Ati advanced med surg RN 46 Exam
Total Questions : 28
Showing 25 questions, Sign in for moreWhile caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery pressure to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?
Explanation
Rationale:
A. Obtaining a stat chest x-ray is important if catheter misplacement is suspected, but in this situation, ensuring the accuracy of the pressure reading through proper leveling and zeroing is the priority.
B. Zero referencing and leveling the catheter at the phlebostatic axis is essential to ensure accurate readings of the pulmonary artery pressure, which is critical for patient assessment and management.
C. Increasing supplemental oxygen is unnecessary given the patient’s stable oxygen saturation and normal respiratory status.
D. While notifying the provider is important, ensuring the accuracy of the pressure reading by leveling and zeroing the catheter should be done first.
The main purpose of critical care certification is to
Explanation
Rationale:
A. Critical care certification validates a nurse's specialized knowledge and skills in critical care, demonstrating competence in this field to both employers and patients.
B. While certification enhances professional credibility, it does not guarantee the absence of mistakes.
C. Preparing for graduate school is not the primary purpose of certification.
D. Certification may contribute to a facility's pursuit of Magnet status, but its primary purpose is to validate nursing expertise.
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?
Explanation
Rationale:
A. This response is dismissive of the patient's concerns and does not address the underlying issue of the patient's misunderstanding of cardiac rehabilitation.
B. This response defers to the physician without providing the patient with helpful information.
C. While true, this statement does not address the patient’s concern about the irreversibility of heart damage.
D. This response directly addresses the patient’s concern by explaining the purpose of cardiac rehabilitation, which is to safely increase activity levels and improve overall heart health, even though the heart damage cannot be undone.
The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action?
Explanation
Rationale:
A. Numbness and tingling in the left hand could indicate compromised blood flow or nerve damage, potentially due to the arterial line, requiring immediate assessment and intervention.
B. Slight bloody drainage is a common finding and typically does not require immediate action.
C. A dressing beginning to lift should be addressed to maintain a sterile environment but is not an emergency.
D. Slight redness at the insertion site may indicate mild irritation or early signs of infection, but it does not require immediate intervention compared to the potential vascular or nerve compromise suggested by numbness and tingling.
A patient is having a cardiac evaluation to assess for possible heart failure and valvular disease. Which study best identifies heart function and measures the size of the cardiac chambers?
Explanation
Rationale:
A. An electrophysiology study assesses the electrical activity of the heart but does not evaluate heart function or chamber size.
B. A 12-lead electrocardiogram records the electrical activity of the heart but does not provide detailed information on heart function or chamber size.
C. Cardiac catheterization is an invasive procedure used to assess coronary artery disease and other structural heart conditions but is not the primary study for evaluating heart function and chamber size.
D. An echocardiogram is a non-invasive ultrasound that provides detailed images of the heart, including its function, chamber size, and valve function, making it the best choice for this purpose.
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial infarction?
Explanation
Rationale:
A. CK-MB is a cardiac enzyme that rises in response to myocardial injury, but it is less specific and takes longer to rise than troponin.
B. BNP is associated with heart failure, not myocardial infarction.
C. Myoglobin is an early marker but is non-specific, as it rises with any muscle damage.
D. Troponin is the most specific and sensitive biomarker for myocardial infarction. It rises within 3-4 hours after myocardial injury and remains elevated for days, making it the most useful test for confirming an MI.
A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level?
Explanation
Rationale:
A. Spironolactone is a potassium-sparing diuretic, so it would not cause hypokalemia.
B. Furosemide is a loop diuretic that causes the kidneys to excrete potassium, leading to hypokalemia.
C. Metoprolol is a beta-blocker and does not directly affect potassium levels.
D. Nitroglycerin is a vasodilator and does not affect potassium levels.
The nurse is educating a patient's family member about a central venous pressure catheter (CVP). Which statement by the family member best indicates understanding of the purpose of the CVP?
Explanation
Rationale:
A. While a CVP catheter might be in place for an extended period, its purpose is not directly related to heart healing.
B. The CVP catheter is used to monitor central venous pressure, which helps guide fluid management and assess right heart function.
C. The CVP catheter does not extend into the left ventricle; it is typically positioned in the superior vena cava or right atrium.
D. The CVP catheter may have multiple lumens for administering fluids, but its primary purpose is hemodynamic monitoring, not just providing IV access.
A patient was admitted for terminal heart failure and is now eligible for a transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life?
Explanation
Rationale:
A. A coronary artery bypass graft is used to treat coronary artery disease but is not typically indicated for end-stage heart failure.
B. Percutaneous coronary intervention is also used for coronary artery disease, not for improving quality of life in terminal heart failure.
C. This option dismisses potential interventions that could improve quality of life, such as an LVAD.
D. An LVAD is a mechanical pump that assists the left ventricle in pumping blood, often used as a bridge to heart transplant or as a long-term solution to improve quality of life in patients with terminal heart failure.
An essential aspect of teaching that may prevent recurrence of heart failure exacerbations is
Explanation
Rationale:
A. Sudden weight gain can indicate fluid retention, a common early sign of heart failure exacerbation. Prompt reporting allows for early intervention.
B. Nitroglycerin is used to treat chest pain, not specifically to prevent heart failure exacerbations.
C. Assessment of the apical pulse is important, but monitoring weight is more directly related to managing heart failure.
D. Compliance with diuretic therapy is important, but recognizing early signs of fluid retention, such as rapid weight gain, is crucial for preventing exacerbations.
Which of the following describes a situation in which the blood pressure is severely elevated and there is evidence of actual target organ damage?
Explanation
Rationale:
A. Secondary hypertension is high blood pressure due to an identifiable cause, such as renal disease, but it does not describe an acute situation with target organ damage.
B. Hypertensive urgency is a situation where the blood pressure is severely elevated but without evidence of target organ damage.
C. Hypertensive emergency is characterized by severely elevated blood pressure with evidence of acute target organ damage, such as encephalopathy, myocardial infarction, or renal failure, requiring immediate medical intervention.
D. Primary hypertension, also known as essential hypertension, is high blood pressure without a known secondary cause and does not describe an acute emergency.
The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of a myocardial infarction (MI)?
Explanation
Rationale:
A. A depressed ST-segment is often associated with ischemia or non-ST elevation myocardial infarction (NSTEMI), not an ongoing MI.
B. A depressed ST-segment with normal cardiac enzymes suggests ischemia rather than an active MI.
C. ST-segment elevation on ECG combined with elevated cardiac biomarkers such as CK-MB or troponin levels is a hallmark of an acute ST-segment elevation myocardial infarction (STEMI), indicating an ongoing MI.
D. A Q wave on ECG indicates an old infarction and is not associated with an acute MI if enzymes and troponin levels are normal.
A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?
Explanation
Rationale:
A. Clustering nursing activities helps to minimize interruptions, allowing the patient to have longer periods of uninterrupted rest, which is essential for recovery and reducing sensory disturbances from sleep deprivation.
B. Silencing alarms could compromise patient safety and is not recommended.
C. Administering sedatives or opioids should be done cautiously and is not a first-line approach for promoting sleep, especially if non-pharmacological methods can be effective.
D. While reducing nighttime assessments may help with sleep, it is not always feasible and should be balanced with the need for monitoring the patient’s condition.
A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
Explanation
Rationale:
A. Referring the patient to the physician without addressing the concern may make the patient feel dismissed.
B. While lifestyle changes are important, this response does not address the patient’s emotional concern directly.
C. Encouraging the patient to express their fears allows the nurse to provide emotional support and address any misconceptions or anxieties, which is crucial for holistic care.
D. This response could be seen as dismissive and may not address the patient’s underlying concerns or fears.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
Explanation
Rationale:
A. Epinephrine is an important drug in resuscitation but is administered after defibrillation in the algorithm.
B. Defibrillation is the priority intervention for ventricular fibrillation, as it is the only treatment that can convert the heart rhythm back to a viable one.
C. Airway management is crucial, but in the context of ventricular fibrillation, defibrillation takes precedence to restore a life-sustaining rhythm.
D. Amiodarone is used in the treatment of refractory ventricular fibrillation, but it is not the immediate priority over defibrillation.
The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 90% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient?
Explanation
Rationale:
A. Coronary artery bypass graft (CABG) surgery is typically recommended for patients with significant occlusion of the left main coronary artery, as it effectively restores blood flow to the heart muscle by bypassing the blocked artery.
B. Radiofrequency catheter ablation is used to treat arrhythmias, not coronary artery occlusions.
C. Implantable cardioverter-defibrillator (ICD) placement is for managing life-threatening arrhythmias, not directly for treating coronary artery blockages.
D. A circulatory assist device is used in severe cases of heart failure, but it does not address the underlying issue of coronary artery occlusion.
A patient is admitted to the emergency department with clinical indications of an ST elevated myocardial infarction. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient?
Explanation
Rationale:
A. Thrombolytic therapy is the priority in managing an ST-elevated myocardial infarction (STEMI) when percutaneous coronary intervention (PCI) is not available. It helps dissolve the blood clot causing the blockage in the coronary artery.
B. Maintaining oxygen saturation is important, but the priority is to restore coronary blood flow.
C. The focus should be on stabilizing the heart rhythm, not specifically maintaining a high heart rate.
D. Diuretics are important in managing heart failure but are not the priority in acute STEMI management.
Which laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure?
Explanation
Rationale:
A. Homocysteine is a marker for cardiovascular risk but is not used to monitor heart failure therapy.
B. LDL levels are associated with cholesterol management and do not directly reflect heart failure treatment effectiveness.
C. Troponin is a marker of myocardial injury, not heart failure severity.
D. B-type natriuretic peptide (BNP) levels correlate with the severity of heart failure and are used to monitor the effectiveness of heart failure therapy.
A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?
Explanation
Rationale:
A. The radial pulse is not as reliable as the carotid pulse in assessing circulation during CPR.
B. The carotid pulse is the most reliable site to assess circulation in an adult during CPR because it is closest to the heart and will reflect the true status of central circulation.
C. The apical pulse is not typically assessed during CPR due to its location and difficulty in palpation.
D. The popliteal pulse is not a recommended site for assessing circulation during CPR.
The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?
Explanation
Rationale:
A. Passive range of motion may be performed, but it is not the priority in this situation.
B. The head of the bed should be elevated 30 degrees or less, not necessarily flat, to prevent complications.
C. Hourly urinary output measurement is essential because the intra-aortic balloon pump (IABP) can impair renal perfusion, and monitoring urine output helps assess renal function.
D. Anticoagulants are often necessary to prevent clot formation associated with the IABP, so avoiding them is not advised unless contraindicated.
While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best?
Explanation
Rationale:
A. Quickly removing the family members may add to their distress and does not respect their right to decide.
B. Telling them it will be stressful assumes their reaction without giving them a choice.
C. Allowing the family members to choose whether to stay respects their autonomy and can provide comfort during a difficult time. It is also in line with current best practices for family presence during resuscitation.
D. Assigning a staff member to wait outside is appropriate but should be done after offering the family the option to stay in the room.
A nurse is teaching a class about organ donation. Which of the following information should the nurse include?
Explanation
Rationale:
A. Deaths of patients with communicable diseases still need to be reported because tissue and organ viability must be assessed on a case-by-case basis.
B. Tissue donation is voluntary and requires consent from the patient or their legal representative.
C. Organ donation can be authorized by a client's surrogate if the client has not previously given or refused consent. This allows for the surrogate to make decisions in line with the client’s wishes or best interests.
D. While facilities may have committees involved in the process, reporting is to organ procurement organizations, not solely to a facility's committee.
A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?
Explanation
Rationale:
A. This response may make the spouse feel pressured by implying that religion should not be a concern, which may not be respectful of the spouse's beliefs.
B. This statement is coercive, focusing on the shortage of organs rather than on the spouse's feelings and the wishes of the deceased.
C. Suggesting that donating organs will make the spouse feel better can be seen as manipulative and may not truly address the spouse's confusion or emotions.
D. Asking what the spouse thinks the deceased would have wanted is appropriate, as it centers on the values and wishes of the deceased, which can guide the spouse in making an informed decision.
Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)
Explanation
Rationale:
A. Crackles are more commonly associated with left ventricular failure, which leads to pulmonary congestion.
B. Hepatomegaly, or an enlarged liver, is a sign of right ventricular failure due to blood backing up in the systemic circulation.
C. Jugular venous distention is a classic sign of right ventricular failure as blood accumulates in the venous system.
D. Orthopnea, or difficulty breathing while lying down, is more indicative of left ventricular failure.
E. Peripheral edema is a hallmark of right ventricular failure, resulting from increased venous pressure.
A patient is being treated for hypertensive emergency. When treating this patient, the nurse recognizes the initial goal is to lower the mean blood pressure (BP) by 20-25% because
Explanation
Rationale:
A. While lowering BP to 120/80 may be an ultimate goal, it is not the initial target in a hypertensive emergency.
B. Rapid reduction in blood pressure can cause hypoperfusion of vital organs such as the brain, heart, and kidneys, leading to ischemic injury. The aim is to reduce the BP gradually to prevent these complications.
C. IV antihypertensive medications generally have a rapid onset, not a slow one.
D. While gradual reduction is important, it is not done to allow rest but to protect organ perfusion.
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