Jean Pahayahay Andig BSN IV Submitted to: Dr. Mary Jane Gallao, OD, RN, MN, MAN.

Acute Biologic Crisis Questions& Answer with Rationale

1. A patient scheduled for a cardiac catheterization expressing concerns that he is not sure if this procedure is the best for him. How should the nurse respond to assess the patients concern? a. tell me more about this procedure concerns you. b. have you signed the consent already? c. How does your wife feel? d. have you read the informational brochure? Answer and Rationale: A. this is an open ended question. Choices b and d are close ended questions and choice C does not address the patients concern. 2. The nurse is educating a patient scheduled to undergo a Percutaneous Transluminal Coronary Angioplasrty (PTCA). The nurse explains that a balloon-tipped catheter will. a. place a mesh device that keeps the coronary artery patent. b. cauterize the plaque blocking the coronary artery. c. be used to measure the coronary artery pressure. d. compress the plaque against the walls of the coronary artery. Answer and Rationale: D. Balloon-tipped catheter is advanced in to the coronary artery where it inflates to compress the plaque 3. A patient is admitted to the hospital for chest pain. The nurse administers a nitroglycerin tablet. What change in vital signs can the nurse expects? a. Decrease in blood pressure, increase in heart rate b. decrease in blood pressure, decrease in heart rate c. increased blood pressure and increase heart rate d. increase in blood pressure and decrease in heart rate. Answer and Rationale: A.Nitroglycerin is a vasodilator leading to a reduction in bp,and reflexive increase in heart rate. 4. A patient goes cardiac arrest and the nurse initiates CPR. A second nurse responds to the call for help. What should be the role of the second nurse be? a. administer cardiac medications b. apply defibrillator pads. c.check the patients advance directive d. compressions or respirations Answer and Rationale: D. when performing CPR with the two persons technique, the American Heart Association recommends the two nurses switch off on compressions and breathing. These are the first steps with the two person technique. 5.The nurse draws blood from a patient with acute chest pain and nausea. Which of the ff.troponin levels would indicate the presence of a myocardial infarction? a. 0.03 ng/mL c. 0.05 ng/mL b. 0.02 ng/mL d. 0.01 ng/mL Answer and Rationale: C. Troponin levels greater than 0.03 is an indicative of a MI. 6. While analyzing a patients EKG, the nurse notes that there are 4 small boxes from the beginning of the P wave to the beginning of the R wave. The PR interval is: a. 0.20 seconds c. 0.12 seconds b. 0.16 seconds d. 0.24 seconds Answer and Rationale: B. each small boxes represents 0.04 x 4 boxes= 0.16 seconds

7. Who is responsible for obtaining informed consent from a patient? a. the physician c. the primary nurse b. the pharmacist d. the charge nurse Answer and Rationale: A. the physician is responsible for obtaining the informed consent for a procedure or surgery after explaining the procedure, as well as the risks involved to the patient 8. A patient is admitted to the hospital with a myocardial infarction. The nurse assesses the patient for pain and is most likely to observe referred pain in what location? a. head c. left lower quadrant b. left shoulder d. sternum Answer and Rationale: B. During MI, pain is usually felt in the left shoulder, arm, neck or jaw. 9. As part of a comprehensive cardiovascular examination, the nurse palpates the apical pulse. At what location should the nurse palpate? rd a. 3 intercostals space, left midclavicular line th b. 4 intercostals space, left sterna border th c. 5 intercostals space, left midclavicular line th d. 5 intercostal space, left sterna border. Answer and Rationale: C. Point of maximal impulse ( PMI ) 10. A 64 year-old patient is found unresponsive. After attaching a heart monitor, his EKG reveals ventricular fibrillation. What drug should the nurse prepare to administer? a. Dobutamine c. Atropine b. Epinephrine d. Dopamine Answer and Rationale: B.Epinephrine is used for ventricular fibrillation, flutter and unstable tachycardia. 11. Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalvas maneuver? a. Use of stool softeners. b. Enema administration C. Gagging while toothbrushing. d. Lifting heavy objects Answer and Rationale: A. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver. 12. The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? A. take the pulse rate once a day, in the morning upon awakening B. may be allowed to use electrical appliances C. have regular follow up care D. may engage in contact sports Answer and Rationale: D. The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator. 13. The nurse is caring for a patient complaining of chest pain related to pericarditis. To help relieve pain, the nurse should instruct the patient to: a. lean forward while sitting b. lie in supine position c. lie in prone position d. lie in dorsal recumbent position Answer and Rationale: A. Instructing the patient to lean forward will pull the heart away from the lungs, preventing pericardial irritation caused by the lungs.

14. The nurse s assessing a patient for coronary artery disease risk factors. Which of the ff. is a modifiable risk factor that the patient can change or improve? a. type 1 diabetes mellitus b. family history of CAD c. elevated HDLs d. elevated LDLs Answer and Rationale: D. elevated LDLs are a major risk factor for the development of CAD. It transport cholesterol to the artery walls. 15. The nurse is assessing a patient with coronary artery disease that has been hospitalized for 3 days. The nurse notes +3 edema and crackles in the lungs. Which of the ff.should the nurse do next? a. request an increase in diuretic dosage b.review the intake and output records since admission c. request an order for daily weights. d. request a sodium restricted diet. Answer and Rationale: B. the nurse should review the intake and output records since admission to determine if there is disparity. Input greater than then output will cause fluid overload, as evidence by edema and crackles 16. The nurse is providing preprocedural education to a patient scheduled to undergo a cardiac catheterization. Which of the following statements should the nurse include? a. The procedure is performed in the operating room. b. There may be some intense pain, but it quickly subsides. c. You may develop a headache, but this normal. d. You may feel various sensations during the procedure including flushing, warmth, and palpitations. Answer and Rationale: D. Normal symptoms due to dye injection and catheter passage. 17. The nurse is caring for a child with Congestive Heart Failure. Which of the ff. indicates the child and her parents are following the prescribed medical regimen? a. normal weight for age c. Pulse rate below 50 bpm b. nausea and vomiting d. use of daily antibiotics Answer and Rationale: A. indicates adequate nutritional intake and fluid balance. 18. A patient has developed the cardiac arrhythmia torsades de pointes. The nurse should prepare to administer: a. Lidocaine c. Amiodarone ( Nexerone) b. Magnesium sulfate. d.Diltiazem ( Cardizem) Answer and Rationale: B. Cardiac arrhythmia torsades de pointes is often caused by hypomagnesemia. 19. The nurse is assessing a patient to the emergency room due to chest pain. To determine whether the patients pain is due to MI, the nurse should note the pain: a. is described as gnawing b. began when chasing the grandchildren c. is unrelieved by nitroglycerin but relieved by morphine. d. is accompanied by nausea and vomiting Answer and Rationale: C. MI pain usually requires morphine. 20. The nurse is evaluating the effectiveness of warfarin( Coumadin) in a patient with atrial fibrillation. The patients prothrombin time(PT) is 20 seconds. The nurse should anticipate: a. increasing the next dose of warfarin b. decreasing the next dose of warfarin c. administeri g the next dose of warfarin d. Holding the next dose of warfarin

Answer and Rationale: D. Therapeutic level for warfarin is 1.5 -2x the normal PT level which is 9.5 to 12 seconds. 21. The nurse is caring for patient with congestive heart failure, hypotension and endocarditis. Which of the ff. lab results should the nurse report to the physician? a. Troponin I, 0.03ng/ml b. Lactate, 5.5 mmol/ L c. ph, 7. 38 d. none of the choices Answer and Rationale: B. Normal range for lactate is 0.5- 2.2 mmol/L. An elevated lactate is a sign of sepsis or tissue ischemia dand should be reported to the physician. 22. After initiating a nitroglycerin infusion, the nurse plans on administering which of the ff. drugs to prevent the common side effect of nitroglycerin? a. Diphenhydramine( Benadryl) c. Acetaminophen ( Tylenol) b. Haloperidol ( Haldol) d. Labetalol ( Normodyne) Answer and Rationale: C. Headaches are the common S/E of nitroglycerin. The nurse may administer acetaminophen to prevent or treat headaches caused by nitrates. 23. The nurse is evaluating a patient with decreased cardiac output related to Myocardial infarction. Which of the ff. indicates improved cardiac output? a. absence of angina and dyspnea with activity b. cardiac output of 2.5 liters c. heart rate of 54 bpm d. bp of 90/50 mmHg Answer and Rationale: A. Adequate cardiac output should not cause angina and dyspnea. 24. The nurse is caring for a deteriorating patient going into cardiogenic shock. The nurse expects to note which manifestation? a. Extreme diuresis c. weak, thready pulses b. slow pulses d. bounding pulse Answer and Rationale: C. Cardiogenic shock results in adequate circulation of blood due to failure of the heart to pump effectively. Manifestation of reduced circulation include tachycardia, hypotension, weak and thready pulse, decrease in urinary output and cool, clammy skin.

25. While caring for a patient that underwent a percutaneous transluminal angioplasty (PTCA), the nurse prepares to remove the femoral sheath. The heparin infusion was stopped 4 hours ago and there appears to be no evidence of bleeding from the insertion site. The nurse will pull the sheath when the partial trombloplastin time(PTT) is: a. 50 seconds or less c. 100 seconds or less b. 65 seconds or less d. 20 seconds or less Answer and Rationale: A. A PTT greater than 50 may result in bleeding after sheath removal. 26. The nurse is admitting a patient suspected of having an Acute MI. the physician orders lab test to confirm the diagnosis. An increase in isoenzyme creatinekinase of cardiac muscle( CK- MB) is expected how soon after the onset of chest pain? a. 8 to 12 hours c. 4 to 6 hours b. 1 to 2 hours d. 30 to 90 minutes Answer and Rationale: C .Serum CK-MB levels start to elevate 4 to 6 hours after the onset of chest pain. Levels usually peak around 12 to 18 hours after the onset of chest pain.

27. The nurse is caring for a patient that had MI 3 days ago. The nurse should assess for which abnormal breath sounds? A. S4 C. ejection click B. Aortic Stenosis d. pericardial friction rub Answer and Rationale: D. a pericardial friction rub often occurs within one week of having MI. due to inflammation of the pericardial sac. 28. The patient has an arteriovenous fistula access for long term dialysis.The would instruct the patient to protect the operative extremity for the first two hours after surgery by keeping extremity: a. elevated, visible and non compressed b. use of arm slings c. covered with bandages d. all of the above Answer and Rationale: A. to prevent constriction of the blood vessels and permit blood circulation to the area. 29. Purposes of hemodynamic monitoring would include: a. early detection, identification and treatment of life threatening conditions such as HF and Cardiac tamponade. b. The nurse able to evaluate the patients immediate response to treatment. c. The nurse can evaluate the effectiveness of cardiovascular functions such as Cardiac output and cardiac index. d. all of the above Answer and Rationale: D. Choices A, B, C are all purposes of Hemodynamic Monitoring 30.It refers to to the measurement of the right arterial pressure or the pressure of the great veins within the thorax. a.CVP Monitoring c. hemodynamic Monitoring b. Pulmonary Artery Pressure d. Swan Ganz Answer and Rationale: A. Right sided functions ( esp. the R arterial pressure) is assessed through the evaluation of CVP. 31. The nurse needs to carefully assess the complaint of pain of the elderly because older people a. are expected to experience chronic pain b. have a decreased pain threshold C. experience reduced sensory perception d. have altered mental function Answer and Rationale: C. Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data. 32. Which of the ff. statements by the client to the nurse indicates a risk factor for CAD? a. I exercise every other day. b. My father died of Myasthenia Gravis. C. My cholesterol is 180. d. I smoke 1 1/2 packs of cigarettes per day. Answer and Rationale: D. Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention.

33. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug? a. It has positive inotropic and negative chronotropic effects b. The positive inotropic effect will decrease urine output C. Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems d. Do not give the drug if the apical rate is less than 60 beats per minute. Answer and Rationale: B. Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output. 34. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching? a. When your chest pain begins, lie down, and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes. b. Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital. C. Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down. d. Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Answer and Rationale: D. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention. 35. A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food? A. Whole milk B. Canned sardines C. Plain nuts D. Eggs Answer and Rationale: B. Canned foods are generally rich in sodium content as salt is used as the main preservative. 36. A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client? a. It dissolves existing thrombi. b. It prevents conversion of factors that are needed in the formation of clots. C. It inactivates thrombin that forms and dissolves existing thrombi. d. It interferes with vitamin K absorption. Answer and Rationale: B. Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot. 37. The nurse is conducting an education session for a group of smokers in a stop smoking class. Which finding would the nurse state as a common symptom of lung cancer? : a. Dyspnea on exertion b. Foamy, blood-tinged sputum C. Wheezing sound on inspiration d. Cough or change in a chronic cough Answer and Rationale: D. Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection.

38. A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. b. c. d. Dyspnea Bradypnea Bradycardia Decreased respirations Answer and Rationale: A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. 39. A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the clients chest wall, the nurse expects to elicit: a. b. c. d. Resonant sounds. Hyperresonant sounds. Dull sounds. Flat sounds. Answer and Rationale: A. When percussing the chest wall, the nurse expects to elicit resonant sounds low-pitched, hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; 40. A male client suffers adult respiratory distress syndrome as a consequence of shock. The clients condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a. b. c. d. Kinking of the ventilator tubing A disconnected ventilator tube An ET cuff leak A change in the oxygen concentration without resetting the oxygen level alarm Answer and Rationale: A. Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on the ET tube, and the clients being out of breathing rhyt hm with the ventilator. 41. Whats the first intervention for a patient experiencing chest pain and an 5p02 of 89%? a. Administer morphine. b. Administer oxygen. c. Administer sublingual nitroglycerin. d. Obtain an electrocardiogram (ECC) Answer and Rationale:B. Administering supplemental oxygen to the patient is the first priority. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage. Sublingual nitroglycerin and morphine are commonly administered after oxygen.

42.While caring for a patient with severe heart failure and coronary artery disease, the nurse understands that preload is most likely decreased by: rd a. 3 spacing c. heart failure b. polyuria and fluid overload d. sepsis and hemorrhage Answer and Rationale:D. preload is decreased by conditions that reduce circulating volume or venous return. This includes hemorrhage, sepsis and anaphylaxis 43. Which of the following positions would best aid breathing for a patient with acute pulmonary edema? a. Lying flat in bed. b. Left side-lying position. c High Fowlers position. d. Semi-Fowlers position. Answer and Rationale: C. High Fowlers position facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen breathing and increase the hearts workload. 44. Anas postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question? a.Put the client in modified Trendelenbergs position. b. Administer oxygen at 100%. c. Monitor urine output every hour. d. Administer Demerol 50mg IM q4h Answer and Rationale:D. Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse. 45. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate? a. Notify his physician. b. Take his vital signs again in 15 minutes. C. Take his vital signs again in an hour. d. Place the patient in shock position. Answer and Rationale:B. Monitoring the clients vital signs following surgery gives the nurse a sound information about the clients condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring. 46. To enhance the percutaneous absorption of nitroglycerine ointment, it would be MOST important for the nurse to select a site that is a. muscular. b. near the heart. c. non-hairy. d. over a bony prominence. Answer and Rationale:D. Skin site free of hair will increase absorption; avoid distal part of extremities due to less than maximal absorption.

47. A man is admitted to the Telemetry Unit for evaluation of complaints of chest pain. Eight hours after admission, the patient goes into ventricular fibrillation. The physician defibrillates the patient. The nurse understands that the purpose of defibrillation is to: a. increase cardiac contractility and cardiac output. b. cause asystole so the normal pacemaker can recapture. c. reduce cardiac ischemia and acidosis. d. provide energy for depleted myocardial cells. Answer and Rationale:B. Cause asystole so the normal pacemaker can recapture; it allows SA node to resume as pacer of heart activity 48. The nurse is evaluating a patient suspected of pericarditis. Which of the ff. are usually present with pericarditis? A low urine output c. edema and crushing chest pain b. heart failure and low urine output d. pleuritic chest pain, fever and leukocytosis Answer and Rationale:D. fever and leukocytosis due to the infection and pleuritic chect pain due to inflammation of the pericardium. 49. A floor nurse is receiving report on a patient being transferred from the intensive care unit. The ICU nurse reports that the patients pulmonary artery wedge pressures are high. The floor nurse should expect to note: a. respiratory alkalosis c. polyuria b. pulmonary crackles d. hypertension Answer and Rationale:B. an increase in pulmonary artery wedge pressure indicates an increase in fluid in the pulmonary circulation, leading to pulmonary edema and crackles. This is an indicated of left-sided heart failure. 50..A patient is schedule to undergo a left femoral-popliteal bypass graft has poor perfusion to the left lower extremity. Due to the poor perfusion, which of the following interventions should the nurse complete before the procedure? a. mark the location of posterior tibial and dorsal pedal pulses. b. obtain baseline coagulation studies. c. complete the preoperative checklist. d. check vital signs to establish a baseline. Answer and Rationale:A. poor perfusion results in weak peripheral pulses. The surese should mark the location of posterior tibial and dorsal pedal pulses to establish a baseline for comparison after the procedure. Choices B,C, D are all routine nursing intervention of most cases.