NRSG 327 EAQ1
A female client who is receiving intravenous antibiotic therapy at home for treatment of toxic shock syndrome is visited by a home health nurse. What statement indicates to the nurse that the client understands the teaching regarding future care? 1 "I will call the clinic if I get a rash." 2 "I will call the clinic if the menstrual cramps return." 3 "I now know how to insert my diaphragm correctly." 4 "I now know how to perform correct tampon hygiene."
1 "I will call the clinic if I get a rash. Toxic shock syndrome may recur during the first 3 months after treatment; a sunburn-like rash with peeling skin often occurs in the late stages of the syndrome. There is no need for the client to call the clinic if menstrual cramps return, because this is not specifically related to toxic shock syndrome. Whether the diaphragm is inserted properly is not the issue; it is linked to toxic shock syndrome if it is not removed 6 to 8 hours after intercourse. Tampons are linked to the development of toxic shock syndrome and should not be worn by this client.
A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond? 1 "This surgery significantly decreases symptoms in most clients." 2 "This procedure will enable your spouse to return to work after healing occurs." 3 "Studies have consistently shown that this surgery increases an individual's life span." 4 "Evidence substantiates that surgery can prevent progression of coronary artery disease."
1 "This surgery significantly decreases symptoms in most clients." The majority of those who have this surgery have marked relief from their symptoms because the flow of blood to myocardial cells is increased. Whether the procedure will enable the client to return to work depends on the client's presurgical condition and occupation, not the surgery itself. So far, studies have failed to show that coronary artery bypass surgery affects life span. The surgery itself does not affect the disease process; clients must reduce risk factors (obesity, smoking, and high-fat/high-cholesterol diet) as well.
A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1 A 59-year-old who had a knee replacement 2 A 60-year-old who has bacterial pneumonia 3 A 68-year-old who had emergency dental surgery 4 A 76-year-old who has a history of thrombocytopenia
1 A 59-year-old who had a knee replacement Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
After cataract surgery, a client reports feeling nauseated. How can the nurse help relieve the nausea? 1 Administer the prescribed antiemetic drug. 2 Provide some dry crackers for the client to eat. 3 Explain that this is expected following surgery. 4 Teach how to breathe deeply until the nausea subsides.
1 Administer the prescribed antiemetic drug. An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Providing some dry crackers for the client to eat, explaining that this is expected following surgery, and teaching how to breathe deeply until the nausea subsides. are unsafe; vomiting increases intraocular pressure, and aggressive intervention is required.
Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? 1 The nurse should minimize the use of tape on the skin. 2 The nurse should keep the client adequately hydrated. 3 The nurse should change the dressings as soon as they get wet. 4 The nurse should provide rest for the client throughout the day.
2The nurse should keep the client adequately hydrated.
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? 1 Arteriolar constriction occurs. 2 The cardiac workload decreases. 3 Contractility of the heart decreases. 4 The parasympathetic nervous system is triggered
1 Arteriolar constriction occurs. The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? 1 Aspirin 2 Midazolam 3 Gabapentin 4 Alprazolam
1 Aspirin
A nurse should employ which technique to maintain surgical asepsis? 1 Change the sterile field after sterile water is spilled on it. 2 Put on sterile gloves and then open a container of sterile saline. 3 Place a sterile dressing no more than half an inch from the edge of the sterile field. 4 Clean the surgical area with a circular motion, moving from the outer edge toward the center.
1 Change the sterile field after sterile water is spilled on it. A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.
A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis? 1 Cold, clammy skin 2 Slow, bounding pulse 3 Increased blood pressure 4 Hyperactive bowel sounds
1 Cold, clammy skin The action of the sympathetic nervous system causes vasoconstriction, and as cellular and peripheral hypoperfusion progresses, the skin becomes cold, clammy, cyanotic, or mottled. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs; it has a low volume (weak, thready) because of peripheral vasoconstriction. The blood pressure decreases because of continued hypoperfusion and multiorgan failure. Bowel sounds are hypoactive or absent, not hyperactive.
A nurse discusses the potential for cross-contamination with the nursing assistants on a surgical unit. What does the nurse explain that standard precautions are designed to do? 1 Decrease the risk of transmitting unidentified pathogens 2 Be used when clients are suspected of having a communicable disease 3 Ensure that hygiene practices by clients are performed in a universal way 4 Create categories in which certain additional precautions must be followed
1 Decrease the risk of transmitting unidentified pathogens Standard precautions are used for all clients in all settings, regardless of their diagnosis or presumed infectiousness. Practices associated with standard precautions require healthcare providers, not a client, to use hand washing and personal protective equipment to protect themselves and others from body fluids. Transmission-based precautions, known as airborne, droplet, and contact precautions, are based on a client's diagnosed infection. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Take deep breaths for a few minutes (or as needed if you feel especially tense) to relax your body and relieve tension.
Which action should the nurse take to decrease abdominal distention following a client's surgery? 1 Encourage ambulation. 2 Give sips of ginger ale. 3 Provide a straw for drinking. 4 Offer an opioid analgesic
1 Encourage ambulation. Ambulation will stimulate peristalsis, which increases passage of flatus and decreases abdominal distention. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.
A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next? 1 Give naloxone intravenous push med (IVP) per protocol. 2 Assess the client's pain level on a 10-point scale. 3 Document the findings and reassess in 2 hours. 4 Call the rapid response team
1 Give naloxone intravenous push med (IVP) per protocol. A respiratory rate of 10 breaths per min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for postoperative opioid-induced respiratory depression. Pain level also is a part of the PCA documentation protocol. According to protocol, PCA status needs to be documented every 2 hours for the first day and then every 4 hours. The rapid response team might still need to be called, but naloxone must be given first.
A client with a history of coronary artery disease is admitted with pneumonia. The healthcare provider prescribes atenolol. What should the nurse monitor to determine the therapeutic effect of atenolol? 1 Heart rate 2 Respirations 3 Temperature 4 Pulse oximetry
1 Heart rate Atenolol, a beta-blocker, slows the rate of sinoatrial (SA) node discharge and AV node conduction, thus decreasing the heart rate; it prevents angina by decreasing the cardiac workload and myocardial oxygen consumption. Atenolol may promote bronchospasm and wheezing; however, the question specified therapeutic effects, not adverse effects. Atenolol is not an antipyretic. Atenolol does not directly affect gas exchange in the lungs.
While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 1 Heredity 2 Hypertension 3 Cigarette smoking 4 Diabetes mellitus
1 Heredity Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.
A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session? 1 It is relieved by rest. 2 It is precipitated by light activity. 3 It is described as sharp or knifelike. 4 It is unaffected by the administration of vasodilators
1 It is relieved by rest. Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload and oxygen need. Angina usually is precipitated by exertion, emotion, or a heavy meal. Anginal pain usually is described as tightness, indigestion, or heaviness. Nitroglycerin, a vasodilator and a standard treatment for angina, dilates coronary arteries, which increases oxygen to the myocardium, decreasing pain.
A nurse is preparing to change a client's dressing. Which information should the nurse recall for using surgical asepsis? 1 Keep the area free of microorganisms. 2 Protect self from microorganisms in the wound. 3 Confine the microorganisms to the surgical incision site. 4 Limit the number of opportunistic microorganisms to a minimum.
1 Keep the area free of microorganisms. Surgical asepsis means that the defined area will contain no microorganisms. The purpose of personal protective equipment is to protect self from microorganisms in the wound. Confining the microorganisms to the surgical incision site and keeping the number of opportunistic microorganisms to a minimum apply to medical, not surgical, asepsis.
A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. How would the nurse expect the client to describe the chest pain? 1 Severe, intense 2 Burning and of short duration 3 Mild, radiating toward the abdomen 4 Squeezing, relieved by nitroglycerin
1 Severe, intense Blockage of myocardial blood supply causes accumulation of unoxidized metabolites in the muscle; this affects nerve endings and causes severe, intense chest pain. Burning chest pain is not the type of pain associated with a myocardial infarction. Mild chest pain, radiating toward the abdomen, is not the type of pain associated with a myocardial infarction. Nitroglycerin relieves pain associated with angina, not pain associated with myocardial infarction.
Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? 1 Troponin 2 Myoglobin 3 Homocysteine 4 Creatine kinase (CK)
1 Troponin Troponin is the biomarker of choice for a myocardial infarction. Troponin, specifically subtypes cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI), reflects myocardial muscle protein released into circulation soon after injury. Troponin increases as quickly as CK and remains increased for 2 weeks. Although myoglobin is one of the first cardiac markers to increase after a myocardial infarction (MI), it lacks cardiac specificity. Homocysteine is produced when proteins break down, but it is more indicative of cardiovascular disease than a myocardial infarction. CK isoenzyme levels, especially the creatine phosphokinase (MB) subunit, begin to increase in 3 to 6 hours, peak in 12 to 24 hours, and are increased for 48 hours after the occurrence of the infarct. Although reliable in assisting with an early diagnosis of MI, it is not as sensitive or specific as the troponin test.
A nurse is teaching a health class about heart disease to older adult women. The nurse discusses the most common prodromal symptom reported by women with acute coronary heart disease that usually is not experienced by men. Which response indicates a woman in the group understands the teaching? 1 Unusual fatigue 2 Shortness of breath 3 Crushing pain in the chest 4 Substernal pressure radiating to the neck
1 Unusual fatigue Studies indicate that women who have myocardial infarctions frequently experience unusual prodromal fatigue; also, during the prodromal period, women more frequently experience upper abdominal fullness instigated by exertion or emotional stress. Substernal pressure that radiates to the neck is experienced more often by men than by women during the acute period of a myocardial infarction. Although women do experience the other symptoms, they do not occur as frequently as fatigue.
A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1 Bradycardia 2 Hypotension 3 Spastic paralysis 4 Bladder dysfunction 5 Increased pulse pressure
1 Bradycardia 2 Hypotension 4 Bladder dysfunction Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.
A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. 1 Oliguria 2 Lethargy 3 Irritability 4 Hypotension 5 Slurred speech
1 Oliguria 3 Irritability 4 Hypotension Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.
A client is considered to be in septic shock when what changes are assessed in the client's labwork? 1 Blood glucose is 70-100 mg/dL 2 An increased serum lactate level 3 An increased neutrophil level 4 A white blood count of 5000 cells/µL
2 An increased serum lactate level The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count > 12,000 cells/µL or < 4,000 cells/µL and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 and >150 mg/dL. Blood glucose levels of 70-100 mg/dL are considered normal.
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. 1 Rapid pulse 2 Deep respirations 3 Warm, flushed skin 4 Increased blood pressure 5 Decreased urinary output
1 Rapid pulse 5 Decreased urinary output The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.
A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply. 1 Stridor 2 Fissuring 3 Hypotension 4 Dyspnea 5 Cracking of the skin
1 Stridor 3 Hypotension 4 Dyspnea Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea. Fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis.
The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. 1 Sudden chest pain 2 Flushing of the face 3 Elevation of temperature 4 Abrupt onset of shortness of breath 5 Pain rating increase from 2 to 8 in the hip
1 Sudden chest pain 4 Abrupt onset of shortness of breath Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea. Flushing of the face and fever are not classic signs of pulmonary embolus. The pain associated with pulmonary embolus generally is sudden in onset, severe, and located in the chest, not the hip.
What should the nurse monitor for when caring for a postoperative client who presents with 180 mL of urine in the urinary drainage bag from the past 8 hours? 1 Renal failure 2 Liver cirrhosis 3 Diabetes mellitus 4 Rheumatoid arthritis
1 renal failure Postsurgical urine output should not be less than 30 mL per hour; urine output of less than that per hour indicates hypovolemia or renal failure. The client has urinated only 180 mL in the past 8 hours, which is less than 30 mL/hour. This indicates that the client may have renal failure. Liver cirrhosis causes scarring of the liver tissue, which may cause variceal bleeding and hepatic encephalopathy, but it is not associated with decreased urine output. Uncontrolled diabetes mellitus is manifested by frequent and excessive urination. Rheumatoid arthritis does not cause renal complications such as decreased urine output.
A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? 1 An irreversible phenomenon 2 A failure of the circulatory pump 3 Usually a fleeting reaction to tissue injury 4 Generally caused by decreased blood volume
2 A failure of the circulatory pump
A healthcare provider prescribes morphine for a client being treated for myocardial infarction. What physiologic response will occur if the client experiences the intended therapeutic effect of morphine? 1 Increased respiratory rate 2 Decreased workload of the heart 3 Reduced size of the clot blocking the coronary artery 4 Diminished metabolites within the ischemic heart muscle
2 Decreased workload of the heart Morphine reduces pain and anxiety. This limits the response of the sympathetic nervous system, ultimately decreasing cardiac preload and the workload of the heart. Reduced respiratory rate is a side effect of morphine; it is not the intended therapeutic effect for a client being treated for myocardial infarction. Decreasing the size of the clot blocking the coronary artery is the action of antithrombolytic therapy. Decreasing metabolites within the ischemic heart muscle is not the action of morphine.
A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment? 1 Decreased breath sounds 2 Elevated serum troponin I 3 Decreased creatine kinase-MB (CK-MB) 4 Elevated brain natriuretic peptide (BNP) level
2 Elevated serum troponin I Elevations of troponin I levels are indicative and specific for cardiac muscle damage. Decreased breath sounds would indicate a pulmonary problem. An increase in CK-MB would indicate MI. Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction.
A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses? 1 Parasympathetic reflexes from the infarcted myocardium cause diaphoresis. 2 Inflammation in the myocardium causes a rise in the systemic body temperature. 3 Catecholamines released at the site of the infarction cause intermittent localized pain. 4 Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
2 Inflammation in the myocardium causes a rise in the systemic body temperature. Temperature may increase within the first 24 hours as a result of the inflammatory response to tissue destruction and persist as long as a week. Diaphoresis is caused by activation of the sympathetic, not parasympathetic, nervous system and may indicate cardiogenic shock. Pain is persistent and constant, not intermittent; it is caused by oxygen deprivation and the release of lactic acid. The blood pressure increases initially but then drops because there is a decrease in cardiac output.
The nurse is providing postoperative care to a kidney transplant recipient. What is the nurse's first priority during this period? 1 Teaching signs of rejection to the client 2 Maintaining fluid and electrolyte balance 3 Providing emotional support to the recipient 4 Advising the client to have frequent blood testing
2 Maintaining fluid and electrolyte balance The first priority while providing postoperative care for a kidney transplant recipient is maintaining fluid and electrolyte balance. The client is taught signs of rejection during the stay and when planning to discharge. Emotional support is provided to the donor and the recipient. The client is advised to have frequent blood tests after discharge.
A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? 1 Hypokalemia 2 Metabolic acidosis 3 Respiratory alkalosis 4 Decreased Pco2 levels
2 Metabolic acidosis Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco2 level will increase in profound shock.
A client who recently had a myocardial infarction is admitted to the cardiac care unit. How can the nurse best determine the effectiveness of the client's ventricular contractions? 1 Observing anxiety levels 2 Monitoring urinary output hourly 3 Evaluating cardiac enzyme results 4 Assessing breath sounds frequently
2 Monitoring urinary output hourly A decreased urinary output reflects a decreased cardiac output; immediate action is indicated if urinary output decreases. Although anxiety may occur, the priority is to monitor urinary output, which reflects cardiac effectiveness. Cardiac enzyme results do not reflect effectiveness of cardiac contractions; they reflect tissue damage. Although the presence of crackles (rales) will indicate pulmonary edema, it will not determine the effectiveness of ventricular contractions.
A client admitted with a myocardial infarction is prescribed docusate and morphine and takes digoxin and fluoxetine at home. Which drug should the nurse recognize as a risk factor for straining due to constipation? 1 Digoxin 2 Morphine 3 Docusate 4 Fluoxetine
2 Morphine Morphine is an opioid. Opioids decrease intestinal peristalsis, which may precipitate constipation; straining at stool should be avoided to prevent the Valsalva maneuver, which increases demands on the heart. Digoxin is unrelated to intestinal peristalsis and the potential for constipation. Docusate sodium is a stool softener which would relieve, not cause, constipation. A side effect of fluoxetine is diarrhea, not constipation.
After a subtotal gastrectomy a client is returned to the surgical unit. Which is the best nursing action to prevent pulmonary complications? 1 Ambulating the client to increase respiratory exchange 2 Promoting frequent turning and deep breathing to mobilize secretions 3 Maintaining a consistent oxygen flow rate to increase oxygen saturation 4 Keeping a plastic airway in place to ensure patency of the client's airway
2 Promoting frequent turning and deep breathing to mobilize secretions To promote drainage of different lung regions, clients should turn every two hours. Deep breathing inflates the alveoli and promotes fluid drainage. During physical effort, individuals with abdominal incisions often revert to shallow breathing. Oxygen administration is a dependent function and generally is not required unless there is underlying cardiac or respiratory disease. The airway is expelled when the gag reflex returns.
A nurse is preparing to teach a client to apply a nitroglycerin patch as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? 1 Apply the patch on a distal extremity. 2 Remove a previous patch before applying the next one. 3 Massage the area gently after applying the patch to the skin. 4 Apply a warm compress to the site before attaching the patch.
2 Remove a previous patch before applying the next one. Removing the previous patch before applying the next patch ensures that the client receives just the prescribed dose. Ideally, a patch should be removed after 12 to 14 hours to avoid the development of tolerance. The patch should be rotated among hair-free and scar-free sites; acceptable sites include chest, upper abdomen, proximal anterior thigh, or upper arm. The patch should be gently pressed against the skin to ensure adherence; it should not be massaged. Applying a warm compress to the site before attaching the patch is unnecessary and can result in an excessive absorption of the medication.
The client receives dosages of sedative and opioid drugs during the postoperative period following surgical correction of a small bowel obstruction. What is the most critical assessment to be performed as a nursing safety priority? 1 Urinary assessment 2 Respiratory assessment 3 Cardiovascular assessment 4 Neuromuscular assessment
2 Respiratory assessment
A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The primary healthcare provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)? 1 QRS complex 2 S-T segment 3 P wave 4 R wave
2 S-T segment
A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? 1 The body initially attempts to compensate by releasing more red blood cells. 2 The body initially attempts to compensate by maintaining peripheral vasoconstriction. 3 The body initially attempts to compensate by decreasing mineralocorticoid production. 4 The body initially attempts to compensate by producing less antidiuretic hormone (ADH).
2 The body initially attempts to compensate by maintaining peripheral vasoconstriction. With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. Although producing more red blood cells is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure. With shock, more ADH is produced to promote fluid retention, which will elevate the blood pressure.
What are the clinical manifestations of myocardial infarction in women? Select all that apply. 1 Anoxia 2 Indigestion 3 Unusual fatigue 4 Sleep disturbances 5 Tightness of the chest
2 Indigestion 3 Unusual fatigue 4 Sleep disturbances Indigestion, unusual fatigue, and sleep disturbances are clinical manifestations of myocardial infarction in women. Anoxia and tightness of the chest are clinical manifestations of angina pectoris, not myocardial infarction.
A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. 1 Weight loss 2 Unusual fatigue 3 Dependent edema 4 Nocturnal dyspnea 5 Increased urinary output
2 Unusual fatigue 3 Dependent edema 4 Nocturnal dyspnea Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia; women more commonly report unusual fatigue than men. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure. Orthopnea, a compensatory mechanism, limits venous return, which decreases pulmonary congestion and promotes ventilation, easing the dyspnea. Weight gain, not loss, occurs because of fluid retention. Urinary output decreases, not increases, with heart failure because the sympathetic nervous system and the renin-angiotensin-aldosterone system stimulate the retention of sodium and water in the kidneys.
A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? 1 "Moderate amount of drainage." 2 "No change in drainage since yesterday." 3 "A 10-mm-diameter area of drainage at 1900 hours." 4 "Drainage is doubled in size since last dressing change."
3 "A 10-mm-diameter area of drainage at 1900 hours." A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a timeframe. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.
A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe? 1 Lactated Ringer solution 2 Serum albumin 3 Blood replacement 4 High molecular dextran
3 Blood replacement Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? 1 Causes mild perspiration 2 Occurs after moderate exercise 3 Continues after rest and nitroglycerin 4 Precipitates discomfort in the arms and jaw
3 Continues after rest and nitroglycerin When neither rest nor nitroglycerin relieves the pain, the client may be experiencing an acute myocardial infarction. Angina may cause mild diaphoresis; acute myocardial infarction causes profuse diaphoresis, which should be reported. Chest pain after exercise is expected; activity increases cardiac output, which can cause angina. Anginal pain can, and often does, radiate.
A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? 1 Increase left ventricular filling and improve cardiac output 2 Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias 3 Decrease the workload on the heart and promote maximum coronary artery filling 4 Increase venous return to the right atrium and increase pulmonary arterial blood flow
3 Decrease the workload on the heart and promote maximum coronary artery filling With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and therefore oxygen to reach cardiac muscle; this increases myocardial efficiency. Increasing left ventricular filling increases the workload of the heart. Oxygenation of vital organs must be maintained. Decreasing oxygen to vital organs of the body may interfere with their ability to function. Increasing venous return to the right atrium increases the workload of the heart.
A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. What does the nurse identify as the purpose of the nitroglycerin patch? 1 Decreased heart rate lowers cardiac output. 2 Increased cardiac output increases oxygen demand. 3 Decreased cardiac preload reduces cardiac workload. 4 Peripheral venous and arterial constriction increases peripheral resistance.
3 Decreased cardiac preload reduces cardiac workload Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect. It decreases blood pressure, not heart rate (which may increase to compensate for the decreased blood pressure). It decreases, not increases, oxygen demand. Nitroglycerin dilates, not constricts, peripheral veins and arteries.
A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. What does the nurse identify as the purpose of the nitroglycerin patch? 1 Decreased heart rate lowers cardiac output. 2 Increased cardiac output increases oxygen demand. 3 Decreased cardiac preload reduces cardiac workload. 4 Peripheral venous and arterial constriction increases peripheral resistance.
3 Decreased cardiac preload reduces cardiac workload.
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. 3 Encourage early mobility. 4 Elevate the knee gatch of the bed.
3 Encourage early mobility. In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk for thrombophlebitis.
The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? 1 PO2 value is 80 mm Hg. 2 PCO2 value is 60 mm Hg. 3 HCO3 value is 50 mEq/L (50 mmol/L). 4 Serum potassium value is 4 mEq/L (4 mmol/L
3 HCO3 value is 50 mEq/L (50 mmol/L). The HCO3 value is elevated. The urinary system compensates by retaining H+ ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO3 value is 21 to 28 mEq/L (21 to 28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis [1] [2] the PCO2 level may be increased, it is the increased HCO3 level that indicates compensation. A K+ level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.
A healthcare provider in the emergency department identifies that a client is in cardiogenic shock. Which type of drug does the nurse anticipate will be prescribed? 1 Loop diuretic 2 Cardiac glycoside 3 Sympathomimetic 4 Alpha-adrenergic blocker
3 Sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output. Diuretics promote excretion of fluid, which is not indicated. Cardiac glycosides slow and strengthen the heartbeat; they do not increase the blood pressure and may decrease it. Alpha-adrenergic blockers decrease peripheral resistance, resulting in a decreased blood pressure.
The client has arrived at the medical surgical unit after discharge from the post anesthesia care unit. Which areas should the nurse observe when making a focused assessment of the airway? 1 The nurse should monitor if the neck is in proper alignment. 2 The nurse should observe the rate and the depth of the respirations. 3 The nurse should look at the quality and the pattern of the breathing. 4 The nurse should see if the client is using accessory muscles to breathe.
3 The nurse should look at the quality and the pattern of the breathing. To make a focused assessment of the airway, the nurse should observe if the neck of the client is in proper alignment with the body. The nurse should monitor the rate and the depth of the respirations while checking the breathing of the client. The quality and the pattern of breathing are also necessary to assess. The nurse should observe the client's use of accessory muscles required for breathing.
A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which physical parameters should the nurse consider to determine the safe resumption of sexual activity? 1 When the client and partner are not fearful of sexual intimacy 2 When the client feels emotionally ready to resume sexual activity 3 The point at which two flights of stairs can be climbed without dyspnea 4 Laboratory data showing that enzyme results have returned to preinfarction levels
3 The point at which two flights of stairs can be climbed without dyspnea The point at which two flights of stairs can be climbed approximates the energy expended during sexual activity. Emotionally, the client or partner may never be ready; studies have shown that individuals fear resumption of sexual activity. The client may be emotionally ready to resume sexual activity before being physically ready. Enzyme studies, such as creatine kinase (CK), creatine kinase myoglobin (CK-MB), lactate dehydrogenase (LDH), and aspartate transaminase (AST), return to expected levels after 3 to 14 days, which may be too soon to resume sexual activity.
A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1 Diuresis, irritability, and fever 2 Lethargy, cold skin, and hypertension 3 Thirst, cool skin, and orthostatic hypotension 4 Bounding pulse, restlessness, and slurred speech
3 Thirst, cool skin, and orthostatic hypotension With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.
A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood
3 To increase oxygen concentration to heart cells Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.
To prevent septic shock in the hospitalized client, what should the nurse do? 1 Maintain the client in a normothermic state. 2 Administer blood products to replace fluid losses. 3 Use aseptic technique during all invasive procedures. 4 Keep the critically ill client immobilized to reduce metabolic demands.
3 Use aseptic technique during all invasive procedures. Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shoc
An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? 1 36.0ºC 2 36.8ºC 3 37.2ºC 4 38.5ºC
4 38.5ºC In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.
Which pulmonary risk may be increased in a postoperative client due to anesthesia? 1 Rhonchi 2 Fremitus 3 Dyspnea 4 Atelectasis
4 Atelectasis Postoperative clients are at risk for atelectasis, which involves the collapse of the alveoli. This condition is caused by the effects of anesthesia. Rhonchi are continuous rumbling or snoring sounds caused by the obstruction of the larger airways. Fremitus is the vibration of the chest wall during vocalization. Dyspnea is shortness of breath; this condition is an after effect of atelectasis.
The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the client is stabilized, what intervention should the nurse do next? 1 Monitor the peripheral pulses. 2 Check the level of consciousness. 3 Take a blood sample for laboratory tests. 4 Control the bleeding with a pressure dressing.
4 Control the bleeding with a pressure dressing. The primary nursing intervention that should be followed in the client's condition with gastrointestinal bleeding is collection of a blood sample for laboratory diagnosis. Peripheral pulses are monitored in an ongoing manner. Level of consciousness may not be required to be monitored based on the client's condition. Controlling bleeding with a pressure dressing is usually done in case of deep lacerations and wounds.
A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? 1 Weak, rapid pulse 2 Decreased blood pressure 3 Radiating anterior chest pain 4 Crackles at bases of the lungs
4 Crackles at bases of the lungs Crackles are the sound of air passing through fluid in the alveolar spaces; in pulmonary edema, fluid moves from the intravascular compartment into the alveoli. Hypervolemia leads to pulmonary edema. The pulse is bounding with hypervolemia. The blood pressure usually is increased with hypervolemia. Radiating anterior chest pain occurs with angina or a myocardial infarction.
After abdominal surgery a client reports pain. What action should the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.
4 Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1 Productive cough 2 Clubbing of the fingertips 3 Crackles at the height of inhalation 4 Diminished breath sounds on auscultation
4 Diminished breath sounds on auscultation Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Crackles at the height of inhalation are not specific to atelectasis. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema.
A client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The healthcare provider prescribes 500 mL of D5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which most common side effect of this medication? 1 Nausea 2 Syncope 3 Bradycardia 4 Hypotension
4 Hypotension The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure. Nausea is not a common side effect of intravenous nitroglycerin. Syncope is an infrequent effect when nitroglycerin is given intravenously. Reflex tachycardia may occur with the decrease in blood pressure.
A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client? 1 Obstructive 2 Neurogenic 3 Cardiogenic 4 Hypovolemic
4 Hypovolemic Hypovolemic shock occurs when an abdominal aneurysm ruptures. Shock ensues because fluid volume becomes depleted as the heart continues to pump blood out of the ruptured vessel. Obstructive shock occurs from physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism. Neurogenic shock results from decreased neuromuscular tone, which reduces vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.
What is the term for shock associated with a ruptured abdominal aneurysm? 1 Vasogenic shock 2 Neurogenic shock 3 Cardiogenic shock 4 Hypovolemic shock
4 Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.
Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? 1 Urticaria 2 Tachycardia 3 Restlessness 4 Laryngeal edema
4 Laryngeal edema Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, cutaneous signs of urticaria, tachycardia, and increasing restlessness, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.
A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action? 1 Abdominal pain 2 Respiratory distress 3 Sudden hemorrhage 4 Postural hypotension
4 Postural hypotension After administration of certain antihypertensives or opioids, a client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when an upright position is assumed. Postural or orthostatic hypotension occurs, and blood supply to the brain is temporarily decreased. Abdominal pain, respiratory distress, and sudden hemorrhage will not be prevented by the intervention described. 92%
A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? 1 Respirations of 10 2 Urine output of 30 mL/hour 3 Lethargy 4 Restlessness
4 Restlessness In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 mL/hour is within normal limits. Lethargy is not a sign of shock.
What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? 1 Wear support hose continuously. 2 Lie down for 30 minutes after taking medication. 3 Avoid tasks that require high-energy expenditure. 4 Sit on the edge of the bed for 5 minutes before standing.
4 Sit on the edge of the bed for 5 minutes before standing. Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.
When a client has a myocardial infarction, one of the major manifestations is a decrease in the conductive energy provided to the heart. When assessing this client, the nurse is aware that the existing action potential is in direct relationship to what? 1 Heart rate 2 Refractory period 3 Pulmonary pressure 4 Strength of contraction
4 Strength of contraction A direct relationship exists between the strength of cardiac contractions and the electrical conductions through the myocardium. The heart rate is related to factors such as sinoatrial (SA) node function, partial pressures of oxygen and carbon dioxide, and emotions. The refractory period is when the heart is at rest, not when it is contracting. Pulmonary pressure does not influence action potential; it becomes elevated in the presence of left ventricular failure.
Which is the priority nursing action to decrease the risk for a client developing a hospital-acquired infection? 1 Using droplet precautions 2 Using contact precautions 3 Using airborne precautions 4 Using standard precautions
4 Using standard precautions The use of standard precautions, which includes hand hygiene, is the priority action to decrease a client's risk for developing a hospital-acquired infection. While transmission-based precautions such as droplet, contact, and airborne precautions may be necessary to prevent the transmission of communicable infection to other clients, these are not nursing actions to decrease a client's risk for developing a hospital-acquired infection.
A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. 1 Spasticity 2 Incontinence 3 Flaccid paralysis 4 Respiratory failure 5 Lack of reflexes below the injury
5 Lack of reflexes below the injury 3 Flaccid paralysis
The nurse is assessing four clients in the post-anesthesia care unit (PCU) who are on opioid treatment. Which client does the nurse expect will benefit from an immediate treatment with naloxone? client A) frequently drowsy, rousable, drifts off to sleep during conversations. RR: 15 Client B) slightly drowsy easy to rouse. RR: 24 C) awake and alert RR:32 D) minimal response to verbal and physical stimuli RR:10
D) minimal response to verbal and physical stimuli RR:10 Client D with severe sedation due to opioids has minimal response to verbal and physical stimulation; this client requires immediate treatment with naloxone to reverse effects of opioids. Client A with level 3 of sedation and respiratory rate of 15 breaths per minute should take acetaminophen to stabilize the condition. Client B who is slightly drowsy and easily aroused with a respiratory rate of 24 breaths per minute has level 2 of sedation, which does not require any intervention. Client C who is awake and alert with respiratory rate of 32 breaths per minute is normal.
