AH1 NCLEX EXAM 2 (CH. 27-28, 32-33, 35, 61, 62, 63)
A 40-year-old client is admitted to the ED with fever, chills, and severe right flank pain. Her heart rate is 114/min and respiratory rate is 30/min. She reports recently being treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA). 1. What condition does the nurse anticipate? 2. What laboratory tests does the nurse anticipate will be ordered?
1. Acute pyelonephritis. 2. Urinalysis—positive leukocyte esterase and nitrite dipstick test, presence of white blood cells (WBCs) and bacteria; urine culture and sensitivity (C&S); blood cultures; C-reactive protein; erythrocyte sedimentation rate.
Two hours later, the client is admitted to the cardiac stepdown unit. Orders include: Saline lock Cardiac diet Oxygen at 2 L per nasal cannula Follow-up cardiac enzymes 12-lead ECG in 6 hours. One hour later, the client reports severe shortness of breath and mild chest pain. Oxygen saturation is 88%, BP is 96/54, and the monitor shows sinus tachycardia with a rate of 116. 2a. What do you suspect is happening to the client? 2b. The client's laboratory values include troponin T 0.6 mg/mL. What is your interpretation of this finding?
2a. Based on the history of the recent CP and now increased shortness of breath with hypoxemia, the nurse can conclude that the client may be experiencing heart failure. 2b. Troponin T is elevated. This substance is not found in healthy clients; any rise indicates cardiac necrosis or acute MI.
During morning care the next day, the client develops shortness of breath, fatigue, and tachycardia. 4a. How does the nurse interpret these findings? 4b. Which nursing interventions are appropriate at this time?
4a. The patient has developed fatigue from too much exertion. 4b. Energy management—provide physical and emotional rest; arrange nursing care to provide periods of rest; provide assistance with any care the client is unable to complete for himself; observe and document the client's response to activity; as the client improves, consult with a physical therapist; gradually increase activity based on the client's responses.
A 20-year-old male client reports to the college health center, reporting burning upon urination. What priority question will the nurse ask? A. "Are you sexually active?" B. "Do you have low back pain?" C. "How long have you had these symptoms?" D. "Have you had a fever in the past 24 hours?"
A. "Are you sexually active?" The most common cause of urethritis in men is sexually transmitted infections (STIs). These include gonorrhea or nonspecific urethritis caused by Ureaplasma (a gram-negative bacterium), Chlamydia (a sexually transmitted gram-negative bacterium), or Trichomonas vaginalis (a protozoan found in both the male and female genital tracts). Other questions can be asked after assessing sexual activity and possible STI exposure.
A client with COPD who smokes 1 PPD presents for a routine appointment. Which client statement causes the nurse to suspect an increase in dyspnea? A. "I prop myself up at night to sleep." B. "I decided to put on some makeup today." C. "I have a productive cough in the morning." D. "I have gained weight since I was here last."
A. "I prop myself up at night to sleep." Clients with COPD, who smoke, may have a productive morning cough. Weight loss (not gain) often occurs when dyspnea is increased due to the increased metabolic demand. A disheveled appearance may indicate an increase in dyspnea, if the client doesn't feel well enough to perform ADLs. Sleeping propped up indicates that breathing may be worse while lying down.
The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."
A. "If you tend to get angry easily, then your risk for heart disease is higher." C. "Do not eat more calories on a daily basis that you are able to burn." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."
The nurse is admitting a client with an ulcer on the right foot. Which client statement indicates venous insufficiency to the nurse? Select all that apply. A. "My ankles swell up all the time." B. "My leg hurts after I walk about a block." C. "My feet are always really cold." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."
A. "My ankles swell up all the time." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."
The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."
A. "Please roll onto your left side."
What teaching will the nurse provide to a client who says, "Smoking doesn't hurt my heart"? A. "Smoking increases risks for heart disease." B. "Lungs are the only organ damaged by smoking." C. "The impact of smoking is only on the heart." D. "Are you worried about smoking?"
A. "Smoking increases risks for heart disease." Cigarette smoking is a major risk factor for CVD, specifically coronary artery disease (CAD) and peripheral vascular disease (PVD). The other options are are incorrect and do not provide necessary teaching.
The nurse is caring for a 38-year-old male with hypertension and stage 1 CKD. The client reports lifestyle changes and feeling "better" and has stopped taking a prescribed diuretic. What is the appropriate nursing response? A. "The diuretic will reduce your blood pressure, which may slow or prevent progression of your chronic kidney disease." B. "Your primary health care provider prescribed the diuretic because it will reverse the damage caused by kidney disease." C. "Taking medications is a personal decision, and you have the right to decline this prescription." D. "Since you have implemented lifestyle changes, the diuretic is likely not needed."
A. "The diuretic will reduce your blood pressure, which may slow or prevent progression of your chronic kidney disease."
The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use? A. "The nitroglycerin should tingle when I put it in my mouth." B. "I will keep nitroglycerin in the glove compartment of my car." C. "Since the pills are small, they won't be hard to swallow." D. "The nitroglycerin should relieve the pain immediately."
A. "The nitroglycerin should tingle when I put it in my mouth."
The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."
A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."
A nursing student is teaching a 72-year-old client about the importance of the pneumonia vaccination. Which teaching will the nurse provide? A. "You will need two vaccines to best protect yourself." B. "There are two vaccines available and you can choose just one." C. "If you have had the PCV13 vaccine, then you will not need the PPSV23 vaccine." D. "Since you are over 64 years old, only the flu vaccine is suggested."
A. "You will need two vaccines to best protect yourself." There are two pneumonia vaccines: pneumococcal polysaccharide vaccine (PPSV23) and pneumococcal conjugate vaccine (PCV13) for prevention of pneumonia (Phillips & Swanson, 2016). The CDC recommends that adults older than 65 years be vaccinated with both, first with PCV13 followed by PPSV23 about 6 to 12 months later. Adults who have already received the PPSV23 should have PCV13 about a year or more later. These recommendations also apply to adults between 19 and 64 years of age who have specific risk factors such as chronic illnesses (CDC, 2018b). Because pneumonia often follows influenza, especially among older adults, urge all adults to receive the seasonal vaccination annually.
You immediately notify the provider and within 45 minutes, the client is transferred to the CCU in serious condition. He has developed crackles bilaterally, and his chest pain level has increased. 3. Which drugs do you anticipate will be ordered? (Select all that apply.) A. Atenolol B. Morphine C. Prednisone D. Furosemide E. Acetaminophen
A. Atenolol B. Morphine D. Furosemide Based on the assessment findings, several medications will be ordered including IV diuretics (furosemide) and supplemental oxygen. If congestion and shortness of breath become critical, the client may need to be placed on a ventilator until the fluid volume overload is under control. Once-a-day beta-adrenergic blocking agents (atenolol) decrease the size of the infarct, the occurrence of ventricular dysrhythmias, and mortality rates in clients with MI. A cardioselective beta-blocking agent is usually prescribed within the first 1 to 2 hours after an MI if the client is hemodynamically stable. Beta blockers slow the heart rate and decrease the force of cardiac contraction. Medical interventions aim to relieve pain and decrease myocardial oxygen requirements through preload and afterload reduction. IV morphine is used to decrease pulmonary congestion and relieve pain.
The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for cardiovascular disease? Select all that apply. A. BMI of 26 B. BP of 120/66 mm Hg C. Triglycerides 140 mg/dL D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cigarette smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease
A. BMI of 26 D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cigarette smoke G. Family history of cardiovascular disease
The nurse is assessing a client with a chest tube following a pneumonectomy. Which assessment finding requires nursing intervention? A. Bandage around the posterior tube is loose. B. 2 cm of water is in the second chest tube chamber. C. The water in the water seal chamber rises and falls with inhalation/exhalation. D. Bubbling present in the water seal chamber when the client coughs.
A. Bandage around the posterior tube is loose. After lung surgery, two tubes, anterior and posterior, are used. Dressings around the wound should not be loose. Other findings are normal.
After the assessment, the nurse documents: Jugular venous distention 2+ edema in feet and ankles Swollen hands and fingers Distended abdomen Bibasilar crackles on auscultation Productive cough with pink-tinged sputum 3. What condition is most likely, based on these results? A. Biventricular failure B. Class IV heart failure C. Left-sided heart failure D. Right-sided heart failure
A. Biventricular failure The client has key features of both right-sided and left-sided heart failure.
A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera
A. Blurry vision G. Yellowing of the sclera
A client has come to the emergency department with a new onset of chest pain rated at 7 on a 0-10 scale. Which laboratory test does the nurse anticipate will be ordered? A. CK B. HDL C. WBC D. Troponin
A. CK Troponins T and I are not found in healthy clients, so any rise in values indicates cardiac necrosis or acute MI. Specific markers of myocardial injury, troponins T and I, have a wide diagnostic time frame, making them useful for clients who present several hours after the onset of chest pain. Even low levels of troponin T are treated aggressively because of increased risk for death from cardiovascular disease (CVD).
For which diagnostic test does the nurse prepare the client suspected of acute pyelonephritis? (Select all that apply.) A. CT scan B. KUB x-ray C. Thoracic MRI D. BUN and creatinine E. WBC with differential
A. CT scan B. KUB x-ray D. BUN and creatinine E. WBC with differential All of these diagnostic tests can be used when acute pyelonephritis is anticipated. A thoracic MRI is not indicated.
Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? A. Carotid artery bruit B. HDL 60 mg/dL C. Palpable peripheral pulses D. BP 120/58 mm Hg
A. Carotid artery bruit
Fifteen minutes after replacing the nasal cannula, the client's oxygen saturation is 97%. What is the appropriate nursing action? A. Continue the assessment B. Encourage deep breathing C. Contact the health care provider D. Increase the oxygen to 5 L per nasal cannula.
A. Continue the assessment Once the patient's oxygen is replaced, he denies shortness of breath. The supplemental oxygen and a period of rest resulted in his oxygen saturation being 96%, which is acceptable. The oxygen should not be increased, nor does he need to take deep breaths because the patient's SaO2 is normal and he is not short of breath.
The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply. A. Denial is common reaction to chest pain. B. A myocardial infarction can occur in minutes. C. Exercise at least 20 minutes three to four times per week. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.
A. Denial is common reaction to chest pain. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.
A client with diabetes has the following assessment changes after a percutaneous nephrolithotomy procedure. Which change requires immediate nursing intervention? A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula B. A point-of-care blood glucose of 150 mg/dL and client report of thirst C. A decreased hematocrit by 1% (compared with preoperative values and hematuria) D. An oral temperature of 38° C (101° F) and cloudiness of urine draining from the nephrostomy tube after IV administration of a broad-spectrum antibiotic
A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula
The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach
A. Digoxin therapy daily
A client with a recently created vascular access for hemodialysis is being discharged. Which discharge teaching will the nurse include? A. Do not allow blood pressure measurements in the affected arm. B. Elevate the affected arm, allowing for total rest of the extremity. C. Assess for a bruit in the affected arm on a daily basis. D. Sleep on the affected side to protect the access device.
A. Do not allow blood pressure measurements in the affected arm.
For which symptom will the nurse assess in an older adult client who is suspected of having pneumonia? Select all that apply. A. Fever B. Cough C. Confusion D. Weakness E. TST induration
A. Fever B. Cough C. Confusion D. Weakness The older adult with pneumonia often has fever, cough, weakness, fatigue, lethargy, confusion, and poor appetite. TST induration is associated with tuberculosis; not pneumonia.
A client for whom the nurse is caring is diagnosed with rhinosinusitis. Which symptom does the nurse anticipate will be found upon assessment? A. Fever B. Fatigue C. Dental pain D. Sore throat E. Ear pressure F. Lack of response to decongestants
A. Fever B. Fatigue C. Dental pain D. Sore throat E. Ear pressure F. Lack of response to decongestants Symptoms of bacterial rhinosinusitis include purulent nasal drainage with postnasal drip, sore throat, fever, erythema, swelling, fatigue, dental pain, and ear pressure. A lack of response to decongestants can also be indicative of a bacterial infection.
The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment finding indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 mL of bloody drainage in chest tube over 4 hours
A. Heart rate of 50 beats/min
A client with chronic heart failure has been prescribed ivabradine. Which assessment data requires the nurse to contact the health care provider before administering this medication? A. Hypotension B. Ejection fraction of 29% C. Resting heart rate 80 beats/min D. Patient is currently on a beta blocker
A. Hypotension Ivabradine is used for HF clients who have an ejection fraction (EF) <32% who are in sinus rhythm with a resting heart rate ≥70 beats/min. This medication is used for clients who are either on the maximally tolerated dose of beta blocker therapy or have a contraindication to beta blocker therapy. Ivabradine is contraindicated with hypotension, sick sinus syndrome, 3rd degree heart block, pacemaker dependence, severe hepatic impairment, and use of cytochrome P4503A4 inhibitors.
The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased
A. ST changes C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased
Which assessment data would the nurse anticipate in a client with acute pyelonephritis? Select all that apply. A. Urinary frequency B. Dysuria C. Oliguria D. Heart rate 120 beats/min E. Uremia F. Costovertebral angle tenderness
A. Urinary frequency B. Dysuria D. Heart rate 120 beats/min E. Uremia F. Costovertebral angle tenderness
Two hours later, the client suspected with pneumonia has a weak cough, crackles in both lower lobes, and an SpO2 reading of 90% by pulse oximetry. 3. What interventions will the nurse implement at this time?
ANS: The client has developed problems with her airway. Interventions should include helping her to cough and deep breathe at least every 2 hours; teaching incentive spirometry every hour while awake; encouraging the client to consume 3 L of fluid per day; monitoring intake and output; and administering bronchodilators if ordered.
The nurse obtains these vital signs: BP—142/90 mm Hg HR—80/min R—18/min T—97.8º F 2. Based on these readings, does the client have hypertension? Explain your response.
ANS: The client's blood pressure indicates he may have hypertension. However, blood pressure should be checked in both arms and two or more readings should be taken at each visit, with the average of the readings used as the value for the visit.
A 58-year-old African-American client is seeing his primary health care provider for an annual examination. His family history includes hypertension and type 2 diabetes. He is 30 pounds overweight and reports smoking a pack of cigarettes daily. He works as a car salesman in a very competitive market. 1. What risk factors for hypertension does the nurse identify for this client?
ANS: This client has several risk factors for hypertension including his age, being African American, having a positive family history for high blood pressure and diabetes, smoking, being overweight, and having job-related stress.
Paramedics arrive at the ED with a 74-year-old client with severe chest pain rated at an 8 on a 0-10 scale. He says he has had chest pain for a few hours which got bad enough that he called 911. He takes "heart medications" but does not recall their names. The electronic health record shows a history of CAD and a myocardial infarction 5 years ago with stent placement in the LAD and the circumflex artery. He says "my doctor said I also have heart failure". 1. What diagnostic tests do you anticipate the provider will order for this client?
ANS: While there is no single ideal test to diagnose MI, the most common tests include troponins T and I and echocardiogram, 12-lead ECG. CAD, coronary artery disease; LAD, left anterior descending artery.
A client with hypertension asks about the cause. Which nursing response is appropriate? A. "Pregnancy can cause essential hypertension." B. "High cholesterol is a big factor in development of essential hypertension." C. "Stopping caffeine intake can cause hypertension to go away." D. "Race is associated with secondary hypertension."
B. "High cholesterol is a big factor in development of essential hypertension."
The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."
B. "I need to take potassium supplements with this medication."
Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."
B. "I was nervous last night, but I still remembered to take my warfarin."
The nurse is preparing a client with stage 3 CKD for discharge. Which client statement indicates the need for further teaching? A. "I will be sure to attend my follow-up appointment with my nephrologist." B. "I will increase my protein intake so my body can heal." C. "I will weigh myself daily and call the doctor if my weight increases by 2 lb or more." D. "I will take my blood pressure each day and keep a daily log."
B. "I will increase my protein intake so my body can heal."
A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm? A. "This year I will get the pneumonia vaccination in addition to a flu shot." B. "Now I will try to rest as much as possible and avoid any unnecessary exercise." C. "Maybe drinking a supplement will help me retain weight and have more energy." D. "Perhaps using a spacer with my metered dose inhaler will make the drug work better."
B. "Now I will try to rest as much as possible and avoid any unnecessary exercise."
A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year, too, as a booster." B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."
B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season."
A client newly diagnosed with stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response? A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it." B. "This drug is approved for use in clients whose lung cancer has metastasized not for early-stage cancers." C. "Why would you want to take a drug for months when you may be cured by surgery alone?" D. "You need to talk about this with your oncologist and your surgeon."
B. "This drug is approved for use in clients whose lung cancer has metastasized not for early-stage cancers."
Which client will the nurse identify as at risk for acute kidney injury? Select all that apply. A. 68-year-old male with diabetes mellitus B. 16-year-old male football player in preseason practice C. 27-year-old female recovering from shock following a car accident D. 52-year-old male with newly diagnosed hypertension E. 30-year-old female in intensive care receiving multiple intravenous antibiotics
B. 16-year-old male football player in preseason practice C. 27-year-old female recovering from shock following a car accident E. 30-year-old female in intensive care receiving multiple intravenous antibiotics
The nurse is caring for four clients. Which client does the nurse identify at highest risk for acute pyelonephritis? A. 18-year-old male with spinal cord injury B. 24-year-old female with urinary reflux C. 31-year-old male with HIV infection D. 40-year-old female with urinary tract stones
B. 24-year-old female with urinary reflux Acute pyelonephritis is most commonly seen in 20 to 30 year old female. Reflux is a key contributor. The conditions of other clients is characteristic of chronic pyelonephritis.
Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)
B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years
A client with a history of asthma reports shortness of breath. The nurse observes that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A. Obtain vital signs. B. Administer rescue drugs. C. Notify the health care provider. D. Repeat the PEF reading to verify results
B. Administer rescue drugs. A PEF reading in the red zone indicates a range that is 50% below the client's personal best PEF reading and indicates serious respiratory obstruction. The client needs to receive rescue drugs immediately, and then the health care provider should be notified. Repeating the PEF reading and taking vital signs are also important, but doing so delays the administration of the rescue drugs. These can be done after rescue drugs are given.
The nurse is caring for a 74-year-old client scheduled for a cardiac catheterization with contrast dye. What nursing action is appropriate? Select all that apply. A. Assess creatinine clearance using a 24-hour urine collection test. B. Assess for coexisting conditions of diabetes, heart failure, and kidney disease. C. Collaborate with the provider about whether IV fluids should be infused before the test. D. Notify the provider regarding changes in serum creatinine from 0.2 to 0.4 mg/dL in 24 hours. E. Alert the provider to a glomerular filtration rate (GFR) below 60 mL/min/1.73 m2.
B. Assess for coexisting conditions of diabetes, heart failure, and kidney disease. C. Collaborate with the provider about whether IV fluids should be infused before the test. E. Alert the provider to a glomerular filtration rate (GFR) below 60 mL/min/1.73 m2.
The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Assist the client to a side-lying position and reassess the water seal chamber for bubbling. C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system. D. No action is needed because these responses are normal for the first postoperative day after lobectomy.
B. Assist the client to a side-lying position and reassess the water seal chamber for bubbling.
A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. Which drug should be held until after the dialysis treatment? A. Calcium B. Atenolol C. Glyburide D. Multivitamin
B. Atenolol Vasoactive drugs such as beta blockers like atenolol can cause hypotension during dialysis and are usually held until after treatment.
A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop
B. Crackles in both lungs C. Tachycardia E. Tachypnea F. S3 gallop
The nurse is caring for a female client with atypical angina. Which symptom does the nurse anticipate? (Select all that apply.) A. Vomiting B. Dizziness C. Indigestion D. Aching jaw pain E. Irregular bowel movements F. Decreased patterns of activity
B. Dizziness C. Indigestion D. Aching jaw pain F. Decreased patterns of activity Rationale: Many women experience atypical angina which manifests as indigestion, pain between the shoulders, an aching jaw, or a choking sensation that occurs with exertion. Other symptoms may include unusual fatigue, shortness of breath, dizziness, palpitations, generalized anxiety or weakness and flu-like symptoms.
The nurse is caring for a client immediately following a cardiac catheterization. Which assessment data require immediate nursing intervention? A. Blood pressure 146/70 mm Hg B. Hematoma developing at insertion site C. Client reports headache pain D. Client reports extreme thirst
B. Hematoma developing at insertion site
While the Rapid Response Team is at the bedside, the client's health care provider arrives. The provider writes several orders. Which order will the nurse implement immediately? A. Transfer to ICU B. Increase O2 to 3 L per nasal cannula C. ABGs 30 minutes after oxygen is increased D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP
B. Increase O2 to 3 L per nasal cannula All of the provider's orders are very important, but based on the client's severe shortness of breath, the first thing that should be done is to increase her oxygen. Once her oxygen is increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes. The client should then be transferred to the ICU as soon as possible. Once the client arrives in the ICU, they can administer the one-time dose of Solu-Medrol.
A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her O2 flow rate by 2 L and reassess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.
B. Increase her O2 flow rate by 2 L and reassess in 5 minutes.
During the evening shift, the patient has a bedside echocardiogram, which reveals an ejection fraction of 30%. Which medication does the nurse anticipate may be prescribed by the health care provider? (Select all that apply.) A. Adenosine B. Lisinopril C. Digoxin D. Lidocaine E. Furosemide
B. Lisinopril C. Digoxin E. Furosemide Commonly prescribed drug classes for patients with heart failure include ACE inhibitors (lisinopril), diuretics (furosemide), nitrates (digoxin), human B-type natriuretic peptides, inotropics, and beta-adrenergic blockers. Adenosine and lidocaine are not indicated in this scenario.
The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? A. Incisional pain with decreased urine output B. Muffled heart sounds with the presence of JVD C. Sternal wound drainage with nausea D. Increased blood pressure and decreased heart rate
B. Muffled heart sounds with the presence of JVD
A 53-year-old client was admitted 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5ʹ8ʺ tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. Upon entering the room, the nurse notes the client sitting on the side of the bed, sweating, and experiencing shortness of breath. He reports just using the bathroom. His nasal cannula is on the bedside table. 1. Which action will the nurse take? A. Obtain vital signs. B. Replace the nasal cannula. C. Sit him up in a bedside chair. D. Call the Rapid Response Team.
B. Replace the nasal cannula. uThe patient has exerted himself in ambulating to and from the bathroom. He also has been without supplemental oxygen. The nurse will replace his nasal cannula. He has a history of heart failure and will often require supplemental oxygen. Taking his vital signs can be done once his oxygen is restored. If he wants to sit up, he should be positioned in bed, not in a bedside chair. Calling the Rapid Response Team is not necessary.
An 81-year-old client who came to the ED has been admitted to the medical-surgical unit with a diagnosis of suspected pneumonia. She reports having a productive cough and fever for 2 days. Assessment reveals that she is flushed and short of breath when talking. She has a history of type 2 diabetes mellitus and hypertension, and no known allergies. A chest x-ray, CBC, and basic metabolic panel (electrolytes, BUN, creatinine) were done in the ED. A saline lock is inserted into her right forearm. Upon arrival to the unit, blood glucose and vital signs are obtained. BG—239 mg/dL BP—138/88 mm Hg HR—128 RR—36 breaths/min O2 saturation—88% (room air) Temperature—101.6º F 1. Which vital sign or test result requires immediate nursing intervention? A.Blood pressure B.Respiratory rate C. Temperature D. Blood glucose
B. Respiratory rate All of the client's vital signs are abnormal. However, the most important one to address immediately is the increased respirations (and decreased oxygen saturation). Even though a diagnosis has not been confirmed, it is very important to address tachypnea.
A 62-year-old client was admitted 2 days ago with traumatic injuries and hypovolemic shock. Which lab result is most important for the nurse to report to the health care provider immediately? A. Serum sodium 132 mEq/L (mmol/L) B. Serum potassium 6.9 mEq/L (mmol/L) C. Blood urea nitrogen 24 mg/dL (mmol/L) D. Hematocrit 32% (0.32 volume fraction); hemoglobin 9.2 g/dL (92 g/L)
B. Serum potassium 6.9 mEq/L (mmol/L)
A 60-year-old woman with COPD who smoked cigarettes for 40 years is admitted to the hospital. The ED nurse reports the following to the medical-surgical nurse: - Has a saline lock in the R forearm and is on oxygen at 2 L per nasal cannula - Had a bronchodilator respiratory treatment in the ED - Has bilateral expiratory wheezes and crackles, anteriorly and posteriorly Which assessment finding does the nurse expect to see when the client arrives? (Select all that apply.) A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance
B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance The client with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These clients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided. Bradycardia is not anticipated.
Which assessment finding does the nurse anticipate for a client with chronic glomerulonephritis? (Select all that apply.) A. Increased urinary output B. Specific gravity of 1.010 C. Red blood cells in the urine D. Serum creatinine of 5 mg/dL E. Sodium level of 130 mEq/L
B. Specific gravity of 1.010 C. Red blood cells in the urine Options B and C are expected findings in a client with chronic glomerulonephritis. This client would also have decreased urinary output, serum creatinine of < 6 mg/dL, and a sodium level of > 135 mEq/L. The other findings are not anticipated.
The nurse is caring for a client receiving intravenous heparin for treatment of DVT who begins to begins to vomit blood. What action should the nurse be prepared to take? A. Administer vitamin K B. Stop the infusion of heparin C. Administer an antiemetic D. Insert a nasogastric tube
B. Stop the infusion of heparin
Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy? A. Avoid breathing into the inhaler or getting it wet. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because of the extreme drowsiness it causes.
B. The drug can only be given by a health care professional.
A 45-year-old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply. A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight
B. Tobacco use D. Diet F. Weight
A client has recently been admitted with a diagnosis of coronary artery disease (CAD). What lab assessment finding requires nursing interventions? (Select all that apply.) A. Cholesterol 120 mg/dL B. Triglycerides 168 mg/dL C. HDLs 40 mg/dL D. CRP 0.8 mg/dL E. Lipids 600 mg/dL
B. Triglycerides 168 mg/dL C. HDLs 40 mg/dL Triglycerides that are elevated signal increased risk for CAD and would be anticipated in a client diagnosed with CAD. Low HDL values indicate an increased risk for CAD and would be anticipated in a client with CAD. The other values are normal values. These values would likely be elevated in a client with CAD.
At the end of the visit, the primary health care provider prescribes hydrochlorothiazide 25 mg PO each morning. Which teaching will the nurse provide? A. "This is a loop diuretic that decreases sodium reabsorption." B. "Eat foods rich in potassium, such as bananas and orange juice." C. "A potassium supplement will be prescribed along with this drug." D. "This drug is a potassium-sparing diuretic that helps prevent the loss of essential potassium."
B."Eat foods rich in potassium, such as bananas and orange juice." Hydrochlorothiazide is a thiazide diuretic. The most frequent side effect is hypokalemia, so it's important to teach clients the signs of low potassium, as well as which foods are rich in potassium. Some clients need a potassium supplement, but this is prescribed based on the client's serum potassium level.
A client who is 9 days post-coronary artery bypass graft presents to a follow-up appointment. Which client statement requires nursing action? A. "My chest hurts when I sneeze or cough." B. "If I get tired when I walk, then I stop and rest for a bit." C. "I have a bandage on my sternum to collect the drainage." D. "I haven't had my normal appetite since the surgery."
C. "I have a bandage on my sternum to collect the drainage."
A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate? A. "You will need both drugs long-term to provide long-term anticoagulation." B. "Warfarin is easier on your stomach so you can take it long-term." C. "It takes several days for warfarin to begin working, so both drugs are required for a shorttime." D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."
C. "It takes several days for warfarin to begin working, so both drugs are required for a short time."
The nurse is providing discharge teaching to a client recovering from kidney transplantation. Which client statement indicates understanding? A. "I can stop my medications when my kidney function returns to normal." B. "If my urine output decreases, I will increase my fluids." C. "The antirejection medications will be taken for life." D. "I will drink 8 ounces (236 mL) of water with my medications."
C. "The antirejection medications will be taken for life."
The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug."
C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug."
A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."
C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting."
The nurse has placed an indwelling urinary catheter via sterile technique into a client. The nurse recognizes that it is how long before bacterial colonization begins? A. 12 hours B. 24 hours C. 48 hours D. 72 hours
C. 48 hours Within 48 hours of catheter insertion, bacterial colonization along the urethra and the catheter itself begins. Risks for infection associated with a catheter increases 3%-10% per day the catheter is in place (Ferguson, 2018).
The nurse is caring for four clients with a history of hypertension. Which client will the nurse see first? A. 30-year-old with pre-eclampsia, BP 120/68 B. 41-year-old with chronic kidney disease, BP 138/80. C. 53-year-old on diuretics, BP 160/80 D. 60-year-old with LDL-C 140 mg/dL, BP 114/84
C. 53-year-old on diuretics, BP 160/80 A client on diuretics that remains hypertensive requires intervention. The other options have a blood pressure that is normal or can be addressed after the nurse sees Client C.
A 68-year-old male client is seeing the primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. A 5 pack-year history of smoking 45 years ago B. Difficulty starting and stopping the urine stream C. A 30-year occupation as a long-distance truck driver D. A recent colon cancer diagnosis in his 72-year-old brother
C. A 30-year occupation as a long-distance truck driver
When performing a medication reconciliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm? A. Record and display the information in a prominent place within the client's medical record. B. Ask the client how long the drugs have been prescribed and how well the asthma is controlled. C. Collaborate with the surgeon to arrange for continuation of this therapy in the perioperative period. D. Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.
C. Collaborate with the surgeon to arrange for continuation of this therapy in the perioperative period.
Which action will the nurse take when having difficulty auscultating the first heart sound, S1? A. Listen at the heart base B. Assess only for higher pitched sounds. C. Direct the client to lay on his or her left side. D. Have the client hold their breath while auscultation takes place
C. Direct the client to lay on his or her left side. If the nurse is having difficulty hearing the heart sounds, ask the client to lean forward or roll to his or her left side. This will make the sounds more audible for auscultation. The first heart sound is low pitched and is best heard at the apex of the heart. Asking the client to hold their breath is not appropriate and while it will decrease respiratory noise, it will not make the heart sounds more audible as with positioning or correct auscultation location.
The nurse is caring for an 80-year-old female client with recurrent cystitis. Which teaching will the nurse include in the plan of care? Select all that apply. A. Drink citrus juices daily. B. Douche regularly; a minimum of two times weekly. C. Encourage fluid intake of 2-3 L of fluid throughout the day. D. Instruct her to always wipe the perineum from front to back after each toilet use. E. Reinforce that she should complete the entire course of antibiotics as prescribed. F. Instruct her to empty her bladder immediately before and after having intercourse.
C. Encourage fluid intake of 2-3 L of fluid throughout the day. D. Instruct her to always wipe the perineum from front to back after each toilet use. E. Reinforce that she should complete the entire course of antibiotics as prescribed. F. Instruct her to empty her bladder immediately before and after having intercourse.
The nurse is caring for a client with many risk factors for hypertension. A. Fainting B. Vomiting C. Headache D. Speech slurring
C. Headache Hypertension is often asymptomatic and has become known as the "silent killer" due to the lack of symptoms. Headaches may occur but not always. Hypertension does not cause slurred speech, fainting, or vomiting.
The nurse expects which outcome in a client who is taking a beta blocker for mild heart failure? A. Increased orthopnea B. Improved urinary output C. Improved activity tolerance D. Increased myocardial contractility
C. Improved activity tolerance Beta-blocker therapy for mild and moderate heart failure can lead to improvement in symptoms, including improved activity tolerance and less orthopnea.
Which assessment finding does the nurse anticipate in a client with right-sided heart failure? (Select all that apply.) A. Pulmonary congestion B. Shortness of breath C. Neck vein distension D. Enlarged abdominal girth E. A third heart sound
C. Neck vein distension D. Enlarged abdominal girth Right ventricular failure is associated with increased systemic venous pressures and congestions, which creates neck vein distension and enlarged abdominal girth. The other options are associated with left-sided heart failure.
A client who performs continuous ambulatory peritoneal dialysis at home reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the priority nursing action? A. Remove the peritoneal catheter. B. Notify the nephrology health care provider. C. Obtain a sample of effluent for culture and sensitivity. D. Teach the client that effluent should be clear or slightly yellow.
C. Obtain a sample of effluent for culture and sensitivity.
BG—239 mg/dL BP—138/88 mm Hg HR—128 RR—36 breaths/min O2 saturation—88% (room air) Temperature—101.6º F After consulting with the health care provider, these orders are received: ◦Full liquid diabetic diet ◦IV fluids 1000 mL 0.9 NS at 60 mL/hr ◦Oxygen at 2 L per nasal cannula ◦Blood cultures × 3 and urinalysis ◦Tylenol grain × every 4 hour for temperature above 101º F ◦Cefazolin (Ancef) 1 g IVP every 8 hour 2. Which order will the nurse implement first? A. Blood cultures and urinalysis B. Cefazolin 1 g IVP every 8 hours C. Oxygen at 2 L per nasal cannula D. IV fluids 1000 mL .9 NS at 60 mL/hr
C. Oxygen at 2 L per nasal cannula All orders are very important. However, the most important one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen is started as soon as possible. IV fluids should be started to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. AP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the antibiotic is administered.
The next morning, the client is taken to the cardiac catheterization laboratory. The cardiologist finds that there is an 80% blockage in the proximal LAD coronary artery. 4. Which procedure is most likely to be performed to correct this condition? A. Coronary atherectomy B. Coronary artery bypass graft surgery C. PTCA with coronary artery stent placement D. Percutaneous transluminal coronary angioplasty (PTCA)
C. PTCA with coronary artery stent placement The most common complication of PTCA is re-blockage of the coronary artery. For this reason, a coronary stent is placed to keep the re-opened artery from closing again.
A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm? A. pH from 7.21 to 7.20 B. HCO3- remains the same at 31 mEq/L C. Paco2 from 45 mm Hg to 68 mm Hg D. Pao2 from 88 mm Hg to 86 mm Hg
C. Paco2 from 45 mm Hg to 68 mm Hg
The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.
C. Place the client in a high-Fowler position.
The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4°F (39.7°C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated
C. Pneumonia may be present
A 28-year-old female client states, "I don't know why I get cystitis every year. I don't drink much at work so that I can avoid using the public toilet." Which teaching by the nurse is most likely to reduce her risk for cystitis? Select all that apply. A. Reinforce her choice to avoid using a public toilet. B. Teach her to shower immediately after having sexual intercourse. C. Suggest that she drink at least 2 to 3 L of fluid throughout the day. D. Urge her to change her method of birth control from oral contraceptives to a barrier method. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before intercourse.
C. Suggest that she drink at least 2 to 3 L of fluid throughout the day. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before intercourse.
The nurse is assessing a client with heart failure. Which assessment data are the best indicator of fluid balance? A. Blood pressure 144/79 mm Hg B. Urine output 200 mL in the last 4 hours C. Weight increase of 9 lb in the past week D. Generalized edema in the lower extremities
C. Weight increase of 9 lb in the past week
The client's daughter asks why her mother must be weighted before and after the dialysis treatment. What is the appropriate nursing response? A."It is part of the protocol for dialysis." B."It ensures that she is getting adequate nutrition." C."It estimates the amount of fluid and sodium your mother is retaining and how much is taken off during dialysis." D."It is essential for calculating the fluid restriction your mother will receive on non-dialysis days."
C."It estimates the amount of fluid and sodium your mother is retaining and how much is taken off during dialysis." The best way to estimate fluid and sodium retention and removal is by weighing the client.
Two days later during the nursing assessment, the client expresses embarrassment. She reports not taking the full treatment of antibiotics prescribed for the UTI she had recently. What is the appropriate nursing response? A. "The next time you will know to do better." B. "Why didn't you take all of your medication?" C. "Superbugs can develop when antibiotics aren't finished." D. "Can you tell me more about why you didn't take all of your antibiotics?"
D. "Can you tell me more about why you didn't take all of your antibiotics?" Response D is nonjudgmental and encourages the client to share more. This response may also offer an opportunity for client teaching. Responses A and C are true, but are nontherapeutic and do not help relieve the client's embarrassment. Response B is judgmental.
The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day." B. "I will restrict my intake of daily dietary lean protein." C. "I am only going to drink one cup of coffee to start my day." D. "I will drink a glass of low-fat milk with my breakfast."
D. "I will drink a glass of low-fat milk with my breakfast."
The nurse is caring for a client with intermittent claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management? A. "I need to reduce the number of cigarettes that I smoke each day." B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."
D. "I'll start to exercise gradually, stopping when I have pain."
For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash B. A 48-year-old man who has established paraplegia and is admitted for pneumonia C. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice
D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice Long-term catheter appropriate for patients with altered tissue integrity who need a dry environment for healing, for those who are terminally ill and need comfort, and for those who are critically ill and require precise measurement of urine output.
A client is diagnosed with renal colic. What would the nurse do first? A. Prepare the client for lithotripsy. B. Encourage oral intake of fluids. C. Strain the urine and send for urinalysis. D. Administer opioids as prescribed.
D. Administer opioids as prescribed.
A client presents to the ED and is diagnosed with an acute MI. The client's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response? A."The pain is controlled, so there is no damage." B."It will take years to know the extent of the damage to the heart muscle." C."The medication will dilate the blood vessels so damage will be corrected." D."A heart attack evolves over several hours. We won't know the extent of the damage immediately."
D."A heart attack evolves over several hours. We won't know the extent of the damage immediately." Infarction is a dynamic process that does not occur instantly. The MI evolves over a period of several hours. Controlled pain does not indicate that there is no cardiac muscle damage. The medications do vasodilate to prevent further damage. They do not correct damage that has already been incurred.
The client is diagnosed with hypertension. He asks what he can do to improve his health. 3. Which teaching points will the nurse include when providing information about reducing the impact, and successfully managing, hypertension?
Lifestyle changes, exercising, weight loss, and alternative therapies are all important components to successfully managing blood pressure. Part of the care plan should include teaching the client to monitor his blood pressure on a daily basis, not just at his clinical visits. Smoking and caffeine intake should be completely avoided.
The client is in the ICU for 3 days and then transferred back to a pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2L/min via nasal cannula. She denies any shortness of breath when resting during the assessment. The health care provider plans to discharge the client on home oxygen in the morning. What will the nurse include in this client's discharge teaching?
Make sure that the client understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress. Because she is being discharged with home oxygen, home health services should be arranged.
When the client arrives to the unit, she is assessed and is in acute respiratory distress. Her respirations are labored with a respiratory rate of 32. Oxygen saturation is 82% on O2 at 2 L/min via nasal cannula. What will the nurse do next?
The Rapid Response Team should be notified immediately. All of these assessment findings indicate acute respiratory difficulty. The oxygen saturation should be at least 90% on 2 L per NC.
The client's condition improves, and he is returned to the cardiac stepdown unit. He is to be discharged after 6 days in the hospital. 5. What client teaching will you provide before he is discharged?
•Assist the client in securing personal medical identification alert devices that provide information regarding his heart condition. •In collaboration with the interdisciplinary health care team, assess the client for activity tolerance and help design an appropriate exercise regimen. •Teach about the signs and symptoms of cardiovascular disease and when to seek medical assistance. •Instruct him about all of his current medications and the most common side effects. •Give him printed information as needed. •Teach him the importance of decreasing the risk for CAD. •Be sure that he has adequate support at home after discharge from the hospital.
