assess the retina and fundus of the patient with severe cataracts?

The patient has undergone an extracapsular cataract extraction. Which discharge instructions does the nurse give the patient? Select all that apply.

The child is brought to the emergency department for lacerations and abrasions to the knees, palms, and face after falling at recess. The parent informs the nurse, “He always bleeds so much with any injury." The nurse suspects which condition?

Rank these conditions from most (1) to least (4) life-threatening.

Which term does the nurse use to document a 1.5 cm, dark red, fluid-filled lesion on the patient's cheek?

Which term does the nurse use to document the pinpoint, non-blanchable rash in the child who has invasive meningococcal disease (IMD) caused by Neisseria meningitidis? 

The patient with vasculitis has a rash of red marks that are greater than 3 mm and do not blanch when pressed. Which term does the nurse use to document this finding? 

The patient presents to the emergency department with left leg pain after landing from a transcontinental flight. Which assessments prompt the nurse to suspect a deep vein thrombosis? Select all that apply.