iggy 4.2

A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your -ANSwer using a whole number.) ____ mL/hr

142 mL/hr The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142). : Analyzing/Analysis REF: 759 : IV fluids| fluid and electrolyte imbalance| critical rescue| sepsis| shock : Integrated Process: Nursing Process: Analysis : Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

5. A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

A, C, D, E The Joint Commissions Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.

8. The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min

ANS: 31 drops/min

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. I get short of breath when I climb stairs. b. I see halos floating around my head. c. I have trouble remembering things. d. I have lost weight over the past month.

ANS: A Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.

ANS: A Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this clients readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider.

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. I wake up to go to the bathroom at night. b. My shoes fit tighter by the end of the day. c. I seem to be feeling more anxious lately. d. I drink at least eight glasses of water a day.

ANS: B Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.

ANS: C Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem.

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine.

ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.

20. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

B A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

28. A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline.

B Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures.

1. A nurse is caring for a client who weighs 220 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your -ANSwer using a whole number.) _____ mg

90 mg The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 220 pounds (110 kg), and so will get the maximal dose.

26. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

A A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

24. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best? a. Assess the reason behind the clients fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

A The first step is to assess the reason behind the clients fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like drugs are safer today do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

25. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the clients lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the clients lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

The nurse caring for hospitalized clients includes which actions on their care pl-ANS to reduce the possibility of the clients developing shock? (Select all that apply.) Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 314 a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does prevent shock but can indicate a change. : Applying/Application REF: 764 : Shock| nursing assessment| infection control : Integrated Process: Nursing Process: Implementation : Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, B, C If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the clients risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

ANS: A, C, E Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. The best way to lose weight is a high-protein, low-carbohydrate diet. b. You should balance weight loss with consuming necessary nutrients. c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you wont need to change your diet.

ANS: B Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

ANS: B The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

ANS: B, C, E Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptomsindigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?

ANS: C Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the clients misconception about recent pain and the cause of that pain.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

ANS: C The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

ANS: D Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

B A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is as critical as the lactate level. : Analyzing/Analysis REF: 762 : Shock| nursing assessment| laboratory values : Integrated Process: Communication and Documentation : Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

B This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. Applying/Application REF: 780 Coronary artery disease| activity intolerance| vital signs| nursing assessment Integrated Process: Nursing Process: Assessment Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Womens health clinics

A African Americ-ANS in the United States have one of the highest rates of hypertension in the world. The nurse Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 299 has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americ-ANS are the priority population for this intervention.

13. A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What -ANSwer by the nurse is best? a. No, women should only have one beer a day as a general rule. b. No, you should not drink any alcohol with hypertension. c. Yes, since you are larger, you can have more alcohol. d. Yes, two beers per day is an acceptable amount of alcohol.

A Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A drink is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The wom-ANS size does not matter.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the clients favorite channel. d. Speak loudly to the client in case of hearing problems.

A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more. Applying/Application REF: 791 Intra-aortic balloon pump| nonpharmacologic comfort measures Integrated Process: Nursing Process: Implementation Client Needs Category: Physiological Integrity: Basic Care and Comfort

10. A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. Could you walk further than that a few months ago? b. Do you walk mostly uphill, downhill, or on flat surfaces? c. Have you ever considered swimming instead of walking? d. How much pain medication do you take each day?

A As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the clients disease is worsening. The other questions are useful, but not as important.

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 317 a. Continue to educate the client on possible healthy changes. b. Emphasize complications that can occur with noncompliance. c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.

A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problemfocused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client. Understanding/Comprehension REF: 780 Coronary artery disease| psychosocial response| coping| therapeutic communication Integrated Process: Communication and Documentation Client Needs Category: Psychosocial Integrity

27. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. I can use a heating pad on my legs if its set on low. b. I should not cross my legs when sitting or lying down. c. I will go out and buy some warm, heavy socks to wear. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 305 d. Its going to be really hard but I will stop smoking.

A Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the clients painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

A, D, E The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is recommended as this can dislodge any clots present, which may lead to pulmonary embolism. : Applying/Application REF: 756 : Shock| nonpharmacologic comfort interventions| delegation : Integrated Process: Communication and Documentation : Client Needs Category: Physiological Integrity: Basic Care and Comfort

A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the clients blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

A Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the clients hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication there is no indication of this in the question. Analyzing/Analysis REF: 780 Coronary artery disease| dysrhythmias| nursing assessment| hemodynamic status Integrated Process: Nursing Process: Implementation Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. Do you have any concerns about sexuality? b. Im glad to hear you are sleeping well now. c. Sleep near your spouse in case of emergency. d. Why would you move into the guest room?

A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive. Applying/Application REF: 792 Coronary artery disease| sexuality| anxiety| therapeutic communication Integrated Process: Caring Client Needs Category: Psychosocial Integrity

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the clients vital signs. d. Obtain consent for a central line.

A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the clients integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working. Applying/Application REF: 784 Inotropic agents| adverse effects| medication safety Integrated Process: Nursing Process: Assessment Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

17. A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the clients temperature every 4 hours c. Clean technique when changing dressings Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 302 d. Monitoring the clients daily white blood cell count

A Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.

A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is the most accurate -ANSwer. The stress of the illness has made the client diabetic. : Understanding/Comprehension REF: 766 : Shock| patient education| hyperglycemia| insulin| endocrine system : Integrated Process: Teaching/Learning : Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

9. The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

12. A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What response by the nurse is best? a. No, it may interfere with the warfarin. b. There isnt any information about that. c. Why would you want to take that? d. Yes, it is a good supplement for you.

A Many foods and drugs interfere with warfarin, St. Johns wort being one of them. The nurse should advise the client against taking it. The other -ANSwers are not accurate.

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, -ANSwering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

A Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so. : Evaluating/Synthesis REF: 760 : Shock| vasoconstrictors| nursing process evaluation| neurologic system : Integrated Process: Nursing Process: Evaluation : Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed. Applying/Application REF: 780 Coronary artery disease| older adult| pathophysiology| nursing assessment Integrated Process: Nursing Process: Assessment Client Needs Category: Health Promotion and Maintenance

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the clients bed. d. Tell the client everything possible is being done.

A The nurses presence will be best to reassure this client. Antianxiety medication is warranted as this will lower the clients blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the clients safety. Telling a confused client that everything is being done is the most helpful response. : Applying/Application REF: 758 : Psychosocial response| communication| caring| shock : Integrated Process: Caring : Client Needs Category: Psychosocial Integrity Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 313

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. ify local law enforcement officials. c. Obtain universal donor blood. d. Prepare the client for emergency surgery.

A The nurses priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may have to prepare the client for emergency surgery. : Applying/Application REF: 756 : Standard Precautions| infection control : Integrated Process: Nursing Process: Implementation : Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

4. A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 298 b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

A There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is an indicator of shock since the pulse is still within the normal range it may indicate the clients pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr. : Analyzing/Analysis REF: 755 : Shock| perfusion| nursing assessment : Integrated Process: Nursing Process: Assessment : Client Needs Category: Safe and Effective Care Environment: Management of Care

29. The nurse is assessing a client on admission to the hospital. The clients leg appears as shown below: What action by the nurse is best? a. Assess the clients ankle-brachial index. b. Elevate the clients leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

A This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the clients ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

7. A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the clients leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.

A, B, C When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the clients feelings.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

A, B, C, D Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is a common risk factor for shock. : Remembering/Knowledge REF: 764 : Shock| older adult| nursing process assessment : Integrated Process: Nursing Process: Assessment : Client Needs Category: Health Promotion and Maintenance

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

A, B, C, E Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD medication use is not. Remembering/Knowledge REF: 771 Coronary artery disease| pathophysiology| patient education Integrated Process: Teaching/Learning Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

A, B, D Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

3. A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

A, B, D The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion. Remembering/Knowledge REF: 773 Coronary artery disease| pathophysiology Integrated Process: Teaching/Learning Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

A, B, E Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours. : Remembering/Knowledge REF: 765 : Shock| critical rescue| medical emergencies : Integrated Process: Nursing Process: Implementation : Client Needs Category: Physiological Integrity: Physiological Adaptation

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

A, C The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are manifestations of shock. : Remembering/Knowledge REF: 753 : Shock| pathophysiology : Integrated Process: Teaching/Learning : Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

A, C, E The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done. Applying/Application REF: 779 Coronary artery disease| coronary artery bypass graft| delegation| activity| unlicensed assistive personnel (UAP) Integrated Process: Communication and Documentation Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

ANS: A, C, E A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

ANS: B The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client.

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the clients medications.

ANS: B The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the clients prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

ANS: B, D, E Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

ANS: B, D, E In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The clients blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

ANS: C A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the clients fluid status. Neurologic changes would take priority.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

ANS: C In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery? c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?

ANS: C The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide false hope or push the clients concerns off on the chaplain. The nurse should address support systems after addressing the clients current issue.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

ANS: D All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

ANS: D Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.

ANS: D The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 318 c. Document the findings in the chart. d. Medicate the client for pain.

B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest the nurse first needs to rule out any emergent bleeding. Applying/Application REF: 782 Coronary artery disease| intra-arterial blood pressure monitoring| equipment safety| vital signs Integrated Process: Nursing Process: Assessment Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best? a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a blood thinner, although laypeople may refer to it as such. Understanding/Comprehension REF: 779 Coronary artery disease| thrombolytic agents| patient education Integrated Process: Teaching/Learning Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

B Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician. : Applying/Application REF: 752 : Critical rescue| shock| primary survey : Integrated Process: Nursing Process: Implementation : Client Needs Category: Safe and Effective Care Environment: Management of Care

8. A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the clients support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the clients obligations.

B All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the clients feelings of control.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients sternal wound has yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. All my friends and neighbors are planning a party for me. b. I hope I can get my water turned back on when I get home. c. I am going to have my daughter scoop the cat litter box. d. My grandkids are so excited to have me coming home!

B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes. : Analyzing/Analysis REF: 766 : Shock| primary prevention| infection control : Integrated Process: Communication and Documentation : Client Needs Category: Physiological Integrity: Reduction of Risk Potential

23. A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an Ask the nurse booth at the pet store.

B An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

14. A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 301 c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

B Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

15. A client had a percutaneous tr-ANSluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

B Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

18. A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the clients neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

B Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the clients manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

B Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 322 Applying/Application REF: 792 Home safety| referrals| coronary artery bypass graft Integrated Process: Communication and Documentation Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for. Analyzing/Analysis REF: 788 Coronary artery disease| coronary artery bypass graft| collaboration Integrated Process: Nursing Process: Assessment Client Needs Category: Safe and Effective Care Environment: Management of Care

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowlers position.

B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings. Applying/Application REF: 781 Coronary artery disease| hemodynamic monitoring| equipment safety Integrated Process: Nursing Process: Implementation Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart. Applying/Application REF: 789 Coronary artery bypass graft| critical rescue| chest tubes| cardiovascular system Integrated Process: Communication and Documentation Client Needs Category: Safe and Effective Care Environment: Management of Care

1. A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

B Lower blood volume will decrease MAP. The other -ANSwers are accurate. : Remembering/Knowledge REF: 752 : Mean arterial blood pressure| shock : Integrated Process: Nursing Process: Assessment : Client Needs Category: Physiological Integrity: Physiological Adaptation

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. Do you have trouble affording your medications? b. Most people with hypertension do not have symptoms. c. You are lucky most people get severe morning headaches. d. You need to take your medicine or you will get kidney failure.

B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. Fish oil is contraindicated with most drugs for CAD. b. The best source is fish, but pills have benefits too. c. There is no evidence to support fish oil use with CAD. d. You can reverse CAD totally with diet and supplements.

B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate. Understanding/Comprehension REF: 772 Coronary artery disease| lipid-reducing agents| supplements| patient education Integrated Process: Teaching/Learning Client Needs Category: Health Promotion and Maintenance

16. A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the clients chart. d. Notify the surgeon immediately.

B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the clients perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 311 d. Take medications as prescribed.

B Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients to get dehydrated is important, but the best -ANSwer because it doesnt give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is as important an issue as staying hydrated. Taking medications as prescribed may or may be related to hydration. : Applying/Application REF: 756 : Older adult| fluid and electrolyte imbalance| patient education| primary prevention : Integrated Process: Teaching/Learning : Client Needs Category: Health Promotion and Maintenance

A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion.

B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is the priority at this time. Documentation should be done thoroughly but is the priority either. The nurse should increase the rate of the IV infusion without an order. : Applying/Application REF: 755 : Shock| perfusion| nursing assessment : Integrated Process: Nursing Process: Assessment : Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 2 mEq/L

B Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 321 The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable. Analyzing/Analysis REF: 785 Coronary artery disease| critical rescue| medical emergencies| hypersensitivities| allergic reaction Integrated Process: Nursing Process: Analysis Client Needs Category: Safe and Effective Care Environment: Management of Care

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

B The Joint Commissions Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed. Remembering/Knowledge REF: 777 Coronary artery disease| Core Measures| The Joint Commission Integrated Process: Nursing Process: Implementation Client Needs Category: Safe and Effective Care Environment: Management of Care

3. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

B The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in tr-ANS fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 310 personnel (UAP) reports the vital signs and the nurse sees they are only slightly ferent from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

B Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP can assess for pain. Repositioning may or may be effective for decreasing restlessness, but does take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation. : Applying/Application REF: 755 : Shock| nursing assessment| renal system| delegation| unlicensed assistive personnel (UAP) : Integrated Process: Nursing Process: Assessment : Client Needs Category: Safe and Effective Care Environment: Management of Care

21. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the clients leg. d. Provide an ice pack.

B Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the clients legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

1. What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

B, C, D The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 324 c. Obesity d. Smoking e. Stress

B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor. Remembering/Knowledge REF: 771 Coronary artery disease| lifestyle factors Integrated Process: Teaching/Learning Client Needs Category: Health Promotion and Maintenance

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the clients sheets. c. Put on a pair of gloves. d. Assess blood pressure.

C For the nurses safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves. Applying/Application REF: 782 Standard Precautions| infection control| intra-arterial blood pressure monitoring| staff safety Integrated Process: Nursing Process: Implementation Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 320

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

B, D, E Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 325 Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures. Applying/Application REF: 792 Coronary artery disease| nonpharmacologic comfort measures Integrated Process: Nursing Process: Implementation Client Needs Category: Physiological Integrity: Basic Care and Comfort

9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the clients blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the clients pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist. Applying/Application REF: 779 Coronary artery disease| neurologic system| critical rescue| Rapid Response Team| thrombolytic agents Integrated Process: Nursing Process: Implementation Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 323 explain the action of these drugs to the client and spouse? a. It constricts vessels, improving blood flow. b. It dilates vessels, which lessens the work of the heart. c. It increases the force of the hearts contractions. d. It slows the heart rate down for better filling.

C A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct. Remembering/Knowledge REF: 783 Coronary artery disease| inotropic agents| patient education Integrated Process: Teaching/Learning Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 319 with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the providers prescription and the clients current medications. Applying/Application REF: 780 Coronary artery disease| critical rescue| medical emergencies Integrated Process: Nursing Process: Implementation Client Needs Category: Safe and Effective Care Environment: Management of Care

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

C Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the clients previous blood pressure or pedal pulses, there is enough information to determine if these are an improvement or . A urine output of 32 mL/hr is acceptable. : Applying/Application REF: 760 : Shock| vasoconstrictors| critical rescue : Integrated Process: Communication and Documentation : Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE

22. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

C Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

6. A student nurse asks what essential hypertension is. What response by the registered nurse is best? a. It me-ANS it is caused by another disease. b. It me-ANS it is essential that it be treated. c. It is hypertension with no specific cause. d. It refers to severe and life-threatening hypertension.

C Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable (smart) IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

C Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a smart pump is necessarily required if the facility does have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety. : Applying/Application REF: 760 : Vasoconstrictors| shock| supervision| communication : Integrated Process: Communication and Documentation : Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 2 mL/kg/hr for 4 hours

C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 2 mL/kg/hr for 4 hours is normal. Remembering/Knowledge REF: 783 Coronary artery disease| critical rescue| nursing assessment Integrated Process: Nursing Process: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

C The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM). Remembering/Knowledge REF: 785 Coronary artery disease| Core Measures| The Joint Commission Integrated Process: Communication and Documentation Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse caring for a client es the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. ify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

C This client has several indicators of sepsis with systemic inflammatory response. The nurse should ify the health care provider immediately. Documentation needs to be thorough but does take priority. The client may appreciate warm blankets, but comfort measures do take priority. The client may or may need insulin. : Applying/Application REF: 762 : Shock| nursing assessment| critical rescue| communication : Integrated Process: Communication and Documentation : Client Needs Category: Safe and Effective Care Environment: Management of Care

6. Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. A good abrasive pumice stone will keep my feet soft. b. Ill always wear shoes if I can buy cheap flip-flops. c. I will keep my feet dry, especially between the toes. d. Lotion is important to keep my feet smooth and soft. e. Washing my feet in room-temperature water is best.

C, D, E Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry wearing good, comfortable shoes using lotion washing the feet in room-temperature water and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flipflops may not fit well and wont offer much protection against injury.

19. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

11. An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. I nearly always wear comfy sweatpants and house shoes. b. Im glad I get energy assistance so my house isnt so cold. c. My daughter makes sure I have plenty of lotion for my feet. d. My hands shake when I try to do things requiring coordination.

D Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the tr-ANSducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The tr-ANSducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated. Applying/Application REF: 781 Coronary artery disease| hemodynamic monitoring| fluid and electrolyte imbalance Integrated Process: Nursing Process: Implementation Client Needs Category: Physiological Integrity: Physiological Adaptation

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the clients stress levels. d. Tell the client that anxiety is common and that you can help.

D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the clients anxiety. Applying/Application REF: 787 Coronary artery disease| preoperative nursing| psychosocial response| anxiety| coping| therapeutic communication Integrated Process: Caring Client Needs Category: Psychosocial Integrity

A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.) a. Assess for further chest pain. b. Call the Rapid Response Team. c. Have the client sit upright. d. Listen to the clients lung sounds.

D The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the clients lung sounds. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound. Applying/Application REF: 773 Coronary artery disease| respiratory assessment| respiratory system| nursing assessment Integrated Process: Nursing Process: Assessment Client Needs Category: Physiological Integrity: Reduction of Risk Potential

1. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

D The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority. Applying/Application REF: 787 Coronary artery disease| infection control| hand hygiene Integrated Process: Nursing Process: Implementation Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

2. A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs

D, E The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.