RN perfusion

A client has extreme fatigue and is malnourished, and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food high in which nutrients? You selected: thiamine, riboflavin, and niacin Incorrect Correct response: vitamins B6 and B12, folate, iron, and copper Explanation: Many vitamin and mineral deficiencies can result in anemia. All of these vitamins and minerals need to be assessed, preferably through a nutrition assessment. Deficiencies of vitamins A, B6, and C result in a small cell, microcytic anemia. Folate and vitamin B12 deficiencies result in a large cell, macrocytic anemia. Iron, copper, and vitamin E deficiencies can also result in anemia.

A client has extreme fatigue and is malnourished, and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food high in which nutrients? You selected: thiamine, riboflavin, and niacin Incorrect Correct response: vitamins B6 and B12, folate, iron, and copper Explanation: Many vitamin and mineral deficiencies can result in anemia. All of these vitamins and minerals need to be assessed, preferably through a nutrition assessment. Deficiencies of vitamins A, B6, and C result in a small cell, microcytic anemia. Folate and vitamin B12 deficiencies result in a large cell, macrocytic anemia. Iron, copper, and vitamin E deficiencies can also result in anemia.

When teaching parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction? You selected: "Relax discipline and limit-setting to prevent crying." Incorrect Correct response: "Try to maintain your child's usual lifestyle to promote normal development." Explanation: The nurse should encourage the parents of a child with a congenital heart defect to treat the child normally and allow self-limited activity. Telling the parents to reduce the child's caloric intake isn't appropriate because doing so wouldn't necessarily reduce cardiac demand. Telling the parents to alter disciplinary patterns and deliberately prevent crying or interactions with other children could foster maladaptive behaviors. Contact with peers promotes normal growth and development.

When teaching parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction? You selected: "Relax discipline and limit-setting to prevent crying." Incorrect Correct response: "Try to maintain your child's usual lifestyle to promote normal development." Explanation: The nurse should encourage the parents of a child with a congenital heart defect to treat the child normally and allow self-limited activity. Telling the parents to reduce the child's caloric intake isn't appropriate because doing so wouldn't necessarily reduce cardiac demand. Telling the parents to alter disciplinary patterns and deliberately prevent crying or interactions with other children could foster maladaptive behaviors. Contact with peers promotes normal growth and development.

A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). In order to determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? You selected: "Is this the first time you experienced this type of pain?" Incorrect Correct response: "What time did your chest pain start?" Explanation: Thrombolytic therapy must be started within 6 hours of the onset of the myocardial infarction (MI). The time the chest pain started is the priority. The nurse can assess for allergies once the time is determined. Nitroglycerine will not impact the administration of thrombolytic therapy. (less)

A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). In order to determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? You selected: "Is this the first time you experienced this type of pain?" Incorrect Correct response: "What time did your chest pain start?" Explanation: Thrombolytic therapy must be started within 6 hours of the onset of the myocardial infarction (MI). The time the chest pain started is the priority. The nurse can assess for allergies once the time is determined. Nitroglycerine will not impact the administration of thrombolytic therapy. (less)

A client has nephrotic syndrome. To aid in the resolution of the client's edema, the health care provider (HCP) prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome? You selected: cool skin temperature in lower extremities Incorrect Correct response: blood pressure elevation Explanation: Albumin is a colloid that remains in the intravascular space, pulling fluid out of the intracellular and interstitial space. The client with nephrotic syndrome loses excessive amounts of protein, mainly albumin, in the urine. Because fluid is drawn into the intravascular space, blood pressure will increase. Crackles in the lung bases and cerebral edema are signs of circulatory overload or fluid volume excess. When edema is present in lower extremities, the skin feels cool to the touch unless an infection is present

A client has nephrotic syndrome. To aid in the resolution of the client's edema, the health care provider (HCP) prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome? You selected: cool skin temperature in lower extremities Incorrect Correct response: blood pressure elevation Explanation: Albumin is a colloid that remains in the intravascular space, pulling fluid out of the intracellular and interstitial space. The client with nephrotic syndrome loses excessive amounts of protein, mainly albumin, in the urine. Because fluid is drawn into the intravascular space, blood pressure will increase. Crackles in the lung bases and cerebral edema are signs of circulatory overload or fluid volume excess. When edema is present in lower extremities, the skin feels cool to the touch unless an infection is present

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? You selected: Assessing B-type natriuretic peptide levels Incorrect Correct response: Assessing troponin 1 levels Explanation: Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority.

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? You selected: Assessing B-type natriuretic peptide levels Incorrect Correct response: Assessing troponin 1 levels Explanation: Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority.

A client with gestational hypertension is likely to exhibit: You selected: headaches, double vision, and vaginal bleeding. Incorrect Correct response: proteinuria, headaches, and double vision. Explanation: A client with gestational hypertension typically complains of headache, double vision, and sudden weight gain. Additional findings include proteinuria. Vaginal bleeding and uterine contractions aren't associated with gestational hypertension.

A client with gestational hypertension is likely to exhibit: You selected: headaches, double vision, and vaginal bleeding. Incorrect Correct response: proteinuria, headaches, and double vision. Explanation: A client with gestational hypertension typically complains of headache, double vision, and sudden weight gain. Additional findings include proteinuria. Vaginal bleeding and uterine contractions aren't associated with gestational hypertension.

A laboring client on oxyitocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings, which of the following would be the best action for the nurse? You selected: Administer pain medicine for reports of increasing discomfort. Incorrect Correct response: Discontinue the oxytocin if the uterus does not relax between uterine contractions. Explanation: One of the nursing responsibilities with the administration of an oxytocic, such as oxytocin, is to assess for uterine hyperstimulation (as per institutional policy, i.e., Q 15 mins). Uterine hyperstimulation is defined as a uterus that does not relax between uterine contractions and/or uterine contractions that occur more frequently than 1:2, exceed 90 seconds duration, and have strong intensity. The priority is the hyperstimulated uterus; pain medicine would not be appropriate. Increasing the oxytocin would endanger the client and placental blood supply to the infant.

A laboring client on oxyitocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings, which of the following would be the best action for the nurse? You selected: Administer pain medicine for reports of increasing discomfort. Incorrect Correct response: Discontinue the oxytocin if the uterus does not relax between uterine contractions. Explanation: One of the nursing responsibilities with the administration of an oxytocic, such as oxytocin, is to assess for uterine hyperstimulation (as per institutional policy, i.e., Q 15 mins). Uterine hyperstimulation is defined as a uterus that does not relax between uterine contractions and/or uterine contractions that occur more frequently than 1:2, exceed 90 seconds duration, and have strong intensity. The priority is the hyperstimulated uterus; pain medicine would not be appropriate. Increasing the oxytocin would endanger the client and placental blood supply to the infant.

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). The nurse should: You selected: restrict the client's sodium intake. Incorrect Correct response: encourage the client to increase fluid intake. Explanation: The client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). The nurse should: You selected: restrict the client's sodium intake. Incorrect Correct response: encourage the client to increase fluid intake. Explanation: The client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.

A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assesses the attendee as being unresponsive. Indicate how the nurse should respond by placing the following actions in chronological order. Use all of the options. You selected: Appoint a person to call 911. Check for normal breathing. Check for a pulse. Perform a head tilt-chin lift maneuver. Deliver two rescue breaths. Perform chest compressions. Incorrect Correct response: Appoint a person to call 911. Check for a pulse. Perform chest compressions. Perform a head tilt-chin lift maneuver. Check for normal breathing. Deliver two rescue breaths. Explanation: Following the 2010 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR), the rescuer should activate the emergency response system and get an automatic external defibrillator (AED) or appoint another person to do this. The next step is to check the pulse for no more than 10 seconds. If no pulse is detected, the rescuer gives 30 chest compressions. Next, the rescuer opens the airway with the head tilt-chin lift or jaw thrust maneuver and checks for breathing. If breathing is not detected, the rescuer gives two rescue breaths and immediately resumes chest compressions. The rescuer should use the AED as soon as it arrives.

A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assesses the attendee as being unresponsive. Indicate how the nurse should respond by placing the following actions in chronological order. Use all of the options. You selected: Appoint a person to call 911. Check for normal breathing. Check for a pulse. Perform a head tilt-chin lift maneuver. Deliver two rescue breaths. Perform chest compressions. Incorrect Correct response: Appoint a person to call 911. Check for a pulse. Perform chest compressions. Perform a head tilt-chin lift maneuver. Check for normal breathing. Deliver two rescue breaths. Explanation: Following the 2010 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR), the rescuer should activate the emergency response system and get an automatic external defibrillator (AED) or appoint another person to do this. The next step is to check the pulse for no more than 10 seconds. If no pulse is detected, the rescuer gives 30 chest compressions. Next, the rescuer opens the airway with the head tilt-chin lift or jaw thrust maneuver and checks for breathing. If breathing is not detected, the rescuer gives two rescue breaths and immediately resumes chest compressions. The rescuer should use the AED as soon as it arrives.

Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the following lab tests (see chart). What should the nurse do first? You selected: Administer the medications. Incorrect Correct response: Withhold the captopril. Explanation: The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.

Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the following lab tests (see chart). What should the nurse do first? You selected: Administer the medications. Incorrect Correct response: Withhold the captopril. Explanation: The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.