Deck 63: Perfusion

Question 1

The nurse receives a prescription to administer blood stat to a client receiving total parenteral nutrition (TPN). Which is the first action the nurse should implement?

A)Administer the blood.
B)Take vital signs.
C)Start a new IV line.
D)Premedicate the client.

Answer 1

Start a new IV line.

Question 2

A client receiving a blood transfusion begins to have difficulty breathing and complains of itchiness. What action should the nurse instruct a new graduate RN to take first?

A)Stop the infusion.
B)Call a code blue.
C)Reassess the client.
D)Administer albuterol.

Answer 2

Stop the infusion.

Question 3

The nurse is providing care to a client who has signs of pacemaker failure. Which will the nurse document for pacemaker failure? Select all that apply.

A)Bradycardia
B)Bradypnea
C)Decreased urine output
D)Increased blood pressure
E)Increase in temperature

Answer 3

Bradycardia
Decreased urine output

Question 4

Before removing a unit of blood from the blood bank, what should the nurse ask first?

A)Verify the client's name, date of birth, and blood type.
B)Review the signed consent form in the client's EMR.
C)Ask if any family members had a reaction to a blood transfusion.
D)Administer prescribed premedications before starting the blood transfusion.

Question 5

A nurse is providing care to a client with a temporary pacemaker. The nurse observes a spike on the ECG. What should the nurse do first?

A)Notify the healthcare provider that the client is having an arrhythmia.
B)Document the client's rhythm, pacing spikes, and post strip in the client's chart.
C)Complete the pain assessment because this is an irregular finding and causes pain.
D)Delegate this client to the UAP until the temporary pacemaker is not needed.

Question 6

The RN is precepting a new graduate RN who is preparing to transfuse blood. For which action by the new graduate nurse will the nurse intervene immediately?

A)Starts blood transfusion immediately upon return to unit
B)Primes infusion set with normal saline solution
C)Educates the client about possible side effects
D)Reviews client chart for history of allergies

Question 7

The nurse is placing electrodes on a client. Which is the correct placement of a 3-lead telemetry?

A)RA (white)-below right clavicle; LA (black)-below left clavicle; LL (red)-left lowest rib cage area
B)RA (white)-right wrist; LA (black)-left wrist; LL (red)-left leg
C)RA (green)-right lowest rib cage; LA (brown)-midaxillary line; LL (red)left lowest rib cage
D)RA (green)-below right clavicle; LA (black)-below left clavicle; LL (red)-left leg

Question 8

The client diagnosed with anemia has the following lab results: hemoglobin 7.8 g/dL, platelets 150,000, white blood cells 4.7, and hematocrit 23.4%. Which lab result indicates the transfusion worked after receiving 2 units of packed red blood cells?

A)Hemoglobin 11 g/dL
B)Platelets 130,000
C)White blood cells 5.3
D)Hematocrit 15%

Question 9

The nurse is providing care to a client with an arrhythmia. For which arrhythmia will the nurse administer prescribed digoxin?

A)Atrial fibrillation
B)Atrial flutter
C)Premature ventricular contractions
D)Sinus bradycardia

Question 10

A nurse is providing care to a client on complete bed rest. Which is the best explanation by the nurse as to the function of sequential compression devices?

A)"Inflatable compartments compress legs in a graduated sequential fashion."
B)"An air compressor fills an inflatable sleeve, then allows the air to drain out of the sleeve."
C)"Proper measurement will provide adequate pressure on the legs to facilitate venous return."
D)"The function is to promote circulation in the upper legs."

Question 11

Which dysrhythmia is considered life threatening?

A)P wave normal; atrial rate > 100; QRS complex width 0.06-0.08 second
B)P wave normal; atrial rate< 60; QRS complex width 0.08 second
C)P wave none identifiable; atrial rate disorganized activity greater 350 beats/min; QRS complex width irregular
D)P wave none; atrial rate cannot differentiate; ventricular rate 130-250 beats/min

Question 12

A new nurse asks the RN why blood needs to be hung within 30 minutes after leaving the blood bank. Which is the most appropriate answer by the nurse?

A)"Coagulation occurs faster the warmer the blood gets."
B)"Rejection occurs when the blood is not administered cold."
C)"Risk for bacterial growth occurs as it gets warmer."
D)"An allergy will occur if administered when cold."

Question 13

How will the nurse know that the electrodes have been placed properly?

A)Lights on the box come on when electrodes are placed properly.
B)Follow the picture on the box for proper placement of electrodes.
C)Call the base station to run an ECG strip to check the signal of transmission.
D)Electrodes are placed correctly unless notified by the monitoring station.

Question 14

The nurse observes an irregular chaotic rhythm. Which arrhythmia should the nurse document?

A)Ventricular tachycardia
B)Ventricular fibrillation
C)Atrial flutter
D)Atrial fibrillation

Question 15

How should the nurse calculate the heart rate from a rhythm strip?

A)Count the number of R waves in 30 large blocks and multiply by 10.
B)Count the number of small squares in a 3-second period and multiply by 0.20.
C)Count the number of large squares and multiply by 3.
D)Count the number of P waves in a 0.04 second and multiply by 5.

Question 16

The nurse is administering a blood transfusion to a client. Which should the nurse implement first when a client is complaining of chills and back pain within the first 15 minutes of this transfusion?

A)Infuse normal saline.
B)Give the client a blanket.
C)Stop the infusion.
D)Notify the charge nurse.

Question 17

The nurse is providing care to a client with a history of a diagnosis of organic heart disease. The nurse received a phone call from the telemetry base station and reported a reading of ventricular rate <40 beats/min from the Purkinje fibers. After the nurse checks the client, what should the nurse do next?

A)Prepare the client for pacemaker insertion.
B)Start CPR at 100 chest compressions/minute.
C)Administer oxygen to maintain tissue perfusion.
D)Assign the UAP to monitor the client.

Question 18

The nurse is providing care to a client with a history of a diagnosis of heart disease who has been placed on a telemetry monitor. The nurse observes an irregular rhythm on the monitor. Which is the first action the nurse should implement?

A)Immediately initiate cardioversion.
B)Place oxygen on the client.
C)Administer calcium channel blockers.
D)Complete a cardiac assessment.

Question 19

The nurse is reading a 12-lead recording. Which lead will the nurse review as the best for monitoring atrial functioning?

A)Lead I
B)Lead II
C)Lead aVL
D)Lead aVF

Question 20

A client asked the nurse "Why do I need to have this transcutaneous pacemaker?" Which is the most appropriate response by the nurse?

A)"It provides close monitoring by your healthcare provider."
B)"It delivers impulses and transmissions to the myocardium."
C)"It is for an emergency when you have an irregular rhythm."
D)"It is for symptomatic bradycardia that is unresponsive to atropine."

Question 21

The nurse is providing care to a client who has a sequential compression device (SCD)on both legs and is complaining of numbness and tingling in the left leg. Which is the first action the nurse should implement?

A)Assess capillary refill in the toes on the left foot.
B)Remove the SCD unit from left leg.
C)Notify the healthcare provider.
D)Administer pain medication.