Purdue Global NU263 Medical Surgical Nursing III Unit 4

Question 1

Purdue Global NU263 Medical Surgical Nursing III Unit 4. A nurse is assessing a client in the ICU who has a central venous pressure (CVP) reading of 1.6 mmHg. The client reports feeling light-headed and weak. Which of the following interventions should the nurse implement based on the client’s low CVP? Purdue Global NU263 Medical Surgical Nursing III Unit 4

• Administer a diuretic as prescribed
• Increase the intravenous (IV) fluid infusion rate as prescribed
• Position the client in a high Fowler’s position
• Prepare the client for dialysis

Question 2

The nurse is evaluating the ECG of a client in the intensive care unit (ICU) and notes the following: heart rate of 75 bpm, regular P wave, and PR intervals ranging from 0.12 to 0.2 second. The nurse recognizes this represents which rhythm?

• Sinus tachycardia
• Sinus bradycardia
• Sinus rhythm
• Sinus arrest

Question 3

The nurse is caring for a critically ill client who has an arterial pressure catheter placed in the left radial artery. The client is now complaining of numbness in the left arm, and the nurse notes capillary refill of 4 seconds, skin is cool to touch, and sensation is decreased compared with the right arm. Identify the nursing priority.

• Notify health care provider immediately.
• Reposition the arm.
• Assess lines for kinks.
• Flush the line with normal saline.

Question 4

A nurse is caring for a patient who has been started on amiodarone therapy for the treatment of ventricular arrhythmias. Which nursing assessment is the highest priority to monitor for potential complications associated with this medication?

• Monitor for changes in respiratory status, such as cough or shortness of breath.
• Assess for symptoms of gastrointestinal upset, such as nausea or constipation.
• Monitor for changes in urine output and assess for signs of fluid retention.
• Assess for peripheral edema and monitor for weight gain.

Question 5

A nurse is assessing a client with cardiovascular disease and understands that managing afterload is essential to improve cardiac output. Which of the following interventions directly reduces afterload?

• Administering furosemide (Lasix)
• Increasing fluid intake
• Monitoring daily weights
• Administering nitroglycerin

Question 6

A nurse is assessing the patient with a permanent pacemaker and notes erythema and inflammation over the insertion site, temperature of 39 degrees Celsius (102.2 F), and WBC count of 21,000/mm³. The nurse anticipates which priority treatment?

• Administer prescribed anti-inflammatory medications Purdue Global NU263 Medical Surgical Nursing III Unit 4
• Obtain blood cultures and administer broad-spectrum antibiotics
• Apply a cold compress to the insertion site
• Increase the patient’s fluid intake

Question 7

While performing a shift assessment, a client on the medical surgical unit begins to complain of palpitations and shortness of breath. After placing the client on a cardiac monitor, the nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. What priority assessment should the nurse perform next?

• Assess for hypotension
• Assess for flat neck veins
• Assess for complaints of nausea
• Assess for complaints of headache

Question 8

A nurse is caring for a client in the ICU with a diagnosis of a non-ST elevated myocardial infarction (NSTEMI). The nurse notes that the client’s cardiac output is 3 L/min on the hemodynamic monitor. Which action should the nurse take based on this finding?

• Continue to monitor the client’s cardiac output
• Prepare to administer a prescribed diuretic
• Prepare to administer a prescribed beta-blocker
• Notify the healthcare provider immediately

Question 9

A patient with a history of hypertension and angina is prescribed a calcium channel blocker (CCB) medication. The nurse is educating the patient about the medication’s effects. Which of the following statements by the patient shows they understand the effects of this medication?

• “This medication should help relax my blood vessels, reducing the workload on my heart and lowering my blood pressure.”
• “CCB may cause an increase in my heart rate, which is a common side effect I should expect.”
• “I should avoid consuming dairy products while taking amlodipine because they can interact with the medication.”
• “If I experience constipation while on amlodipine, I should increase my intake of high-fiber foods and consult my doctor if it persists.”

Question 10

The nurse observes the following cardiac rhythm for a client who is admitted the medical-surgical unit. What assessment should the nurse perform first?

• Prepare for immediate cardioversion.
• Begin cardiopulmonary resuscitation (CPR).
• Check for a pulse.
• Prepare for immediate defibrillation.

Question 11

Which of the following types of pain is most characteristic of angina?

• Knifelike
• Sharp
• Shooting
• Tightness

Question 12

A nurse is assessing a client who presents with symptoms of dizziness, palpitations, and mild shortness of breath. An ECG reveals the following rhythm on the monitor:

Vital signs reveal a ventricular rate of 120 beats per minute, a blood pressure of 110/68, and a respiratory rate of 18. Which intervention should the nurse anticipate for this client?

• Administering IV metoprolol to slow the ventricular rate
• Preparing the client for immediate cardioversion
• Initiating anticoagulation therapy
• Encouraging the client to perform the Valsalva maneuver

Question 13

A client who is recovering from a myocardial infarction (MI) asks the nurse what causes an MI. How should the nurse best describe an MI to the client?

• During an MI, your heart’s electrical conduction is disrupted, leading to a decrease in function that causes the pain you felt.
• During an MI, the heart muscle is not getting enough blood flow due to high blood pressure.
• An MI occurs when the heart pumps too fast, which can strain and damage the muscle.
• An MI happens when an area of your heart muscle dies due to lack of blood flow and oxygen supply from a clot.

Question 14

A client presents to the emergency department who is reporting constant severe midsternal chest pain and pressure. The client indicates this pain is different from past pain and is unrelieved by rest or three nitroglycerin tablets at home. What priority action will the nurse implement next?

• Administer another nitroglycerin tablet.
• Obtain a 12-lead electrocardiogram.
• Use anxiety reduction techniques.
• Teach risk-reduction strategies.

Question 15

A client admitted to the intensive care unit (ICU) in cardiac failure is scheduled for a ventricular assist device (VAD). The nurse recognizes that this device is typically a bridge to what intervention?

• Intra-aortic balloon pump counter pulsation
• Heart transplantation
• Coronary artery bypass graft surgery
• Percutaneous transluminal coronary angioplasty

Question 16

A nurse is working with multiple heart clients in the critical care unit. The nurse recognizes that clients with which conditions will require defibrillation? Select all that apply.

• [ ] Ventricular tachycardia without a pulse
• [ ] Atrial Flutter Purdue Global NU263 Medical Surgical Nursing III Unit 4
• [ ] Atrial Fibrillation
• [ ] Asystole
• [x] Ventricular Fibrillation
• [ ] Pulseless Electrical Activity

Question 17

A client admitted with normal sinus rhythm converts to the rhythm below on the cardiac monitor. For which symptoms should the nurse assess the client? Select all that apply.

• [ ] Diffuse abdominal pain
• [x] Light-headedness
• [ ] Bradycardia
• [x] Palpitations
• [x] Shortness of breath
• [x] Numbness in extremities

Question 18

The nurse is preparing a client, who suffered a myocardial infarction (MI), for transfer to cardiac rehabilitation. Family members are asking what are some components of cardiac rehabilitation programs. What information should the nurse provide? Select all that apply.

• [x] Supervised physical exercise programs
• [x] Emotional and psychological support
• [x] Dietary modifications to lower cholesterol
• [ ] Resuming all activities as soon as possible
• [x] Education about prescribed medications
• [ ] Strict bed rest to prevent overexertion

Question 19

The nurse is to administer 1500 mL of 0.9% normal saline over 12 hours. The gtt factor is 15 gtt/mL. Calculate the gtt/min.

• 31 gtt/min
• 32 gtt/min
• 100 gtt/min
• 10 gtt/min

Question 20

A 190-pound patient is started on a nitroglycerin IV drip. The order is to administer the nitroglycerin at 25 mcg/min. The pharmacy sends nitroglycerin 25 mg in 250mL. Calculate the rate in mL/hr.

• 2 mL/hr.
• 1 mL/hr.
• 15 mL/hr.
• 4.25 mL/hr.