NCLEX study Flashcards

Standardized Tests
Terms Definitions
dysarthria
...
diplopia
double vision
dysphasia
difficulty swallowing
Ptosis:
drooping of eyelids
Ulcerative Colitis
CHRONIC symptoms
Chronic inflammation of the inner-most lining of large intestine (colon) and rectum
in CONTINUOUS STRETCHES of colon, only.
Can be debilitating or life-threatening.
NO CURE, w/ occasional remission.
Bacterium most commonly causing UTI's?
E.coli
Diverticulosis:
out pouching in intestinal wall
Peritonitis s/s:
rebound tenderness, muscular rigidity, laying still w/fast shallow breaths, distended abd, ascites, fever
Most important assessment if pyleonephritis is suspected?
check temperature
s/s of phlebitis:
palpable cord, pain, redness
Appendicitis
Cause: Inflammation of the appendix r/t obstruction of lumen by stool, tumors or foreign bodies.
S/S: N/V, fever, pain in RLQ, rebound tenderness, abd. muscle guarding
Tx: Surgery
Critical: Perforation/rupture will likely lead to peritonitis
Brudzinski's Sign:
pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine
-Paresis:
weakness or incomplete loss of muscle function
Bowel Perforation:
s/s
Spillage of gastric or duodenal contents into peritoneal cavity.
S/S: Sudden, severe pain unrelated to intensity & location at admittance, Rigid, boardlike abdomen, shallow, grunting respirations
Steatorrhea
fat in feces with strong-foul smell, frothy urine and stool
BELL'S PALSY :
disease discription
Facial nerve inflammation;
Peripheral facial paralysis due to CN VII motor dysruption; affects one side of face.
Inflammation, edema, ischemia, demyelination of nerve, causing sensory and motor loss.
Outbreak of herpes vesicles in or around ear; Caused by a reactivation of herpes simplex virus, although other infections (e.g., syphilis or Lyme disease) are sometimes implicated
hemianopsia
visual field cut; defective vision or blindness 1/2 visual field
MENINGITIS :
S/S
Complication
Crisis
s/s: Severe HA, fever, delirium,
Nuchal Rigidity: stiff neck
Kernig's Sign: from bent leg/knee to strait is painful
Brudzinski's Sign: pain; resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine
Photo/Phonophobia;
Increased ICP
Edema and inflammation of the optic nerve
Purpuric rash on the skin and mucous membranes
Assess for IICP: LOC, VS, Eyes, Motor function
Crisis: COMA- Acute complication from IICP
SEIZURES- Acute cerebral edema/ IICP
Components of a neurological examination
LOC, pupillary evaluation, neuromuscular response, vital signs
What is Steven-Johnson's Syndrome?
severe allergic reaction to meds flu-like symptoms, followed by a painful red or purplish rash leads to top layer of skin necrosising if pt develops lesions in the lungs, death may result.
In what phase is the RN maintaining the contract, gathering further data, promoting self-sufficiency and continuing the nursing process?
working phase
Plasmapheresis (plasma exchange)
Removal of patients plasma and plasma components Produces a temporary reduction in the antibodies Does not treat the underlying abnormality
Glomerulonephritis is commonly related to what infection?
Strep.
Intervention- prevent and treat strep quickly!
Also: Immune dz such as Lupus. Vasculitis, Scarring from: HTN, Diabetic kidney dz.
Intervention- control blood sugars and hypertension.
What is the PPE transmission precaution for meningococcal meningitis?
Respiratory Isolation = Droplet precautions: Gloves, Gown, Mask within 3 ft of pt.
The Glasgow Coma Scale
System for assessing the degree of consciousness, or impairment in the critically ill and for predicting the duration + outcome of coma.
NSG Interventions for ICP:
elevate HOB 30-45 degrees to promote venous return, place neck in neutral position, avoid flexion of hip as well as head, restrict fluids, avoid val salves maneuver, insert foley, admin O2 via mask or cannula, and increase body temp.
PD: PARKINSON'S DISEASE :
disease discription
slow, progressive disorder of the nervous system that affects movement.
Characterized by tremor at rest, muscle rigidity and akinesia due to lack of dopamine.
Cholelithiasis:
If pt presents w/ acute pain related to stones lodged in duct, what urine and feces characteristics are expected?
clay colored stools and dark amber urine
The client has experienced an episode of Myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
◦ A. Getting too little exercise
◦ B. Taking excess medication
◦ C. Omitting doses of medication
◦ D. Increasi
C- Omitting doses of medication
When performing a physical assessment, the nurse discovers a client's urinary drainage bag lying next to him. Based on this finding, the nurse identifies which priority nursing diagnosis?
- 1. Risk for infection
- 2. Reflex urinary incontinence
- 3.
RATIONALE: 1) The drainage bag shouldn't be placed alongside the client or on the floor because of the increased risk of infection caused by microorganisms. It should hang on the bed in a dependent position. The other nursing diagnoses are not appropriate for this assessment finding.
A client is receiving pancrelipase (Viokase) for the treatment of chronic pancreatitis. Which observation by the nurse best indicates the treatment is effective?
1) Aspirate for gastric secretions with a syringe
2) Begin feeding slowly to prevent cramping
RATIONALE: 1) before starting a feeding, it's essential to ensure that the tube is in the proper location. Aspiration for stomach contents confirms correct placement.
Giving the feeding without confirming proper placement puts the client at risk for aspiration.
If an x-ray is ordered, it should be done immediately, not in 24 hrs.
Clamping the tube provides no information about tube placement.
The nurse is admitting a client with Guillian- Barre syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complication of the disorder, the nurse brings which of the following items into the client's r
D- Electrocardiographic monitoring electrodes and intubation tray
A client returns from the operating room after extensive abdominal surgery. He has 1,000ml of lactated Ringer's solution infusing via central line. The physician orders the I.V. fluid to be infused at 125ml/hr plus the total output of the previous hour. T
RATIONALE: 65ggt/min. First calculate the volume to be infused in milliliters: 75ml + 50ml + 10ml = 135ml total output for the previous hour; 135ml + 125ml ordered as a constant flow = 260ml to be infused over the next hour.
Next, used the formula: Volume to be infused/ Total minutes to be infused x Drip Factor = Drops per min.
In this case, 260ml divided by 60min x 15 ggt/min = 65 ggt/min
PD: PARKINSON'S DISEASE :
S/S
Complication
Crisis
Classic s/s: tremor at rest, muscle rigidity, bradykinesia.
Complications: risk for fall, aspiration, urinary retention/UTI, dysphagia, oculogyric crisis: fixed lateral and upward gaze.
The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits:
◦ A. A negative Kernig's sign
◦ B. Absence of nucha
C- A positive Brudzinski's sign
who are the most susceptible pts for UTI?
pregnant and/or sexually active women
If alkaline-ash diet is ordered to increase pH of urine what will it include:
Milk, veggies, beef, halibut, trout, salmon
No prunes or plums
What allergy would you assess for in pts being given Pancrelipase?
Pork - used as enzyme supplement to aid in break down of food so that it can be utilized for energy, cell growth and repair
CVA:S/S
Hemiplegia
Hypertension
Tachycardia
BUN
10-20
Cerebellum
Maintains balance
phenytoin (Dilantin)
10-20 mcg/mL
theophylline derivatives
10-20 mcg/mL
Cholinergic Blockers Action
Parasympatholytic
Subjective data
Interview the client
Occular infections:S/S
Increased lacrimation
Blurred vision
Hepatic encephalopathy: late s/s
Hyperventilation
Stupor
Decerebrate/decorticate posturing
7 year old: death
punishment
Normal Hgb female
12-16 g/dL
Linear skull fractures
blunt trauma
First trimester weight gain
2-5 lbs
Schizophrenia: S/S
Paranoia, hallucinations, disturbed thought process, hypervigilance
Tachycardia
associated with hypoxia and anxiety
cardiac glycosides
digoxin, increased contractility, force of myocardial contraction
Mononucleosis: S/S
Fatigue
Sore throat
Flu like symptoms
perphenzine (Trilafon): S/E
Antiemetic/Antipsychotic
Head turned to side
Neck arched at an angle
Stiffness and muscle spasms in neck
haloperidol (Haldol)
Antipsychotics
Never massage injectoin site because medication is very irritating to subcutaneious tissue
Give deep IM in large muscle mass
Use 2 inch 21 guage needle
Administer in single dose
Pt. should be recumbent position for 1/2 hour after admnistration
Epiglotitis
Inflammation and swelling of epiglottis, primarily affecting children ages 2 to 8, the child sits with mouth open and chin thrust forward. child appears sick. fever, drooling anxiety, intubation ANTTIBIOTIC treatment
Primary Metabolic Disturbance
causes respiratory compensation
Protein
Protein needed to slow down degenerative process of aging
Antipsychotic Agents S/E
Restlessness, shuffling gait, involuntary muscle movements, elevated WBC, fever, orthostatic hypotension
Stage II pressure ulcer
*epidermis broken
*superficial partial-thickness skin loss iwth appearance resembling an abrasion or blister, may look like a shallow crater
Fever: S/S
Respirations and heart rate increase
BP and pulse increase
Diaphoresis, but skin will remain warm
Grand mal seizures
Late sign of ICP
Barbiturate Withdrawal: S/S
Nausea and vomiting
Tachycardia
Coarse tremors
Seizures
Anorexia: S/S
Edema of lower extremities
Physical exam reveals presence of lanugo
Epidural
Used for pain relief
Monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting
imipramine (Tofranil): S/E
Antidepressant tricyclic
Sore throat, fever, increased fatigue, V/D
Report to doctor to resolve by altering dose or changing medication
Normal female RBC
3.5 - 5.5 million
Hyperparathryoidism
55% of hyperparathryoid patients have renal calculi
Hematuria is a sign of renal calculi
Carbohydrates
apples, beans, bran, cabbage, fruits, honey, carrots, corn, date,s grapes, oranges, milk, barley, beets, peas, oats, potatoes, pasta, rye wheat, apricots, table sugar, honeydew, cantaloupe, molasses, peaches, plums
Normal Venous Blood pH
7.32 to 7.42
Hematocrit
Female 37-47 percent, male 40-54 percent, newborn 53-62 percent: values reflect the volume of RBCs found in 100 ml of whole blood, low levels in anemia, bone marrow depression, and effective indicator of hydration status. An increase in hematocrit may be indicative of decrease in fluid volume, resulting in hemoconcentration
Blood Transfusion: allergic reaction
uticaria, itching, respiratory distress
Autonomy vs. shame and doubt
Toddler stage
1-3 years
Cystoscopy
Directly able to obeserve the renal pelvis
rifampin (Rifadin)
Treatment of TB
S/S Fever, chills, night sweats, weight loss, anorexia
Stab Wound
Continues to drain untiul wound seals
Nurse should keep wound clean and dry
Remove dressing, replace with more absorbent drainage
Reinforcing the dressing might cause infection
Admnistration of oxytocin
Oxytocin stimulates uterus to contract, which necessitates frequent assessment of the uterus
Prolonged tetanic contraction can lead to rupture of the uterus
Paly therapy
Play is how children express themselves
Children have difficulty putting feelings into words
Incision Line
Should be pink, not red
Slight swelling is expected during healing
Slight crusting of incision line is normal
Should be approximated
Systemic Lupus (SLE)
Maternal morbidity aned ortality increase
Should be in remision 5 months prior to conveiving
Woman should wait 2 years before conceiving
Phobias involve ?
projection: attritubing one's thoughts or impulses to another
displacement: redirection of emotions or feelings to a subject that is more acceptable or less threatening
Vitamin K
Green leafy vegetables, cauliflower & cabbge
What is the normal HCO3 (bicarbonate) value?
22-26
What are normal magnesium values?
1.5 - 2.5
deceleration injury
collision between a rapidly moving body part and a stationary object
TB clinical manifestations
Fatigue, malaise, anorexia, weight loss, chronic cough, productive cough, low-grade fever, night sweats
Delusional thinking: Behavior
Client expresses belief physician is out to get him
Elderly: Risk Factor
At high risk for developing pneumonia
Child with gastroenteritis
Environments with increased number of children (daycare)are more likely to promote infections due to close living conditions and increased likehood of disease transmission
Fluid draining from ear
Indicates a rupture of meninges
Presents possible complication of meningitis
Cough and deep breath
Prevents respiratory complications due to immoblitiy following surgery
Paraplegic: readiness for discharge
Independent in transfers and wheelchair mobility
oxytocin (Pitocin)
Stop infusion if contractions occur at 2 minute intervals and last more than 90 seconds
Petruding Sternum: S/S
Seen with pigeon breast, pectus carinatum
Bio feedback
One learns to control the autonomic nervous system
Is usually more for stress associated with physiological disorders
Buck's traction:Circulation Issue
Notify doctor immediately if no further assessments are necessary
10 year old child
Explain procedure in simple terms
Allow choices when possible
Cardiac Catheterization
May feel burnning sensation when dye is injected
On bedrest 8-12 hours after procedure with pressure dressing applied over catheter insertion site
Peripheral pulses checked every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every 4 hour
NPO midnight before procedure
Dopaminergic Therapy Nursing Interventions
Change Positions slowly, Minimize Vitamin B6 foods (meat, eggs, poultry, sweet potatoes)
Hemothorax
the presence of blood in the pleural cavity. may arise from chest injury, complication in chest surgery, malignancies or rupture of a great vessel such as an aortic aneurysm.
Which cranial nerve is our sense of smell or Olfactory?
1
Nuero Checks PERLMAE
Clients remain alert and oriented
P- Pupils
E- Equal
R- Reactive
L- Light
M- Moving
A- All
E- Extremities to commands
Compare to last nuero check is the client easy to arouse
Squeeze your hands
Left side of brain controls right body
Right side of brain controls left body
If CVA on right left affected
If Hemi on right right is affected
Strong side allways leads ex hemi on left side put chair on right side
CVA on left put chair on left side
A client has cognitive-perceptual difficulties and problems with fine motor coordination. The nurse working with this client should read the progress notes from which of the following health team members to obtain suggestions for working with him or her?
4. Occupational therapist
Rationale: The occupational therapist focuses on the development or relearning of fine motor skills. Social workers, speech pathologists and recreational therapists do not address these types of client problems.
Alcoholic patient: tremors and irritability
Describes normal mild withdrawal symptoms
Decrease in metabolic rate: S/S
Slow sluggish pulse
Cool clamy skin
Husky, slow speech
Nursing assistant: plants
Should not be taking care of plants
Psychiatric patient: election
Can vote by absentee ballot
Do not forfeit constitutional rights
Heroin Withdrawal: S/S
Narcotic withdrawal is very similar to that of the flu
Running nose
Yawning
Fever
Muscle joint and pain
Diarrhea
estrogen (Premarin): S/E
Nausea - common at breakfast time, will subside after weeks of medication use, take after eating to reduce incidence
Visual disturbances - seen with long term use
Tinnitus - long term use
Improve regular bowel elimination
Eat more food with increased bulk
whole grains, legumes, vegetables, fruit, seeds, nuts
bulk promotes peristalis
Rinne Test
Stem of vibrating tunning fork is held against mastoid bone until patient can no longer hear sound
Tuning fork is then moved in front of auditory cannel
Air conduction is better than bone conduction to hear
Sitting with suppot
6 month old should sit with help
Spinal Cord Patient: Attention Seeking Behaviors
Awarenes of vulnerability
Fosters increased dependency needs that are real due to injury
Is trying to determine who is consistent and trustworthy to met his significant physical needs
Which test is used to check Rh status?
Coombs Test
What is HELLP Syndrome?
This is preeclampsia with Liver involvement:
Hemolysis(breakdown of RBCs)
Elevated Liver Function Tests
Low Platelet Count
Cranial Nerves
1 Olfactory God gave us one nose Smell
2 Optic God gave us two eyes to see with
3,4,6 Ocular motor trocular and abducns makes my eyes do tricks
3 is assessed by pupil constriction assess PERLLA
4 Asses eye movement
6 Asses lateral eye movement
5 Trigeminal rhymes with 5 and tri hot and cold
7 Facial
8 Acoustic assess hearing and balance
9,10 Glossopharyngal Vagus is under my chin Gag reflex
11 Spinal accessory shrug the shoulder
12 Hypoglossal tounge movement
cystic fibrosis clinical manifestations
1. Steatorrhea or fatty foul-smellijng stools, ↑ bulk in feces and undigested foods, rectal prolapsed in infants, meconium ileus may occur in newborn, abd. distention, ↑dyspnea, ↑tachypnea, chronic cough,pulmonary inflammation, chronic bronchitis, problems with hypoxia, mucus provides medium for bacteria growth and infection, salty taste when kissed.
Urinanalysis: Bladder infection
WBC and RBC should be present
WBC are response to inflammation process and irritation of urethrea
RBC increase when bladder mucosa is irritated and bleeding
Post surgery: Distended abdomen and hyoactive bowel sounds
Check patency of NG tube
Salem sump NG tube placement
Elevate head of bed 60-90 degrees
Facilitates swallowing and movement of tube through GI tract
Turn, cough, deep breathe
Purpose is to ventilation and prevent respiratory acidosis
What are the actions of calcium channel blockers?
decrease oxygen demand
decrease conductivity
decrease HR and PVR
block calcium access to the cells
decrease force of myocardial contractility
Decrease in LOC
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Air embolism: Intervention
Lower head of bed and place patient on left side
Air will rise to right artrium, minimizes chances of air bubbles entering cerebral circulation
Breast-feeding moms and calories
increase by 500 daily because of mild production
What is the normal heart rate of a neonate
120-160 per minute
The physician prescribes the following for a patient with rheumatoid arthritis: aspirin 5 g po daily. The pharmacy informs the LPN/LVN that the dosage strength of aspirin is 5 grains. How many tablets should be distributed for this patient in each 24-hour
(C) 15
Rationale: One gram (g) contains approximately 15 grains. Therefore, 5 grams contain 75 grains (5 X 15 = 75). Solve for x tablets using the following ratio method:
1 tablet/5 grams = x tablets/75 grains
5x = 75
x = 75/5
x = 15 tablets
Which of the following pressure points is most likely to be at risk for developing a pressure wound while a client is in the prone position?
(A) Occiput
(B) Elbows
(C) Toes
(D) Coccyx
(C) Toes
Rationale: Prone position involves the client lying with the anterior surface of the body compressed against the bed or lying area. The occiput, elbow and coccyx (also called the tailbone) are all pressure points that would be compromised if the client were to lay with the posterior surface against the bed or lying area. The toes would be compressed against the lying area with the client in the prone position. Therefore, the correct answer is (C).
Sengstaken-Blakemore tube: working properly
Pressure of 25 mm HG in the inflated ballon
Develpmental stage of 7 year old
Periods of shyness are expected as child begins to show independence from parents
Nightmares are frequently experienced at this age
Should not be encouraged to be responsible for sibling, inappropriate for this age
How many arteries and veins are in the umblical cord?
2 arteries, 1 vein
For the client with congestive heart failure, left-sided failure causes pulmonary edema or edema of the lungs. Right-sided failure causes peripheral edema. Note the "L" in Left and Lungs. If you learn to associate left-sided failure with the lungs, right-
Remembering the antidote for commonly administered medications is easier when associative cues are used. For example, the antidote for Heparin is Protamine sulfate. Note the "H"and "P," as in Hewlett-Packard, the well-known computer, printer, and camera products company. The antidote for Coumadin is
vitamin K. Note the "C" and "K," as in Calvin Klein, a well-known clothing manufacturer and fashion designer.
Humulin NPH insulin is administered at 7am. At what time would the nurse anticipate the peak action to take place?
1. 9am
2. 12 noon
3. 5pm
4. 11pm
3. NPH is an intermediate-acting insulin. The peak action takes place 8-12 hours after administration. If NPH was given at 7am, the peak would occur between 3pm and 7pm.
5 year old child: lumbar puncture
Do a mock run through of the procedure
Child may not know enough to ask many questions
When referring to fetal heart rate decelerations, remember the following associations: early decelerations are caused by fetal head compression. Look for the letters "EA" in EArly and hEAd. Late decelerations are caused by placental insufficiency. Look fo
When placing cardiac electrodes on the chest of a client, remember to place the white electrode on the right side of the chest (note the rhyme) and place the black (representative of smoke) above the heart on the left and the red (representative of fire) below the heart, remembering that smoke comes before, or rises above, fire.
A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks if the will needs to be updated. The most appropriate nursing res
4. "A living will should be reviewed yearly with your physician."
Rationale: The client should discuss the living will with the physician, and it should be reviewed annually to ensure that it contains the client's current wishes and desires. Options 1 and 2 include inaccurate information. Option 3 is not an appropriate response and places the client's question on hold.
An 11 year old child is experiencing seizure activity. When reporting the event in the medical record, the LPN/LVN would record all of the following in the medical record, except:
(A) Time of seizure onset
(B) Duration of the seizure
(C) Demographic data
(C) Demographic data of the client
Rationale: The nurse will need to record a description of events leading to the seizure activity, time of onset, duration of seizure activity, initial position of body parts (eyes, head, mouth, body, and extremities), any changes in position or lack thereof, skin characteristics, and facial expressions. These assessments will help in determining any details that contribute to or are associated with the client's seizure activity. The child's demographic data should be recorded elsewhere in the medical record and does not need to be repeated with every new entry.
Mrs. Wilkins, is a 60 year-old client with advanced diabetic neuropathy, is two days post-op from a right-above-the-knee
amputation. During assessment, the LPN/LVN asks the client if she is experiencing any pain. Mrs. Wilkins replies. "I've been afraid to
(D) "You may be experiencing a sensation called 'phantom pain' from the site of the amputation."
Rationale: Phantom pain is a real sensation that some people feel after loss of a limb or other body part. This can be felt differently by different individuals. Many have described it as burning, cramping, or itching. Some people sense that the limb is still there. referred pain is the sensation of pain localized in an area distant from the actual injury or area of pathology. Psychosomatic pain or illness is a discomfort or array of symptoms caused by mental processes or emotional responses as opposed to physiological causes. Intractable pain is an often unexplained, severe, and unrelenting pain. Combined therapies are usually necessary to treat intractable pain.
A physician orders a 12-lead electrocardiogram (CG) to be performed on a client. The client is concerned about the safety of the test, and the nurse provides information to the client. Which of the following would indicate that the client understands the
2. "I should lie still while the ECG is being done."
Rationale: good contact between the skin and electrodes is necessary to obtain a clear 12-lead ECG printout. Therefore the electrodes are placed on the flat surfaces of the skin just above the ankles and wrists. Movement may cause a disruption in that contact and artifact, which makes the ECG printout difficult to read. The client does not have to hold the breath or take a deep breath during the procedure. The client should be reassured that the procedure will not produce a shock.
The LPN/LVN is preparing for a sterile procedure that requires using sterile 4 X $ gauze. Which of the following would indicate contamination of the open 4 X $s?
(A) The LPN/LVN pours sterile saline onto the sterile 4 X 4s that are sitting on the bedside
(A) The LPN/LVN pours sterile saline onto the sterile 4 X4s that are sitting on the bedside table
Rationale: Keeping the 4 X 4s within sterile packaging borders on a surface that is at or above waist level and avoiding prolonged exposure to air are principles used to maintain sterility of equipment and supplies. To prevent contamination, the 4 X 4s should not be touched with any materials that have failed to maintain sterile technique themselves.
It is proper to use sterile forceps or hands with properly applied sterile gloves to move sterile 4 X 4s while maintaining sterility. The correct answer (A), allows contamination through capillary action of the 4 X 4s. As the saline solution contacts the surface of the bedside table, the sterility is compromised because bacteria from the table travel through the fluid to contact the 4 X 4s.
A nurse is collecting data about the lethality risk of a suicidal client. Which of the following is the best question for the nurse to ask the client?
1. "Do you have a death wish?"
2. "Do you wish your life was over?"
3. "Do you ever think about ending i
4. "Have you ever thought of killing yourself?"
Rationale: A lethality assessment requires direct communication between the client and nurse. It is important to provide a question that is directly related to lethality. Options 1, 2 and 3 do not directly address the subject of the question. Option 4, is the most direct option.
A physician schedules a client for a stress electrocardiogram. The client asks the LPV/LVN why this test is needed. The most accurate explanation from the nurse would be:
(A) "The test will determine the heart rate you want to achieve during exercise."
(
(C) "The doctor is looking to see how exercise affects your heart."
Rationale: A stress electrocardiogram monitors the heart while the client progressively increases exercise levels. The physician will read the electrocardiogram, a graph of the client's heart function, to determine if cardiac dysfunction occurred during exercise. The physician is looking to see how the stress of exercise affects the client's heart. The "target heart rate" or rate that the client should reach during normal exercise is determined based on the client's age and gender. The test may indicate if a client needs to alter his/her daily exercise routine, but this is not the purpose of performing the test. An ECG will not determine the likelihood of a client suffering from a heart attack.
As a nurse comes upon a situation, his or her first assessments or interventions should be directed toward the client. The client is typically the priority, followed by family members, equipment, and then the environment.
Try to stay away from the urge to say to yourself "What if . . ." or "Suppose. . . ." Reading into questions is never a good idea and often leads to the wrong answer. The questions have all the information you need to know. There are no "trick" questions.
The item writers cannot give you less information than
you need to answer the question, but they can give you more. Learning to sift through the unimportant information takes practice.
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