Elevate 2

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine

3. Correct: Although the rhythm strip looks like ventricular fibrillation, you must first check the client. Assess for consciousness, airway, breathing, circulation first.

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

Correct: A client with acute renal failure will have an increased (BUN). Significant elevation in BUN may result in nausea, vomiting, lethargy, fatigue, impaired thought processes, and headache.

The client is being admitted for a myocardial infarction (MI). Which assessment finding is expected? 1. Reports of nausea and vomiting 2. Elevated temperature higher than 102 degrees F (38.89 degrees C) in the first 24 hours. 3. Pain relieved by two aspirin tablets. 4. Myoglobin will be negative.

Correct: Pain with MI may have associated symptoms that include nausea, vomiting, diaphoresis, palpitations, and shortness of breath.

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? 1. Dysuria 2. Costovertebral angle tenderness 3. Weight loss 4. Chills 5. Urinary frequency

1., 2., 4., & 5. Correct: The client with acute pyelonephritis, will often exhibit these signs/symptoms due to the kidney infection.

The nurse is teaching a male client how to perform intermittent self-catheterization. In what order should this procedure be taught?

Correct Order: First, clean the meatus. Second, lubricate several inches of the tip of the catheter. Third, hold your penis on both sides just behind the head. Next, insert the catheter six inches into the urethra, using a steady gentle pressure. Fifth, use gentle but firm pressure on the catheter until the muscle relaxes and the catheter becomes easier to advance. It will be necessary to pass the catheter another two or three inches before it enters the bladder. Sixth, allow urine to drain completely.

After assessing a client, the nurse determines that the client has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which interventions would the nurse include for this client? You answered this questionCorrectly 1. Have client attempt to void again (double voiding). 2. Encourage the client to void every 8 hours. 3. Perform Credé method. 4. Have client listen to sound of running water. 5. Teach intermittent catheterization for retention, if needed.

1., 3., 4. & 5. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Place bedpan, urinal, or bedside commode within reach. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. Perform Credé method over bladder to increase bladder pressure. If these methods are unsuccessful, the client will need education on intermittent catheterization.

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."

1., 3., 4., & 5. Correct: Minimize stationary standing as much as possible. Protect legs from trauma as this can lead to ulcerations. Elastic compression stockings are recommended for clients with chronic venous insufficiency to prevent pooling and promote venous return. Leg elevation decreases edema, promotes venous return, and provides symptomatic relief. Legs should be elevated frequently throughout the day (for at least 15-30 minutes every 2 hours). During the night, the client should sleep with the foot elevated approximately 6 inches (15.24 cm).

What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis? 1. Petechiae on trunk 2. Muffled heart sounds 3. Pericardial friction rub 4. Pulsus paradoxus 5. Chest pain on deep inspiration

2., 3., & 5. Correct: Muffled heart sounds are indicative of pericarditis. Fluid is between the heart and the chest wall; heart sounds are lowered and distant. A pericardial friction rub is a classic symptom of acute pericarditis. Chest pain is the most common symptoms of pericarditis, and is aggravated by deep inspiration, coughing, position change, and swallowing.

The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? 1. Monitor PT and aPTT 2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count

2., 3., 4. & 5. Correct: The main complication of anticoagulant therapy is bleeding. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment with enoxaparin sodium Injection. Bedrest will reduce the risk of a clot dislodging. Elevate left leg to decrease swelling and promote venous return.

A nurse is planning care for a newly admitted client diagnosed with acute nephrotic syndrome. What interventions would the nurse include in the plan of care? 1. Monitor triglyceride level 2. Educate client on a 3 gm sodium diet. 3. Auscultate lung sounds. 4. Monitor blood pressure. 5. Assess for venous thrombo-embolism (VTE).

1, 3, 4, & 5. Correct: The liver increases the release of cholesterol and triglycerides while producing more needed albumin. This client is at risk for heart failure, and pulmonary edema so the lungs should be auscultated and the blood pressure should be monitored. Without proteins, the blood can clot and put the client at risk for thrombosis or embolism.

A client has sublingual (SL) nitroglycerin prn added to their medication regimen. Which statements made by this client indicates teaching has been effective? 1. "I will take this medication if I have an episode of chest pain." 2. "I will wait at least 1 hour after I take my erection agent before using Nitroglycerin." 3. "I can take up to 3 tablets every 10 minutes if my angina occurs." 4. "I know that I must put this tablet under my tongue for it to work." 5. "I will keep my medication handy, in a pocket."

1. & 4. Correct: Nitroglycerin should be used for chest pain and sublingual should be placed under the tongue.

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)? 1. Increase daily intake to at least 9 cups (2160 mL) of water. 2. Urinate within one hour after sexual intercourse. 3. Take a low dose antibiotic. 4. Urinate at least twice a day.

1. Correct: Water helps to dilute urine and flush out bacteria.

What would the nurse include in the teaching plan for a client with right sided heart failure? 1. There is a backup of blood in the right upper chamber of the heart. 2. There is swelling of lower extremities. 3. The heart rate decreases. 4. You may experience fatigue and depression. 5. You may have nausea and anorexia.

1., 2. 4. & 5. Correct: The blood backs up into the right atrium and venous circulation. Vascular congestion is evident by swelling of the lower extremities. Clients usually experience fatigue and depression. Ascites may increase pressure on the stomach and intestines causing GI upset with nausea and anorexia.

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? 1. Regular rhythm 2. Rate of 101-200 3. P wave normal 4. P-R interval not measurable 5. QRS complex normal

1., 2., 3. & 5. Correct: Sinus tachycardia indicates a regular rhythm, although the rate is elevated. The term tachycardia is defined as a heart rate above 100. The P-wave is normal in a sinus rhythm. Sinus rhythms have a normal QRS complex.

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1., 2., 3., & 4. Correct: These signs and symptoms indicate an emergency with loss of circulation to the extremity. This is an emergency, and the primary healthcare provider is the only one that can save this foot from ischemia. Don't delay. Epigastric pain could indicate the client is having an MI. Always assume the worse!

A nurse is attempting to help a client who has self-care difficulty due to left-sided hemiparesis. Which interventions should the nurse plan to include? 1. Provide the client with a button hook for dressing. 2. Discourage use of electric razors and toothbrushes. 3. Have client comb own hair. 4. Offer to take the client to the toilet every four hours. 5. Avoid relying on furniture for support when walking

1., 3. & 5. Correct: The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. This is a one handed task that will enable the client to maintain autonomy for as long as possible. Having client comb own hair helps maintain autonomy. The client should use prescribed assistive devices for ambulation. Furniture may move or not be in the correct place for support while walking.

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

2., 3., 4., & 5. Correct: Caffeine, stress, and nicotine cause vasoconstriction and vasospasm, which impedes peripheral circulation. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling. Vasodilation will be increased by providing warmth in the environment. Cold causes vasoconstriction. Isometric exercise and walking promote the development of collateral circulation.

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? 1. Develope a response plan for each potential disaster. 2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

2., 3., 4., & 5. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. Consideration must be given to the proximity of chemical plants, nuclear facilities, schools, and areas where large groups gather.

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? 1. Anti-embolic stockings 2. Smoking cessation 3. Moderate exercise 4. Application of heat 5. Low cholesterol diet 6. Decrease blood pressure

2., 3., 5. & 6. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Smoking is a major risk factor in developing PAD by contributing to arterial constriction. Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. A low cholesterol, heart healthy diet with more fruits and vegetables helps reduce cholesterol while decreasing blood pressure, both important goals towards controlling PAD.

A client had a coronary artery bypass surgery (CABG) x 3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade? 1. Bradycardia with wet lungs 2. Increased central venous pressure 3. Distended bilateral neck veins 4. A widening pulse pressure 5. Decreasing blood pressure

2, 3, and 5. CORRECT: Cardiac tamponade occurs when blood or fluid enters the pericardial sac, causing compression of the heart chambers. Such pressure prevents blood from either entering or leaving the heart, thus decreasing cardiac output. Central venous pressure (CVP) increases because of the compression of the right atria, but because no fluid is exiting the heart, blood pressure drops. Since the returning blood cannot enter the heart, neck veins become distended, though lungs remain clear.

In order to maintain asepsis, what would the nurse teach the client on home peritoneal dialysis? 1. Drink only bottled water. 2. Cap Tenckhoff catheter when not in use. 3. Soak the dialysate in warm water. 4. Clean the arteriovenous fistula with hydrogen peroxide twice a day. 5. Wash around the catheter insertion site daily.

2., & 5. Correct: Capping the Tenckhoff catheter prevents dialysate leakage and bacterial invasion. Clean around insertion site to decrease risk of bacterial infection.

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective? 1. Fixed urine specific gravity 2. Serum K+ 4.9 mEq (4.9 mmol/L) 3. Serum Na+ 143 mEq (143 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours

2., 3. & 5. Correct: The serum potassium is within normal range. The serum potassium level would be elevated if the client was still in the oliguric phase. This is a normal sodium level, which indicates that the client is improving. The serum sodium level would be low in the oliguric phase due to increased dilution of the blood. This urine output is adequate to indicate proper kidney perfusion

A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC

3. Correct: Blood Pressure. We said that all of this ascites is coming from the vascular space and it's getting worse, So what could happen to my blood pressure? It will drop!

An elderly client with a history of coronary artery disease (CAD) has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? 1. Request order for a foley catheter. 2. Assist client with the use of a bedpan. 3. Provide a bedside commode chair. 4. Perform in and out straight catherization.

CORRECT. The exhibit shows bradycardia with premature ventricular contractions (PVCs), and more specifically, bigeminy. The safest approach for a syncopal client with this rhythm is the use of a bedpan for bathroom needs. Even with assistance, this client would be at risk for falls when ambulating.

When an explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention? 1. An elderly adult with a traumatic left eye enucleation. 2. A child with an open, compound fracture of the femur. 3. An adult with a head laceration bleeding profusely. 4. An adolescent with a rigid, board-like lower abdomen.

CORRECT: This client's symptoms indicate the presence of internal bleeding. Without emergency surgery, this client will quickly develop hypovolemic shock and may not survive.