Deck 1: Assessment of Chest Pain

Question 1

A client has a serum sodium level of 129 mEq/L. The nurse should prepare to administer which of the following intravenous solutions?

A)Dextrose 5% and Lactated Ringer
B)Dextrose 5% and 0.45% Normal Saline
C) 0.9% Normal Saline
D)Dextrose 5% and 0.9% Normal Saline

Answer 1

0.9% Normal Saline

Question 2

A client has a serum potassium level of 2.9 mEq/L. Which of the following should be done to assist this client? (Select all that apply.)

A)Implement continuous cardiac monitoring.
B)Check for an elevated ST segment.
C)Assess muscle strength, tone, and reflexes.
D)Monitor digoxin levels.
E)Monitor for seizure activity.

Answer 2

Implement continuous cardiac monitoring.
Assess muscle strength, tone, and reflexes.
Monitor digoxin levels.

Question 3

A client is diagnosed with a serum calcium level of 11.2 mEq/L. Which of the following interventions would be appropriate for this client? (Select all that apply.)

A)Administer diuretics as prescribed.
B)Restrict fluids.
C)Administer intravenous fluids as prescribed.
D)Continuous cardiac monitoring.
E)Administer intravenous sodium as prescribed.
F)Change to a low fat diet.

Answer 3

Administer diuretics as prescribed.
Administer intravenous fluids as prescribed.
Continuous cardiac monitoring.
Administer intravenous sodium as prescribed.

Question 4

The nurse is evaluating a client who is experiencing chest pain. Which of the following should be included in this assessment? (Select all that apply.)

A) Grade the pain on a scale of 1 to 10.
B) Precipitating factors.
C) Assess for sleep disturbance.
D) Determine what was used to eliminate the pain.
E) Assess for sweating.
F) Determine if the pain is related to an injury or surgery.

Question 5

The nurse suspects a clients heart is failing when which of the following heart sounds is assessed?

A)S1
B)S2
C)S3
D)S4

Question 6

The nurse is analyzing a clients electrocardiogram tracing and realizes that each small square on the paper is equal to:

A) 0.04 second.
B) 0.12 second.
C) 0.20 second.
D) 0.40 second.

Question 7

The nurse is reading an ECG rhythm strip and notes that there are nine QRS complexes in a 6-second strip. The heart rate is:

A) 36.
B) 54.
C) 81.
D) 90.

Question 8

A clients electrocardiogram tracing shows a sawtooth pattern with F waves. The nurse realizes this client is demonstrating:

A) atrial flutter.
B) atrial fibrillation.
C) premature atrial contractions.
D) atrial tachycardia.

Question 9

A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this clients medical diagnosis? (Select all thatapply.)

A)Serum cholesterol 300 mg/dL
B)LDL 125 mg/dL
C)Blood glucose 90 mg/dL
D)HDL 45 mg/dL
E)Triglycerides 400 mg/dL
F)Serum potassium 4.0 mEq/L

Question 10

A client is diagnosed as being obese. The nurse realizes that this clients body mass index (BMI) is most likely:

A) between 15 and 19.
B) between 20 and 24.
C) between 25 and 29.
D) greater than 30.

Question 11

The nurse is instructing a client on ways to reduce formation of future kidney stones. Which of the following should be included in these instructions? (Select all that apply.)

A) Drink plenty of fluids.
B) Drink soft drinks.
C) Limit the intake of spinach.
D) Take a vitamin B-12 supplement or eat foods rich in vitamin B-12.
E) Take a magnesium citrate supplement or eating foods rich in magnesium citrate.
F) Adjust calcium intake.

Question 12

A young adult female client is concerned that she does not have enough eggs since she has not yet become pregnant. The nurse should assure her that the number of ova available to produce a pregnancy would be around:

A) 500.
B) 10,000.
C) 300,000.
D) 2,000,000.

Question 13

The nurse is preparing to administer medications to a client diagnosed with varicella. Which of the following personal protective equipment should the nurse use when entering the clientsroom?

A)Face shield with mask and gown
B)Gloves and gown
C)A high-efficiency particulate air filter mask
D)Surgical mask

Question 14

During the assessment of a clients muscle status, the nurse notes the client is able to complete range of motion against gravity with some resistance. The nurse would document this assessment finding as being:

A) 2.
B) 3.
C) 4.
D) 5.

Question 15

A client is going to have tender points examined to determine the diagnosis of fibromyalgia. The nurse should instruct the client the number of tender points that must be positive for the diagnosis would be:

A) 11.
B) 13.
C) 15.
D) 17.

Question 16

A client is scheduled for surgery to fuse the vertebra in the lumbar region of the spine. Thenurse should instruct the client that the number of vertebra being affected by this surgery wouldbe:

A) 7.
B) 12.
C) 5.
D) 4.

Question 17

A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.)

A) Minor ischemic stroke within 30 days
B) Glucose level 120 mg/dL
C) Blood pressure 190/120 mmHg
D) Lumbar puncture 2 days ago
E) Stroke onset 5 hours ago
F) INR 1.0

Question 18

A client being treated for a spinal cord injury needs immediate ventilatory support. The nurse realizes that this clients level of injury is most likely:

A) C3.
B) C6.
C) T3.
D) L3.