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Ati nur 211 med surg quiz
Ati nur 211 med surg quiz
Total Questions : 28
Showing 10 questions Sign up for moreA nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?
Explanation
A. Laboratory testing of serum potassium is important in assessing electrolyte balance, particularly when the patient is on diuretics or experiencing fluid shifts related to heart failure or MI.
B. Bumetanide is a loop diuretic, commonly prescribed to help manage fluid retention in heart failure.
C. Normal saline (0.9% NaCl) is a volume-expanding fluid, and its continuous infusion at 100 mL/hr could exacerbate fluid overload in a client with acute heart failure. Heart failure patients typically require careful fluid management, often involving diuretics, and IV fluids should be closely monitored to avoid exacerbating pulmonary edema or worsening heart failure.
D. Morphine sulfate is often used for pain and anxiety relief in clients with acute heart failure and MI.
A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?
Explanation
A. Droplet precautions are not sufficient for TB, as it is transmitted via airborne particles.
B. While proper PPE is important, the focus should be on airborne precautions, not modification of the protocol.
C. Tuberculosis (TB) is airborne, so the client should be placed in an airborne infection isolation room with negative pressure ventilation to prevent the spread of TB particles in the air. This room ensures that air does not circulate to other parts of the hospital.
D. An N95 mask is necessary, but the key precaution is placing the patient in a room with a specialized ventilation system, not just wearing PPE.
A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?
Explanation
A. Weight loss is uncommon in heart failure; more typically, there is weight gain due to fluid retention.
B. Orthopnea, difficulty breathing when lying flat, is a common symptom of heart failure in toddlers. The child may need to be propped up with pillows to help ease breathing.
C. Increased urine output is usually seen after diuretic therapy; in heart failure, urine output can be reduced due to decreased renal perfusion.
D. Bradycardia is not a typical finding in heart failure, as tachycardia (elevated heart rate) is more common due to the heart's effort to compensate for inadequate cardiac output.
A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?
Explanation
A. Sudden weakness in one arm and leg may indicate a stroke, which is a potential complication of atrial fibrillation. The nurse should assess for signs of a stroke and alert the healthcare provider immediately.
B. Irregular heart rate without P waves is a hallmark of atrial fibrillation, but this is expected and does not require immediate intervention.
C. Cloudy and odorous urine may suggest a urinary tract infection, but it is not as critical as the possibility of a stroke.
D. The aPTT of 80 seconds may be elevated, but it is within the therapeutic range for heparin. However, sudden weakness takes priority in this case.
A nurse is caring for a client who has coronary artery disease.
For each potential provider's prescription, click to specify if the prescription is a priority or non-priority for the client.
Explanation
Priority:
Aspirin 160 mg PO STAT: Aspirin is an antiplatelet that helps limit clot propagation and reduce infarct size. It should be administered immediately during suspected MI.
Prepare for cardiac catheterization: Cardiac catheterization is used to visualize coronary arteries and assess blockage. Early cath lab evaluation is vital for treatment planning.
Morphine 8 mg IV STAT: Morphine helps relieve chest pain, reduce anxiety, and decrease myocardial oxygen demand, which is crucial in acute MI management.
Prepare for PCI: PCI is the definitive treatment for ST-elevation myocardial infarction (STEMI) and should be performed promptly to restore perfusion.
Non-Priority:
Captopril 12.5 mg PO TID: Although ACE inhibitors are part of long-term management for CAD and heart failure, they are not a priority during the acute phase of MI.
Atenolol 50 mg BID: Beta-blockers can be beneficial, but initiating oral atenolol in an unstable patient with evolving MI should be deferred until the acute event is stabilized.
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?
Explanation
A. Morphine is used to manage pain and reduce anxiety in the acute phase of a myocardial infarction. It also helps in reducing preload and afterload, which eases the heart's workload.
B. Oxygen is typically administered early in the acute phase of MI, but after the initial phase, it may not be the primary medication to manage pain and anxiety.
C. Nitroglycerin is used for chest pain relief and to reduce myocardial oxygen demand, but after the initial phase, morphine is more commonly used for ongoing pain management.
D. Aspirin is given early to prevent clot formation but is not used specifically for pain and anxiety relief in the later phases of MI management.
A nurse is caring for a client in the emergency department.
Which of the following interventions should the nurse expect when planning care for this client? (Select All that Apply.)
Explanation
A. The client reports acute back pain, which may suggest an abdominal aortic aneurysm (AAA) or other vascular concerns. Monitoring for abdominal pain is essential, as it could indicate rupture or impending rupture.
B. Administering an antihypertensive is not appropriate at this time, as the client’s blood pressure is not critically high, and the cause of dizziness and back pain needs to be identified first.
C. The nurse should monitor the client’s back pain and assess for changes in intensity or new symptoms, as this can help guide diagnosis.
D. The client may not require emergency surgery yet; the priority is to further assess for conditions like an aneurysm or other causes of back pain.
E. While smoking cessation education is important for long-term health, it is not an immediate priority given the current acute symptoms.
F. Given the family history of prostate cancer and the risk for aneurysm, the nurse should provide education about the signs of a growing aneurysm, including increasing back or abdominal pain, dizziness, and weakness.
G. A complete blood count (CBC) could provide valuable information about potential infection or anemia, which may inform the clinical decision-making process.
A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave. (Selectable areas, or "Hot Spots," can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.)
Explanation
The T-wave on an electrocardiogram (ECG) represents the repolarization of the ventricles. In cases of hyperkalemia, T-waves may appear tall and peaked, which is an important characteristic to identify.
A nurse is providing care for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?
Explanation
A. Troponin T is more specific and sensitive but rises later than CK-MB (within 4–6 hours but peaks later and stays elevated longer).
B. CK is a general marker of muscle damage, not specific to the heart.
C. BNP is a marker for heart failure, not MI.
D. CK-MB levels rise within 4 to 6 hours after MI, peak at 18 to 24 hours, and return to normal within 2–3 days. It’s specific for myocardial injury.
A nurse is planning to teach a community group about preventative measures for heart disease. Which of the following recommendations should the nurse include in the teaching plan? (Select All that Apply.)
Explanation
A. Limit exercise to 10 min, 2 days/week is inadequate. Guidelines recommend at least 150 minutes of moderate activity per week.
B. Monitor blood pressure: Early detection of hypertension helps prevent heart disease.
C. Lose weight if necessary: Obesity is a modifiable risk factor for heart disease.
D. Eat a diet high in saturated fats increases LDL and risk of heart disease.
E. Maintain current cholesterol level: Controlling cholesterol is essential for preventing atherosclerosis.
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