2400: Unit 3 Review- EAQ

Sublingual nitroglycerin has been prescribed for a client with unstable angina. Which client response indicates that nitroglycerin is effective? A. Pain subsides as a result of arteriole and venous dilation. B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves as a response to increased collateral circulation.

A Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain. An increased pulse rate does not indicate effectiveness; it is a side effect of nitroglycerin. The tingling indicates that the medication is fresh; relief of pain is the only indicator of effectiveness. Nitroglycerin does not promote the formation of new blood vessels.

Which is the priority intervention for the unconscious client in ventricular fibrillation? A. Defibrillation B. Starting intravenous (IV) access C. Bag-mask ventilation D. High-quality chest compressions

A Research indicates that rapid defibrillation is the most successful intervention when resuscitating a client who has cardiac arrest due to ventricular fibrillation. Guidelines recommend defibrillation as the initial action. IV access for emergency medication is needed, but would be done after defibrillation. Bag-mask ventilation is necessary, but would be done after defibrillation. High-quality chest compressions are needed if defibrillation is unsuccessful in restoring a more normal rhythm.

Which are the actions of oxytocin? Select all that apply. One, some, or all responses may be correct. A. Promotes milk ejection during lactation B. Controls uterine bleeding after delivery C. Induces labor when uterine contractions are weak D. Prevents uterine fibrosis in women of reproductive age E. Prevents high-risk intrauterine fetal positions before delivery

A, B, C Oxytocin is a hormone supplement that is indicated for milk ejection during lactation because it promotes the movement of milk from the mammary glands to the nipples. Oxytocin also controls uterine bleeding after delivery. Oxytocin stimulates uterine contraction during childbirth, which induces labor when uterine contractions are weak. Oxytocin is contraindicated in uterine fibrosis. Hormones cannot prevent high-risk intrauterine fetal positions before delivery.

Digoxin is prescribed for a client with heart failure. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply. One, some, or all responses may be correct. A. Nausea B. Yellow vision C. Irregular pulse D. Increased urine output E. Heart rate of 64 beats/minute

A, B, C Signs and symptoms of digoxin toxicity include bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). In addition, electrocardiogram (ECG) findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of improved cardiac output. A pulse rate of 64 beats/minute is an acceptable rate when a client is receiving digoxin.

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct. A. Wearing a medical alert bracelet B. Initiating bleeding precautions C. Refraining from estrogen therapy D. Obtaining routine prothrombin times E. Notifying providers of anticoagulation

A, B, C, D, E A client taking anticoagulants would be instructed to wear a medical alert bracelet and take bleeding precautions, such as shaving with an electric razor. A client taking anticoagulants should be advised to refrain from estrogen therapy because this can lead to clot formation. All clients on anticoagulation therapy need to have routine prothrombin time testing and need to inform all health care providers of their anticoagulant use.

Which action would the nurse perform when a client is in ventricular fibrillation? Select all that apply. One, some, or all responses may be correct. A. Initiating CPR B. Assessing the EKG C. Using a defibrillator D. Obtaining electrolytes E. Administering epinephrine

A, B, C, D, E Ventricular fibrillation is an abnormal heart rhythm that can be fatal. Key nursing interventions include initiating CPR, continuing to assess the heart rhythm through an EKG while performing interventions, and using a defibrillator to try to convert the client back to a normal sinus rhythm. An electrolyte panel can be used to determine if hyperkalemia led to the dysrhythmia as this imbalance would need to be corrected. Epinephrine and/or amiodarone may be administered when attempting to change the abnormal rhythm.

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. A. Diuretics B. Low-salt diet C. Daily weight checks D. Fluid restriction E. Intake and output F. Oxygen administration

A, B, C, D, E, F Interventions for a client with heart failure who has sustained a 20-pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; a low-salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs.

Which conditions increase the risk for postpartum hemorrhage? Select all that apply. One, some, or all responses may be correct. A. Twin birth B. Overdistended bladder C. Hypertonic uterine dysfunction D. Retained placental fragments E. Mild gestational hypertension

A, B, D Overdistention of the uterus may lead to delayed or inadequate uterine contractions. An overdistended bladder may inhibit uterine contractions. Retained placental fragments inhibit uterine contractions. Clients with ineffective uterine contractions are treated with rest and sedatives; although labor is prolonged, postpartum hemorrhage is not expected. Mild gestational hypertension does not interfere with uterine involution.

Which medication prescribed for a client with an acute episode of heart failure would the nurse question? A. Diuretic B. Beta blocker C. Long-acting nitrate D. Angiotensin receptor blocker

B Beta blockers reduce cardiac output and are contraindicated for clients with acute heart failure, although they are frequently used to prevent progression of chronic heart failure. Diuretics are used in acute heart failure to decrease hypervolemia and congestion. Long-acting nitrates are used in heart failure to reduce preload. Angiotensin receptor blockers are used in heart failure to decrease fluid overload and afterload.

Which statement by a woman with preeclampsia indicates the need for further teaching about needed dietary changes? A. "I should avoid excess salt." B. "I should limit my fluid intake." C. "I should eat whole grains and raw produce." D. "I should eat 60 to 70 grams of protein each day."

B Women with preeclampsia should not limit fluid intake and should drink between 6 and 8 cups of water each day. Salt should be limited to 1.5 g of sodium daily. The client also should eat plenty of fiber from whole grains and raw fruits and vegetables as well as 60 to 70 grams of protein each day.

A preterm infant is started on digoxin and furosemide for persistent patent ductus arteriosus. Which nursing assessment provides the best indication of the effectiveness of the furosemide? A. Pedal edema is reduced. B. Digoxin toxicity is prevented. C. Fontanels appear depressed. D. Urine output exceeds fluid intake.

D Urine output exceeding fluid intake is the expected outcome. Output exceeding intake indicates that furosemide is causing diuresis. Although it is important to determine whether pedal edema is reduced, this could be influenced by other factors. Furosemide can cause hypokalemia, which may precipitate digoxin toxicity; it is not given to prevent digoxin toxicity. Depressed fontanels are not the desired outcome; this finding indicates dehydration, which may occur with excessive diuresis.

A 6-year-old child with sickle cell disease is admitted with a vasoocclusive crisis (pain episode). Which are the priority nursing concerns? Select all that apply. One, some, or all responses may be correct. A. Nutrition B. Hydration C. Pain management D. Prevention of infection E. Oxygen supplementation

B, C, E The triad of treatment for a client experiencing a sickle cell crisis is: hydration, oxygenation, and pain management. Hydration will provide more circulating volume for the sickle cells. Supplemental oxygen will provide more oxygen molecules to attach to the red cells, providing more oxygen to the tissue and joints. Pain management is typically the primary reason this client presents for treatment; the pain becomes unbearable. Other interventions such as nutrition and keeping the client safe from infection should be addressed but are not priorities.

A 3-month-old infant with tetralogy of Fallot suddenly becomes cyanotic and begins breathing rapidly. In which position would the nurse immediately place the infant? A. Supine B. Lateral C. Knee-chest D. Semi-Fowler

C The infant is experiencing a hypercyanotic ("tet" spell) episode caused by a sudden decrease in pulmonary blood flow and an increase in right-to-left shunting. It usually occurs after increased activity. The knee-chest position decreases venous return from the legs, which increases systemic vascular resistance, thereby increasing pulmonary blood flow. The supine and lateral positions increase venous return, which exacerbates the problem. Although the semi-Fowler position is recommended for infants with cardiac disease, it is not adequate for an infant experiencing a tet spell.

Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene? A. Spinal shock B. Brain herniation C. Hypovolemic shock D. Increased intracranial pressure

D Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.

What would the nurse include in the plan of care to minimize the potential for a sickling episode in a child with sickle cell anemia? A. Providing an iron-rich diet B. Ensuring hemoconcentration C. Enforcing periods of quiet play D. Promoting adequate oxygenation

D Low oxygen tension may precipitate sickling; therefore adequate oxygenation is desirable. Oral intake of iron may contribute to iron overload. Some children with sickle cell anemia receive frequent transfusions to suppress the production of red blood cells containing the sickle hemoglobin. Hemoconcentration results in increased viscosity, which promotes thrombus formation and sickling. Quiet play is desirable during a painful episode, but it is not used routinely to prevent a crisis.

Which medication may be used to treat postpartum hemorrhage? A. Clomiphene B. Menotropins C. Dinoprostone D. Methylergonovine

D Methylergonovine is a medication of choice used to treat postpartum hemorrhage. Clomiphene and menotropins are ovulation stimulants given to induce ovulation in infertile women. Dinoprostone is used to induce cervical ripening and cause termination of a pregnancy.

Which medication is administered to women after delivery to prevent postpartum uterine atony and hemorrhage? A. Dinoprostone B. Mifepristone C. Indomethacin D. Methylergonovine

D Methylergonovine is given to prevent postpartum uterine atony and hemorrhage but should not be used for the augmentation of labor or during a spontaneous abortion. Dinoprostone is used to terminate a pregnancy. Mifepristone is also used to induce an elective termination of a pregnancy. Indomethacin is used to maintain a pregnancy during preterm labor.

The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching? A. "I'll use a straight razor when I start shaving." B. "I plan on trying out for the swim team next year." C. "If I injure a joint, I'll keep it still, elevate it, and apply ice." D. "If I get a little scratch, I can apply gentle pressure for 10 to 15 minutes."

A A straight razor should not be used by the adolescent with hemophilia, so further teaching is required. The adolescent with hemophilia should be taught to use an electric razor for shaving. Contact sports should be avoided, but swimming is a recommended activity, so trying out for the swim team indicates that the adolescent understands the teaching. If a superficial injury occurs, gentle, prolonged pressure should be applied until the bleeding has stopped. If a muscle or joint injury occurs, the area should be immobilized, elevated, and iced.

Which problem predisposes a client to postpartum hemorrhage? A. Preeclampsia B. Multifetal pregnancy C. Prolonged first-stage labor D. Cephalopelvic disproportion

B The presence of more than one fetus overdistends the uterus, which may result in uterine atony and thus postpartum hemorrhage. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.

A beta blocker is prescribed for the client with persistent ventricular tachycardia. Which response indicates that the beta blocker is working effectively? A. Decreased anxiety B. Reduced chest pain C. Decreased heart rate D. Increased blood pressure

C A decreased heart rate is the expected response to a beta blocker. Beta blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart. A beta blocker is not an anxiolytic and does not reduce anxiety. A beta blocker is not an analgesic and does not reduce chest pain. Beta blockers reduce blood pressure.

Which is an important nursing intervention when a client receives intravenous (IV) magnesium sulfate for preeclampsia? A. Limiting IV fluid intake B. Preparing for a possible precipitous birth C. Maintaining a quiet, darkened environment D. Obtaining magnesium gluconate as an antagonist

C A quiet, darkened room reduces stimuli, which is essential for limiting or preventing seizures. IV fluid infusions are not limited. Infusions are monitored closely and usually maintained at a volume of 125 mL/h. Precipitous birth is not a usual side effect of magnesium therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be kept on hand in case signs of toxicity appear.

Which is a clinical manifestation of worsening preeclampsia? A. Polyuria B. Vaginal spotting C. Proteinuria of 3+ D. Blood pressure of 130/80 mm Hg

C As preeclampsia worsens, blood pressure and edema increase and degenerative changes of the kidney cause increasing proteinuria (3+). With worsening preeclampsia, oliguria, not polyuria, is expected. Vaginal spotting is not a sign of worsening preeclampsia. A blood pressure of 130/80 mm Hg is within acceptable limits; however, there is insufficient information to determine whether it is increased in this client.

A 2-year-old child who is hospitalized for repair of tetralogy of Fallot is seen squatting in the playroom. In response to this behavior, which would the nurse do? A. Administer oxygen through a mask. B. Call the respiratory therapist for a nebulizer treatment. C. Continue to observe the child if there are no other signs of distress. D. Notify the health care provide that the child's condition is deteriorating.

C Squatting is a physiologic adaptation for children with tetralogy of Fallot. By squatting, the child decreases the amount of arterial blood that is flowing to the extremities, which in turn decreases venous return to the heart and reduces preload. Oxygen is not indicated. The child has a heart, not respiratory problem, so a nebulizer treatment is not indicated. The child's condition has not deteriorated; squatting is a physiologic adaptation.

Which description would the nurse provide the parents of an infant who are asking about what a patent ductus arteriosus (PDA) is? A. The diameter of the aorta is enlarged. B. The wall between the right and left ventricles is open. C. It is a narrowing of the entrance to the pulmonary artery. D. It is a connection between the pulmonary artery and the aorta.

D Before birth, oxygenated fetal blood is shunted directly into the systemic circulation by way of the ductus arteriosus, a connection between the pulmonary artery and the aorta. After birth, the increased oxygen tension causes a functional closure of the ductus arteriosus. Occasionally, particularly in preterm infants, this vessel remains open, a condition known as patent ductus arteriosus. Enlargement of the diameter of the aorta is not the problem in patent ductus arteriosus. A defective wall between the right and left ventricles is a description of ventricular septal defect. A narrowing of the entrance to the pulmonary artery is a description of pulmonic stenosis.

Which nursing care would the nurse provide an 8-month-old infant with tetralogy of Fallot? A. Restriction of fluid intake to conserve energy B. Provision of iron-fortified formula to prevent anemia C. Administration of coagulants to control bleeding tendencies D. Prevention of increased respiratory effort to promote oxygenation

D Preventing respiratory distress minimizes the workload of the heart; this is accomplished with such interventions as positioning, maintaining diet restrictions, administering medications, and promoting conservation of energy. Restriction of fluid intake will promote hemoconcentration (increasing thrombus risk) and dehydration (increasing risk of tet spell); if oral fluids are limited to conserve energy, intravenous fluids may be indicated. Additional iron intake will aggravate the polycythemia that results from hypoxia caused by reduced pulmonary blood flow. Administration of coagulants along with hemoconcentration is conducive to thrombus formation.

An adolescent is admitted with an acute hemophilia episode. What are rest, ice, compression, and elevation most helpful for? A. Encouraging immobilization B. Decreasing swelling and inflammation C. Providing pain relief and reducing anxiety D. Controlling bleeding and retaining joint function

D Rest, ice, compression, and elevation (RICE) therapy is implemented to prevent bleeding into joints and to support joints and during an acute hemophilia episode. Reducing inflammation is not the goal of treatment for the hemophiliac process. Total immobilization is not required. Pain may be relieved to some degree but is not assured.

To determine whether a client is experiencing acute coronary syndrome (ACS), which component of the electrocardiogram would the nurse analyze? A. P wave B. PR interval C. QRS complex D. ST segment

D Elevation or depression of ST segment is indicative of ACS because of changes in cardiac electrical activity that occur with ischemia and injury. P wave changes are not used to diagnose ACS. Changes in the QRS complex do not occur with ACS. Changes in the PR interval are not diagnostic of ACS.

During administration of a whole-blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions. 1. Apply oxygen via nasal cannula. 2. Elevate the head of the bed to 45 degrees. 3. Document findings in the client record. 4. Reduce the flow rate of the transfusion. 5. Administer furosemide per provider prescription.

2, 1, 4 5, 3 These symptoms represent circulatory overload. First, the nurse's priority is to facilitate gas exchange by elevating the head of the bed to decrease dependent pulmonary edema, then applying oxygen. Next, the transfusion rate should be slowed to reduce further circulatory overload and client compromise, followed by the administration of a diuretic to reduce circulating volume. Lastly, the findings and interventions should be documented.

In which order would the nurse complete these steps when administering a blood transfusion? 1. Ascertain that intravenous catheter size is 18 or 20 gauge. 2. Check primary health care provider's prescription. 3. Change main line solution to normal saline. 4. Check client identification before hanging unit of blood. 5. Obtain vital signs and history of transfusions.

2, 5, 1, 3, 4 The nurse should first check the health care provider's prescription to notify the blood bank of which product will be needed. The next step is to obtain the client's baseline vital signs and ask whether the client has had previous transfusions and whether there were any adverse effects or any transfusion reaction. Ascertaining that the intravenous catheter size is at least 18 gauge will prevent hemolysis of red blood cells. The main line solution must be normal saline 0.9% to flush the line and use as a main line if the blood administration is discontinued because of a reaction. Checking the client identification and verification of blood product is done just before starting the infusion.

A 12-year-old child with sickle cell anemia is admitted during a vasoocclusive crisis. Which is the priority of care for this child? A. Relieving pain B. Exercising joints C. Increasing urine output D. Improving respirations

A A vasoocclusive crisis is accompanied by severe pain because the clumped red blood cells block small vessels. Swollen limbs are painful and should not be exercised during a pain episode. Although increased urine output, associated with appropriate hydration, is an important objective, pain relief is the priority. Improved respiratory function occurs as pain is relieved.

When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first? A. Attach the cardiac monitor. B. Auscultate the heart sounds C. Check the intravenous fluid rate. D. Assess alertness and orientation.

A Because fatal dysrhythmias may occur in the first hours after myocardial infarction, cardiac monitoring is a priority. The nurse will also do auscultation of the heart, but changes in heart sounds are not expected with ACS and PCI. Checking the intravenous line for patency and correct infusion rate is also important, but would be done after establishing cardiac monitoring. Neurological status would be assessed, but changes in neurological status are not expected after PCI, which does not require general anesthesia.

When caring for a client who has heart failure, with blood pressure 102/70 mm Hg, pulse 106 beats/minute, and bilateral lung crackles, which prescribed action would the nurse question? A. Infuse normal saline at 100 mL/h. B. Give furosemide 40 mg intravenous now. C. Administer potassium chloride 10 mEq orally now. D. Titrate oxygen by mask to keep oxygen saturation 93% or higher.

A Because the likely cause of hypotension, tachycardia, and lung crackles in this client is decreased cardiac output and increased pulmonary congestion caused by heart failure, infusing normal saline would worsen the symptoms of fluid overload and should be questioned by the nurse. Administration of diuretics such as furosemide will decrease fluid overload in the left ventricle and improve cardiac output. Because furosemide does lead to lower potassium, the administration of potassium is appropriate. Titration of oxygen to assure adequate oxygen saturation is appropriate for a client with pulmonary congestion.

Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation? A. Take pulse apically for a full minute. B. Monitor blood pressure at least every 2 hours. C. Ask client to call for assistance when ambulating. D. Teach client to avoid taking over-the-counter aspirin.

A Because the pulse with atrial fibrillation is irregularly irregular, there is a difference between apical and radial pulse rate (pulse deficit) and the apical pulse is used for an accurate heart rate. Although some clients with atrial fibrillation may have hypotension, there is no indication that this client needs frequent blood pressure monitoring. Because the client does not have hypotension or dizziness, there is no indication that the client needs assistance when ambulating. Because atrial clots may form in atrial fibrillation and lead to stroke, many clients are prescribed daily aspirin to decrease stroke risk.

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? A. Stop the blood transfusion and infuse saline. B. Administer the prescribed antipyretic. C. Obtain a prescription for an antihistamine. D. Notify the blood bank about the symptoms.

A Fever, chills, and low back pain indicate an acute hemolytic reaction, which is potentially life threatening; discontinuing the transfusion immediately and infusing saline limits kidney damage. Although the client has a fever, administering an antipyretic before stopping the transfusion would allow the transfusion reaction to continue. The client's safety must be addressed first. Obtaining a prescription for an antihistamine may be done after stopping the transfusion and infusing saline. Although the blood bank generally is notified if a reaction occurs, this would be done after stopping the transfusion.

A 20-year-old client seen in the emergency department reports frequent "skipped heart beats," and the nurse notes frequent premature ventricular complexes (PVCs) on the cardiac monitor. Which action would the nurse take first? A. Ask the client about use of caffeine or stimulant drugs. B. Teach the client that PVCs may lead to cardiac arrest unless treated. C. Question the client about any family history of sudden cardiac death. D. Prepare to insert an intravenous catheter, anticipating medication administration.

A In a 20-year-old, a common cause of PVCs is use of stimulants such as caffeine-containing drinks or stimulant drugs such as methamphetamine. PVCs may cause ventricular tachycardia or ventricular fibrillation in clients with coronary artery disease, but educating a young person about these complications would not be the priority action. Questioning the client about any family history of sudden cardiac death is appropriate, especially if the client does not ingest any cardiac stimulants. When there is no underlying heart disease, PVCs are not usually treated except by eliminating any possible causes, such as stress or overuse of caffeine.

The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client? A. Shortening and eventual atrophy of the affected muscles will occur. B. Hypertrophy of the muscles eventually will result from disuse. C. Extension rigidity can occur, making therapy painful and difficult. D. Decreased movement on the affected side predisposes the client to infection.

A Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertrophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose the client to infection but does predispose the client to muscle atrophy and contractures if there are delays in beginning therapy.

In which position would the nurse place an infant with tetralogy of Fallot who begins to cry and exhibits worsening cyanosis and dyspnea? A. Knee-chest B. Orthopneic C. Lateral Sims D. Semi-Fowler

A The knee-chest position decreases circulation to and from the extremities, thereby improving circulation to the heart and lungs and increasing oxygenation. The knee-chest position has the same effect as the squatting that is seen in the older child with tetralogy of Fallot. Blood circulating in the heart and lungs has a lower oxygen content when the child is in the orthopneic position than it does with the child in the knee-chest position. Blood circulating in the heart and lungs has a lower oxygen content when a person is in the semi-Fowler position or lateral Sims position.

Which laboratory value will be most important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)? A. Troponin T (cTnT) B. C-reactive protein (CRP) C. Low-density lipoprotein (LDL) D. B-type natriuretic protein (BNP)

A These are released into circulation within hours after myocardial injury or infarction, and elevation in troponin levels helps determine that the client is experiencing ACS. The other three values will also be monitored but are not markers for ACS or acute myocardial infarction. C-reactive protein is a marker for inflammation and elevated levels can predict cardiac disease. Elevated LDL is a risk factor for atherosclerosis and coronary artery disease. Elevated BNP is diagnostic for heart failure.

Ten minutes after the initiation of a blood transfusion, a client reports chills and flank pain. Which nursing action would be performed first? A. Stop the transfusion. B. Obtain the vital signs. C. Notify the health care provider. D. Maintain the flow with normal saline.

A This is a sign of an acute hemolytic transfusion reaction, indicating that the recipient's blood is incompatible with the transfused blood; pain is caused by hemolysis, agglutination, and capillary plugging in the kidneys. Obtaining the vital signs is important but must not precede stopping the transfusion because more incompatible blood will be infused, increasing the severity of the transfusion reaction. After the infusion is stopped, the provider should be notified and normal saline should be infused to keep the line patent.

Which interventions would be included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. One, some, or all responses may be correct. A. Monitoring deep tendon reflexes B. Assessing urine output every 8 hours C. Maintaining a dark, quiet environment D. Using a pump to regulate the medication E. Having calcium gluconate available at the bedside F. Notifying the health care provider if the respiratory rate is slower than 20 breaths/min

A, C, D, E Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/h must be reported to the primary health care provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary health care provider.

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The health care provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. Which nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition? A. Performing daily weights B. Auscultating breath sounds C. Monitoring intake and output D. Assessing for dependent edema

B Maintaining adequate gas exchange and minimizing hypoxia with pulmonary edema are critical; therefore assessing the effectiveness of furosemide therapy as it relates to the respiratory system is most important. Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, causing diuresis; as diuresis occurs fluid moves out of the vascular compartment, thereby reducing pulmonary edema and the bilateral crackles. Although a liter of fluid weighs approximately 2.2 pounds (1 kg) and weight loss will reflect the amount of fluid lost, it will take time before a change in weight can be measured. Although identifying a greater output versus intake indicates the effectiveness of furosemide, it is the client's pulmonary status that is most important with acute pulmonary edema. Although the lessening of a client's dependent edema reflects effectiveness of furosemide therapy, it is the client's improving pulmonary status that is the best indicator of how furosemide improves the client's condition.

A client with hypertensive heart disease who had an acute episode of heart failure is to be discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate when metoprolol is administered with digoxin? A. Headaches B. Bradycardia C. Hypertension D. Junctional tachycardia

B Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate. Metoprolol reduces, not produces, headaches. These medications may cause hypotension, not hypertension. These medications may depress nodal conduction; therefore junctional tachycardia would be less likely to occur.

The mother of a toddler with hemophilia A asks the nurse, "Can I give my child ibuprofen for fever or pain?" How will the nurse respond? A. "Ibuprofen is a good choice for fever or pain." B. "Give your child acetaminophen. Ibuprofen may cause bleeding." C. "No. I'll explain why your child isn't allowed pain medications." D. "You seem concerned about giving medications to your child."

B The parent is asking a specific question that should be answered by the nurse. Ibuprofen is contraindicated because it interferes with platelet function and may cause more bleeding; therefore an analgesic such as acetaminophen should be administered because it does not interfere with coagulation. Analgesics are permitted, provided they do not have anticoagulant effects.

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? A. Body weight control B. Decreased fluid retention C. Lowering of blood pressure D. Prevention of hypernatremia

B The purpose of a low-sodium diet for clients with heart failure is to decrease fluid retention. Clients with heart failure may or may not need weight loss, but a low-sodium diet will not help with weight control. Although sodium restriction may lower blood pressure in clients with hypertension, because of the Frank-Starling law, lower sodium intake may lead to improved cardiac output and higher blood pressures in clients with heart failure. Dietary sodium intake plays very little role in serum sodium levels (high serum sodium levels is called hypernatremia), which are controlled by multiple hormonal mechanisms, including antidiuretic hormone, aldosterone, and natriuretic peptide.

The nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which assessment finding would prompt the nurse to withhold the medication and notify the primary health care provider? A. Urine output of 30 mL/h B. Respirations of 14 breaths/min C. Absence of deep tendon reflexes D. Blood pressure of 140/100 mm Hg

C A side effect of magnesium sulfate is depressed reflex responses; this may indicate toxicity, and intervention is necessary. The amount of urine output is important, because oliguria may signify magnesium toxicity, but 30 mL/h is within the acceptable range. A respiratory rate of 14 breaths/min is a positive sign that toxicity has not occurred. A respiratory rate of 12 breaths/min or slower is a concern that requires nursing intervention. The blood pressure is expected to increase; this medication is administered to prevent a seizure, not to lower blood pressure.

During a procedure, the client's heart rate drops to 38 beats/min. Which medication is indicated to treat bradycardia? A. Digoxin B. Lidocaine C. Amiodarone D. Atropine sulfate

D Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate. Digoxin slows the heart rate; hence, it would not be indicated in this situation. Lidocaine decreases myocardial sensitivity and will not increase the heart rate. Amiodarone is an antidysrhythmic medication used for ventricular tachycardia; it will not stimulate the heart rate.

The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I give him two baby aspirins?" Which statement by the nurse is appropriate? A. "You seem concerned about giving medications to your child." B. "It's all right to give him baby aspirin when he hurts himself." C. "Aspirin may cause more bleeding. Give him acetaminophen instead." D. "He should be given acetaminophen every day. It'll prevent bleeding."

C Aspirin, which has an anticoagulant effect, is contraindicated because it may harm a child with bleeding problems; in addition, aspirin is contraindicated for all children because of its relationship to Reye syndrome. Stating that the parent seems concerned about giving medications to the child does not answer the mother's question and may cause the mother to feel defensive. Acetaminophen cannot prevent bleeding episodes; it is an analgesic.

When a client in the coronary care unit develops ventricular tachycardia, which action will the nurse take first? A. Initiate immediate defibrillation. B. Perform synchronized cardioversion. C. Assess client pulse and blood pressure. D. Start cardiopulmonary resuscitation (CPR).

C Because ventricular tachycardia (VT) can be stable or unstable, the nurse's first action will be to assess the client, including pulse and blood pressure. If the client is pulseless with the VT, defibrillation is used to try to end the rhythm. Synchronized cardioversion may be performed if the VT is stable and treatment with antidysrhythmic medications is unsuccessful. CPR may be initiated in pulseless VT if a defibrillator is not immediately available.

When a client with heart failure reports a 9-pound (4-kilogram) weight gain in the past 2 weeks, which assessment is the priority? A. Palpate the abdomen. B. Check for ankle edema. C. Auscultate breath sounds. D. Ask about dietary salt intake.

C The client's history of heart failure and recent weight gain suggests fluid retention. The nurse would assess lung sounds first because hypoxemia may result from severe pulmonary congestion and rapid administration of treatment such as oxygen and diuretics may be needed. Right upper quadrant abdominal tenderness or ascites may also occur with heart failure exacerbation, but would not be life threatening. Ankle edema is also likely with fluid excess associated with heart failure exacerbation, but is not life threatening and does not need immediate action. The nurse would want to assess for reasons for the weight gain and changes in salt intake are a likely cause, but this data can be obtained after any pulmonary congestion has been treated.

Which assessment finding would the nurse expect in a client with untreated preeclampsia? A. Increased blood pressure of 150/100 mm Hg B. Increased blood pressure that is accompanied by a headache C. Blood pressure above the baseline that fluctuates with each reading D. Blood pressure higher than 140 mm Hg systolic accompanied by proteinuria

D A blood pressure higher than 140 mm Hg systolic and 90 mm Hg diastolic along with proteinuria is diagnostic of preeclampsia; assessments should be performed twice, 4 to 6 hours apart. Hypertension alone does not support a diagnosis of preeclampsia. Hypertension accompanied by a headache is not necessarily indicative of preeclampsia. Blood pressure above the baseline and fluctuating with each reading may occur at any time, not specifically in a client with untreated preeclampsia.

The parent of a child with sickle cell anemia tells the nurse that the family is going camping by a lake in the mountains this summer. The parent inquires what activities are appropriate. Which activity would the nurse suggest? A. Swimming in the lake B. Soccer with the family C. Climbing the mountain trails D. Motorboat rides around the lake

D Motorboating is a relatively passive activity that will not increase the child's oxygen demands, which can precipitate sickling and a painful episode. Mountain lakes are usually cold; temperature extremes can contribute to sickling, which may precipitate a painful episode. Playing soccer may lead to increased cellular metabolism and increased tissue hypoxia, which can precipitate sickling that could progress to a painful episode. High altitudes should be avoided because the lower oxygen concentration of the air might trigger a painful episode.

The nurse will evaluate the client receiving oxytocin for which desired response? A. Limitation of the discomfort of the episiotomy B. Relaxation of the uterus so that it may be emptied C. Stimulation of the client's breasts so that breast-feeding may be started D. Prevention of the occurrence of profuse bleeding after placental separation

D Oxytocin will cause the uterus to contract after the placenta has been expelled, preventing hemorrhage. Oxytocin does not have an analgesic effect. Relaxation of the uterus is undesirable because it promotes bleeding. Prolactin, not oxytocin, stimulates milk production; oxytocin stimulates the let-down reflex.

Which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain? A. Unchanged by rest B. Precipitated by light activity C. Described as a knifelike sharpness D. Relieved by sublingual nitroglycerin

D Relief by sublingual nitroglycerin is a classic reaction because it causes vasodilation of peripheral veins and arteries, thereby decreasing oxygen demand by decreasing preload. To a lesser extent, sublingual nitroglycerin dilates coronary arteries, which increases oxygen to the myocardium, thereby decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness.