<P>

<Q>The
<TYPE>single</TYPE>
nurse observes that a client being monitored is in ventricular fibrillati
on. The first Defibrillation
<MC1>Administer
<MC2>Initiate
<MC3>Immediately
<MC4>Administer
<F>Rationale:
<CORRECT>3</CORRECT>
action
cardiopulmonary
sodium
oxygen</MC4>
defibrillate
should
bicarbonate
beisthe
resuscitation
totheclient
dofor
definitive
which
developing
with
of(CPR)</MC2>
the
200
treatment
following?</Q>
acidosis</MC1>
joules</MC3>
for this life-threateni
ng arrhythmia when a defibrillator is immediately accessible (option 3). CPR wou
ld be used if defibrillation is not successful in converting this arrhythmia (op
tion 2). Oxygen should be administered but does not take priority over defibrill
ation (option 4); sodium bicarbonate is used to treat acidosis that may develop
with prolonged
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
Physiological
Adult
correct
CPRAnalysis
but
Nursing
Health:
distracter
alsoIntegrity:
does is
Process:
Cardiovascular
notthe take
Implementation
Physiological
definitive
priority treatment
(option
Adaptation
1).for this dysrhythmi
a. Use specific
Reference: Ignatavicius,
nursing knowledge
D. D., & Workman,
to make your M. L.selection.
(2006). <i>Medical-surgical nur
sing: Critical thinking for collaborative care</i> (5th ed.). Philadelphia: W. B
. Saunders,
<Q>The
<TYPE>single</TYPE>
<P>
</P> nursepp.
is caring
730-731,for740.</F>
a client with a tracheostomy. While performing trache
ostomy care,
<MC1>Is
<MC2>Creates
<MC3>Is
<MC4>Is
<F>Rationale:
<CORRECT>4</CORRECT>
neverathe
deflated
inflated
deflated.</MC1>
The
very
nurse
for
to
cuff
tight
allow
5 should
makes
minutes
aseal
slight
sure
beevery
between
inflated
that
airhour.</MC3>
thetocuff
leak atallow
the
of aheight
and the
the
minimal
tracheostomy
trachea.</MC2>
of seal
inspiration.</MC4>
ontube:</Q>
inspiration
so as not to cause tracheal tissue necrosis from circulatory obstruction (optio
n 4). The cuff should not provide a tight seal, which may cause necrosis (option
2). It may be deflated to allow suctioning of secretions that are above the cuf
f but does
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Eliminate
notPhysiological
Process:
Adult
require
Analysis
Nursing
Health:
any routine
distracter
Integrity:
Process:
Respiratory
deflation
that
Implementation
Physiological
isthroughout
untrue. Select
the shift
Adaptation
the distracter
(options 1 that
and 3).
wi
ll preserveIgnatavicius,
Reference: the integrityD.ofD., the&trachea.
Workman, M. L. (2006). <i>Medical-surgical nur
sing: Critical thinking for collaborative care</i> (5th ed.). Philadelphia: W. B
. Saunders,
<Q>The
<TYPE>single</TYPE>
<P>
</P> nursepp.
prepares
555, 557.</F>
a client for insertion of a pulmonary artery catheter. Pre
procedural teaching for this client will include which of the following statemen
<MC1>"The catheter will assist in directly monitoring your arterial pressure."</
ts?</Q>
<MC2>"The catheter will provide information about your left
MC1>
<MC3>"The cardiac
ventricular
output."</MC2>
function
<MC4>"The catheter
."</MC3>
<F>Rationale:
<CORRECT>3</CORRECT>
A pulmonary
will provide
arteryinformation
catheter will about
provide
your information
cardiac index."</MC4>
about the fun
ction of the left ventricle when the balloon is wedged (option 3) and is the mos
t global response. The pulmonary artery catheter does not directly determine the
cardiac output (option 2) or cardiac index (option 4). An arterial line is used
Cognitive
Client
Integrated
Content
Strategy:
to directly
Need:
Area:
Level:
Eliminate
Process:
monitor
Physiological
AdultApplication
Nursing
Health:
distracters
the client's
Integrity:
Process:
Cardiovascular
that
arterial
Implementation
are
Reduction
inconsistent
pressure
of Risk
(option
with
Potential
the
1).direct actions of
Reference:
a pulmonaryLeMone,
arteryP., catheter
& Burke, andK.choose(2008).a global
<i>Medical-surgical
answer. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 703.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse suspects that the client is in cardiogenic shock based upon which o
f the following
<MC1>Decreased
<MC2>Cardiac
<MC3>Bounding
<MC4>Cardiac
<F>Rationale:
<CORRECT>1</CORRECT>
index
output
pulses</MC3>
Cardiogenic
orfindings?</Q>
muffled
>2.2
5 L/min</MC4>
L/min/m₂²</MC2>
heart is
shock sounds</MC1>
caused by a decrease in pumping ability of th
e myocardium. The decrease can be caused by a weakened myocardium or restriction
of the myocardium by fluid or blood. Decreased or muffled heart sounds would be
indicative of a fluid restriction in the pericardial sac, causing restriction o
f the heart's ability to pump effectively (option 1). Decreased pumping ability
would cause a decrease in the cardiac index (option 2), thready, weak pulses (op
tion 3),Need:
Cognitive
Client
Integrated
Content
Strategy:Area:
and
Level:
The
Process:
decreased
Physiological
Adult
correct
Analysis
Nursing
Health:
distracter
cardiac
Integrity:
Process:
Cardiovascular
output
is related
Assessment
(optionto4).
Physiologicalone ofAdaptation
the mechanical causes of c
ardiogenic shock. Eliminate distracters that are inconsistent with the shock sta
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
te.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 274.</F>
<Q>The
<TYPE>multi</TYPE>
<P>
</P> nurse is caring for a client with a diagnosis of acute myocardial infarct
ion (AMI). The client's cardiac alarm sounds, and the nurse assesses the client,
who is unresponsive, pulseless, and not breathing. Which of the following rhyth
ms is the client most likely to be in when placed on a monitor? Select all that
<MC1>Ventricular
apply.</Q>
<MC2>Atrial
<MC3>Ventricular
<MC5>Pulseless
<MC4>Asystole</MC4>
<F>Rationale:
<CORRECT>[3,4,5]</CORRECT>
flutter</MC2>
Inelectrical
tachycardia</MC1>
fibrillation</MC3>
ventricular activity</MC5>
fibrillation, asystole, or PGA there is no effectiv
e electrical activity in either the atria or ventricles. As a result the client
is unresponsive, pulseless, and not breathing. The other rhythms demonstrate pos
sible orNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
actual
Level:
Use
Process:
Physiological
Adult
the effective
Analysis
steps
Nursing
Health:
forventricular
Integrity:
Process:interpretation:
Cardiovascular
rhythm Assessment
contraction.
Reduction of P-P
Riskand
Potential
R-R interval; P and R
rate; PR interval. There is no evidence of either atrial or ventricular activit
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
y.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 999-1000.</F>
<Q>During
<TYPE>single</TYPE>
<P>
</P> the insertion of a pulmonary artery (Swan-Ganz) catheter, the client r
eports shortness of breath and the nurse notes labored respirations, decreased b
reath sounds on the side of the insertion, and asymmetrical chest movement. The
nurse should question the healthcare provider inserting the catheter about the r
isk of development
<MC1>Pulmonary
<MC2>Myocardial
<F>Rationale:
<CORRECT>3</CORRECT>
<MC4>Anxiety</MC4>
<MC3>Pneumothorax</MC3>
The
embolism</MC1>
infarction</MC2>
anatomical
of which ofproximity
the following?</Q>
of the apex of the lung and the subclavia
n vein increases the possibility of the development of a pneumothorax caused by
accidental puncture of the lung. The client was demonstrating classic signs of p
neumothorax (option 3). Pulmonary embolism, myocardial infarction, and anxiety d
o not cause
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
asymmetrical
Physiological
Adult
principle
Analysis
Nursing
Health:
being
chest
Integrity:
Process:
Cardiovascular
tested
movement. Assessment
is
Reduction
that withofany Riskinsertion
Potentialof a central ven
ous catheter there is a risk of collapsing the lung from a puncture during inser
Reference:
tion. SelectLeMone,
the distracter
P., & Burke, thatK.is(2008).
consistent<i>Medical-surgical
with this complication.
nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1297-1299.</F>
presents in acute respiratory distress after an automobile collision
. The nurse observes that the client has facial trauma. The most urgent nursing
diagnosis for Facial
<MC1>Impaired
<MC2>Ineffective
<MC3>Decreased
<F>Rationale:
<CORRECT>2</CORRECT>
<MC4>Anxiety.</MC4> this
gas
cardiac
airway
exchange.</MC1>
client
trauma
output.</MC3>
clearance.</MC2>
would
can prevent
be:</Q> the client from having a patent airway a
nd lead to subsequent respiratory distress (option 2). Impaired gas exchange wil
l occur as a result of the client's inability to maintain a patent airway (optio
n 1). Decreased cardiac output can be a result of tissue hypoxia (option 3). Anx
iety may be an appropriate diagnosis for this client, but is not the most life-t
hreatening
Cognitive
Client
Integrated
Content
Strategy: Need:
Area:
Level:
In(option
Process:
Physiological
any
Adult
Analysis
emergency
4).
Nursingsituation
Health: Integrity:
Process: always
Respiratory Analysis
Physiological
instituteAdaptation
the ABCs to stabilize the
client. ThisLeMone,
Reference: is especially
P., & Burke,
true K. with(2008).
injuries<i>Medical-surgical
around the head andnursing:
neck. Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 257.</F>
presents with circumferential burns to the chest and shortness of br
eath following an electrical burn injury. The nurse identifies that the priority
<MC1>Deficient
<MC2>Risk
<MC3>Ineffective
<MC4>Decreased
<F>Rationale:
<CORRECT>3</CORRECT>
nursing diagnosis
for Electrical
injury.</MC2>
fluid
cardiac
breathing
forvolume.</MC1>
<i>this</i>
output.</MC4>
burns
pattern.</MC3>
causeinjury
massivewould
softbe:</Q>
tissue and muscle injury from
the inside out. Circumferential burns to the chest wall will decrease chest expa
nsion and ventilation and will compromise breathing. An ineffective breathing pa
ttern is evident as a result of this injury (option 3). There is potential for f
urther tissue damage (option 2), decreased cardiac output (option 4), and fluid
volume deficit (option 1) caused by hypoxia and edema formation for burn with th
ird-spacing of fluids. However, breathing and airway are priorities in this case
.Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
This
Process:
Safe
Adult
item
Analysis
Effective
Nursing
Health:
is testing Careknowledge
Process:
Integumentary
Environment:
Analysis
of theManagement
mechanismofofCare
injury for an elect
rical burn and the implications for the client. Select the distracter that refle
cts the extent
Reference: LeMone,
of injury
P., & Burke,
and associated
K. (2008). risk.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 488.</F>
is brought to the emergency department after being found with a body
temperature of 106<deg> F. The client is unresponsive, hypotensive, and tachypn
eic. A medical diagnosis of heat stroke is made. What would be the nurse's prior
ity nursing all
<MC1>Obtain
<MC2>Obtain
<MC3>Contact
<MC4>Remove
<F>Rationale:
<CORRECT>4</CORRECT>
aintervention
an
next
health
Heat
oral
clothing,
ofstroke
temperature
history
kin inis
for
wrap
the
andlife-threatening
aany
into
care
assessment.</MC1>
advance
wet
monitor
ofsheets,
this
directives.</MC3>
effectiveness
client?</Q>
andsituation,
cool with
ofand
treatment.</MC2>
fans.</MC4>
interventions to
cool the body must be accomplished quickly. Removing the clothing and cooling by
evaporation is the most effective intervention to accomplish cooling quickly. A
health assessment and communication are important but after the cooling process
has begun. Core body temperatures (not oral) will be utilized to monitor effect
ivenessNeed:
Cognitive
Client
Integrated
Content
Strategy: ofThe
Area:
Level:
treatment.
Process:
Physiological
Adult
immediate
Application
Nursing
Health:
priority
Integrity:
Process:
Endocrine
is toImplementation
Physiological
and
begin
Metabolic
coolingAdaptation
the client so long-term dam
age or death is avoided. Select the distracter that indicates that this is the p
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
riority.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 61-62.</F>
is brought to the triage area unresponsive and in acute respiratory
distress with a respiratory rate of 44/min and labored. He is cyanotic and the n
urse notes multiple missing and loose teeth along with facial trauma. The most a
ppropriate nursing
<MC1>Decreased
<MC2>Ineffective
<MC3>Ineffective
<F>Rationale:
<CORRECT>3</CORRECT>
<MC4>Pain.</MC4> The
cardiac
tissue
airway
unresponsiveness
diagnosis
output.</MC1>
perfusion.</MC2>
clearance.</MC3>
for thisandclient
loose teeth
would indicate
be:</Q> a possible airway ob
struction. The airway should be opened and cleared immediately. Labored respirat
ions, cyanosis, and tachypnea are the result of an obstructed airway and hypoxia
.Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Recognize
Process:
Physiological
Adult
Analysis
Nursing
Health:
that theIntegrity:
Process:
Respiratory
mechanismAnalysis
Reduction
of injuryofforRisk
trauma
Potential
in combination with
the presenting
Reference: LeMone,
symptoms
P., &areBurke,
clearly
K. (2008).
respiratory
<i>Medical-surgical
in nature. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 257-258.</F>
</P>