online solution: 1.      A patient presents with complaints of ripping back p

1.      A patient presents with complaints of ripping back pain, dizziness,dyspnea and widening mediastinum in the chest radiograph. Which of the following should the nurse anticipate that this patient most likely has?A.    An abdominal aortic aneurysm, which requires a blood transfusion and surgery if the aneurysm is greater than 5 cmB.     Cardiac tamponade, which requires fluids and emergent pericardiocentesis C.     A dissecting thoracic aneurysm, which requires aggressive blood pressure control and emergent surgery D.    A dissecting thoracic aneurysm, which requires vasopressors and surgery if the aneurysm is greater than 6 cm2.      The nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP needs to be reduced?A.    The patient has a first-degree atrioventricular heart block with a rate of 58 beats/minB.     The patient has bronchial breath sounds in both the lung fields C.     The patient has bronchial breath sounds in both the lung fields D.    The patient has subcutaneous emphysema on the upper thorax 3.      A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to infusion?A.    Temperature B.     Fluid intake C.     Skin color D.    Hemoglobin level 4.      The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider?A.    Blood pressure 138/88B.     Weak pedal pulses C.     25 ml or urine output over the past hourD.    Absent bowel sounds5.      The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding?A.    Reposition the patient every 1 to 2 hours.B.     Instill 5 ml of sterile saline into the ET before suctioning C.     Increase suctioning frequency to every hour D.    Add additional water to the patient’s enteral feedings.6.      A nurse is interpreting a client’s ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?A.    QT interval B.     QRS complex C.     PR intervalD.    ST segment 7.      The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states A.    “I won’t lift the arm on the pacemaker side until I see the health care provider”B.     “I will avoid cooking with a microwave oven or being near one in use”C.     “I will notify the airlines when I make a reservation that I have a pacemaker”D.    “It will be several weeks before I can return to my usual activities”8.      Which option isn’t a method of weaning a patient from mechanical ventilation?A.    Spontaneous breathing trials B.     Pressure support ventilation C.     Assist controlD.    SIMV9.      A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg and reports feeling faint. Which action should the nurse take?A.    Apply the transcutaneous pacemaker (TCP) padsB.     Have the patient perform the Valsalva maneuver C.     Reposition the patient on the left sideD.    Give the schedule dose of diltiazem (Cardizem)10.  After surgery for an abdominal aortic aneurysm, a patient’s control venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take?A.    Elevate the head of the patient’s bed to 45 degrees B.     Increase the IV fluid infusion per protocol C.     Increase the infusion rate of IV vasodilators D.    Administer IV diuretic medications11.  What positive hemodynamic effects do nitrates provide for chest pain secondary to coronary artery disease?A.    They increase afterload and decrease the myocardial oxygen demand B.     They decrease preload and decrease the myocardial oxygen demand C.     They decrease afterload and increase myocardial contractility D.    They increase preload and increase myocardial contractility 12.  Which finding on a patient’s nursing admission is congruent with the initial medical diagnosis of a 6 cm thoracic aortic aneurysm?A.    Changes in the bowel habits B.     Trouble swallowing C.     Low back pain D.    Abdominal tenderness 13.  The decision has been made to wean a patient from the ventilator. Which of the following would be an indication to the stop the weaning trial?A.    A productive cough with activation of the ventilator alarm within the first 5 minutes of the weaning trial B.     The patient remains disoriented with demonstration of mild anxiety and agitation C.     An increase in hear rate from 82 beats/ minute to 96 beats/minute with the first 5 minutes of the weaning trialD.    The development of a paradoxical breathing pattern with accessory muscle use14.  Which finding by the nurse caring for a patient with a right arterial line indicates a need for the nurse to take immediate action?A.    The flush bag and tubing were changed 2 days previously B.     The right hand feels cooler than the left handC.     The mean arterial pressure (MAP) is 77 mm HgD.    The system is delivering 3 mL of flush solution per hour 15.  The nurse obtains a rhythm strip on a patient who has had an MI and makes the following analysis: P wave not apparent, ventricular rate 170, RR interval not measurable with a wide and distorted QRS complex. The nurse interprets this rhythm as:A.    Ventricular tachycardia B.     Sinus bradycardia C.     Atrial fibrillation D.    Sinus Tachycardia 16. A nurse enters a client’s room and finds the clients pulseless. The family requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?A.    Respect the family’s wishes and do nothingB.     Call the provider for a stat DNR orderC.     Call the emergency response team D.    Seek immediate help from the risk manager 17. A nurse is assessing a client who is receiving a unit of packet red blood cells. Which of the following findings is a manifestations of acute hemolytic reaction?A.    Client report of low back painB.     Distended neck veinsC.     Client report of tinnitus D.    A productive cough 18. A nurse is caring for a client who reports new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?A.    Determine if pain radiates to the left armB.     Perform a 12-lead ECGC.     Auscultate heart tonesD.    Check the client’s blood pressure 19. A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?A.    Perform synchronized cardioversionB.     Apply supplemental O2 via non-rebreather maskC.     Give atropine per agency dysrhythmia protocol D.    Start cardiopulmonary resuscitation (CPR)20. Which of the following interventions has been demonstrated to decrease ventilator associated pneumonia?A.    Deflate the endotracheal tube cuff prior to suctioning B.     Provide sedation C.     Maintain the head of the bed at 20 degrees or greater D.    Adhere to a month care protocol 21. The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the endotracheal tube on the floor. Which action should the nurse take next?A.    Call the health care provider to reinsert the tubeB.     Manually ventilate the patient with 100% oxygen C.     Provide reassurance to the patient D.    Activate the rapid response team 22. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?A.    Lower the positive end-expiratory pressure (PEEP)B.     Decrease the fraction of inspired oxygen (FIO2)C.     Increase the tidal volume and respiratory rate D.    Perform endotracheal suctioning more frequently 23. A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse’s priority?A.    Amiodarone administrationB.     Epinephrine administration C.     Airway management D.    Defibrillation 24. A nurse enters a client’s room and finds him responsive. After notifying the rapid response team, which of the following actions should the nurse take first?A.    Begin chest compressionsB.     Check for cardiac pulse C.     Deliver two breathsD.    Attach defibrillator pads to the client 25. A patient with which of the following signs most likely has a tension pneumothorax?A.    Absent breath sounds on the affected side, hypotension distended neck veins B.     Diminished breath sounds on the affected side, tracheal deviation to the affected side, hypotensionC.     Absent breath sounds on the affected side, tracheal deviation to the opposite side, flat neck veins D.    Dull to percussion on the affected side, hypertension, flat neck veins26. Pressure support ventilation has which of the following positive effects?A.    It decreases the work of breathing B.     It decreases the oxygen requirements C.     It decreases the work of all muscles D.    It decreases the tidal volume requirements27. The nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?A.    Encourage oral intake of at least 3,000 ml of fluids per day B.     Offer high-protein and high-carbohydrates foods frequently C.     Administer low-flow oxygen continuously via nasal cannula D.    Place in a prone position28. The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?A.    Pain level is 5 (on 0 to 10 scale) with a deep breath B.     O2 saturation is 88%C.     Respiratory rate is 24 breath/min when lying flatD.    Blood pressure is 155/90 mm Hg29. A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?A.    Flattened neck veins B.     Sudden lethargy C.     Muffled heart sounds D.    Bradycardia 30. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?A.    Stop the procedure and reoxygenate the clientB.     Continue to suction C.     Ensure that the suction is limited to 15 secondsD.    Notify health care provider immediately 31. A nurse in the intervention care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?A.    A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removedB.     Avoid speaking for long periods C.     Rest in a side lying position after the tube is removedD.    Use the incentive spirometer every 4 hr after the tube is removed 32. The needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be the fastest to use?A.    Court the number of large squares in the R-R interval and divide by 300B.     Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes C.     Calculate the number of small squares between one QRS complex and the next and divide into 1500 D.    Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 1033. A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor the client to monitor for which of the following complications?A.    Bradycardia B.     Peripheral vascular disease C.     Hypertension D.    Pulmonary embolism 34. A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply)A.    Headache B.     Orthopnea C.     Diaphoresis D.    Tachycardia E.     Nausea 35. An orientee asks the preceptor how IABP will benefit a patient who was just admitted from the cardiac catherization suite. The preceptor’s best response would be to explain IABP therapy will increase:A.    Left ventricular diastolic pressure B.     Coronary artery perfusion during systole C.     Patients myocardial oxygen supply D.    Patient’s left ventricular filling volume 36. A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations A.    Sneezing B.     Fatigue C.     Increased urine output D.    Rapid pulse37. A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?A.    Pacemaker spikes with each T waveB.     Pacemaker spikes before each P waveC.     Pacemaker spikes after each QRS complexD.    Pacemaker spikes before each QRS complex38. Which of the following statements about lung compliance is TRUE?A.    The plateau pressure is used to calculate the dynamic compliance B.     A decrease in compliance increases the work of breathingC.     An increase in the peak inspiratory pressure will decrease static compliance D.    Static compliance is decreased with an asthma exacerbation 39. A patient has a blood pressure of 150/96, a heart rate of 110 beats/minutes, a respiratory rate of 32 breaths/minute, and an SpO2 of 89. Auscultation reveals diminished breath sounds over the right lung fields, and tracheal deviation to the right is present. Which of the following interventions is the definition of treatment?A.    Prepare for right-sided chest tube insertion B.     Prepare for a right-sided needle thoracostomy C.     Call the provider for the insertion of an endotracheal tube D.    Initiate oxygen and observe the response oxygen 40. a nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?A.    Sinus tachycardia B.     Sinus bradycardia C.     First-degree AV block D.    Atrial fibrillation41. While waiting for heart transplantation, a patient with end stage heart failure has a ventricular assist device (VAD) implanted. What should the nurse anticipate when planning care for his patient?A.    Administering immunosuppressants medications B.     Monitoring the incision for signs of infection C.     Teaching the patient the reason for bed restD.    Preparing the patient for a permanent VAD  42. A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. Which of the following actions is the nurse’s priority?A.    Stop the transfusion B.     Notify the blood bankC.     Begin an infusion of 0.9% sodium chloride through new tubing D.    Collect urine specimen 43. which of the following is indicative of cor pulmonale?A.    Pulmonary edema secondary to right ventricular failure B.     Right ventricular enlargement secondary to pulmonary hypertension C.     Left ventricular failure secondary to chronic hypoxemia D.    Right ventricular failure secondary to pulmonary hypertension Health Science Science NursingShare