Your Duties as a Nurse Quiz: Test Your Nursing Knowledge

1. What is the first action a nurse should take when they see VT[tachy] on monitor?

Check patients urine output

Check pulse

Prepare for defibrillation

Prepare for cardioversion

shockable or not?

Explanation

shockable or not?

2. Which of the following is true of the QT interval

Measures atrial and ventricular depolarization

Measures ventricular depolarization and repolarization. it should be corrected for HR

It is an unimportant measure and rarely considered

Measurement of resting membrane potential

The QT interval is a measurement on an electrocardiogram (ECG) that represents the time it takes for the ventricles of the heart to both depolarize and repolarize. It is an important measure as it provides information about the electrical activity of the heart and can help identify certain cardiac conditions. However, the QT interval should be corrected for heart rate (HR) because the duration of the interval can vary depending on the individual's heart rate. This correction is done using formulas such as the QTc (corrected QT) interval, which takes into account the heart rate to provide a more accurate assessment of ventricular depolarization and repolarization.

Explanation

The QT interval is a measurement on an electrocardiogram (ECG) that represents the time it takes for the ventricles of the heart to both depolarize and repolarize. It is an important measure as it provides information about the electrical activity of the heart and can help identify certain cardiac conditions. However, the QT interval should be corrected for heart rate (HR) because the duration of the interval can vary depending on the individual's heart rate. This correction is done using formulas such as the QTc (corrected QT) interval, which takes into account the heart rate to provide a more accurate assessment of ventricular depolarization and repolarization.

3. A patients cardiac monitor frequently sounds false rate alarms. Which nursing intervention is indicated?

Ask the patient to lie still

Adjust the high and low rates on the alarm

Shut the room door so the alarm will not disturb the other patients

Set the alarms on silent

from article

Explanation

from article

4. A patient with a moderate diffuse head injury is demonstrating a variety of neruo symptoms. What is the priority when caring for this patient?

Supporting nutritional needs

Maintaining stable CPP

Electrolyte replacements

Maintaining adequate fluid volume

This is the pressure needed to ensure blood flow to the brain and is the MOST IMPORTANT SINGLE FACTOR IN MAINTAINING BRAIN HEALTH

increased CPP (by increasing MAP and decreasing ICP)

Explanation

This is the pressure needed to ensure blood flow to the brain and is the MOST IMPORTANT SINGLE FACTOR IN MAINTAINING BRAIN HEALTH

increased CPP (by increasing MAP and decreasing ICP)

5. A pt is admitted to the ED for a suspected MI. Which lab test should the nurse anticipate being performed for this PT[ which is most accurate]

Serum potassium

Troponin

C-reactive protein

Lipid profile

CK-MB

CKMB is good, but troponin is gold standard for MI

Explanation

CKMB is good, but troponin is gold standard for MI

6. A patient arrives in the ICU with an altered LOC. After an initial assessment of ABCs[including VS and spo2] and GCS, the next test should be...

Non contrast head CT

ETOH level

CXR

Finger stick glucose

remember, in the brain it is 30 percent less than the regular BG. want above 120 for finger stick glucose for stroke patients

Explanation

remember, in the brain it is 30 percent less than the regular BG. want above 120 for finger stick glucose for stroke patients

7. An adult patient with a heart rate of 50bpm should be?

Worked up for possible bradycardic cardiomyopathy

Assessed for his perfusion response to this HR[ this may be perfectly normal in a healthy adult]

Given 0.5mg atropine and repeated to a total of 3mg

Placed on transcutaneous pacing until HR is at least 60

An adult patient with a heart rate of 50bpm should be assessed for his perfusion response to this heart rate as it may be perfectly normal in a healthy adult. This means that the patient's blood flow and oxygen delivery to the tissues should be evaluated to determine if there are any signs of inadequate perfusion. It is important to consider that a heart rate of 50bpm may be within the normal range for some individuals, especially athletes or those with a naturally lower heart rate. Therefore, further investigation is needed to ensure that the patient's cardiovascular system is functioning properly and there are no underlying issues causing the bradycardia.

Explanation

An adult patient with a heart rate of 50bpm should be assessed for his perfusion response to this heart rate as it may be perfectly normal in a healthy adult. This means that the patient's blood flow and oxygen delivery to the tissues should be evaluated to determine if there are any signs of inadequate perfusion. It is important to consider that a heart rate of 50bpm may be within the normal range for some individuals, especially athletes or those with a naturally lower heart rate. Therefore, further investigation is needed to ensure that the patient's cardiovascular system is functioning properly and there are no underlying issues causing the bradycardia.

8. The nurse is reviewing pharm management for HA patient diagnosed with unstable angina[UA]. Which collaborative therapy should the nurse expect to see in a plan of care?

Hydrochlorothiazide

Metoprolol

Mannitol

Furosemide

beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure.

Explanation

beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure.

9. A patients admission VS were BP 128/64, HR 86, RR 16, Temp 98.6F. The patient has a spiked temp of 101.6. Which change in heart rate would the nurse anticipate?

Increased to 116 bpm

Increase 100 bpm

Decrease 75 bpm

Increase or decrease no more than 5bmp

high temp indicates fever

Explanation

high temp indicates fever

10. Your patient has a HR of 108. The rhythm is regular, patient has a p wave before each QRS complex, PR interval is .20 seconds and the QRS that follows each p is narrow. How would you label this rhythm?

Normal sinus rhythm

First degree heart block

SVT

Sinus tachycardia

Based on the given information, the patient's heart rate is elevated (HR of 108), but the rhythm is regular. There is a P wave before each QRS complex, indicating that the atria are depolarizing normally. The PR interval is within normal range (.20 seconds), and the QRS complexes are narrow, suggesting that the ventricles are also depolarizing normally. These characteristics are consistent with sinus tachycardia, which is a normal rhythm that occurs when the heart rate is faster than usual due to factors such as exercise, stress, or fever.

Explanation

Based on the given information, the patient's heart rate is elevated (HR of 108), but the rhythm is regular. There is a P wave before each QRS complex, indicating that the atria are depolarizing normally. The PR interval is within normal range (.20 seconds), and the QRS complexes are narrow, suggesting that the ventricles are also depolarizing normally. These characteristics are consistent with sinus tachycardia, which is a normal rhythm that occurs when the heart rate is faster than usual due to factors such as exercise, stress, or fever.

11. Which of the following is the priority in treating a patient with pulseless electrical activity [PEA]

Immediate defibrillation

Good CPR, epinephrine q 5minutes, assess H's and T's

Check rhythm in another lead before assuming this is PEA

Treatment is transcutaneous pacing

The H’s and T’s are 12 reversible conditions, 7 that start with H and 5 that start with T.

Hypovolemia
Hypoxia
Hydrogen ion excess (acidosis)
Hypoglycemia
Hypokalemia
Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade – Cardiac
Toxins
Thrombosis (pulmonary embolus)
Thrombosis (myocardial infarction)

Explanation

The H’s and T’s are 12 reversible conditions, 7 that start with H and 5 that start with T.

Hypovolemia
Hypoxia
Hydrogen ion excess (acidosis)
Hypoglycemia
Hypokalemia
Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade – Cardiac
Toxins
Thrombosis (pulmonary embolus)
Thrombosis (myocardial infarction)

12. Which assessment finding increases the concern that a patient with cerebral vascular accident would aspirate?

Absence of interest in eating or drinking

Continuous clearing of the throat

Eating only foods on one side of the tray

Refusal to allow the nurse to assist with feeding

Continuous clearing of the throat increases the concern that a patient with a cerebral vascular accident would aspirate. Clearing the throat frequently can be a sign of difficulty swallowing or a weak gag reflex, which increases the risk of food or liquid entering the airway instead of going to the stomach. Aspiration can lead to pneumonia or other respiratory complications. Therefore, this assessment finding raises concerns about the patient's ability to safely swallow and increases the risk of aspiration.

Explanation

Continuous clearing of the throat increases the concern that a patient with a cerebral vascular accident would aspirate. Clearing the throat frequently can be a sign of difficulty swallowing or a weak gag reflex, which increases the risk of food or liquid entering the airway instead of going to the stomach. Aspiration can lead to pneumonia or other respiratory complications. Therefore, this assessment finding raises concerns about the patient's ability to safely swallow and increases the risk of aspiration.

13. You have a patient dx with CAD, and is started on simvastatin. What baseline lab test is required prior to initiation of therapy.

CBC

Sedimentation rate

Liver function test

Triglycerides

PTT

Occasionally, statin use could cause an increase in the level of enzymes that signal liver inflammation.

Explanation

Occasionally, statin use could cause an increase in the level of enzymes that signal liver inflammation.

14. The nurse has administered thrombolytic therapy to a 65 yr old female patient diagnosed with STEMI. Ten hours following administration of the thrombolytic, the patient is uncharacteristically irritable and somnolent. Which complication should the nurse suspect?

Allergic reaction

Cardiac tampondae

Intracranial hemorrhage

Reocclusion

The nurse should suspect intracranial hemorrhage as a complication in this case. Thrombolytic therapy can increase the risk of bleeding, and the patient's symptoms of irritability and somnolence could be indicative of a bleed in the brain. This is a serious complication that requires immediate medical attention.

Explanation

The nurse should suspect intracranial hemorrhage as a complication in this case. Thrombolytic therapy can increase the risk of bleeding, and the patient's symptoms of irritability and somnolence could be indicative of a bleed in the brain. This is a serious complication that requires immediate medical attention.

15. The nurse is performing an assessment on a HA patient with severe right sided heart failure. Which finding should indicate to the nurse an exacerbation of this condition?

Movement at the fifth intercostal space at the precordium

Lower extremity edema

Increased urine output

The presence of an s2 sound

congesitive HF=edema

Explanation

congesitive HF=edema

16. An ICU nurse is documenting a high- acuity patient's clinical response following administration of morphine sulfate for anginal pain using PQRST. What data should the nurse expect to document as "s"

Patient reports burning in the chest area

Patient states that the pain subsided after 10 mins

Patient reports pain has decreased from a 9 to a 6 on pain scale

Patient reports that the majority of pain is located in left jaw

The nurse should expect to document that the patient reports a decrease in pain from a 9 to a 6 on the pain scale. This information indicates a positive response to the administration of morphine sulfate for anginal pain. It shows that the medication has effectively reduced the intensity of the patient's pain.

Explanation

The nurse should expect to document that the patient reports a decrease in pain from a 9 to a 6 on the pain scale. This information indicates a positive response to the administration of morphine sulfate for anginal pain. It shows that the medication has effectively reduced the intensity of the patient's pain.

17. The nurse is preparing to administer tPA thearpy to a HA patient with an acute ischemic stroke. which findings should cause the nurse to abort procedure

Stroke symptoms suddenly appearing an hour ago

Lumbar puncture 2 months ago

Current use of warfarin

Evidence of embolic stroke on a ct scan

since you are completely getting rid of a clot with tPA, one must not be on an anticoagulant

Explanation

since you are completely getting rid of a clot with tPA, one must not be on an anticoagulant

18. HA patient has a suspected acute stoke. Which patient condition may result in impaired airway clearance

Hemiplegia

Nausea

Aphasia

Loss of vision

half of side of body not working

Explanation

half of side of body not working

19. The nurse is providing post procedure care for HA patient after a carotid endarterectomy. Which action should the nurse take to facilltate carotid blood flow?

Elevate the head of the bed 30 degrees

Position patient on the non operative side

Maintain head and neck alignment

Support the head during position change

To facilitate carotid blood flow after a carotid endarterectomy, it is important for the nurse to maintain head and neck alignment. This helps to ensure that the carotid arteries are not compressed or restricted in any way, allowing for optimal blood flow. By keeping the head and neck in a neutral position, the nurse can help prevent any potential complications or disruptions to the blood flow in the carotid arteries.

Explanation

To facilitate carotid blood flow after a carotid endarterectomy, it is important for the nurse to maintain head and neck alignment. This helps to ensure that the carotid arteries are not compressed or restricted in any way, allowing for optimal blood flow. By keeping the head and neck in a neutral position, the nurse can help prevent any potential complications or disruptions to the blood flow in the carotid arteries.

20. A patient with a.flutter with a 4:1 block is to be started on medications to convert this new rhythm. Which of the following meds would be appropriate?

Calcium channel blocker [like diltiazem] or an antiarrhythmic[amiodrane]

A beta blocker [lopressor or digoxin]

A magnesium salt to buffer the effects of calcium in the atria

An ace inhibitor to affect afterload- addressing cause of rhythm

(diltiazem) for ventricular rate control.

[ACE) inhibitors help relax your veins and arteries to lower your blood pressure. doesnt matter here]

Explanation

(diltiazem) for ventricular rate control.

[ACE) inhibitors help relax your veins and arteries to lower your blood pressure. doesnt matter here]

21. A patient with a TBI continues to have increased ICP despite conventional therapeutic interventions. The nurse would anticipate which tier three intervention?

Hyperosmolar thearpy

Hyperbaric oxygen thearpy

High-dose barbiturate thearpy

High volume intravenous fluids

reasons you give barbiturate, to stop shivering before tier 3 cooling

Explanation

reasons you give barbiturate, to stop shivering before tier 3 cooling

22. You are caring for a patient who arrived from the cath lab post PCI. They have an angioseal device to the L femoral artery. Which is your priority nursing action?

Maintain head of the bed at 30 degrees

Maintain manual pressure to affected area for at least 2 hours

Maintain patient flat for at least 30 minutes

Early ambulation

Lay patient on good side

The priority nursing action in this situation is to maintain the patient flat for at least 30 minutes. This is because after a percutaneous coronary intervention (PCI) with an angioseal device, it is important to keep the patient in a supine position to prevent bleeding and promote hemostasis at the femoral artery site. This allows the device to properly seal the artery and reduces the risk of complications such as hematoma or bleeding. Once the recommended time has passed, the patient can be gradually mobilized and ambulated.

Explanation

The priority nursing action in this situation is to maintain the patient flat for at least 30 minutes. This is because after a percutaneous coronary intervention (PCI) with an angioseal device, it is important to keep the patient in a supine position to prevent bleeding and promote hemostasis at the femoral artery site. This allows the device to properly seal the artery and reduces the risk of complications such as hematoma or bleeding. Once the recommended time has passed, the patient can be gradually mobilized and ambulated.

23. Your head injury patient develops decreased urinary output 20-30ml/hour, his serum NA+ is < 130mg/dl and they have +3 generalized edema. What is the treatment of this pathology in the head injured patient?

SIADH is treated with administration of vasopressin and rapid replacement of sodium

SIADH is best treated with fluid restriction and strict I&O

Syndrome of inappropriate anti-diuretic hormone (SIADH) the opposite of DI. excessive ADH causes water intoxication and hyponatremia treated with fluid restriction, electrolyte replacement, and Lithium or Phenytoin to increase free water loss

Explanation

Syndrome of inappropriate anti-diuretic hormone (SIADH) the opposite of DI. excessive ADH causes water intoxication and hyponatremia treated with fluid restriction, electrolyte replacement, and Lithium or Phenytoin to increase free water loss

24. A client who experienced a minor hemorrhagic stroke from an aneurysm 1 week ago[aneurysm was not repaired] reports a severe headache accompanied by nausea and vomiting. What is your immediate concert.

The client may be re-bleeding

The clients warfarin dose is inadequate

The client is experiencing stroke related pyschological stress

The client is experiencing increased ICP

always major risk for rebleed with HEMORRHAGIC stroke.

Explanation

always major risk for rebleed with HEMORRHAGIC stroke.

25. When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?

Hx of atherosclerosis of cerebral arteries

A.fib

Hypertension

Use of anticoagulants

embolic means from somewhere else.. a-fib can cause that somewhere else clot.

Explanation

embolic means from somewhere else.. a-fib can cause that somewhere else clot.

26. The nurse has determined that the patients has a bundle branch block. Which condition likely exists?

PR interval longer than .20 seconds

An elevated ST segment

A QRS segment longer than 0.12 seconds

A PR interval that lengthens with each beat

A bundle branch block is a condition in which there is a delay or blockage in the electrical conduction through the bundle branches of the heart. This causes a delay in the activation of one of the ventricles, resulting in a widened QRS complex on the electrocardiogram (ECG). Therefore, a QRS segment longer than 0.12 seconds is likely to be indicative of a bundle branch block.

Explanation

A bundle branch block is a condition in which there is a delay or blockage in the electrical conduction through the bundle branches of the heart. This causes a delay in the activation of one of the ventricles, resulting in a widened QRS complex on the electrocardiogram (ECG). Therefore, a QRS segment longer than 0.12 seconds is likely to be indicative of a bundle branch block.

27. A client who is s/p clipping for an aneurysm in the past 48 hours reports severe intermittent headache. He is notably less alert while he is experiencing the headache. As a nurse, what is your immediate concern?

These are expected post clipping symptoms, continue to monitor and record progress.