AH2 CARDIAC ADAPTIVE

Twenty-four hours after a penile implant the client's scrotum is edematous and painful. What should the nurse do?

- Elevate the scrotum using a soft support Elevating the scrotum using a soft support increases lymphatic drainage, reducing edema and pain. Assisting the client with a sitz bath and applying warm soaks to the scrotum increase circulation to the area, intensifying edema and pain in this client. Preparing for an incision and drainage procedure is not indicated; scrotal swelling is caused by the trauma of surgery, not infection.

The 1-day urine sample results of a client reveal that the calcium level is 800 mg/24 hr. What does the finding indicate?

- The client has hyperparathyroidism

Which natural physiologic process helps prevent bacterial infections within the client's bladder containing urine?

- The secretions of the urothelium The urothelium is the innermost epithelial lining of the bladder. The cells of the urothelium naturally produce antibacterial secretions that prevent bacterial growth within the bladder where urine is stored. The combined effect of relaxation of the detrusor muscle, contraction of external sphincter, and muscle tone of the internal sphincter help maintain continence.

A client with a suspected kidney disorder reports flank pain. Which nursing interventions should be conducted while performing flank assessment? Select all that apply.

-Asking the client to assume a sitting position -Placing one hand flat on costovertebral angle (CVA) While assessing the flank regions of a client with a suspected kidney disorder, the nurse should ask the client to assume a sitting position. The nurse should place one hand on the costovertebral angle (CVA) during assessment. The nurse should first percuss the nontender flank; percussing the tender flank first may aggravate the client's pain. A clenched fist should be formed with one hand. The nurse should deliver a firm hand thump over the costovertebral angle (CVA).

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms are most likely to be associated with this disorder?

-Burning pain after exposure to cold Thromboangiitis obliterans is characterized by vascular inflammation in the hands and feet, leading to thrombus formation. As a result of impaired circulation, burning pain and intermittent claudication occur. General blanching of the skin, easy fatigue of extremities, and presence of Homans sign when ambulating are not related to thromboangiitis obliterans.

After reviewing the testosterone levels of four female clients, the nurse discovers an abnormal finding in one of the clients. Which client's finding is abnormal?

client A: 90 ng/dL serum testosterone The normal levels of testosterone in females range between 15-70 ng/dL. Client A has 90 ng/dL of testosterone, which is greater than the normal value. Therefore the findings of client A are abnormal. Client B has a serum testosterone concentration of 70 ng/dL, which is a normal finding. Client C has a serum testosterone concentration of 50 ng/dL, which is a normal value. Client D has a serum testosterone concentration of 30 ng/dL, which is a normal value.

The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen?

- "With the enclosed towelettes, wipe your labia from front to back before collecting the specimen." The client must use the packaged towelettes and wipe the labia from front to back before urinating. The client needs to urinate a small amount in the toilet first and then hold the cup under the perineal area and finish urinating in the cup. If the client cannot void enough for a specimen, the insufficient sample should be discarded and another specimen obtained when the client can void a sufficient amount. The client should notify the nurse immediately after the specimen is collected so it can be sent to the laboratory for analysis.

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." Which action should the nurse take?

- Call the rapid response team These are classic symptoms of a myocardial infarction; further medical evaluation and intervention are needed immediately. Performing a nutritional assessment presumes a dietary problem when a more serious situation may exist. Discussing possible sources of stress for the panic attack considers only an emotional source of the reported symptoms and ignores a potential medical emergency. Providing reassurance while helping the client to deep breathe provides false reassurance and ignores a potential medical emergency.

A client with hypertension is starting a 2-gram sodium diet. The nurse should teach the client to avoid which foods? Select all that apply.

- Canned chili - Luncheon meat Canned chili is high in sodium and should be avoided. Luncheon meats are processed and have high sodium levels to help with their preservation and should be avoided. Ground beef is lower in sodium than are processed meats; however, beef is high in saturated fat. Canned salmon is high in sodium, but fresh salmon is not. Cooked, unprocessed broccoli does not have significant sodium levels.

A client has been diagnosed with anemia. Which decreased hormone level may be the cause?

- Erythropoietin Erythropoietin stimulates the production of red blood cells (RBCs) in the bone marrow. Deficiency of erythropoietin causes a decrease in RBCs, thereby resulting in anemia. Bradykinin increases blood flow and vascular permeability. Prostaglandins regulate kidney perfusion. Activated vitamin D promotes the absorption of calcium in the gastrointestinal (GI) tract.

A client is admitted to the hospital with ureteral calculus. Which urinary clinical findings will the nurse expect upon assessment?

- Hematuria with sharp pain when voiding Hematuria and pain may result from damage to the ureteral lining as the calculus moves down the urinary tract; the urine may become cloudy or pink tinged. Although severe pain may be present, urgency is not associated with renal calculi; urgency may be associated with an enlarged prostate, cystitis, or other genitourinary problems. The odor of urine is not foul with this condition; the color of urine is not dark with this condition, although it may be cloudy, pink, or red from hematuria. Frequency may occur when the calculus reaches the bladder.

A client with a history of heart failure on daily weights has a 2-pound (0.9 kilogram) weight gain and pitting edema in lower extremities bilaterally. Which action should the nurse take next?

- Perform a head-to-toe assessment, including vital signs. Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary issues (crackles) associated with left-sided heart failure. Checking the record for code status is not a priority and should have been established and known on an elderly client. Increasing intake will make the problem of fluid retention worse. Continuing to monitor daily weights without an assessment may miss worsening symptoms.

the nurse is caring for a client with a history of atrial fibrillation and a diagnosis of dehydration. What does the nurse anticipate that the plan of care will include?

- Small, frequent intake of juices, broth, or milk Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. Water does not supply the necessary electrolytes, and hyponatremia may result. No data are present to indicate that the client cannot take fluids orally; a nasogastric tube is not necessary when the client can take fluids by mouth. Rapid correction of a fluid and electrolyte imbalance is dangerous; therapy should promote a gradual correction.

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify?

- Support systems that can assist the client at home The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.

A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. The nurse notifies the primary healthcare provider to have the packing removed. What is the primaryreason that the packing needs to be removed immediately?

- The radioactive packing will injure healthy tissue. Packing maintains a radium implant in its correct placement; correct placement minimizes the effect on healthy tissue. There should not be active bleeding with a radium implant; cellular sloughing is expected. Although exposure to the radioactive packing damages healthy tissue, it is not life threatening.

A nurse is working with a cardiologist for a client needing temporary pacing. Which methods are examples that the cardiologist with the assistance of the nurse might use? Select all that apply.

- Transcutaneous pacing - Transvenous pacing - Epicardial pacing Types of temporary pacemakers include transcutaneous, where electrical stimulation is delivered through the skin via external electrode pads connected to an external pacemaker; transvenous, where a pacing catheter is inserted percutaneously into the right ventricle where it contacts the endocardium near the ventricular septum and is connected to a small external pulse generator by electrode wires; and epicardial, where pacing wires are inserted into the epicardial wall of the heart during cardiac surgery, are brought through the chest wall, and can be connected to a pulse generator if needed. Permanent pacemakers have electrode wires that are typically placed transvenously through the cephalic or subclavian vein into the heart chambers. The leads are attached to the pulse generator and placed in a surgically created pocket just below the left clavicle. ICDs and biventricular pacemakers are permanent pacemakers that have an additional electrode wire placed through the coronary sinus into the left ventricle. Additional pacing wires are in the atria and the ventricle. Pacing both ventricles simultaneously improves heart function in a certain number of heart failure clients. Synchronous depolarization of both ventricles improves cardiac output and ejection fraction.

The nurse is performing bedside sonography for a female client who underwent a hysterectomy. Which nursing intervention needs correction?

- Using the female icon on the bladder scanner Before performing a bedside sonography, the male or female icon on the scanner should be selected. The male icon should be selected for men and for women who have undergone a hysterectomy. An ultrasound gel pad should be placed right above the pubic bone. The scan head should be pointed in such a way that the ultrasound is projected towards the client's coccyx. The midline of the probe should be placed over the abdomen about 1.5 inches (3.8 cm) above the pubic bone.

A client with a human immunodeficiency virus (HIV) infection reports genital discharge associated with irritation, pain, and itching. Which actions of the client might have lead to this condition? Select all that apply.

- wearing tight jean pants - using antibiotic medications Discharge from the genital area is commonly observed in clients with sexually transmitted diseases such as human immunodeficiency virus (HIV). Genital discharge causes irritation, pain, and itching and may trigger when the client wears tight jean pants, fabric underwear, and when the client is using antibiotics. Diethylstilbestrol, iron supplements, and Kegel exercises do not cause genital discharge.

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response by the nurse is most appropriate?

-"There will be an indwelling urinary catheter and a continuous bladder irrigation in place." The presence of an indwelling urinary catheter and a continuous bladder irrigation are routine postoperative expectations after a TURP; they provide for hemostasis and urinary excretion. An abdominal incision and dressing are present with a suprapubic, not transurethral, prostatectomy. After a TURP, the client initially can expect hematuria and some blood clots; the continuous bladder irrigation keeps the bladder free of clots and the catheter patent. An incision between the scrotum and rectum is associated with a perineal prostatectomy, not a TURP.

During chest physiotherapy (CPT) a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next?

-Interrupt the therapy. The client's response indicates lack of physiologic tolerance to the procedure, and it must be interrupted. Encouraging deep breathing may be encouraged, but it is not the first intervention. Deep breathing must be done cautiously because it may precipitate respiratory alkalosis. The high-Fowler or orthopneic position is more appropriate for clients who are experiencing cardiopulmonary difficulties. Having the client complete the therapy before resting is contraindicated because the client is not tolerating the procedure. The therapy is intended to clear the respiratory passages of sputum and increase oxygenation. The heart rate should remain the same or decrease, not increase.