HESI week 11

A client had surgery for a strangulated hernia. One hour after surgery the client's blood pressure drops from 134/80 to 114/76 mm Hg. Assessment reveals that the client does not have postoperative bleeding. What action should the nurse take?

The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return.

The nurse providing immediate postoperative care to a client who had an abdominoperineal resection should assess for which clinical indicator of complications?

Bloody drainage on the abdominal or rectal dressings may indicate hemorrhage. Blood in the NG tube is expected immediately after surgery. Peristalsis will not return for several days.

At 20 hours of age a newborn is found to have a bilirubin concentration of 13 mg/dL (274 mcmol/L). Which finding most likely contributed to this bilirubin level?

Cephalhematoma Cephalhematoma, bleeding into the periosteum of the skull, leads to hyperbilirubinemia. A child with a clubfoot does not have an increased risk of hyperbilirubinemia. Caput succedaneum is edema of the presenting part. It does not involve any bleeding. The postmature infant can better handle the bilirubin than the preterm infant.

A client is admitted to the postanesthesia care unit after surgery, and electronic blood pressure monitoring is to be performed. How frequently should the nurse assess the client's blood pressure?

During the first 2 postoperative hours, the blood pressure is monitored every 10 to 15 minutes to detect unstable vital signs that might indicate shock.

A 25-year-old woman on estrogen therapy has a history of smoking. Which complication does the nurse anticipate in the client?

Estrogen therapy increases the risk of pulmonary embolisms in clients who have a history of smoking because the medication affects blood circulation and hemostasis.

A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch the client becomes diaphoretic and has palpitations. What probable cause of this response does the nurse recognize?

Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome). Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with the dumping syndrome.

Who would the nurse explain would go through the initiative versus guilt stage of Erikson's theory?

Preschoolers between the ages of 3 to 6 years of age are in the initiative versus guiltstage. During this stage, children like to pretend and play new roles. Toddlers will go through the autonomy versus guilt stage. By this stage, a growing child is more accomplished in some basic self-care activities, including walking, feeding, and toileting.

The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. How should the nurse interpret this rhythm?

Sinus rhythm with first degree AV block. In first degree block, P and QRS waves are consistent in shape. A P wave precedes every QRS complex, which is followed by a T wave. PR interval is prolonged and is greater than 0.20 seconds. NSR reflects normal conduction of the sinus impulse through the atria and ventricles; PR interval is 0.12 to 0.20 seconds. In second degree AV block, QRS may be normal or widened and have at least one or more nonconducted QRS complexes. In third degree AV block, QRS has no relationship with P waves.

The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply.

Unexplainable profuse diaphoresis, indigestion not relieved by antacids, acute chest pain after rigorous exercise, and nonremitting chest pain after three sublingual nitroglycerine tablets are clinical indicators of inadequate oxygen to the heart. The client should be instructed to seek immediate medical intervention. Dyspnea on exertion and fatigue the day after a rigorous walk are expected.

A primary health care provider prescribes total parenteral nutrition for a client with cancer of the pancreas. A central venous access device is inserted. What does the nurse identify as the most important reason for using this type of access?

Unless diluted, the highly concentrated solution can cause vein irritation or occlusion.

After reviewing blood test reports, in which client's care plan does the nurse document monitoring jaundice as a prioritynursing intervention?

Clients with severe anemia can be jaundiced. A hemoglobin level of less than 6g/dL indicates severe anemia. Therefore the client with a hemoglobin level of 4g/dL is in need of monitoring for jaundice.

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common?

With anemia, the heart works harder to compensate for the reduced oxygen-carrying ability of the blood. With polycythemia, the heart works harder to propel more viscous blood through the circulatory system.

A client is admitted to the emergency department with a possible myocardial infarction. Three hours after admission, the client experiences a new onset of severe chest pain. The client is diaphoretic with a pulse rate of 110 beats per minute. Which action should the nurse take immediately?

The client requires immediate relief of pain by administering morphine. The client needs increased oxygen, not less. ECG monitoring is continuous in the ED, so the nurse does not need to obtain an ECG. Acetaminophen does not relieve the pain associated with a myocardial infarction.

A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response?

In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in turn contributes to the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure diminishes, and there may be no permanent damage.

An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply.

Dyspnea Crackles Hacking cough Left-sided heart failure causes impaired tissue perfusion, pulmonary congestion, and pulmonary edema, which also cause signs and symptoms such as dyspnea, crackles, and hacking cough. Peripheral edema and jugular distention are signs of right-sided heart failure.

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is uniquely related to heart failure?

Dyspnea on exertion occurs with heart failure because of the heart's inability to meet the oxygen needs of the body.

A client with a history of hypertension develops pedal edema and hepatomegaly. Which condition does the nurse determine the client is experiencing?

The failing right ventricle fails to contract effectively, which causes a backup of blood into the right atrium and venous circulation, causing peripheral edema and hepatomegaly.

A client with osteomyelitis is receiving antibiotic therapy via a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics, and peak levels were obtained 30 minutes after the infusion was completed. The laboratory results reveal that the trough level is higher than the peak level. What does the nurse conclude that this finding probably indicates?

Peak levels will always be higher than trough levels; therefore this result indicates some mix-up in the drawn samples. Increasing the dose would be an appropriate action if the trough level were too low.

Hydrochlorothiazide, a thiazide diuretic, has been prescribed for a client with hypertension. The client reports hearing that furosemide is more effective and requests a prescription change. How should the nurse respond?

Side effects from thiazides generally are minor and rarely result in discontinuation of therapy. Dizziness is a side effect of all diuretics. There is a potential for dehydration with all diuretics. All diuretic medications are taken regularly as directed.

A woman has been administered oxytocin to induce labor. After delivery, the woman complains of tiredness and feels a spinning sensation. Which effect of oxytocin can be inferred from these symptoms?

The client is most likely experiencing hypotension caused by oxytocin.

The nurse provides medication discharge instructions to a client who received a prescription for digoxin following the client's myocardial infarction. Which statement by the client leads the nurse to conclude that the teaching was effective?

"It will be important to check my radial pulse daily." Checking the radial pulse rate daily is necessary for monitoring cardiac function; digoxin slows and strengthens the heart rate. Digoxin should be withheld and the healthcare provider notified if the pulse rate falls below a predetermined rate (e.g., 60 beats per minute).

The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply.

Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea.

The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse will look for potential causes. Which causes will the nurse look for in this client? Select all that apply.

The dysrhythmia itself is not treated, but the cause is identified and treated appropriately. Causes of sinus tachycardia include hypovolemia, heart failure, anemia, exercise, use of stimulants, fever, sympathetic response to fear or pain. Hypothermia will cause sinus bradycardia.

A client at 37 weeks' gestation is brought to the emergency department because of sudden abdominal pain. Abruptio placentae is suspected, and the client is transferred to the birthing unit. What should the nurse assess the client for?

Uterine tenderness and increased fetal activity When the placenta initially separates, the fetus may become hyperactive as a response to acute hypoxia; the uterus is tender because of the accumulation of blood at the abrupted placental site.

A client comes to the emergency department with pressure in the chest and shortness of breath. The client is admitted for observation after receiving a tentative diagnosis of a myocardial infarction. Which assessment finding should the nurse monitor for in this client that supports this diagnosis?

Vomiting Nausea and vomiting are clinical manifestations that are associated with a myocardial infarction. The heart rate will increase, not decrease, in an attempt to meet oxygen demands of the body. Headaches are associated with a stroke, not with a myocardial infarction. Chest pain associated with a myocardial infarction may radiate to the jaw, back, or left shoulder and arm, not the abdomen.