MS RLE: P3 Part 1 Long Quiz  

(11/3)
Total points50/50
 
The respondent's email ([email protected]) was recorded on submission of this
form.
0 of 0 points
SURNAME, FIRST NAME*
INTAO, CONRADO III. L.
SECTION*
F
MULTIPLE CHOICE 1-50
50 of 50 points
CHOOSE THE BEST ANSWER.
 
The nurse is assessing a patient whose respiratory disease in characterized by chronic
hyperinflation of the lungs. What would the nurse most likely assess in this patient?*
1/1
Signs of oxygen toxicity
Chronic chest pain
A barrel chest
 
Long, thin fingers
 
A 58-year-old man calls for emergency medical services from his home after he
experiences excruciating substernal chest pain. He’s rushed to the emergency
department where he’s given nitroglycerin and morphine for the pain. Electrocardiogram
results show changes consistent with an acute anterior wall myocardial infarction (MI). A
main complication of an anterior wall MI is heart failure. Which chamber of the heart is
most likely to fail in this patient?*
1/1
Right atrium
Right ventricle
Left atrium
Left ventricle
 
 
A malnourished 55-year-old patient with a history of alcohol abuse arrives in the
emergency department complaining of muscle weakness and cramps.
Electrocardiogram tracings show evidence of arrhythmias, and laboratory tests reveal
hypomagnesemia. Which electrolytes are typically depleted with magnesium
deficiency?*
1/1
Calcium and phosphorus
Potassium and phosphorus
 
Potassium and chloride
Chloride and calcium
 
The nurse is checking the peripheral pulses of a client who underwent cardiac
catheterization through the left groin. Where will the nurse palpate the left posterior tibial
artery?*
1/1
The posterior tibial pulse is located behind and just below the lateral malleolus of the foot.
 
The posterior tibial pulse is located behind and just below the anterior malleolus of the foot.
The posterior tibial pulse is located ventral and just below the lateral malleolus of the foot.
The posterior tibial pulse is located anterior and just below the lateral malleolus of the foot.
 
The nurse is caring for a client who has just returned from the cardiac catheterization
lab. Which complications of cardiac catheterization require immediate intervention by
the nurse? Select all that apply.*
1/1
chest pain
 
decreased appetite
difficulty swallowing
hematoma formation
decreased pulses in the affected extremity
 
A client returns to his room after a cardiac catheterization. Which of the following
assessments by the nurse would justify calling the physician?*
1/1
Pain at the site of the catheter insertion
Absence of a pulse distal to the catheter insertion site
 
Drainage on the dressing covering the catheter insertion site
Redness at the catheter insertion site
 
To evaluate a client’s condition following cardiac catheterization, the priority intervention
is to palpate the pulse*
1/1
In all extremities.
At the insertion site.
Distal to the catheter insertion.
 
Above the catheter insertion
 
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which
is the proper procedure?*
1/1
Place the fingertips against the wrist bone.
Place the stethoscope over the apex of the heart.
Place the fingertips against the side of the neck.
Place the fingertips on top of the foot.
 
 
An adult who is waiting for a cardiac catheterization is joking with the staff. The nurse
understands that this behavior is most likely:*
1/1
a coping mechanism for the client.
 
an inappropriate behavior for a serious procedure.
a defense mechanism of denial.
a defense mechanism of rationalization.
 
A patient who is for cardiac catheterization is anxious about the outcome of the
procedure. Which of the following nursing diagnoses is appropriate for the patient’s
present needs?*
1/1
Fear r/t possible outcome of interventional procedure
 
Ineffective peripheral Tissue Perfusion r/t vasospasm, hematoma formation
Risk for Bleeding
Risk for decreased Cardiac tissue perfusion
 
After cardiac catheterization, one of the complications of this procedure is bleeding. In
planning for care for a patient ,what nursing diagnoses will you formulate to help prevent
the occurrence of bleeding and address possible negative outcome?*
1/1
Ineffective peripheral Tissue Perfusion r/t vasospasm, hematoma formation
Risk for Bleeding
 
Risk for decreased Cardiac tissue perfusion
Fear r/t possible outcome of interventional procedure
 
At 0730 hours, a nurse receives a verbal order for a cardiac catheterization to be
completed on a client at 1400 hours. Which action should the nurse initiate first?*
1/1
Initiate NPO (nothing per mouth) status for the client.
 
Teach the client about the procedure.
Start an intravenous (IV) infusion of 0.9% NaCl.
Ask the client to sign a consent form.
 
The client is scheduled for a right femoral cardiac catheterization. Which nursing
intervention should the nurse implement after the procedure?*
1/1
Perform passive range-of-motion exercises.
Assess the client’s neurovascular status.
 
Keep the client in high Fowler’s position.
Assess the gag reflex prior to feeding the client.
 
A nurse is caring for a client who just underwent cardiac catheterization through a
femoral access site. Which nursing interventions should the nurse expect in the care
plan for the next 8 hours? Select all that apply.*
1/1
Maintain pressure over the femoral access site.
 
Allow the client to sit upright for meals.
Check the dressing and access site for bleeding.
 
Monitor vital signs every 4 hours.
Keep the extremity straight.
 
Allow use of the bedside commode.
 
The nurse is assigned to assist with caring for a client after cardiac catheterization. The
nurse should plan to maintain bed rest for this client in which position?*
1/1
High Fowler’s position
Lateral (side-lying) position
Head elevation of 45 degrees
Head elevation of no more than 30 degrees
 
 
Can a patient with metal dental fillings undergo an MRI?*
1/1
No, the MRI metal alert alarm sounds.
Yes, but the patient may experience a tingling sensation in his/her mouth.
 
No, there is a risk that the fillings will be extracted by the MRI.
Yes, but a plastic cap must be placed over each filling
 
During a shift assessment, the nurse is identifying the client's point of maximum impulse
(PMI). Where will the nurse best palpate the PMI?*
1/1
Left midclavicular line of the chest at the level of the nipple
Left midclavicular line of the chest at the fifth intercostal space
 
Midline between the xiphoid process and the left nipple
Two to three centimeters to the left of the sternum
 
A patient with a history of heart failure calls you to her room because she’s short of
breath. You assess her and find that her heart failure is worsening because the heart
doesn’t pump effectively. What will be your nursing diagnosis?*
1/1
Excess Fluid Volume
Decreased Cardiac Output
 
Activity Intolerance
Ineffective Airway Clearance
 
 A 58-year-old man calls for emergency medical services from his home after he
experiences excruciating substernal chest pain. Electrocardiogram results show
changes consistent with an acute anterior wall myocardial infarction (MI). What will be
your nursing diagnosis?*
1/1
Activity Intolerance
Risk for Decreased Cardiac Output
Acute Pain
 
Fear/Anxiety
 
On assessment of a central venous access device (CVAD) site, the nurse observes that
the transparent dressing is loose along two sides. What should the nurse do
immediately?*
1/1
Wait and change the dressing when it is due.
Tape the two loose sides down and document.
Apply a gauze dressing over the transparent dressing and tape securely.
Remove the dressing and apply a new transparent dressing using sterile technique.
 
 
A nurse is caring for a client in the immediate post–cardiac catheterization period.
Which intervention should the nurse include in the client’s care?*
1/1
monitor vital signs every 30 minutes for the first 2 hours
assess the insertion site
 
maintain the client in a prone position
keep the client NPO for 2 hours
 
An elderly client with diabetes who has been maintained on metformin (Glucophage)
has been scheduled for a cardiac catheterization. The nurse should verify that the
physician has written a prescription to:*
1/1
Limit the amount of protein in the diet prior to the cardiac cath.
Withhold the Glucophage prior to the cardiac catheterization.
 
Administer the Glucophage with only a sip of water prior to the cardiac catheterization.
Give the Glucophage before breakfast.
 
A client is scheduled for a cardiac catheterization. The nurse should do which of the
following pre-procedure tasks? Select all that apply.*
1/1
Administer all prescribed oral medications.
Check for iodine sensitivity.
 
Verify that written consent has been obtained.
 
Withhold food and oral fluids before the procedure.
 
Insert a urinary drainage catheter.
 
Which is the most important initial post procedure nursing assessment for a client who
has had a cardiac catheterization?*
1/1
Monitor the laboratory values.
Observe neurologic function every 15 minutes.
Observe the puncture site for swelling and bleeding.
 
Monitor skin warmth and turgor.
 
The nurse takes report on a client returning from left-sided cardiac catheterization. The
client also underwent a percutaneous transluminal coronary angioplasty (PTCA), with
drug-eluding stents placed in the right coronary artery and left coronary artery, and the
site was closed with a collagen plug. The nurse would expect to assess the entry site on
the client at which of the following locations?*
1/1
A
B
 
C
D
Feedback
The nurse would expect to assess the entry site in the left femoral artery. This is the preferred site for
left-sided cardiac catheterization and PTCA.
 
The nurse is preparing a female client for a cardiac catheterization with the femoral
approach. The nurse should do which of the following when the client returns to her
room after the procedure?*
1/1
Elevate the head of the bed 45 degrees.
Keep the client’s arm immobilized for the first 24 hours.
Keep the client’s leg immobilized for the first 12 hours.
 
Tell the client to lie on the procedural side for 2 hours.
 
The nurse is preparing a client for a cardiac catheterization. Which action would the
nurse expect to take?*
1/1
Administer a radioisotope as ordered.
Give the client a cleansing enema.
Locate and mark peripheral pulses.
 
Encourage high fluid intake before the test.
 
When assessing an ECG, the nurse knows that the P-R interval represents the time it
takes for?*
1/1
Impulse to begin atrial contraction.
Impulse to traverse the atria to the AV node.
SA node to discharge the impulse to begin atrial depolarization.
Impulse to travel to the ventricles.
 
 
Which ECG finding is most likely to be present in the client with a potassium of 6.0
mEq/L?*
1/1
Depressed S-T segment
Presence of U wave
Peaked T wave
 
Fusion of the T and U waves
 
A client is admitted to the emergency room with complaints of substernal chest pain
radiating to the left jaw. Which ECG finding is suggestive of acute myocardial infarction?
*
1/1
Peaked P wave
Changes in ST segment
 
Minimal QRS wave
Prominent U wave
 
A client enters the emergency department complaining  of severe chest pain. A
myocardial infarction is  suspected. A 12-lead ECG appears normal, but the doctor
admits the client for further testing until cardiac  enzyme studies are returned. All of the
following will be  included in the nursing care plan. Which activity has the highest
priority?*
1/1
Monitoring vital signs.
Completing a physical assessment.
Maintaining cardiac monitoring.
 
Maintaining at least one IV access site.
 
The nurse is performing a 12-lead ECG on a client who has come to the emergency
room reporting chest pain. Where should the nurse place lead V1?*
1/1
A
 
D
C
B
 
When a client questions the nurse as to the purpose of exercise electrocardiography
(ECG) in the diagnosis of cardiovascular disorders, the nurse’s response should be
based on the fact that:*
1/1
The test provides a baseline for further tests
The procedure simulates usual daily activity and myocardial performance
The client can be monitored while cardiac conditioning and heart toning are done
Ischemia can be diagnosed because exercise increases O2 consumption and demand
 
 
The nurse is talking with a client who has just had an ECG. The client says to the nurse,
“The doctor said I had a sinus rhythm. What does that mean?” Which response to the
client is best?*
1/1
“I wouldn’t worry about that. It’s pretty normal.”
“Sinus rhythm means that the heartbeat starts where it should. That is a place called the
sinoatrial node. Sinus rhythm is good.”
 
“Many people have a sinus rhythm and do very well. It is not a bad rhythm.”
“Sinus rhythm means that the heartbeat is starting in the sinus of the heart. The physician will
monitor your rhythm frequently to make sure it does not get worse.”
 
What is the most significant factor in identifying a normal ECG strip?*
1/1
P-R interval falls before the QRS complex on the strip.
 
T wave is in the inverted position on the strip.
P-R interval is no longer than 0.12 second.
QRS interval is no longer than 0.20 second.
 
The client is admitted to the emergency room with shortness of breath, anxiety, and
tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130
beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine,
the nurse should monitor his ECG for:*
1/1
Peaked P wave
Elevated ST segment
Inverted T wave
Prolonged QT interval
 
 
In the emergency room, the nurse is caring for a client who reports substernal pain
radiating to the arm and jaw, shortness of breath, and a feeling of impending doom. The
client had a stroke one month ago. The client’s vital signs are blood pressure 146/72,
pulse 128, and respirations 36. The 12-lead ECG reveals evolving acute myocardial
infarction (MI). Which of the following physician orders should the nurse question?*
1/1
Beta-adrenergic blocker
Morphine for pain
IV nitroglycerin
Thrombolytic therapy
 
 
How are images taken in coordination with the patient’s breathing?*
1/1
Metal transducers are placed on the patient’s body.
Plastic transducers are placed inside the patient’s body.
A belt is placed around the patient’s chest.
 
Plastic transducers are placed both on and inside the patient’s body
 
Can a patient who is claustrophobic undergo an MRI scan?*
1/1
Yes, the patient can be given a sedative.
Yes, the patient can be scheduled for an open MRI.
Yes, the MRI should not be cancelled.
All of the above
 
 
What is used to assess the speed, direction, and flow of blood?*
1/1
MRI
MRA
 
X-ray
All of the above
 
What test is used to assess changes in the brain chemistry caused by disease?*
1/1
Magnetic resonance spectroscopy
 
MRA
Diffusion–perfusion imaging
MRI
 
The patient tells you she is fearful that the tracer will destroy her tissues. How should
you respond?*
1/1
Explain that the tracer contains a very low dose of radiation that remains in the body for 24 days
after the test and causes minor tissue damage.
Explain that the tracer contains a very low dose of radiation that is flushed from the body within
24 hours of the test and rarely causes any tissue damage.
 
Explain that the tracer contains the same amount of radiation as the sun and causes no more
than a minor sunburn.
You won’t feel anything
 
Can a patient receive an MRI with contrast if the patient is allergic to shellfish?*
1/1
No, the MRI must be cancelled.
The practitioner will evaluate the benefit and risk of continuing with the MRI.
 
Yes, the MRI continues as scheduled.
Yes, but a crash-cart must be standing by before continuing with the MRI
 
A patient is having pulmonary-function studies performed. The patient performs a
spirometry test, revealing an FEV1 /FVC ratio of 60%. How should the nurse interpret
this assessment finding?*
1/1
Strong exercise tolerance
Exhalation volume is normal
Respiratory infection
Obstructive lung disease
 
 
A nurse is describing the process by which blood is ejected into circulation as the
chambers of the heart become smaller. The instructor categorizes this action of the
heart as what?*
1/1
Systole
 
Diastole
Repolarization
Ejection fraction
 
A 74-year-old man with a 3-day history of worsening chronic obstructive pulmonary
disease is hospitalized. His breathing is labored, breath sounds are congested with
rhonchi throughout. The Physician diagnosed respiratory acidosis. What will be your
nursing diagnosis?*
1/1
Impaired Gas Exchange related to ventilation perfusion imbalance as evidenced by labored
breathing and congested sound.
 
Acute Pain
Activity Intolerance
Ineffective airway clearance
 
Nurse Jasmine, who is a senior staff nurse at George Medical Hospital, is assessing the
patient with pulmonary hypertension. She notes tiredness, shortness of breath and
swelling in the legs. What will be the nursing diagnosis?*
1/1
Decrease cardiac output related to arrhythmias secondary to pulmonary hypertension.
 
Acute Pain related to increased strain in cardiac muscles secondary to pulmonary hypertension.
Risk for Bleeding`
Activity Intolerance
 
Which intervention should the nurse implement when administering a loop diuretic to a
client diagnosed with coronary artery disease?*
1/1
Assess the client’s radial pulse.
Assess the client’s serum potassium level.
 
Assess the client’s glucometer reading.
Assess the client’s pulse oximeter reading
 
The nurse is discussing the importance of exercise with the client diagnosed with
coronary artery disease. Which intervention should the nurse implement?*
1/1
Perform isometric exercises daily.
Walk for 15 minutes three (3) times a week.
Do not walk outside if it is less than 40˚F.
 
Wear open-toed shoes when ambulating
 
 You’re caring for a 54-year-old patient who has smoked two packs of cigarettes per day
for the past 35 years. He’s been admitted with worsening chronic obstructive pulmonary
disease (COPD). Why is it important for supplemental oxygen to be carefully monitored
in this patient?*
1/1
Increasing the PaO2 beyond what’s needed will lead to oxygen toxicity.
High oxygen levels will promote microbial growth in the patient’s lungs.
Increased PaO2 levels can depress the drive to breathe in patients with COPD.
 
Increased PaO2 levels can elevate the drive to breathe in patients with COPD.
This form was created inside of Phinma Education.

 Forms

MS RLE: PART 2 PERIODICAL 3 LONG

QUIZ (11/3/21)
Total points43/50
 
The respondent's email ([email protected]) was recorded on submission of this
form.
0 of 0 points
SURNAME, FULLNAME*
INTAO, CONRADO III. L.
SECTION*
F
TIME
Time
:
AM
MULTIPLE CHOICE
43 of 50 points
50 ITEM. CHOOSE THE BEST ANSWER
A patient has undergone an MRI scan and found out that he has a spinal cord tumor.
The nurse is planning the patient's subsequent care for the home setting. What nursing
diagnosis should the nurse address when educating the patients family?*
0/1
Self-care deficit related to neuromuscular impairment related to the disease condition.
Impaired spontaneous ventilation
Acute Pain
Risk for Ineffective Breathing Pattern
The client is one (1) day postoperative coronary artery bypass surgery. The client
complains of chest pain. Which intervention should the nurse implement first?*
1/1
Check the client’s telemetry monitor
Medicate the client with intravenous morphine.
Assess the client’s chest dressing and vital signs.
Encourage the client to turn from side to side.
Feedback
TEST-TAKING HINT: The stem asks the nurse to identify the first intervention that should be
implemented. Therefore, the test taker should apply the nursing process and select an assessment
intervention. Both options “2” and “4” involve assessment, but the nurse—not a machine or diagnostic
test— should always assess the client. Content – Surgical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Synthesis.
Why would a woman who is positive for BRCA1 receive an annual MRI scan?*
1/1
BRCA1 interferes a normal mammogram is necessary.
A positive BRCA1 means that the patient is not at risk for cancer and does not need an MRI
scan
The patient is at high risk for breast cancer and the MRI provides highly detailed views of the
patient’s breasts.
Only radio waves can penetrate the BRCA1 so an MRI is not necessary.
Feedback
ANS. . A. The patient is at high risk for breast cancer and the MRI provides highly detailed views of the
patient’s breast
A client is being seen in the clinic to R/O mitral valve stenosis. Which assessment data
would be most significant?*
1/1
The client complains of shortness of breath when walking.
The client has jugular vein distention and 3+ pedal edema.
The client complains of chest pain after eating a large meal.
The client’s liver is enlarged and the abdomen is edematous
Feedback
TEST-TAKING HINT: Whenever the test taker reads “rule out,” the test taker should look for data that
would not indicate a severe condition of the body system that is affected. Chest pain, JVD, and pedal
edema are late signs of heart problems. Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis.
The client is one (1) day postoperative coronary artery bypass surgery. The client
complains of chest pain. Which intervention should the nurse implement first?*
1/1
Medicate the client with intravenous morphine.
Check the client’s telemetry monitor
Assess the client’s chest dressing and vital signs.
Encourage the client to turn from side to side.
Feedback
TEST-TAKING HINT: The stem asks the nurse to identify the first intervention that should be
implemented. Therefore, the test taker should apply the nursing process and select an assessment
intervention. Both options “2” and “4” involve assessment, but the nurse—not a machine or diagnostic
test— should always assess the client. Content – Surgical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Synthesis
Priority Decision: On assessment of a central venous access device (CVAD) site, the
nurse observes that the transparent dressing is loose along two sides. What should the
nurse do immediately?*
1/1
Tape the two loose sides down and document.
Remove the dressing and apply a new transparent dressing using sterile technique.
Apply a gauze dressing over the transparent dressing and tape securely.
Wait and change the dressing when it is due.
Feedback
Answer: d. the greatest risk with CVAD is systemic infection. Dressings that are loose should be
changed immediately to reduce this risk

 A patient is scheduled to have a tunneled catheter placed for administration of

chemotherapy for breast cancer. When preparing the patient for the catheter insertion,
what does the nurse explain about this method of chemotherapy administration?*
0/1
Does not become occluded as peripherally inserted catheters can
Decreases the risk for extravasation at the infusion site
Reduces the incidence of systemic side effects of the drug
Allows continuous infusion of the drug directly to the area of the tumor
Feedback
Answer: a. Catheters tunneled to the distal end of the superior vena cava or the right atrium are
vascular access devices inserted into central veins, which decrease the incidence of extravasation,
provide for rapid dilution of chemotherapy, and reduce the need for venipuncture. Most right atrial
catheters, except for a Groshong catheter, need to be flushed with heparin to prevent clotting in the
tubing. Regional chemotherapy administration delivers the drug directly to the tumor and is the only
administration route that can decrease the systemic effects of the drugs.
The male client is diagnosed with coronary artery disease (CAD) and is prescribed
sublingual nitroglycerin. Which statement indicates the client needs more teaching?*
1/1
“I should keep the tablets in the dark-colored bottle they came in.”
“If the tablets do not burn under my tongue, they are not effective.”
“I should keep the bottle with me in my pocket at all times.”
“If my chest pain is not gone with one tablet, I will go to the ER.”
The physician has placed a central venous pressure (CVP) monitoring line in an acutely
ill patient so right ventricular function and venous blood return can be closely monitored.
The results show decreased CVP. What does this indicate?*
1/1
Possible hypovolemia
Left-sided heart failure
Possible myocardial infarction (MI)
Aortic valve regurgitation
Feedback
Ans: A Feedback: Hypovolemia may cause a decreased CVP. MI, valve regurgitation and heart failure
are less likely causes of decreased CVP.
A common collaborative problem related to both hyperkalemia and hypokalemia is
which potential complication?*
1/1
Acute kidney injury
Dysrhythmias
Seizures
Paralysis
Feedback
Answer: B. Potassium maintains normal cardiac rhythm, transmission and conduction of nerve
impulses, and contraction of muscles. Cardiac cells demonstrate the most clinically significant
changes with potassium imbalances because of changes in cardiac conduction. Although paralysis
may occur with severe potassium imbalances, cardiac changes are seen earlier and much more
commonly.
A new nurse is managing the care of a pediatric client preparing for a cardiac
catheterization under the supervision of an experienced nurse. Which factor identified
by the new nurse demonstrates an understanding of the information that can be
collected during cardiac catheterization? SELECT ALL THAT APPLY*
0/1
Oxygen saturation of blood within the chambers and great vessels
Pressure of blood flow within the heart chambers
Cardiac output (CO)
Anatomic abnormalities
Ankle brachial index (ABI)
Ejection fraction
Feedback
Rationale:
In cardiac catheterization, a small radiopaque catheter is passed through the major vein in the arm,
leg, or neck into the heart. Blood specimens can be obtained to determine oxygen saturation levels,
and contrast dye can be injected for angiography and to assess for anatomic abnormalities such as
septal defects or obstruction of flow. Pressure of blood flow in the heart chambers, CO, stroke volume,
and ejection fraction can be evaluated during the procedure. ABI is a ratio of the ankle systolic
pressure to the arm systolic pressure and an objective measurement of arterial disease that quantifies
the degree of stenosis. It is not related to a cardiac catheterization procedure
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus
is scheduled for cardiac catheterization. Which medication would need to be withheld
for 24 hours before the procedure and for 48 hours after the procedure?*
1/1
Glipizide (Glucotrol)
Metformin (Glucophage)
Regular insulin
Repaglinide (Prandin)
Feedback
Rationale: Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after
cardiac catheterization because of the injection of contrast medium during the procedure. If the
contrast medium affects kidney function, with metformin in the system, the client would be at
increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld
24 hours before and 48 hours after cardiac catheterization.
After a cardiac catheterization procedure, the nurse should ask the client to remain in
which position?*
1/1
high-Fowler’s position
semi-Fowler’s position
on the left side, with both knees bent slightly
supine with a small pillow under the head
While a client scheduled for a cardiac catheterization is being admitted, the client states
to the nurse, “I always get a rash when I eat shellfish.” Following safety protocol, the
most appropriate initial nursing intervention is to?*
1/1
Notify the dietitian of the reaction and request a “no shellfish” diet.
Ask the client if there are any other foods that cause such a reaction.
Notify the physician.
Place a note on the chart regarding this reaction.
Feedback
Rationale:
Because the dye used during a cardiac catheterization contains iodine, the physician must be aware of
this client’s reaction to iodine (shellfish). The other interventions should be carried out, but they should
follow notifying the physician.
An older adult is scheduled for coronary arteriography during a cardiac catheterization.
Which nursing intervention will be essential as she recovers from the diagnostic
procedure on the hospital unit?*
1/1
Limiting dietary fiber to prevent diarrhea
Encouraging frequent ambulation to prevent deep vein thrombosis
Assessing the arterial puncture site when taking vital signs
Limiting fluid intake to prevent fluid overload
Feedback
Rationale: Following a cardiac catheterization in which an arterial site is used for access, the puncture
or cutdown site should be assessed at least as often as vital signs are monitored. The client is at risk
for development of bleeding, hemorrhage, hematoma formation, and arterial insufficiency of the
affected extremity. When the arterial access site is used, the client is on strict bed rest for at least
several hours. Fluids are encouraged after catheterization to increase urinary output and flush out the
dye used during the procedure. There is no need to restrict dietary fiber. In fact, constipation can be
dangerous for cardiac clients if they strain at stool (Valsalva maneuver.)
Kayexalate is ordered for a client with a serum potassium level of 5.5 mEq/L. If this
substance is effective, the nurse should expect to see an ECG with*
1/1
Return of T-wave width and amplitude to normalcy.
Absence of P waves.
Broad, flat P waves.
Return of QRS to upright configuration.
Feedback
Return of T-wave width and amplitude to normalcy.
Broad, flat P waves.
Absence of P waves.
Return of QRS to upright configuration.
A client admitted with gastroenteritis and a potassium level of 2.9mEq/dL has been
placed on telemetry. Which ECG finding would the nurse expect to find due to the
client’s potassium results?*
1/1
An elevated T wave
An absent P wave
A flattened QRS
A depressed ST segment
Feedback
Rationale: . ECG changes associated with hypokalemia are peaked P waves, flat T waves, depressed
ST segments, and prominent U waves.
A patient has been admitted to the neurologic unit for the treatment of a newly
diagnosed brain tumor. The patient has just exhibited seizure activity for the first time.
What will be the nursing diagnosis for prioritization of care?*
1/1
Knowledge Deficit related to disease condition.
Teach the patients family about the relationship between brain tumors and seizure activity.
Risk for injury related to effector dysfunction as evidence by seizure activity
Implement precautions to ensure the patients safety.
A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of
motor function and sensation. The physician suspects the patient has a spinal cord
tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose spinal
cord compression from a tumor, the nurse will most likely prepare the patient for what
test?*
1/1
Lumbar puncture
MRI
Anterior-posterior x-ray
Ultrasound
Feedback
Feedback: The MRI scan is the most commonly used diagnostic procedure. It is the most sensitive
diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral
bone metastases.
Why should a patient with kidney disease avoid being administered contrast material
prior to an MRI?*
1/1
Patients with kidney disease should never receive an MRI.
The contrast material contains metallic elements.
None of the above.
The patient might have difficulty excreting the contrast material.
The client is scheduled for a right femoral cardiac catheterization. Which nursing
intervention should the nurse implement after the procedure?*
1/1
Keep the client in high Fowler’s position.
Perform passive range-of-motion exercises.
Assess the gag reflex prior to feeding the client
Assess the client’s neurovascular status.
Feedback
TEST-TAKING HINT: The nurse should apply the nursing process when determining the correct
answer. Therefore, either option “2” or option “4” could possibly be the correct answer. The test taker
then should apply anatomy concepts—where is the left femoral artery? Neurovascular assessment is
performed on extremities. Content – Surgical: Category of Health Alteration – Cardiovascular:
Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Reduction of Risk
Potential: Cognitive Level – Synthesis.
The client with coronary artery disease asks the nurse, “Why do I get chest pain?”
Which statement would be the most appropriate response by the nurse?*
1/1
“Chest pain occurs when the lungs cannot adequately oxygenate the blood.”
“Chest pain is caused by decreased oxygen to the heart muscle.”
“The heart muscle is unable to pump effectively to perfuse the body.”
“There is ischemia to the myocardium as a result of hypoxemia.”
You’re caring for a 54-year-old patient who has smoked two packs of cigarettes per day
for the past 35 years. He’s been admitted with worsening chronic obstructive pulmonary
disease (COPD). Why is it important for supplemental oxygen to be carefully monitored
in this patient?*
1/1
Increased PaO2 levels can elevate the drive to breathe in patients with COPD.
High oxygen levels will promote microbial growth in the patient’s lungs.
Increased PaO2 levels can depress the drive to breathe in patients with COPD.
Increasing the PaO2 beyond what’s needed will lead to oxygen toxicity.
Feedback
Answer: C. Increased PaO2 can depress the patient’s drive to breathe, which is largely driven by
hypoxemia.
Mr. See, a 46 year old male patient is diagnosed with chronic obstructive pulmonary
disease, and is experiencing pneumonia. The nurse applies oxygen at 2 L/min via nasal
cannula. When the nurse leaves the room, Mr. See’s family member increases the
oxygen to 5 L. Which complication may occur?*
1/1
Metabolic Acidosis
Angina
Apnea
Respiratory Alklasos
Feedback
ANS: 2
The COPD clients drive to breathe is hypoxia. Increasing the oxygen removes this drive and leads to
apnea. Angina occurs because of decreased oxygen to the myocardial tissues. Neither respiratory
alkalosis nor metabolic acidosis would occur with the increased oxygen level.
Immediately following a cardiac catheterization, the client asks to go to the toilet. What
is the best response by the nurse?*
1/1
Assist the client to a bedside commode
Assist the client to the toilet
Assist the client onto a bedpan
Show the client where the toilet is and allow him/her to walk there if stable
Other:
Feedback
Rationale: Immediately following a cardiac catheterization, the client is not allowed to bend the groin
catheter insertion site. The client is not allowed to walk or sit up more than 30 degrees. The best
response is to assist the client onto a bedpan and raise the head of the bed no more than 30 degrees
A client has returned to the cardiac unit following a cardiac catheterization performed
through the left femoral artery. Which item is an appropriate part of the nursing care
plan for this client?*
0/1
Out of bed as soon as awake from anesthesia
Neurovascular check to the insertion site times two
Pressure dressing and immobility for the insertion site
Range of motion exercises to the left leg every two hours.
Feedback
Rationale:The site is kept immobile for up to 24 hours after cardiac catheterization to reduce the risk
of a severe arterial bleed. Range of motion exercises would be contraindicated. The client would be on
bedrest. Neurovascular checks should be performed at least hourly for the first 24 hours due to the
risk of thrombosis.
The nurse is caring for a patient admitted with angina who is scheduled for cardiac
catheterization. The patient is anxious and asks the reason for this test. What is the best
response?*
1/1
Cardiac catheterization is most commonly done to evaluate cardiac electrical activity.
Cardiac catheterization is most commonly done to detect how efficiently a patient's heart
muscle contracts.
Cardiac catheterization is usually done to assess how blocked or open a patients coronary
arteries are.
Cardiac catheterization is usually done to evaluate cardiovascular response to stress.
Feedback
Rationale:
Cardiac catheterization is usually used to assess coronary artery patency to determine if
revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after
stress. An ECG shows the electrical activity of the heart.
The client is having a cardiac catheterization. During the procedure, the client tells the
nurse, “I’m feeling really hot.” What is the correct explanation for the client’s statement?
*
1/1
“The feeling of warmth” indicates that the clots in the coronary vessels are dissolving.
He has increased anxiety due to the invasive procedure.
He is having an allergic reaction to the contrast media.
A feeling of warmth is normal when the contrast media is injected.
Feedback
Rationale:. During cardiac catheterization, a warm sensation is expected when the contrast media is
injected. Answers A, C, and D are incorrect explanations for the client’s statement.
The nurse is performing discharge teaching for a client after a cardiac catheterization.
Which statement by the client indicates a need for further teaching?*
1/1
“I should not bend, strain, or lift heavy objects for one day.”
“I should talk to the doctor to find out when I can go back to work.”
“If bleeding occurs, I should place an ice bag on the site for 10 minutes.”
“I need to call the doctor if my temperature goes above 101°F.”
Feedback
Rationale: If there is any bleeding, new bruising, or pain at the puncture site, the physician should be
notified. The information in answers A, C, and D are correct discharge teaching statements, so these
answers are incorrect.
The nurse caring for a client scheduled for an angiogram should prepare the client for
the procedure by telling him to expect:*
1/1
Dizziness as the dye is injected
Nausea and vomiting after the procedure is completed
A warm sensation as the dye is injected
A decreased heart rate for several hours after the procedure is completed
Feedback
Rationale: The client undergoing an angiogram will experience a warm sensation as the dye is
injected. Answers A, B, and C are not associated with an angiogram
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate
greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR
interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse’s
interpretation of this rhythm?*
1/1
Sinus tachycardia
Supraventricular tachycardia
Atrial flutter
Premature atrial complex
Feedback
Rationale:
The systemic analysis of the electrocardiogram shows the information in the question as criteria for
sinus tachycardia. Answer A would reveal an irregular rhythm and an early or different P wave. Answer
C is incorrect because the P waves would be saw-toothed and the P: QRS ratio would be 2:1, 3:1, or
4:1.
A client is seen to have dysrhythmia, she asked you,” What does dysrhythmia refer to?
What is your best response?*
1/1
a device that measures heart activity.
any cardiac disease or condition.
abnormal electrical impulses of the heart.
a pacemaker device.
You are conducting an information drive regarding CAD in a group of senior citizens.
One  asked you what causes a decrease in heart rate. What is your response?*
1/1
Ingestion of caffeine
Activation of the sympathetic nervous system
Increased exercise
Stimulation of the vagus nerve
What does a patient wear during an MRI?*
1/1
The patient removes all clothing and wears a gown during the MRI.
The patient needs only to expose the area of the body that is being assessed. C. The patient
removes all clothing during the MRI.
The patient can remain in street clothes during the MRI
The client diagnosed with a myocardial infarction is six (6) hours post–right femoral
percutaneous transluminal coronary angioplasty (PTCA), also known as balloon
surgery. Which assessment data would require immediate intervention by the nurse?*
1/1
The client is keeping the affected extremity straight.
The pressure dressing to the right femoral area is intact.
The client is complaining of numbness in the right foot.
The client’s right pedal pulse is 3+ and bounding.
Feedback
TEST-TAKING HINT: This question requires the test taker to identify abnormal, unexpected, or life-
threatening data. The nurse must know that a PTCA is performed by placing a catheter in the femoral
artery and that internal or external bleeding is the most common complication. Content – Surgical:
Category of Health Alteration – Cardiovascular: Integrated Nursing Process – Implementation: Client
Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis.
The client is scheduled for a right femoral cardiac catheterization. Which nursing
intervention should the nurse implement after the procedure?*
1/1
Perform passive range-of-motion exercises.
Keep the client in high Fowler’s position.
Assess the client’s neurovascular status.
Assess the gag reflex prior to feeding the client.
The intensive care department nurse is assessing the client who is 12 hours post–
myocardial infarction. The nurse assesses an S3 heart sound. Which intervention
should the nurse implement?*
1/1
Document this as a normal and expected finding.
Notify the health-care provider immediately.
Administer morphine intravenously
Elevate the head of the client’s bed.
Feedback
TEST-TAKING HINT: There are some situations in which the nurse must notify the
health-care provider, and the test taker should not automatically eliminate this as a possible correct
answer. The test taker must decide if any of the other three options will help correct a life-threatening
complication. Normal assessment concepts should help identify the correct option. The normal heart
sounds are S1 and S2 (“lubb-dupp”); S3 is abnormal. Content – Medical: Category of Health Alteration
– Cardiovascular: Integrated Nursing Process – Implementation: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive Level – Synthesis.
A client had a cardiac catheterization with angiography and thrombolytic therapy with
streptokinase. The nurse should initiate which of the following interventions immediately
after he returns to his room?*
1/1
Ambulate him to the bathroom to void.
Place him on NPO restriction for 4 hours.
Place him in a high Fowler position.
Monitor the catheterization site every 15 minutes.
Feedback
RATIONALE
A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be
encouraged to drink plenty of liquids to assist the kidneys in eliminating the dye
Streptokinase activates plasminogen, dissolving fibrin deposits. To prevent bleeding, pressure is
applied at the insertion site. The client is assessed for both internal and external bleeding.
The extremity used for the insertion site must be kept straight and be immobilized because of the
potential for bleeding.
The client is kept on bed rest for 8–12 hours following the procedure because of the potential for
bleeding
An adult who is admitted for a cardiac catheterization asks the nurse if she will be
asleep during the cardiac catheterization. What is the best initial response for the nurse
to make?*
1/1
“The doctor will give you an anesthetic if you are having too much pain.”
“You will be sedated but not asleep.”
“You will be given general anesthesia.”
“Why do you want to be asleep?”
Feedback
Rationale:
Persons who are undergoing cardiac catheterization will receive a sedative but are not put to sleep.
Their cooperation is needed during the procedure. Asking “why” makes the client defensive and is not
appropriate for this client at this time. Give the client the information asked for.
The nurse preparing a client for a cardiac catheterization and revascularization should
include which information in the pre-op teaching.*
0/1
The client will be on fluid restrictions until the gag reflex returns
There may be a sand bag placed over the cannulated site following the procedure
The client will be asleep during the procedure
The client may experience chest pain when the balloon is inflated The client will experience a
headache as the dye is injected
The client may experience a hot flash as the dye is injected
Feedback
Rationale: The client is generally awake during the procedure and fluid intake is encouraged in order to
assist the kidneys with excretion of the dye. Generally a client may experience a metallic taste in the
mouth or a hot flash when the dye is injected.
*Which of the following would be correctly identified in a normal sinus rhythm?*
1/1
PR interval is 0.18 seconds
QRS width is 0.24 seconds
ST segment is above the isoelectric line
P wave follows each QRS complex
*In order for the QT interval to be considered normal it should be:*
0/1
greater than half the R-R interval.
has nothing to do with the R-R interval.
less than half the R-R interval.
equal to the R-R interval.
*A patient has 22 small boxes in between two QRS complexes. Which of the following
would be the correct heart rate?*
1/1
13 beats per minute
76 beats per minute
68 beats per minute
60 beats per minute
*A patient has nine QRS complexes on a 6-second rhythm strip. Which of the following
would be the correct estimated heart rate?*
1/1
75 beats per minute
100 beats per minute
90 beats per minute
60 beats per minute
*A prolonged QT interval places a patient at risk for which of the following life
threatening dysrhythmias?*
1/1
Ventricular standstill
Third-degree AV block
Torsades de pointes
Asystole
*Which of the following pieces of equipment would be useful in determining regularity of
a heart rhythm?*
1/1
Calipers
Scissors
Magnifying glass
Fine point tweezers
*Which of the following patients would normally have a very short PR interval?*
0/1
36-year-old female
1-month-old female
84-year-old male
18-year-old male
*The normal parameter for the PR interval is:*
1/1
0.06-0.10 seconds.
0.36-0.44 seconds
0.12-0.20 seconds.
0.28-0.32 seconds.
*The ST segment is crucial in the diagnosis of:*
1/1
myocardial infarction.
premature ventricular contractions.
lyme disease.
sick sinus syndrome.
*The point at which the QRS complex meets the ST segment is known as the:*
1/1
Z point
U point
A point
J point
This form was created inside of Phinma Education.

 Forms

MS RLE: PART 1 PERIODICAL 3  TERM

EXAM (11/8/21)
Total points37/50
 
The respondent's email ([email protected]) was recorded on submission of this
form.
0 of 0 points
SECTION*
F
TIME
Time
:
AM
SURNAME, FULLNAME
INTAO, CONRADO III. L.
MULTIPLE CHOICE
37 of 50 points
50 ITEMS. CHOOSE THE BEST ANSWER
 
A nurse is preparing a patient for scheduled transesophageal echocardiography. What
action should the nurse perform?*
1/1
Instruct the patient to drink 1 liter of water before the test.
Administer IV benzodiazepines and opioids.
Inform the patient that she will remain on bed rest following the procedure.
 
Inform the patient that an access line will be initiated in her femoral artery.
Feedback
Ans: C
Feedback: During the recovery period, the patient must maintain bed rest with the head of the bed
elevated to 45 degrees. The patient must be NPO 6 hours preprocedure. The patient is sedated to
make him or her comfortable, but will not be heavily sedated, and opioids are not necessary. Also, the
patient will have a peripheral IV line initiated preprocedure.
 
A patient with a complex cardiac history is scheduled for transthoracic
echocardiography. What should the nurse teach the patient in anticipation of this
diagnostic procedure?*
1/1
The test is noninvasive, and nothing will be inserted into the patients body.
 
The patients pain will be managed aggressively during the procedure.
The test will provide a detailed profile of the hearts electrical activity.
The patient will remain on bed rest for 1 to 2 hours after the test.
Feedback
Ans: A
Feedback: Before transthoracic echocardiography, the nurse informs the patient about the test,
explaining that it is painless. The test does not evaluate electrophysiology and bed rest is unnecessary
after the procedure.
 
Which of the following is a true statement regarding the QRS complex?*
0/1
The QRS complex will always have a Q wave, an R wave, and an S wave.
 
The QRS complex normal duration is 0.24 seconds.
The QRS complex will show a negative deflection in lead II.
The QRS complex may actually be only a qs complex.
Correct answer
The QRS complex may actually be only a qs complex.
 
The client is scheduled for an MRI scan. Which is most important for the nurse to
include prior to the client’s MRI scan?*
1/1
SBAR-format report to the receiving unit
 
Accurate documentation of the client’s vital signs
Accurate documentation of the client’s intake and output
Inclusion of a discharge planning report
 
A young adult with a history of rheumatic fever  as a child is to have a cardiac
catheterization.  She asks the nurse why she must have a cardiac  catheterization. The
nurse’s response is based on  the understanding that cardiac catheterization can
accomplish all of the following EXCEPT:*
1/1
assessing heart structures.
determining oxygen levels in the heart chambers.
evaluating cardiac output.
obtaining a biopsy specimen.
 
Feedback
Rationale: A biopsy specimen cannot be obtained during a cardiac catheterization. Heart structures
can be assessed, oxygen levels in the heart chambers can be determined, and cardiac output can be
measured during a cardiac catheterization.
 
You are reviewing an ECG strip of a cardiac patient. You noted a positive deflection that
represents a depolarization of atria. Which of the following does this deflection indicate?
*
1/1
P wave
 
Q wave
R wave
T wave
 
Heart failure is one of the indications of Pulmonary Artery Catheterization. What nursing
diagnosis can we formulate?*
1/1
Risk for Impaired Skin Integrity r/t risk of accident
Deficient Knowledge r/t misconception of the situation
Decreased Cardiac Output r/t poor cardiac reserve
 
Hyperthermia r/t complications
 
Nurse Joana is providing a health education to the group of student nurses regarding
pulmonary artery catheter. The following statements by the student nurse regarding the
insertion site is correct except:*
0/1
Internal jugular vein provides a short, direct route to the vena cava.
External jugular vein is a difficult passage to the central veins but is easily accessible due to its
superficial location.
 
Femoral vein is easily accessible but its difficult to identify in obese patients
Peripheral access enables greater control in bleeding from the site with possible difficulty
advancing the catheter to the central veins from this distal site
All of the above
Correct answer
All of the above
 
When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the
appropriate blood vessel or heart chamber. When assessing a patient who has such a
device in place, the nurse should check which of the following components? Select all
that apply.*
1/1
A transducer
A flush system
A leveler
A pressure bag
 
An oscillator
Feedback
Ans: A, B, D Feedback: To perform hemodynamic monitoring, a CVP, pulmonary artery, or arterial
catheter is introduced into the appropriate blood vessel or heart chamber. It is connected to a
pressure monitoring system that has several components. Included among these are a transducer, a
flush system, and a pressure bag. A pressure monitoring system does not have a leveler or an
oscillator.
 
The point at which the QRS complex meets the ST segment is known as the:*
1/1
U point
J point
 
A point
Z point
 
To maintain the monitoring system of the PAP monitoring the nurse responsibility is to:*
0/1
Prime the tubing and transducer carefully to avoid or remove air bubbles in the system.
Let family members know how they can safely interact with the patient to avoid accidental
dislodgement of the PA catheter.
Keep the pressure on the flush bag > 300 mm Hg.
Follow your facility’s policies and procedures for accessing the PA catheter lumens.
 
Correct answer
Keep the pressure on the flush bag > 300 mm Hg.
 
The critical care nurse is caring for a patient who has had an MI. The nurse should
expect to assist with establishing what hemodynamic monitoring procedure to assess
the patients left ventricular function?*
1/1
Central venous pressure (CVP) monitoring
Pulmonary artery pressure monitoring (PAPM)
 
Systemic arterial pressure monitoring (SAPM)
Arterial blood gases (ABG)
Feedback
Ans: B
Feedback: PAPM is used to assess left ventricular function. CVP is used to assess right ventricular
function; SAPM is used for continual assessment of BP. ABG are used to assess for acidic and
alkalotic levels in the blood.
 
The below information are nursing responsibilities during insertion of PAC except;*
1/1
Prepare all the equipment needed.
Inflation and deflation of balloon as directed.
Flush all ports of the catheter after its insertion.
 
Confirm placement with x ray
Correlate waveforms with location of catheter tip
All of the above
 
 A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial
pressure monitoring. After this intervention is performed, what assessment should the
nurse prioritize in the plan of care?*
1/1
Fluctuations in core body temperature
Signs and symptoms of esophageal varices
Signs and symptoms of compartment syndrome
Perfusion distal to the insertion site
 
Feedback
Ans: D
Feedback: The radial artery is the usual site selected. However, placement of a catheter into the radial
artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to
the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary.
Alterations in temperature and the development of esophageal varices or compartment syndrome are
not high risks.
 
You are performing an ECG procedure in your patient with a complaint of chest pain.
The ECG reading looks fine and you noticed a P wave in lead II, recalling its
characteristics which of the following portrays P wave?*
0/1
Negative deflection
 
Isoelectric
Positive deflection
Horizontal
Correct answer
Positive deflection
 
A patient is admitted to the hospital for a carotid angiogram with stent placement. The
patient's spouse states, "I don't want my spouse to find out there is a risk of a stroke
connected with this procedure because he or she won't sign the consent form." The
cardiac-vascular nurse's most appropriate action is to:*
1/1
assess the patient's level of understanding of risks, benefits, and alternatives.
 
assure the patient's spouse that the risk of stroke is minimal.
offer the patient emotional support and reinforce the benefits of the procedure.
perform a neurologic assessment to establish a baseline.
 
A hospital implemented computerized provider order entry (CPOE).Which additional
task related to CPOE is required for the nurse to provide safe care?*
0/1
Checking the computer periodically for new orders
Checking the computer every hour for medications due
The HCP telephoning the nurse about the new computer orders
Documenting blood sugars in the computer for HCP viewing
 
Correct answer
Checking the computer periodically for new orders
 
 The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the
resting state of the patient's heart?*
1/1
P wave
T wave
 
U wave
QRS complex
Feedback
Ans: B
Feedback: The T wave specifically represents ventricular muscle depolarization, also referred to as the
resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS
complex.

 
A client was seen with ischemia on his ECG result and complained of exertional
dyspnea. His nurse is creating a nursing care plan of which of the following nursing
diagnosis?*
0/1
Activity Intolerance related to imbalance of oxygen demand and supply as evidenced by
ischemia in the ECG result.
Impaired Tissue perfusion related related to decrease cardiac output
 
Imbalanced Nutrition related to exertional dyspnea
Risk for electrolyte imbalance
Correct answer
Activity Intolerance related to imbalance of oxygen demand and supply as evidenced by
ischemia in the ECG result.
 
The nurse is caring for a client admitted due to congestive heart failure . Which finding
would the nurse expect if the failure was on the right side of the heart?*
0/1
Jugular vein distension
Dry nonproductive cough
Dyspneic when supine
Crackles on chest auscultation
 
Correct answer
Jugular vein distension
 
Which action by the healthcare worker indicates a need for further teaching?*
1/1
The nursing assistant wears gloves while giving the client a bath.
The nurse wears goggles while drawing blood from the client.
The doctor washes his hands before examining the client.
The nurse wears gloves to take the client’s vital signs.
 
 
The client has a hearing loss from a possible acoustic neuroma. The nurse should
prepare the client for which diagnostic test to confirm the presence of a tumor?*
1/1
Tympanometry
Arteriogram of the cranial vessels
Magnetic resonance imaging (MRI)
 
Auditory canal biopsy
 
During assessment with a client , an ECG reading was done and you noticed high
peaked T waves. In what disorder does this usually occur?*
1/1
hyperkalemia.
 
myocardial ischemia
Cerebral hemorrhage.
hypomagnesemia.
 
 The physician has ordered an MRI for a client with an orthopedic ailment. An MRI
should not be done if the client has:*
1/1
The need for oxygen therapy
A history of claustrophobia
A permanent pacemaker
 
Sensory deafness
 
A patient was admitted with severe diarrhea and sudden paralysis. ECG reading reveals
flattening and inversion of T waves, Q-T interval prolongation, visible U wave and mild
ST depression. What nursing diagnoses will the nurse take priority in planning the
patient’s nursing care?*
1/1
Electrolyte Imbalance
 
Risk for fluid deficit
Impaired physical mobility
Risk for fall
 
The critical care nurse is caring for a patient with a pulmonary artery pressure
monitoring system. The nurse is aware that pulmonary artery pressure monitoring is
used to assess left ventricular function. What is an additional function of pulmonary
artery pressure monitoring systems?*
1/1
To assess the patients response to fluid and drug administration
 
To obtain specimens for arterial blood gas measurements
To dislodge pulmonary emboli
To diagnose the etiology of chronic obstructive pulmonary disease
Feedback
Ans: A
Feedback: Pulmonary artery pressure monitoring is an important tool used in critical care for
assessing left ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating
the patients response to medical interventions, such as fluid administration and vasoactive
medications. Pulmonary artery monitoring is preferred for the patient with heart failure over central
venous pressure monitoring. Arterial catheters are useful when arterial blood gas measurements and
blood samples need to be obtained frequently. Neither intervention is used to clear pulmonary emboli.
 
The following options are relative contraindications or needs further evaluation by their
primary physician before MRI procedure except:*
0/1
Intrauterine device (IUD)
 
Medication Patch
Tattoo that is 2 years old
Stent
Correct answer
Tattoo that is 2 years old
 
The below statements are responsibilities of a nurse regarding prevention of infection
on the Pulmonary Artery Pressure (PAP) monitoring except:*
1/1
Ensure aseptic technique with maximal barrier precautions during PA catheter insertion.
Use only the syringe provided with the PA catheter for wedge readings.
 
Follow your facility’s policies and procedures for accessing the PA catheter lumens.
Observe the insertion site for redness, swelling, or other signs of infection.
Monitor patient temperature while the catheter in place
 
 Which laboratory test is used to identify injury to the myocardium and can remain
elevated for up to 3 weeks?    *
1/1
Total CK
CK-MB
Myoglobulin
 
Troponin T or I
 
A client with chest pain is scheduled for heart catheterization. Which of the following
would the nurse include in the client's care plan?*
0/1
Keep the client NPO for 12hours afterward
Inform the client that general anesthesia will be administered throughout the procedure
Assess the site for bleeding or hematoma once per shift
 
Instruct the client that he might be asked to cough and breathe deeply during the procedure.
Correct answer
Instruct the client that he might be asked to cough and breathe deeply during the procedure.
 
A discharge nurse is providing instructions to the mother of the patient regarding safety
measures at home to prevent complications. Which statement by the mother indicates a
need for further instruction?*
1/1
Don’t do vigorous exercise until your healthcare provider says you are ready.
Make sure you keep all your follow-up visits with your healthcare provider.
Call your healthcare provider if you have a fever, increased draining from where the needle was
inserted, chest pain, or any severe symptoms.
The insertion site should be assessed for infection and the dressing changed every 96 hours
and prn.
 
 
 A patient with heart failure has an ejection fraction of 25%. What does this information
indicate to the nurse about the patient’s health status?*
1/1
Ventricular function is severely impaired.
 
Cardiac output is greater than normal, which overtaxes the heart.
The amount of blood being ejected from the ventricles is within normal limits.
Twenty-five percent of the blood entering the ventricle remains in the ventricle after systole.
 
A 24-year-old female client is scheduled for surgery in the morning. Which of the
following is the primary responsibility of the nurse?*
1/1
Obtaining the permit
Explaining the procedure
None of the Above
Taking the vital signs
 
 
What is the most important nursing action when measuring a pulmonary capillary wedge
pressure (PCWP)?*
1/1
Have the client bear down when measuring the PCWP
Place the client in a supine position before measuring the PCWP
Flush the catheter with heparin solution after the PCWP is determined.
Deflate the balloon as soon as the PCWP is measured
 
 
A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected
brain tumor. The nurse should implement which action to prepare the client for this test?
*
1/1
Shave the groin for insertion of a femoral catheter.
Remove all metal-containing objects from the client.
 
Keep the client NPO (nothing by mouth) for 6 hours before the test.
Instruct the client in inhalation techniques for the administration of the radioisotope.
 
he nurse preparing a client for a cardiac catheterization and revascularization should
include which information in the pre-op teaching.*
1/1
The client will be asleep during the procedure
The client may experience a hot flash as the dye is injected
There may be a sand bag placed over the cannulated site following the procedure
The client will be on fluid restrictions until the gag reflex returns
The client may experience chest pain when the balloon is inflated The client will experience a
headache as the dye is injected
 
Feedback
Rationale: The client is generally awake during the procedure and fluid intake is encouraged in order to
assist the kidneys with excretion of the dye. Generally a client may experience a metallic taste in the
mouth or a hot flash when the dye is injected.

 
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is
aware that electrical conduction of the heart usually originates in the SA node and then
proceeds in what sequence?*
1/1
SA node to bundle of His to AV node to Purkinje fibers
SA node to AV node to Purkinje fibers to bundle of His
SA node to bundle of His to Purkinje fibers to AV node
SA node to AV node to bundle of His to Purkinje fibers
 
Feedback
Ans: D
The normal electrophysiological conduction route is SA node to AV node to bundle of HIS to Purkinje
fibers.
 
The nurse is caring for an acutely ill patient who has central venous pressure monitoring
in place. What intervention should be included in the care plan of a patient with CVP in
place?*
1/1
Apply antibiotic ointment to the insertion site twice daily.
Change the site dressing whenever it becomes visibly soiled.
 
Perform passive range-of-motion exercises to prevent venous stasis.
Aspirate blood from the device once daily to test pH.
Feedback
Ans: B
Feedback: Gauze dressings should be changed every 2 days or transparent dressings at least every 7
days and whenever dressings become damp, loosened, or visibly soiled. Passive ROM exercise is not
indicated and it is unnecessary and inappropriate to aspirate blood to test it for pH. Antibiotic
ointments are contraindicated.
 
A patient is brought into the ED by family members who tell the nurse the patient
grabbed his chest and complained of substernal chest pain. The care team recognizes
the need to monitor the patients cardiac function closely while interventions are
performed. What form of monitoring should the nurse anticipate?*
1/1
Left-sided heart catheterization
Cardiac telemetry
Transesophageal echocardiography
Hardwire continuous ECG monitoring
 
Feedback
Ans: D
Feedback: Two types of continuous ECG monitoring techniques are used in health care settings:
hardwire cardiac monitoring, found in EDs, critical care units, and progressive care units; and
telemetry, found in general nursing care units or outpatient cardiac rehabilitation programs. Cardiac
catheterization and transesophageal echocardiography would not be used in emergent situations to
monitor cardiac function.
 
Nursing diagnoses meet specific criteria so they accurately reflect both the client’s
problem and the possible etiology involved. Of the following statements, which one is an
example of an appropriately written nursing diagnosis?*
1/1
Deficient knowledge related to need for cardiac catheterization
 
Impaired gas exchange related to altered blood gases
Need for high protein diet related to alteration in nutrition
Acute pain related to left mastectomy
 
A critical care nurse is caring for a patient with a hemodynamic monitoring system in
place. For what complications should the nurse assess? Select all that apply.*
1/1
Pneumothorax
 
Infection
Atelectasis
Bronchospasm
Air embolism
Feedback
Ans: A, B, E
Feedback: Complications from use of hemodynamic monitoring systems are uncommon, but can
include pneumothorax, infection, and air embolism. Complications of hemodynamic monitoring
systems do not include atelectasis or bronchospasm.
 
A client was seen in ED with deeply inverted T waves. Upon assessment, which of the
following will you be watchful for for its signs and symptoms?*
0/1
Subarachnoid hemorrhage
Hyperkalemia
Myocardial injury
 
Sick sinus syndrome
Correct answer
Subarachnoid hemorrhage
 
 For an R wave to have an R1 , it must have which of the following characteristics?*
1/1
The second R wave must cross the isoelectric line.
 
The second R wave will have a notch in it.
The first R wave will simply change directions.
The first R wave will be shorter than expected.
 
A 56-year old female was in the ED for admission with a chief complaint of chest pain.
During the interview the client was crying excessively and shared stressful events at
home in which her daughter disapproved and claimed that her mother has been
emotionally unstable after sustaining brain injury. A nursing care plan was laid out that
may include which of the following nursing diagnoses?*
0/1
Labile Emotional Control related Risk for fall
Decreased Intracranial adaptive capacity
 
Risk for acute Confusion
Risk for compromised Human Dignity
Correct answer
Labile Emotional Control related Risk for fall
 
You are assisting in performing and ECG procedure to an adult female patient. A staff
member asked you what QRS complex is indicative of. What is your response?*
1/1
repolarization of the atria.
depolarization of the ventricles.
 
depolarization of the atria.
repolarization of the ventricles.
 
A client with end-stage chronic obstructive pulmonary disease has selected guided
imagery to help cope with psychological stress. Which client statement indicates an
understanding of this stress-reduction measure?*
1/1
“This will help only if I play music at the same time.”
. “This will work for me only if I am alone in a quiet area.”
“I need to do this only when I lie down in case I fall asleep.”
“The best thing about this is that I can use it anywhere, anytime.”
 
 
MRI is a procedure in which radio waves and a powerful magnet linked to a computer
are used to create detailed pictures of areas inside the body. Which of the following
choices is a relative contraindication for this procedure?*
0/1
Metallic implants
 
Sharpnel
Artificial limb
Airway stents/tracheostomy
Correct answer
Airway stents/tracheostomy
 
Nursing diagnoses meet specific criteria so they accurately reflect both the client’s
problem and the possible etiology involved. Of the following statements, which one is an
example of an appropriately written nursing diagnosis?*
1/1
Risk for change in body image related to cancer
Cardiac output decreased related to motor vehicle accident
Potential for injury related to improper teaching in the use of crutches
Ineffective airway clearance related to increased secretions
 
 
 The nurse is reviewing orders for the 10-year- old about to undergo a pulmonary artery
catheterization in two hours. Which prescription should the nurse question with the
HCP?*
0/1
Clear liquid diet
Obtain CBC now
Obtain height and weight
Place IV and saline lock
 
Correct answer
Clear liquid diet
 
A client in the cardiac step-down unit requires suctioning for excess mucous secretions.
The dysrhythmia most commonly seen during suctioning is:*
1/1
Bradycardia
 
Tachycardia
Premature ventricular beats
Heart block
This form was created inside of Phinma Education.

 Forms

MS RLE: Part 1 Final Examination 11/10

Total points40/50
 
The respondent's email ([email protected]) was recorded on submission of this
form.
0 of 0 points
SURNAME, FIRST NAME*
INTAO, CONRADO III. L.
SECTION*
F
MULTIPLE CHOICE
40 of 50 points
ANSWER YOUR EXAMINATION HONESTLY. CHOOSE THE BEST ANSWER.
A nurse is performing surgical hand hygiene, how should she position her hand after ?*
1/1
Above the elbows
Below the elbows
At a 45-degree angle
In a comfortable position
The nursing educator is presenting a case study of an adult patient who has abnormal
ventricular depolarization. This pathologic change would be most evident in what
component of the ECG?*
1/1
P wave
T wave
QRS complex
U wave
A gown should be worn when:*
1/1
The client's hygiene is poor.
The client has acquired immunodeficiency syndrome (AIDS) or hepatitis.
The nurse is assisting with medication administration.
Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.
You are cleaning a  deep wound infection. Which of the following actions would result in
the contamination of your sterile gloves?*
1/1
The nurse grasps a sterile cotton-tipped swab to clean wound edges.
The nurse takes a gauze pad in hand and places it in the wound.
The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound.
The nurse pulls up the sheet over the client's perineum for better draping.
When removing PPE it is important to know what areas of the PPE are considered
"clean" vs "contaminated". Select ALL the areas on PPE that are considered "clean"*
1/1
Ties on the gown
Outside of the mask
Sleeves of the gown
Back of the gown
Inside of the gloves
Straps on the goggles
A physician has written a prescription to discontinue an IV line. The nurse obtains which
of the following supplies from the unit supply area for applying pressure to the site after
removing the IV catheter?*
1/1
Elastic wrap
Betadine swab
Adhesive bandage
Sterile 2x2 gauze
The nurse is caring for a client who is receiving IV fluids. Which observation by the
nurse indicates the IV has infiltrated?*
0/1
Pain at the site.
A change in flow rate.
Coldness around the insertion site.
Redness around the insertion site.
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary
disease to deliver a precise oxygen concentration. Which oxygen delivery system would
the nurse anticipate to be prescribed?*
1/1
Face tent
Venturi mask
Aerosol mask
Tracheostomy collar
Option 5
Ellah, 15 years old and currently admitted in the hospital diagnosed with Dengue
hemorrhagic fever. Doctor ordered a blood transfusion as soon as possible. Upon
getting the consent, the mother refused to sign as her daughter doesn’t need one. What
would be the best nursing diagnosis can we formulate?*
1/1
Deficient knowledge related to unfamiliarity with the transfusion process.
Risk for Injury related to hemolytic reactions.
Ineffective Breathing Pattern related to complications
Ineffective Tissue Perfusion related to decreased hemoglobin.
Option 5
A 15-year-old client contracted Coronavirus disease (COVID 19) when traveling abroad
with her parents. The nurse knows she must put on personal protective equipment to
protect herself while providing care. Based on the mode of COVID 19 transmission,
which personal protective equipment should the nurse wear?*
1/1
Gloves
Gown and gloves
Gown, gloves and and mask
Gown, gloves, mask, and eye goggles or eye shield
An adult has a central line in his right subclavian vein. The nurse is to change the
tubing. Which of the following should be done?*
0/1
Use the present solution with the new tubing.
Connect the new tubing to the hub prior to running any fluid through the tubing.
Close the roller clamp on the new tubing after priming it.
Have the client roll to the right side to prevent an air embolus.
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 most appropriate?*
1/1
Continue to suction.
Notify the health care provider immediately.
Stop the procedure and reoxygenate the client.
Ensure that the suction is limited to 15 seconds.
Which of the following is true about surgical handwashing? Select all that apply.*
0/1
Requires removal and killing of transient microorganisms.
Protects the surgical team from cross contamination
Option 5
Reduction of skin flora for the duration of the operation
Nails are kept short and clean
You are preparing to assist in a major surgical operation. Which of the following does
not state one of the purposes of surgical handwashing.*
0/1
Specific attention is paid to the palms as this area has the highest bacterial load.
To remove dirt, oils and bacteria from the hands and forearms of operating personnel.
Brushes should be soft enough to not damage skin
Should not irritate skin or be time consuming.
In preparing for surgical hand scrubbing, the following are correct except?*
0/1
Wear suitable surgical attire,with sleeves rolled and tuck tops into trousers.
Cut nails short.
Apply scrub solution first and rinse in running water.
Clean nails with disposable pick under running water.
Before doing surgical hand scrubbing, which of the following should you do first?*
0/1
Inform the anesthesiologist and surgeon that the patient is ready.
Make sure the patient's surgical site is already prepped with povidone iodine.
Let the patient sign informed consent.
Open gown and gloves and make sure they remain sterile.
As you do surgical handwashing, in which fashion should you scrub your fingers?*
1/1
Scrub brush perpendicular to the fingers.
Brush all four sides of each finger.
Brush each finger in circular motion.
Brush each finger in back and forth motion
The rationale of gowning is correctly stated in which of the following.*
1/1
Protects the caregiver from contamination.
Protects the patient from infection.
Protects both the caregiver and patient from cross contamination.
Protects the family members.
After a procedure, the nurse will remove her contaminated gloves by doing which of the
following?*
0/1
Rinse the glove before removing it to minimize contamination.
Pull the glove off the back of the hand until it slides off the entire hand and discard it.
Grasp the outside of the cuff or palm of the glove and pull it away from the hand without
touching the wrist or fingers.
Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the
hand by the other gloved hand.
The nurse recognizes which pathophysiologic changes are occurring when caring for
the client with respiratory acidosis? Select all that apply.*
1/1
Increased CO2
Vasoconstriction
Decreased intracranial pressure (ICP)
Increased pulse rate
An elderly patient was rushed to the ED with an assessment of palpable peripheral
pulses, urinary output of 30 mL per hour, and no respiratory distress. He has a history of
hemolytic transfusion reaction. What is the appropriate nursing diagnosis with this
patient?*
1/1
Ineffective Breathing Pattern
Ineffective Tissue Perfusion
Deficient Knowledge
Risk for Injury
Option 5
The nurse is caring for the child with bronchial asthma. Which statement is most
important for the nurse to make when teaching the parents?*
1/1
“Bronchial asthma is also called hyperactive airway disease.”
“Cold air and irritating odors can cause severe bronchoconstriction.”
“Frequent occurrences of bronchiolitis before age 5 could indicate asthma.”
“Severe respiratory alkalosis can result from respiratory failure in asthma.”
A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage,
the nurse should instruct the patient to perform which of the following?*
1/1
Apply a cold pack to the affected area.
Apply a mustard poultice to the forehead.
Perform postural drainage.
Increase fluid intake.
Airway suctioning is used to remove secretions from the airway.  The following options
are patient’s health education except?*
0/1
Keep patient calm if in distress
Explain your steps as you take them
Explain procedure, it may make them cough
Explain purpose for suctioning
None of the above
The child with asthma is prescribed albuterol MDI. Which statement should the nurse
include when teaching the child how to administer this medication?*
1/1
“When administering medication via an MD], avoid shaking the canister before discharging the
medication.”
“Breathe out as much air as possible, put the mouthpiece in the mouth, press the canister, and
then slowly inhale.”
“When giving two ‘puffs,’ press on the canister twice in succession to discharge the
medication.”
“There should be a tight seal around the mouth- piece of the inhaler before the medication is
discharged.”
A client is to be discharged to home on oxygen therapy. What information will the nurse
teach the client?*
1/1
"The D or C cylinder can be carried."
"Roll the tank gently when transporting."
"Only use the E tank when stationary."
"Carry the H cylinder tank with you wherever you go."
During a pre-surgical admission assessment, the client states, “I’ve told my surgeon that
I am Jehovah’s Witness, and I won’t accept a blood transfusion.” Which statement by
the nurse would be most appropriate?*
1/1
“Tell me more about your fear of receiving a blood transfusion.”
“Your request not to receive a transfusion would be honored.”
“Don’t worry; there is less blood loss with our newer equipment.”
“Are you sure you wouldn’t want a transfusion if one is needed?”
Which nursing intervention is appropriate for the nurse to take when setting up supplies
for a client who requires a blood transfusion?*
1/1
Add any needed IV medication in the blood bag within one-half hour of planned infusion.
Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to
infusion.
Prime tubing of blood administration set with 0.9% NS solution, completely filling filter.
Use a small-bore catheter to prevent rapid infusion of blood products that may lead to a
reaction.
Option 5
A client who is in acute renal failure develops pulmonary edema.  Nursing interventions
for this person should include except?*
0/1
Administering oxygen.
Encouraging coughing and deep breathing.
Placing the client in a semi-sitting position.
Replacing lost fluids
A client with the recent diagnosis of MI and impaired renal function is recuperating on
the step-down cardiac unit. The client's blood pressure has been borderline low and IV
fluids have been infusing at 100 mL /hr via a central line catheter in the right internal
jugular for approx 24 hours to increase renal output and maintain the blood pressure.
Upon entering the client's room, the nurse notes that the client is breathing rapidly and
is coughing. The nurse determines that the client is most likely experiencing
complications of IV therapy.*
1/1
Hematoma
Air embolism
Systemic infection
Circulatory overload
A man’s blood type is AB and he requires a blood transfusion. To prevent complications
of blood incompatibilities, which blood type(s) may the client receive?*
1/1
Type A or B blood only.
Type AB blood only.
Type O blood only.
Either type A, B, AB, or O blood.
Your patient tells you that he has just been told that his computed tomography results
were abnormal. You can expect that his sympathetic nervous system has stimulated his
adrenal gland to release what?*
1/1
Endorphins
Dopamine
Epinephrine
Testosterone
Computed tomography of a 72-year-old woman reveals lung cancer with metastasis to
the liver. The patient's son has been adamant that any bad news be withheld from him
in order to protect her from stress, stating that this is a priority in his culture. How should
the nurse and the other members of the care team best response?*
1/1
Explain to the son the team's ethical obligation to inform the patient.
Refer the family to social work.
Have a nurse or physician from the patient's culture make contact with her and her son.
Speak with the son to explore his rationale and attempt to reach a consensus.
The physician has ordered a peripheral IV to be inserted before the patient goes for
computed tomography. What should the nurse do when selecting a site on the hand or
arm for insertion of an IV catheter?*
1/1
Choose a hairless site if available.
Consider potential effects on the patient's mobility when selecting a site.
Have the patient briefly hold his arm over his head before insertion.
Leave the tourniquet on for at least 3 minutes.
A patient has been scheduled for cardiovascular computed tomography (CT) with
contrast. To prepare the patient for this test, what action should the nurse perform?*
1/1
Keep the patient NPO for at least 6 hours prior to the test.
Establish peripheral IV access.
Limit the patient's activity for 2 hours before the test.
Teach the patient to perform incentive spirometry.
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care
procedure constitutes the highest risk for anaphylaxis?*
1/1
Administration of the measles-mumps-rubella (MMR) vaccine
Rapid administration of intravenous fluids
Computed tomography with contrast solution
Administration of nebulized bronchodilators
A patient will be undergoing abdominal computed tomography (CT) with contrast. The
nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst)
before the study as ordered. What would indicate that these medications have had the
desired therapeutic effect?*
1/1
The patient's BUN and creatinine levels are within reference range following the CT.
The CT yields high-quality images.
The patient's electrolytes are stable in the 48 hours following the CT.
The patient's intake and output are in balance on the day after the CT.
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt
abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse
should anticipate what diagnostic test?*
1/1
Radiograph
Computed tomography (CT) scan
Complete blood count (CBC)
Barium swallow
A nurse is caring for a patient who is being assessed following complaints of severe and
persistent low back pain. The patient is scheduled for diagnostic testing in the morning.
Which of the following are appropriate diagnostic tests for assessing low back pain?
Select that apply.*
1/1
Computed tomography (CT)
Angiography
Magnetic resonance imaging (MRI)
Ultrasound
X-ray
A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology
department. The nurse who prepares the patient for the MRI should prioritize which of
the following actions?*
1/1
Withholding stimulants 24 to 48 hours prior to exam
Removing all metal-containing objects
Instructing the patient to void prior to the MRI
Initiating an IV line for administration of contrast
The nurse is caring for a patient admitted with angina who is scheduled for cardiac
catheterization. The patient is anxious and asks the reason for this test. What is the best
response?*
1/1
Cardiac catheterization is usually done to assess how blocked or open a patient's coronary
arteries are.
Cardiac catheterization is most commonly done to detect how efficiently a patient's heart
muscle contracts.
Cardiac catheterization is usually done to evaluate cardiovascular response to stress.
Cardiac catheterization is most commonly done to evaluate cardiac electrical activity.
A patient has been admitted with an aortic valve stenosis and has been scheduled for a
balloon valvuloplasty in the cardiac catheterization lab later today. During the admission
assessment, the patient tells the nurse he has thoracolumbar scoliosis and is concerned
about lying down for any extended period of time. What is a priority action for the nurse?
*
1/1
Arrange for an alternative bed.
Measure the degree of the curvature.
Notify the surgeon immediately.
Note the scoliosis on the intake assessment.
A patient has been diagnosed with a valvular disorder. The patient tells the nurse that
he has read about numerous treatment options, including valvuloplasty. What should
the nurse teach the patient about valvuloplasty?*
1/1
For some patients, valvuloplasty can be done in a cardiac catheterization laboratory.
Valvuloplasty is a dangerous procedure, but it has excellent potential if it goes well.
Valvuloplasty is open heart surgery, but this is very safe these days and normally requires only
an overnight hospital stay.
It's prudent to get a second opinion before deciding to have valvuloplasty.
A cardiovascular patient with a previous history of pulmonary embolism (PE) is
experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse
recognizes the characteristic signs and symptoms of a PE. What is the nurse's best
action?*
1/1
Rapidly assess the patient's cardiopulmonary status.
Arrange for an ECG.
Increase the height of the patient's bed.
Manage the patient's anxiety.
A 6-year-old is admitted to the ED after being rescued from a pond after falling through
the ice while ice skating. What action should the nurse perform while rewarming the
patient?*
···/1
Assessing the patient's oral temperature frequently
Ensuring continuous ECG monitoring
Massaging the patient's skin surfaces to promote circulation
Administering bronchodilators by nebulizer
A patient is brought into the ED by family members who tell the nurse the patient
grabbed his chest and complained of substernal chest pain. The care team recognizes
the need to monitor the patient's cardiac function closely while interventions are
performed. What form of monitoring should the nurse anticipate?*
1/1
Left-sided heart catheterization
Cardiac telemetry
Transesophageal echocardiography
Hardwire continuous ECG monitoring
The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II,
and III differ from one another on the cardiac rhythm strip. How should the nurse best
respond?*
1/1
Recognize that the view of the electrical current changes in relation to the lead placement.
Recognize that the electrophysiological conduction of the heart differs with lead placement.
Inform the technician that the ECG equipment has malfunctioned.
Inform the physician that the patient is experiencing a new onset of dysrhythmia.
The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the
resting state of the patient's heart?*
1/1
P wave
T wave
U wave
QRS complex
The nurse assesses a client’s surgical incision for signs of infection. Which finding by
the nurse would be interpreted as a normal finding at the surgical site?*
1/1
Red, hard skin
Serous drainage
Purulent drainage
Warm, tender skin
The nurse receives a telephone call from the post anesthesia care unit stating that a
client is being transferred to the surgical unit. The nurse plans to take which action first
on the arrival of the client?*
1/1
Assess the patency of the airway.
Check tubes or drains for patency.
Check the dressing to assess for bleeding.
Assess the vital signs to compare with preoperative measurements.
This form was created inside of Phinma Education.

 Forms

MS RLE: Part 2 Final Examination 11/10

Total points41/50
 
The respondent's email ([email protected]) was recorded on submission of this
form.
0 of 0 points
SURNAME,FIRST NAME*
INTAO, CONRADO III. L.
SECTION*
F
MULTIPLE CHOICE
41 of 50 points
ANSWER YOUR EXAMINATION HONESTLY. CHOOSE THE BEST ANSWER.
A patient presents to the ED in distress and complaining of crushing chest pain. What is
the nurse's priority for assessment?*
1/1
Prompt initiation of an ECG
Auscultation of the patients point of maximal impulse (PMI)
Rapid assessment of the patients peripheral pulses
Palpation of the patients cardiac apex
An adult patient with third-degree AV block is admitted to the cardiac care unit and
placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most
likely show?*
1/1
PP interval is equal to RR interval.
PP interval and RR interval are irregular.
Fewer QRS complexes than P waves
PR interval is constant.
The nurse is caring for a patient who has just had an implantable cardioverter
defibrillator (ICD) placed. What is the priority area for the nurses assessment?*
1/1
Assessing the patient's activity level
Facilitating transthoracic echocardiography
Vigilant monitoring of the patient's ECG
Close monitoring of the patient's peripheral perfusion
A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because
the patient is pulseless, the nurse should prepare for what intervention?*
1/1
Defibrillation
ECG monitoring
Implantation of a cardioverter defibrillator
Angioplasty
An ECG has been ordered for a newly admitted patient. What should the nurse do prior
to electrode placement?*
1/1
Clean the skin with povidone-iodine solution.
Ensure that the area for electrode placement is dry.
Apply tincture of benzoin to the electrode sites and wait for it to become tacky.
Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.
A group of nurses are participating in orientation to a telemetry unit. What should the
staff educator tell this class about ST segments?*
1/1
They are the part of an ECG that reflects systole.
They are the part of an ECG used to calculate ventricular rate and rhythm.
They are the part of an ECG that reflects the time from ventricular depolarization through
repolarization.
They are the part of an ECG that represents early ventricular repolarization.
The nurse is caring for a patient on telemetry. The patient's ECG shows a shortened PR
interval, slurring of the initial QRS deflection, and prolonged QRS duration. What does
this ECG show?*
1/1
Sinus bradycardia
Myocardial infarction
Lupus-like syndrome
Wolf-Parkinson-White (WPW) syndrome
The nurse is caring for a patient who is in the recovery room following the implantation
of an ICD. The patient has developed ventricular tachycardia (VT). What should the
nurse assess and document?*
1/1
ECG to compare time of onset of VT and onset of devices shock
ECG so physician can see what type of dysrhythmia the patient has
Patients level of consciousness (LOC) at the time of the dysrhythmia
Patients activity at time of dysrhythmia
 A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What
goal should guide the planning and execution of the patient's care?*
1/1
Ablate the area causing the dysrhythmia.
Freeze hypersensitive cells.
Diagnose dysrhythmia.
Determine the nursing plan of care.
A 48-year-old man presents to the ED complaining of severe substernal chest pain
radiating down his left arm. He is admitted to the coronary care unit (CCU) with a
diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on
admission to the CCU?*
1/1
Begin ECG monitoring.
Obtain information about family history of heart disease.
Auscultate lung fields.
Determine if the patient smokes.
The nurse is caring for a patient who is believed to have just experienced an MI. The
nurse notes changes in the ECG of the patient. What change on an ECG most strongly
suggests to the nurse that ischemia is occurring?*
1/1
P wave inversion
T wave inversion
Q wave changes with no change in ST or T wave
P wave enlargement
The nurse is admitting a patient with complaints of dyspnea on exertion and fatigue. The
patient's ECG shows dysrhythmias that are sometimes associated with left ventricular
hypertrophy. What diagnostic tool would be most helpful in diagnosing cardiomyopathy?
*
1/1
Cardiac catheterization
Arterial blood gases
Echocardiogram
Exercise stress test
Dressings  recommended for acute wounds to:*
1/1
Keep the wound clean
Enhance growth factors and cytokines within wound fluid
Promote autolysis
Promote cell proliferation because of low pH and hypoxia
In acute wound healing:*
1/1
Ointments promote bacterial growth
Topical antibiotics should be applied to clean wounds
The wound should not be washed because water prevents healing
Polyurethane self-adhesive patches reduce the risk of hypertrophic scars
Select the wound dressing shown in the image below:*
0/1

Hydrocolloid
Foam
Alginate
Film
Which type(s) of dressing requires the least amount(s) of time*
1/1
wet to dry dressing
hydrocolloid dressing
film dressing
both b. and c.
Option 5
The following note would be supportive documentation for dressing changes:*
1/1
Sacral ulcer rinsed and covered with clean dressing.
Sacral pressure ulcer rinsed with normal saline and covered with 6 4x4s
Sacral ulcer cleansed
Sacral ulcer treatment done as ordered
For hydrocolloid dressings, which of the following statements apply?*
0/1
Replacement of dermal matrix and epidermis is required
They may adhere directly to the skin
They cool the wound and can provide excellent pain relief
They are useful for partial thickness wounds from resurfacing procedures and skin graft donor
sites
The cardinal rule when determining a dressing change for a pressure ulcer is*
1/1
Keep the ulcer tissue dry and the surrounding intact skin moist
Keep the ulcer tissue moist and the surrounding intact skin dry
Keep the ulcer tissue and surrounding intact skin moist
Keep the ulcer tissue and surrounding intact skin dry
A stage I pressure ulcer will present with*
1/1
Warmth and edema
Induration or hardness
Nonblanchable erythema
Discoloration of the skin
All of the above
When floating heels off of the mattress, the heels should be raised*
1/1
Enough for your hand to fit between the bed and the heels
2 inches off of the bed
Just enough for a piece of paper to pass between the bed and the heels
At least one inch off the bed
Removal of devitalized tissue in pressure ulcers when appropriate for the resident’s
condition and consistent with resident goals is*
1/1
Irrigation
Sterile technique
Debridement
exudates
Mrs. Ellah is a 75-year-old patient in a long-term care facility and has a history of
chronic obstructive pulmonary disease (COPD) verbalized to the nurse in charge, “I’m
feeling short of breath and tired today.” The nurse obtained V/S and recorded
respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C and noted that she is
using accessory muscles to breathe and is sitting up in the tripod position. She also has
a barrel chest. What nursing diagnosis is most appropriate?*
1/1
Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea
and use of accessory muscles to breathe and patient stating, “I’m feeling short of breath and
tired today.”
Ineffective Airway Clearance related to hypoxia as evidenced by use of accessory muscles to
breathe and patient stating, “I’m feeling short of breath and tired today.”
Impaired Gas Exchange related to abnormal breathing pattern as evidenced by use of accessory
muscles to breathe and patient stating, “I’m feeling short of breath and tired today.”
Ineffective Airway Clearance related to difficulty of breathing as evidenced by use of accessory
muscles to breathe and patient stating, “I’m feeling short of breath and tired today.”
Personal Protective Equipment is one of the most important necessities for safety from
infections and viruses. It helps save ourselves from many different kinds of transferable
germs and viruses and protects us from serious diseases. What nursing diagnosis can
we formulate based on the facts given?*
1/1
Risk for Infection related to increased environmental exposure to pathogens.
Risk for infections related to compromised host defense.
Deficient Knowledge related to Insufficient knowledge to avoid exposure to pathogens.
Deficient Knowledge related to increased contact to infectious agents.
The nursing diagnosis is Risk for impaired skin integrity related to immobility and
pressure secondary to pain and presence of a cast. Which of the following desired
outcomes should the nurse include in the care plan?*
1/1
Client will be able to turn self by day 3
Client will state pain relieved within 30 minutes after medication
Pressure will be prevented by repositioning client every 2 hours
Skin will remain intact and without redness during hospital stay
*A surgeon has made an incision at a patient’s abdomen for exploratory laparotomy. As
the scrub nurse, which of the following instruments will you anticipate to hand over to
the surgeon to expose the site to be explored?*
1/1
Option 1

Option 2
Option 3

Option 4
While the surgeon explores the patient’s abdominal cavity. He found a bleeder. Which
of the following instruments will you anticipate and prepare to hand to the surgeon to
temporarily occlude the bleeder?*
1/1

Option 1
Option 2

Option 3

Option 4
A scrub nurse must be familiar with the surgical procedure and the surgeon’s
preferences. How should she hand an instrument to the surgeon?*
0/1
Held at the shank between the cushions of the small fingers and first two fingers with the tip
visible and the handle is free for the surgeon’s palm.
Held at the handle between the cushions of the thumb and first two fingers with the tip visible
and the handle is free for the surgeon’s palm.
Held at the shank between the cushions of the thumb and first two fingers with the tip visible
and the handle is free for the surgeon’s palm.
Held at the shank between the cushions of the thumb and first two fingers with the tip visible
and the handle is free for your palm.
A woman begins using an albuterol inhaler and a beclomethasone inhaler for her
asthma. Which statement by the client indicates further teaching is necessary?*
1/1
I use the albuterol inhaler first. After 5-10 minutes I use my beclomethasone inhaler.
I should rinse my mouth with warm tap water after using my inhalers.
I use my albuterol inhaler first then immediately use my beclomethasone inhaler.
I can only use my albuterol inhaler when I am having an acute asthma attack.
The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer
a corticosteroid. Which of the following indicates that the client is using the MDI
correctly? Select all that apply.*
1/1
The inhaler is held upright
The head is tilted down while inhaling the medicine
The client waits 5 minutes between puffs
The client rinses the mouth with water following administration
The client lies supine for 15 minutes following administration
Select the basic sterile asepsis procedures that are accurate. Select all that apply:  *
0/1
Sterile items ONLY are placed on the sterile field.
The nurse must keep the sterile field below waist level.
Coughing or sneezing over the sterile field contaminates the sterile field.
The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
Moisture and wetness contaminate the sterile field.
Sterile masks are used by staff and the client when a sterile field is being set up and/or
maintained
A  female patient is scheduled to undergo a partial mastectomy for the treatment of
breast cancer. What nursing diagnosis should the nurse prioritize when planning this
patient's postoperative care?*
1/1
Risk for Infection related to reduced immune function
Risk for Impaired Memory related to old age
Risk for Decisional Conflict related to discharge planning
Risk for Delayed Growth and Development related to prolonged hospitalization
The clinical instructor asks her students the rationale for handwashing. The students are
correct if they answered that handwashing is expected to remove:*
1/1
transient microorganisms
skin flora
parasites
opportunistic organisms
The client is reporting severe chest pain radiating down the left arm and is nauseated
and diaphoretic. The HCP suspects the client is having an MI and has ordered
morphine sulfate for the pain. Which interventions should the nurse implement? Select
all that apply.*
1/1
Administer the morphine sulfate slowly over 5 minutes.
Question the order because morphine sulfate should not be administered to a client with an MI.
Dilute the morphine sulfate to a 10-mL bolus with normal saline.
Instruct the client not to get out of the bed without notifying the nurse.
A clinic nurse is conducting a preoperative interview with an adult patient who will soon
be scheduled to undergo cardiac surgery. What interview question most directly
addresses the patient's safety?*
1/1
What prescription and nonprescription medications do you currently take?
Have you previously been admitted to the hospital, either for surgery or for medical treatment?
How long do you expect to be at home recovering after your surgery?
Would you say that you tend to eat a fairly healthy diet?
The sterile areas of the gown include the:*
1/1
front from two inches below the neck to waist or table level
gloves and gown sleeve to two inches above the elbow
sides from axillae to waist or table level
back of a wraparound gown
A patient underwent a CT of the heart and calcium scoring. Which of the following
results indicates minimal risk for coronary artery disease?*
0/1
101-400
>400
<100
~100
You are reviewing a client's laboratory and diagnostic results.  Cardiac scoring CT
reveals >400 calcified plaque in his coronary arteries. This result signifies which of the
following?*
0/1
Client has a greater risk of myocardial infarction.
Client is developing coronary artery disease.
Client has a critical narrowing of his coronary arteries due to plaques.
Client needs to quit smoking.
After cardiac scoring, what will you instruct to your patient?*
0/1
"Do not drive, contrast can make you drowsy."
"You may now eat a meal and drink your medicines."
"Take full glass of milk to eliminate contrast in your blood stream."
"Take antihistamine and sleep."
Which statement made by the client diagnosed with chronic bronchitis indicates a need
for further health teaching.*
1/1
“I should contact my health-care provider if my sputum changes color or amount.”
“I will take my bronchodilator regularly to prevent having bronchospasms.”
“This metered-dose inhaler gives a precise amount of medication with each dose.”
“I need to return to the HCP to have my blood drawn with my annual physical.”
When two nursing diagnoses appear closely related, what should the nurse do first to
determine which diagnosis most accurately reflects the needs of a patient?*
1/1
Reassess the patient
Examine the related to factors
Analyze the secondary to factors
Review the defining characteristics
A male client abruptly sits up in bed, reports having difficulty breathing and has an
arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely
reverse the manifestations?*
1/1
Simple mask
Non-rebreather mask
Face tent
Nasal cannula
A male client is admitted to the health care facility for treatment of chronic obstructive
pulmonary disease. Which nursing diagnosis is most important for this client?*
1/1
Activity intolerance related to fatigue
Anxiety related to actual threat to health status
Risk for infection related to retained secretions
Impaired gas exchange related to airflow obstruction
The child with asthma is prescribed albuterol MDI. Which statement should the nurse
include when teaching the child how to administer this medication?*
1/1
“When administering medication via an MD], avoid shaking the canister before discharging the
medication.”
“When giving two ‘puffs,’ press on the canister twice in succession to discharge the
medication.”
“There should be a tight seal around the mouth- piece of the inhaler before the medication is
discharged.”
“Breathe out as much air as possible, put the mouthpiece in the mouth, press the canister, and
then slowly inhale.”
The client has been placed on 6 L of humidified oxygen via nasal cannula. What will be
the highest priority action of the nurse?*
1/1
Ensuring that condensation is drained back into the humidifier to maintain a closed system
Replacing sterile water by draining the water collected in the water trap back into the humidifier
Emptying condensation in tubing into a sterile container for bacterial analysis
Removing condensation in tubing by disconnecting and emptying into trash can.
The nurse completes teaching the parent of the child with asthma about the peak flow
meter. Which statement indicates that the teaching was effective?*
0/1
“I’ll have my child obtain the meter reading each morning before getting out of bed while lying
flat; the meter will be set on the average peak flow.”
“I’ll have my child obtain the meter reading after completing a morning exercise routine to
encourage better airflow before testing the peak flow.”
“I’ll encourage my child to set the meter at zero before testing and test peak flow every day; we’ll
record the best reading once a month.”
“I’ll set the meter gauge on zero; then my child should stand and ‘huff and cough’ two or three
times to clear the airway before testing the peak flow.”
The nurse is evaluating a client's response to medication therapy for asthma. The client
reports daily peak flowmeter readings in the yellow zone. How will the nurse interpret
this information?*
0/1
No change is needed in the client's therapy.
The client needs to use rescue drugs immediately.
The client needs additional daily medication.
The client has an infection.
The nurse is preparing to initiate a blood transfusion. The client has a peripheral
intravenous infusion in their left arm that the physician has ordered not be slowed or
rate reduced. The nurse prepares to start another line in the right arm. The client asks
the nurse to use the existing site to avoid the trauma of having another line started.
Which of the following statements by the nurse is correct?*
1/1
"I will let the physician know about your preferences."
"I will need to infuse the blood through a separate IV line."
"We will need to assess the line before I can make a determination about your request."
"That will be fine""
The nurse has just reassessed the condition of a postoperative client who was admitted
1 hour ago to the surgical unit. The nurse plans to monitor which parameter most
carefully during the next hour?*
1/1
Urinary output of 20 mL/hour
Temperature of 37.6 ° C (99.6 ° F)
Blood pressure of 100/70 mm Hg
Serous drainage on the surgical dressing
Option 5
 The nurse is reviewing a health care provider’s (HCP’s) prescription sheet for a
preoperative client that states that the client must be NPO after midnight. The nurse
would telephone the HCP to clarify that which medication should be given to the client
and not withheld?*
1/1
Prednisone
Ferrous sulfate
Cyclobenzaprine (Flexeril)
Conjugated estrogen (Premarin)
This form was created inside of Phinma Education.

 Forms