1.
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?
Correct Answer
B. The client may be experiencing transient vasospams and may need his Nimodipine dose increased - call provider who may wish to order a transcranial Doppler study.
Explanation
transcranial Doppler study is used to detect vasospasms
Nimodipine gold standard for vasospasms
2.
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.
Correct Answer
A. The client may be re-bleeding
Explanation
always major risk for rebleed with HEMORRHAGIC stroke.
3.
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?
Correct Answer
D. SIADH is best treated with fluid restriction and strict I&O
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
4.
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...
Correct Answer
D. Finger stick glucose
Explanation
remember, in the brain it is 30 percent less than the regular BG. want above 120 for finger stick glucose for stroke patients
5.
When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?
Correct Answer
B. A.fib
Explanation
embolic means from somewhere else.. a-fib can cause that somewhere else clot.
6.
Which assessment finding increases the concern that a patient with cerebral vascular accident would aspirate?
Correct Answer
B. Continuous clearing of the throat
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.
7.
A patient with a moderate diffuse head injury is demonstrating a variety of neruo symptoms. What is the priority when caring for this patient?
Correct Answer
B. Maintaining stable CPP
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)
8.
A patient with a TBI continues to have increased ICP despite conventional therapeutic interventions. The nurse would anticipate which tier three intervention?
Correct Answer
C. High-dose barbiturate thearpy
Explanation
reasons you give barbiturate, to stop shivering before tier 3 cooling
9.
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"
Correct Answer
C. Patient reports pain has decreased from a 9 to a 6 on pain scale
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.
10.
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
Correct Answer
C. Current use of warfarin
Explanation
since you are completely getting rid of a clot with tPA, one must not be on an anticoagulant
11.
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?
Correct Answer
C. Maintain patient flat for at least 30 minutes
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.
12.
HA patient has a suspected acute stoke. Which patient condition may result in impaired airway clearance
Correct Answer
A. Hemiplegia
Explanation
half of side of body not working
13.
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?
Correct Answer
C. Maintain head and neck alignment
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.
14.
You have a patient dx with CAD, and is started on simvastatin. What baseline lab test is required prior to initiation of therapy.
Correct Answer
C. Liver function test
Explanation
Occasionally, statin use could cause an increase in the level of enzymes that signal liver inflammation.
15.
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?
Correct Answer
C. Intracranial hemorrhage
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.
16.
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?
Correct Answer
B. Metoprolol
Explanation
beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure.
17.
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]
Correct Answer
B. Troponin
Explanation
CKMB is good, but troponin is gold standard for MI
18.
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?
Correct Answer
B. Lower extremity edema
Explanation
congesitive HF=edema
19.
What is the first action a nurse should take when they see VT[tachy] on monitor?
Correct Answer
B. Check pulse
Explanation
shockable or not?
20.
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?
Correct Answer
D. Sinus tachycardia
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.
21.
Which of the following is true of the QT interval
Correct Answer
B. Measures ventricular depolarization and repolarization. it should be corrected for HR
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.
22.
An adult patient with a heart rate of 50bpm should be?
Correct Answer
B. Assessed for his perfusion response to this HR[ this may be perfectly normal in a healthy adult]
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.
23.
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?
Correct Answer
A. Calcium channel blocker [like diltiazem] or an antiarrhythmic[amiodrane]
Explanation
(diltiazem) for ventricular rate control.
[ACE) inhibitors help relax your veins and arteries to lower your blood pressure. doesnt matter here]
24.
A patients cardiac monitor frequently sounds false rate alarms. Which nursing intervention is indicated?
Correct Answer
B. Adjust the high and low rates on the alarm
Explanation
from article
25.
The nurse has determined that the patients has a bundle branch block. Which condition likely exists?
Correct Answer
C. A QRS segment longer than 0.12 seconds
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.
26.
Which of the following is the priority in treating a patient with pulseless electrical activity [PEA]
Correct Answer
B. Good CPR, epinepHrine q 5minutes, assess H's and T's
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)
27.
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?
Correct Answer
A. Increased to 116 bpm
Explanation
high temp indicates fever