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WorksheetsNRS421 Perfusion
Total questions: 15
Worksheet time: 7mins
What occurs during the refractory stage of shock?
Cardiac output (CO) is decreased, and tissue perfusion is threatened.
Compensatory mechanisms begin failing.
Homeostatic mechanisms begin to work.
Shock becomes unresponsive to therapy.
A patient arrives to the ER complaining of chest heaviness and shortness of breath. What is the first action the nurse takes?
Prepare patient for the heart catheterization lab.
Submit standing orders for triage lab and CXR.
Start IV and give IV morphine & oral aspirin.
Obtain vital signs and focused cardiac assessment.
The nurse notes the following rhythm on a patient being admitted for pneumonia. What does the nurse interpret this rhythm to mean?
The patient has had an MI in the past.
The patient is in sinus tachycardia.
The patient is requiring immediate defibrillation.
The patient has a normal cardiac rhythm.
The nurse caring for a patient who is status post CABG 4 hours is concerned that the patient is developing cardiogenic shock. Which of the following is a manifestation of cardiogenic shock? Select all that apply.
low urine output
bradycardia
respiratory distress
high fever
confusion
The nurse gathers the following assessment data on a patient who is 8 hours status post CABG: elevated respiratory rate, crackles throughout lungs, use of accessory muscles for breathing, temp 99.9, pain 7/10. The nurse takes which action first?
Administer oral acetaminophen.
Get the patient up to ambulate.
Encourage patient to deep breath.
Administer IV morphine
The nurse admitting a patient into the ER who is complaining of chest pain and pressure notes the following rhythm. What intervention does the nurse prepare the patient for?
defibrillation
heart catheterization
cardioversion
anticoagulant therapy
The nurse caring for a patient status post CABG notes the patient is in cardiogenic shock. The nurse understands the reason the patient has decreased urinary output is related to
decreased blood shunted to the kidneys.
portal vein hypertension.
parasympathetic nervous system response.
low fluid volume and fluid loss.
The nurse caring for a patient in the ICU who is recovering from a myocardial infarction. The patient alternates between lethargy and combativeness. The patient answers questions inappropriately and continually is trying to get out of bed. What does the nurse recognize as the best intervention?
Keep the patient sedated with anti-pyschotic medications.
Ask the patient's wife and daughter to take turns at the bedside.
Institute restraints on the patient per protocol.
Discharge patient ASAP to a dementia unit for stabilization.
The nurse caring for a patient suffering acute pulmonary edema related to recent myocardial infarction realizes the acute pulmonary edema is directly related to
right-sided heart failure
left-sided heart failure
The nurse is caring for a patient in the ER who is having an anaphylactic reaction to accidentally ingesting peanuts. The patient has a low blood pressure, increased pulse and difficulty breathing. What action does the nurse take first?
Interview the patient's support
Give epinephrine 0.5mg IM
Initiate BiPAP
Give IV methylprednisolone 125mg
Upon reading the following 12 lead EKG, the nurse understands the patient is experiencing the following cardiac problem.
Myocardial infarction
Symptomatic bradycardia
AV heart block
Cardiac ischemia
The nurse is caring for a patient in the ICU after a 4 vessel coronary artery bypass graft. The nurse recognizes the cause of low cardiac output and low central venous pressure is likely which of the following?
hypovolemia
increased blood pressure
poor respiratory effort
pain
The nurse caring for a patient with a blood pressure of 135/65 notes which of the following statements is accurate?
The MAP is too low to perfuse the heart well.
The pulse pressure is indicates the heart is not pumping well.
The MAP is 70 and the pulse pressure is around 88.
The MAP indicates the patient is perfusing well.
The nurse is caring for a severely ill patient with an arterial blood pressure of 101/88, a central venous pressure of 1.2 mm Hg, and cardiac output of 3L/min. Which of the following is accurate about this patient? Select all that apply.
The pulse pressure is 13.
The MAP indicates cardiac valve disease.
The cardiac output indicates possible heart failure.
The MAP indicates adequate perfusion.
The CVP reading is normal.
The nurse documents a MAP of 65 for the patient who suffered a myocardial infarction. Which of the following blood pressures could be the blood pressure of this patient? Select all that apply.
75/60
98/55
112/30
111/42
95/65
