Final Study Guide Med Surg 2
2. Which disciplines would the nurse include when planning care for a *relatively healthy* 45-year-old asthma patient? SATA a. Pharmacy? b. Case management? c. Nursing? d. Occupational therapy? e. Speech therapy?
***1. Nursing is the one discipline that is with the client around the clock. Therefore nurses have knowledge of the client that the other disciplines might not know. ***2. The pharmacist will be able to discuss the medication regimen that the client is receiving and make suggestions regarding other medications or medication interactions. ***3. The social worker may be able to assist with financial information or home care arrangements. 4. Occupational therapists help clients with activities of daily living and modifications to home environments; nothing in the stem indicates a need for these services. 5. Speech therapists assist clients with speech and swallowing problems; nothing in the stem indicates a need for these services
A nurse is assisting the physician with chest tube removal. To remove the chest tube, the client is instructed to:
*Take a deep breath, exhale, and bear down* also could ask pt to perform Valsalva Maneuver
A nurse is assigned to assist with caring for a client after femoral cardiac catheterization. The nurse plans to maintain bedrest with: 1 Head elevation of no more than 30 degrees 2 Bedrest for a duration of 24 hours 3 High Fowler's position, 4 Position leg to the level of the heart
1- The head of the bed is not elevated to *NO more than 30 degrees* to keep the affected leg straight at the groin and prevent arterial occlusion. If the femoral artery was used, strict bed rest is ONLY necessary for 4 to 6 hours. High Fowler's position, the head of the bed is elevated 90 degrees.
A patient with a chest tube asks the nurse about the bubbling he sees in the water seal chamber of his drainage equipment. Which response by the nurse is MOST appropriate? 1. "It shows your lung has not yet re-expanded" 2 "It's supposed to bubble." 3. "Why don't we ask your doctor." 4. "We need to call a Rapid Response"
1. "It shows your lung has not yet re-expanded" It is normal to find intermittent (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing intermittent bubbles.
A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last) Notify the client's healthcare provider Call the rapid response team to assist Move the crash cart to the client room Inform the family of the critical situation
1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation
A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? 1 It should be elevated on a pillow. 2 It should be kept straight while on bed rest. 3 It will be positioned dependent to the level of the heart. 4 It will be put through range-of-motion exercises several times an hour.
2 After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period. The client may turn from side to side.
After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take? 1 Explain the procedure again in detail and clarify any misconceptions. 2 Notify the healthcare provider of the client's lack of understanding. 3 Call the client's next of kin and have them provide verbal consent. 4 Postpone the procedure until the client understands the risk and benefits.
2 Notify the healthcare provider of the client's lack of understanding. Rationale: *the nurse is only witnessing the signature, and is not responsible for the client's understanding of the procedure* The healthcare provider needs to clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider's legal responsibility. The other options are not indicated.
A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? 1. Serum potassium is 3.5 mEq/L. 2. Blood pressure is 88/46. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61.
2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.
What nursing intervention would be inappropriate in the immediate post-op care of a pt who has had a bronchoscopy: 1.put pt in semi-fowler position 2. offer fluids to assess swallowing ability 3. assess for diminished breath sounds 4. assess for stridor
2. offer fluids to assess swallowing ability
Upon assessment of a client admitted for dehydration, the nurse observes that the client appears restless and reports difficulty breathing. Upon auscultation of the client's lungs, the nurse notes bilateral basilar crackles. Which action should the nurse take first? 1. Place the client on 2 liters of oxygen per nasal cannula and auscultate the lungs. 2. Elevate the head of the bed and stop the IV infusion. 3. Decrease the IV flow rate and administer furosemide as ordered. 4. Stop the IV infusion and notify the health care provider.
4. Stop the IV infusion and notify the health care provider. fluid overload
A client had a thoracotomy three hours ago. For the past two hours, there has been 100 ml/hour of bloody chest drainage. Which of the following actions should the nurse take FIRST? 1. Increase the IV fluid rate. 2. Administer oxygen at 5 L/minute per oxygen mask. 3. Elevate the head of the bed. 4. Advise the physician of the amount of drainage.
4. Advise the physician of the amount of drainage. * per PPT DRAINAGE MORE THAN 100 ml/hour is excessive and may indicate bleeding (MD SHOULD BE NOTIFIED)*
A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? A Reduce preload. B Decrease afterload. C Increase contractility. D Promote vasodilation.
A Reduce preload. Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.
The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?
A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.
pulse pressure formula MAP (mean arterial pressure) formula and normal range is
=SBP-DBP widened PP indicates increasing ICP MAP 2(DBP) + SBP/3 MAP should be >65
The nurse is interviewing a patient who suddenly becomes faint, immediately loses consciousness, and becomes pulseless and apneic. There is no blood pressure, and heart sounds are absent. What does the nurse do next? a. Begin compressions. b. Defibrillate the patient. c. Establish or ensure IV access. d. Give supplemental oxygen.
A the nurse should call a Code Blue and begin CPR.
A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum F. Hemoptysis G. Dyspnea
ACDEFG A. CORRECT: The nurse should include in the teaching that a persistent cough is a manifestation of tuberculosis. C. CORRECT: The nurse should include in the teaching that fatigue is a manifestation of tuberculosis. D. CORRECT: The nurse should include in the teaching that night sweats is a manifestation of tuberculosis. E. CORRECT: The nurse should include in the teaching that purulent sputum is a manifestation of tuberculosis. F. CORRECT: Hemoptysis is a manifestation of tuberculosis G. Dyspnea is a manifestation of tuberculosis B IS INCORRECT BECAUSE TB CAUSES WEIGHT LOSS
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night
ANS: A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)
ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.
The nurse is reviewing antiepileptic drug (AED) therapy. Which statements about AED therapy are accurate? (Select all that apply.) a. AED therapy can be stopped when seizures are stopped. b. AED therapy is usually lifelong. c. Consistent dosing is the key to controlling seizures. d. A dose may be skipped if the patient is experiencing adverse effects. e. Do not abruptly discontinue AEDs because doing so may cause rebound seizure activity. f. There is no issues if you take OTC medications concurrently
ANS: B, C, E Patients need to know that AED therapy is usually lifelong, and compliance (with consistent dosing) is important for effective seizure control. Abruptly stopping AED therapy may cause withdrawal (or rebound) seizure activity.
A patient reports having crushing chest pain that radiates to the jaw. You administer sublingual nitroglycerin and obtain a 12 lead EKG. Which of the following EKG findings confirms your suspicion of a possible myocardial infraction? A. absent Q wave B. QRS widening C. absent P-wave D. ST segment elevation
Answer: D ST segment elevation This is a common finding on an EKG when a patient is having a myocardial infraction due to muscle damage.
A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a."Do you have any allergies?" b."Do you take aspirin on a daily basis?" c."What time did your chest pain begin?" d."Can you rate your chest pain using a 0 to 10 scale?"
ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.
When a patient is receiving diuretic therapy, which of these assessment measures would best reflect the patient's fluid volume status? a.Blood pressure and pulse b.Serum potassium and sodium levels c.Intake, output, and daily weight d.Measurements of abdominal girth and calf circumference
ANS: C Urinary intake and output and daily weights are the best reflections of a patient's fluid volume status.
A patient has a 9-year history of a seizure disorder that has been managed well with oral phenytoin (Dilantin) therapy. He is to be NPO (consume nothing by mouth) for surgery in the morning. What will the nurse do about his morning dose of phenytoin? a. Give the same dose intravenously. b. Give the morning dose with a small sip of water. c. Contact the prescriber for another dosage form of the medication. d. Notify the operating room that the medication has been withheld.
ANS: C If there are any questions about the medication order or the medication prescribed, contact the prescriber immediately for clarification and for an order of the appropriate dose form of the medication. Do not change the route without the prescriber's order. There is an increased risk of seizure activity if one or more doses of the AED are missed.
A client with a history of HF will be started on spironolactone (Aldactone). Which of the following drug groups should NOT be used, or used with extreme caution in patients taking potassium-sparing diuretics? a. NSAIDs b. Corticosteroids c. Loop diuretics d. ACE inhibitors or ARBs
Answer: d. ACE inhibitors or ARBs Rationale: ACE inhibitors and ARBs taken concurrently with potassium-sparing diuretics increase the risk of hyperkalemia.
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure 137/88 mm Hg d. 25 mL urine output over last hour
ANS: C The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that β-blockers or other antihypertensive medications can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.
Which patient(s) are most at risk for developing coronary artery disease? Select-all-that-apply: A. A 25 year old patient who exercises 3 times per week for 30 minutes a day and has a history of cervical cancer. B. A 35 year old male with a BMI of 30 and reports smoking 2 packs of cigarettes a day. C. A 45 year old female that reports her father died at the age of 42 from a myocardial infraction. D. A 29 year old that has type I diabetes.
Answers: B,C, D. Remember risk factors for developing CAD include: smoking, family history, diabetes, being overweight or obese, and high cholesterol
A patient is prescribed isoniazid for treatment of tuberculosis. Which of the following statements regarding isoniazid are correct? (Select ALL that apply.) A) It is an hepatic enzyme inducer. B) It should be taken on an empty stomach. C) Store the oral solution in the refrigerator. D) It can turn the urine a reddish color. E) It is associated with hepatitis and liver function tests may need to be monitored.
B & E Rationale: Isoniazid is an hepatic inhibitor and needs to be taken on an empty stomach (Take 1 hour before or 2 hours after a meal) The oral solution is stored at room temperature. Monitor liver function. D-orange urine is Rifampin
Nursing interventions for a patient after a cardiac catheterization include which of the following a.Allow ambulation as tolerated. b.Assess the puncture site frequently for hematoma formation or bleeding. c.Assess the affected extremity for temperature and color. d.Check pulses distal to the cath site e. Monitor intake and output f. HOB at 60 degrees
B, C, D, E The extremity that was used for access for the cardiac catheterization must be checked for temperature, color and bleeding.. Coolness and blanching may indicate arterial occlusion. The urine output is an important indicator of cardiac function.
A client with hypoparathyroidism tells the nurse, "my lips feel funny"and complains of numbness and tingling in his fingers. Which assessment of the client should the nurse immediately make? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia
B. Hypocalcemia Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl.
The client is prescribed a beta-blocker as adjunct therapy to treatment of heart failure. The nurse recognizes that beta blockers act by A.Increasing contractility and cardiac output. B.Decreasing preload. C.Slowing the heart and decreasing afterload. D.Decreasing peripheral resistance
C. Rationale: Beta-blockers improve symptoms of HF by slowing heart rate and decreasing blood pressure. The decreased afterload causes decreased workload on the heart.
A patient with a brain tumor is receiving radiation after having had a craniotomy. The nurse will explain that the purpose of the ordered methylprednisolone (Solu-Medrol) is to a. eliminate the remaining tumor cells. b. prevent an increase in intracranial pressure (ICP). c. promote wound healing after the craniotomy. d. decrease the risk of metastasis of the cancer.
Correct Answer: B Rationale: Radiation can lead to cerebral edema and rapid ICP increases and corticosteroids are administered to prevent this. Corticosteroids do not damage tumor cells, promote wound healing, or decrease risk for metastasis.
Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility? A Beta-adrenergic blockers B Calcium channel blockers C Diuretics D Inotropic agents
D Inotropic agents are administered to increase the force of the heart's contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? • Hypokalemia • Ketonuria. • Peripheral edema • Elevated blood pressure
Hypokalemia Rationale: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias
Which labs would you expect to be drawn for patient being treated with TB drugs?
Liver function tests (assess for jaundice if on TB regimen)
A patient who has experienced atrial fibrillation is admitted to the cardiac care unit. In addition to administering an antidysrhythmia medication, the healthcare provider should anticipate which of these orders? Prepare the patient for AV node ablation Give atropine IV push Initiate a heparin infusion Prepare for immediate cardioversion
Initiate a heparin infusion: Because blood tends to pool and clot in the fibrillating atria, patients with atrial fibrillation are at high risk for embolic stroke, so heparin will be given. The antidysrhythmic will help control rhythm and rate, so atropine (an anticholinergic which increases HR) is not indicated. Cardioversion or ablation is usually reserved for patients who have not responded to antidysrhythmic medications.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences • Bradycardia and constipation • Lethargy and lack of appetite • Muscle cramping and dry, flushed skin • Palpitations and shortness of breath
Palpitations and shortness of breath
A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system (CDU). What should the nurse do? Obtain a new sterile drainage system. Use two clamps to close the drainage tube. Place the client in the high-Fowler position. Reconnect the client's tube to the drainage system.
Reconnect the client's tube to the drainage system.
Why do you give morphine to patients with heart failure?
Reduce anxiety, decreases preload and afterload, reduces respirations, and reduces pain related to MI.
A patient is complaining of a nagging cough that is continuous. Which medication below can cause this side effect? A. Losartan B. Lisinopril C. Cardizem D. Lipitor
The answer is B. ACE inhibitors, such as Lisinopril, can cause a nagging cough that is continuous. The patient may be switched to an ARB (angiotensin receptor blocker) if the cough is troublesome.
What are important dietary restrictions for a COPD patient? a. Increase protein b. Decrease carbs c. Increase calories d. Increase fiber e. 6 small meals/day f. Limit Fluids
a b c d e (f is wrong because we dont want to limit fluids EXCEPT at meal times) *soft, high-calorie, low carbohydrate, high-fat, protein, small frequent feedings* Don't want pressure on diaphragm-reduces lung function DON'T WANT fluids with meals (causes bloating=pressure), gassy foods, large meals
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.
a b c d e you don't need a rationale, you know why After the seizure (post-ictal phase) place pt in Recovery position: side lying
What is the purpose of pursed lip breathing? How is it done?
To control SOB & Releases trapped air in the lungs and keeps airways open. Breath in slowly through your nose (2 sec) pucker lips and exhale for 4 sec.
The nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he complains of dizziness. Which medication would be used to treat his bradycardia? a. Atropine b. Dobutamine (Dobutrex) c. Amiodarone (Cordarone) d. Lidocaine (Xylocaine)
a. Atropine I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.
Which complication of chronic kidney disease is treated with erythropoietin (EPO)? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder
a. Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.
Keeping these A meds straight: Atropine is an anticholinergic....it's going to dry things up and will increase HR "dries the licker and speeds the ticker"....given to dry secretions up and also during bradycardia. Amiodarone is a Class III antiarrhythmic which prolongs phase 3 of the cardiac action potential. Commonly used in afib, vfib, and vtach. Adenosine (causes a scene-stops the heart so SA node can start it back up). Useful for pharmacological conversion of SVT.
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The nurse understands a patient who is treated for hypertension may be switched to an angiotensin receptor blocker (ARB) because of which angiotensin-converting enzyme (ACE) inhibitor adverse effect? a) Fatigue b) Hypokalemia c) Orthostatic hypotension d) Dry, nonproductive cough
d) dry, nonproductive cough Rationale ACE inhibitors block the breakdown of bradykinins and may cause a dry, nonproductive cough. ARBs do not block this breakdown, thus minimizing this adverse effect. ACE inhibitors and ARBs are equally effective for the treatment of hypertension, but ARBs do not cause cough.
A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do? a. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. b. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician. c. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. d. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
d. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system
d. Insertion of a chest tube with a chest drainage system *Unequal chest expansion occurs when part of the lung is collapsed-treatment is Chest Tube*
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine. This will encourage pt to take deeper breaths
While caring for a client who has sustained a MI, the nurse notes eight premature ventricular contractions (PVC's) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2L/min. The nurse should first: 1. increase the IV infusion to 150 mL/h 2 notify the HCP 3. increase the oxygen concentration to 4L/min 4. administer prescribed analgesic
2 PVC's are usually a precursor of life threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. *An occasional PVC is not considered dangerous,* but if PVC's occur at a rate greater than 5 or 6 per minute in the post-MI client, the HCP should be notified immediately. More than 6 PVC's per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion would not decrease the number of PVC's. Increasing the oxygen concentration should not be the nurses first course of action rather the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
The nurse is preparing a teaching plan for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which of the following should the nurse include in the teaching plan? 1. Tell the client to avoid salt substitutions. 2. Instruct the client to increase foods high in potassium. 3. Inform the client that he may have a sore throat for the first few days of therapy. 4. Advise the client to report facial swelling or difficulty breathing immediately. 5. Tell the client that it may take 2 weeks for the full effect 6. Advise the client not to change position suddenly to minimize orthostatic hypotension.
1, 4, 6 RATIONALES: When teaching the client about enalapril maleate, the nurse should tell him to avoid salt substitutions because these products may contain potassium. ACE inhibitors block aldosterone secretion, which results in sodium loss and potassium retention. *Hyperkalemia may occur, so teach about low potassium foods* Facial swelling or difficulty breathing should be reported immediately; the drug may cause angioedema, which would require discontinuation of the drug. The client should also be advised to change position slowly to minimize orthostatic hypotension. *The nurse should tell the client to report light-headedness, especially in the first few days of therapy, so dosage adjustments can be made*. 3-The client should report signs of infection, such as sore throat and fever, because the drug may decrease white blood cell count. White blood cell and differential counts should be performed before treatment, every 2 weeks for 3 months, and periodically thereafter. 5-Takes 4-12 weeks for the *full effect*, although you will notice immediate benefits once started
The nurse is preparing a teaching plan for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which of the following should the nurse include in the teaching plan? 1. Tell the client to avoid salt substitutions. 2. Instruct the client to increase foods high in potassium. 3. Inform the client that he may have a sore throat for the first few days of therapy. 4. Advise the client to report facial swelling or difficulty breathing immediately. 5. Tell the client that it may take 2 weeks for the full effect 6. Advise the client not to change position suddenly to minimize orthostatic hypotension.
1, 4, 6 RATIONALES: When teaching the client about enalapril maleate, the nurse should tell him to avoid salt substitutions because these products may contain potassium. ACE inhibitors block aldosterone secretion, which results in sodium loss and potassium retention. *Hyperkalemia may occur, so teach about low potassium foods* Facial swelling or difficulty breathing should be reported immediately; the drug may cause angioedema, which would require discontinuation of the drug. The client should also be advised to change position slowly to minimize orthostatic hypotension. *The nurse should tell the client to report light-headedness, especially in the first few days of therapy, so dosage adjustments can be made*. 3-The client should report signs of infection, such as sore throat and fever, because the drug may decrease white blood cell count. White blood cell and differential counts should be performed before treatment, every 2 weeks for 3 months, and periodically thereafter. 5-Takes 4-12 weeks for the *full effect*, although you will notice immediate benefits once started
A nurse cares for a client who is on a cardiac monitor. The monitor displayed Ventricular tachycardia. Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).
ANS: A Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which nursing actions should the nurse take? Select all that apply. 1. Contact the physician. 2. Check the level of the drainage bag. 3. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.
ANS: 2, 3, 4, 5 Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Increasing the flow rate is an inappropriate action and is not associated with the amount of outflow solution
The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a.43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain b.52-year-old with a BP of 212/90 who has intermittent claudication c. 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL d. 48-year-old with a BP of 172/98 whose urine shows microalbuminuria
ANS: A The patient with chest pain may be experiencing acute myocardial infarction, and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.
To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation
ANS: A The purpose of mthylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone. *Per the HESI Spinal Cord--Methylprednisolone if given within 8 hours of injury decreases inflammation and damage to cell membranes*
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 client's 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.
ANS: 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 client's 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.* KEY WORD MOST APPROPRIATE although ACE inhibitors can cause a nagging cough
A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. which of the following client findings should the nurse report to the provider? A. mediastinal drainage 100mL/hr B. blood pressure 160/80 mm Hg C. Temperature 37.1 (98.9) D. Potassium 3.8 mEq/L
B. blood pressure 160/80 mm Hg the nurse should report an elevated blood pressure following a CABG procedure because increased vascular pressure can cause bleeding at the incision sites.
A patient is taking digoxin (Lanoxin) and a loop diuretic daily. When the nurse enters the room with the morning medications, the patient states, "I am seeing a funny yellow color around the lights." What is the nurse's next action? a.Assess the patient for symptoms of digoxin toxicity. b.Withhold the next dose of the diuretic. c.Administer the digoxin and diuretic together as ordered. d.Document this finding, and reassess in 1 hour.
ANS: A Seeing colors around lights is one potential indication of developing digoxin toxicity. If a patient complains of this, the nurse needs to assess for other signs and symptoms of digoxin toxicity including bradycardia, headache, dizziness, confusion, nausea, and blurred vision, and then notify the prescriber. Administering the drug or withholding the diuretic are incorrect options. KNOW DIG LEVELS! The normal therapeutic drug level of digoxin is between 0.5 and 2 ng/mL.* *Hypokalemia increases the chance of digitalis toxicity SO KNOW K+ LEVEL 3.5-5.0 IF OUTSIDE PARAMETERS- HOLD THE DIG!* Digoxin is used for the treatment of atrial fibrillation and heart failure
The nurse is taking VS on a patient and sees the patient stare off into space. What should the nurse do? a.Keep taking vitals-no b.Observe time seizure begins and what happens c.Orient the patient to reality d. Administer rectal diazepam
B Note the time, duration, and type of seizure Rationale: Accurate assessment by the nurse during the seizure provides important data used in determining the area in which focal activity originates, the area of the brain involved, and the type of seizure. It is important to document whether the beginning of the seizure was observed.
Two hours after a cardiac catheterization that was accessed via the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? A. Call the HCP B. Check the clients pedal pulses C. Take the clients BP D. Recognize the response is expected
B. Check the clients pedal pulses Rationale: These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site.
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.
B. Place a sterile dressing over the site and tape it on three sides and notify the physician
The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate pulmonary edema? A. Fatigue, orthopnea, and dependent edema B. Severe dyspnea and pink-streaked, frothy sputum C. Temperature is 100.4o F and pulse is 102 beats/minute D. Respirations 22 breaths/minute despite oxygen by nasal cannula
B. Severe dyspnea and pink-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? a. Ejection fraction is 25%. b. Client states that she is able to sleep on one pillow. c. Client was hospitalized five times last year with pulmonary edema. d. Client reports that she experiences palpitations.
B: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal ejection fraction of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.
AED electrodes are placed on a patient who is unconscious and pulseless. The nurse prepares to immediately defibrillate if the monitor shows which cardiac anomaly? a. Third-degree heart block b. Pulseless electrical activity c. Ventricular fibrillation d. Idioventricular rhythm
C When ventricular fibrillation appears, the nurse must immediately initiate CPR until the defibrillator is engaged, and should defibrillate up to three times if needed. The only true effective treatment for ventricular fibrillation is defibrillation, which should occur as soon as possible.
A patient had CABG surgery with the radial artery used as a graft. The nurse performs which assessment specific to this patient? A. Check the blood pressure every hour on the unaffected arm or use the legs b. Check the fingertips, hand, and arm for sensation and mobility every shift c. Assess hand color, temperature, ulnar/radial pulses, and capillary refill every hour initially d. Note edema, bleeding, and swelling at the donor site, which are expected
C Assess hand color, temperature, ulnar/radial pulses, and capillary refill every hour initially ON THE AFFECTED ARM
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. The nurse knows the hyperventilation is effective when she notes: a.PaO2 went from 91 to 94 (normal is 80-100 so WNL) b.paCO2 went from 38 to 35 (normal is 35-45 WNL) c.ICP went from 20 to 15 (ICP should be 10-15 so this reduction is GOOD) d. Clear breath sounds
C Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective a.PaO2 went from 91 to 94 (normal is 80-100 so WNL) b.paCO2 went from 38 to 35 (normal is 35-45 WNL) c.ICP went from 20 to 15 (ICP should be 10-15 so this reduction is GOOD) d. Clear breath sounds (WNL)
A pt who is in hypovolemic shock has the following clinical signs: HR 120, BP 80/55, and UOP 20/hr. After admin of IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion? a. right atrial pressure increase b. systolic increase to 85 c. UOP goes up to 30/hr d. HR drops to 100
C. perfusion involves blood and o2 delivery to the tissues. all of these options indicate improvement in the status, but the best indication of tissue perfusion is increased UOP
A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol. C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock.
C. Give IV dose of adenosine rapidly over 1-2 seconds. Adenosine (causes a scene-stops the heart so SA node can start it back up). Useful for pharmacological conversion of SVT*
A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.
C. The water in the chamber will decrease during inspiration and increase during expiration. When a patient is receiving mechanical ventilation the water in the water seal chamber will oscillate oppositely than if the patient were breathing on their own. Option A is correct if pt breathing on their own
A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120, BP 80/55, urine output 20 ml/hr. After administering an IV fluid bolus, which of these signs if noted by the healthcare provider is the best indication of improved perfusion? A. Right atrial pressure increases B. SBP increases to 85 C. Urine output increases to 30 ml/hr D. HR drops to 100 bpm
C. Urine output increases to 30 ml/hr Why? Perfusion indicates blood and O2 getting to tissues!
The nurse developing a teaching plan for a client receiving thiazide diuretics should include the following. A.Teaching the client to take apical pulse. B.Decreasing potassium-rich foods in the diet. C.Including citrus fruits, melons, and vegetables in the diet. D.Teaching the client to check blood pressure t.i.d.
C.Including citrus fruits, melons, and vegetables in the diet. Rationale: Thiazide diuretics are potassium wasting, and levels should be closely monitored. Encouraging foods rich in potassium could help maintain potassium levels. Taking an apical pulse is indicated before administering cardiac glycosides and beta blockers. It would not be necessary to check blood pressure TID unless the client was experiencing hypotension.
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. 1 Appoint a person to call 911. 2 Check for a pulse. 3 Deliver two rescue breaths. 4 Check for normal breathing. 5 Perform chest compressions. 6 Perform a head tilt-chin lift maneuver.
Correct response: 1,2,5,6,4,3 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 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.
Which postoperative intervention should be *questioned* for a pt after a cardiac catheterization? a. Continue intravenous (IV) fluids until the pt is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.
D The pt should be positioned with the affected leg straight for 4 to 6 hours after the procedure. IV fluid administration continues until the pt is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the pt to check for pooled blood. Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity.
A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? A. Unstable angina B. Cardiac tamponade C. Sudden cardiac death D. Cardiac dysrhythmias
D. Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death
A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? • Bring the crash cart to the room to defibrillate the client. • Determine the client's responsiveness and respirations • Immediately initiate chest compressions. • Notify the emergency response team
Determine the client's responsiveness and respirations Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation delivered as indicated by the client's rhythm. Based on as assessment of the client, CPR as summoning the emergency response team may be indicated.
A patient has left sided heart failure. Which nursing interventions are included in the plan of care for this patient? (Select all that apply.) a. Weekly weight monitoring b. Auscultate breath sounds every 4 to 8 hours. c. Provide supplemental oxygen to maintain oxygen saturation at 90% or greater. d. Place the patient in a supine position with pillows under each leg. e. Assist the patient in performing coughing and deep-breathing exercises every 2 hours. f. Sodium and fluid restriction g. Slow infusion of hypotonic saline h. Administration of loop diuretics
abcefh Position in semi-Fowler's to high-Fowler's position Give Isotonic not hypotonic
The patient has decreased oxygenation and impaired tissue perfusion. Which clinical manifestations are evidence of shock? (Select all that apply) a urine output 20 ml/hr b Increased PH c narrowing pulse pressure d decreased heart rate e increased heart rate f. increased serum lactate
acef signs of shock: Urine should be at least 30 ml/hr PH will be low (lactic aciDosis D=Down) narrowing or decreased pulse pressure Tachy not brady is seen in shock Serum lactate will decrease as acidosis resolves.
The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.) a. It is relieved by rest and inactivity. b. It is substernal in location. c. It is sudden in onset and prolonged in duration. d. It is viselike and radiates to the shoulders and arms. e. It subsides after taking nitroglycerin.
b. It is substernal in location. c. It is sudden in onset and prolonged in duration. d. It is viselike and radiates to the shoulders and arms.
A patient has heart failure, and a high dose of furosemide (Lasix) is ordered. What suggests a favorable response to Lasix? a.Decrease in level of consciousness and sleeping more b.Respiratory rate decreases from 28/min to 20/min and the depth increases. c.Increased congestion heard in breath sounds and complains of shortness of breath d.Urine output of 50 mL/4 h and intake of 200 mL
b.Respiratory rate decreases from 28/min to 20/min and the depth increases.
