Exam #2

A client with hypertension asks about the cause. Which nursing response is appropriate? A. "Pregnancy can cause essential hypertension." B. "High cholesterol is a big factor in development of essential hypertension." C. "Stopping caffeine intake can cause hypertension to go away." D. Race is associated with secondary hypertension.

ANS: B High cholesterol is a causative agent of essential hypertension. The other statements are inaccurate.

As the nurse evaluates a laboratory report for a client scheduled for surgery, which finding requires nursing intervention? A. Hemoglobin 10.4 g/dL B. Serum potassium 2.5 mEq/L C. Serum sodium level 145 mEq/L D. Fasting blood glucose 110 mg/dL

ANS: B

During morning care the next day, the client develops shortness of breath, fatigue, and tachycardia. 4a. How does the nurse interpret these findings? 4b. Which nursing interventions are appropriate at this time?

4a. The patient has developed fatigue from too much exertion. 4b. Energy management—provide physical and emotional rest; arrange nursing care to provide periods of rest; provide assistance with any care the client is unable to complete for himself; observe and document the client's response to activity; as the client improves, consult with a physical therapist; gradually increase activity based on the client's responses.

While applying compression stockings and pneumatic compression devices, a client questions the purpose of these devices. What is the appropriate nursing response? A. "These will help to prevent blood clots." B. "They make your legs feel more comfortable." C. "These prevent skin breakdown from immobility." D. "The use of these right after surgery makes is easier to start to ambulate."

ANS: A

A client with chronic heart failure has been prescribed ivabradine. Which assessment data requires the nurse to contact the health care provider before administering this medication? A. Hypotension B. Ejection fraction of 29% C. Resting heart rate 80 beats/min D. Patient is currently on a beta blocker

ANS: A Ivabradine is used for HF clients who have an ejection fraction (EF) <32% who are in sinus rhythm with a resting heart rate ≥70 beats/min. This medication is used for clients who are either on the maximally tolerated dose of beta blocker therapy or have a contraindication to beta blocker therapy. Ivabradine is contraindicated with hypotension, sick sinus syndrome, 3rd degree heart block, pacemaker dependence, severe hepatic impairment, and use of cytochrome P4503A4 inhibitors.

2. Fifteen minutes after replacing the nasal cannula, the client's oxygen saturation is 97%. What is the appropriate nursing action? A. Continue the assessment B. Encourage deep breathing C. Contact the health care provide D. Increase the oxygen to 5 L per nasal cannula.

ANS: A Once the patient's oxygen is replaced, he denies shortness of breath. The supplemental oxygen and a period of rest resulted in his oxygen saturation being 96%, which is acceptable. The oxygen should not be increased, nor does he need to take deep breaths because the patient's SaO2 is normal and he is not short of breath.

The nurse is caring for a hospitalized client on a medical marijuana plan (MMP) who asks for the nurse to administer cannabis. What is the appropriate nursing action? A. "You must administer your own cannabis." B. "Nurses need special training to give cannabis." C. "I will be right back as soon as I gather up the supplies." D. "I can take you to the smoking area to provide the drug."

ANS: A Only the patient or designated caregiver identified through the MMP can administer cannabis.

After the assessment, the nurse documents: - Jugular venous distention - 2+ edema in feet and ankles - Swollen hands and fingers - Distended abdomen - Bibasilar crackles on auscultation - Productive cough with pink-tinged sputum 3. What condition is most likely, based on these results? A. Biventricular failure B. Class IV heart failure C. Left-sided heart failure D. Right-sided heart failure

ANS: A The client has key features of both right-sided and left-sided heart failure.

To advocate for safe transition in care, for which process will the nurse advocate? Select all that apply. A. Providing patient history and current assessment information B. Communicating updates and changes in condition C. Verbally verifying that the receiving nurse understands the report D. Using a standardized hand-off communication tool E. Encouraging the receiving nurse to interrupt to ask questions during report

ANS: A, B, C, D

At the end of the visit, the primary health care provider prescribes hydrochlorothiazide 25 mg PO each morning. Which teaching will the nurse provide? A. "This is a loop diuretic that decreases sodium reabsorption." B. "Eat foods rich in potassium, such as bananas and orange juice." C. "A potassium supplement will be prescribed along with this drug." D. "This drug is a potassium-sparing diuretic that helps prevent the loss of essential potassium."

ANS: B Hydrochlorothiazide is a thiazide diuretic. The most frequent side effect is hypokalemia, so it's important to teach clients the signs of low potassium, as well as which foods are rich in potassium. Some clients need a potassium supplement, but this is prescribed based on the client's serum potassium level.

The nurse is preparing to discharge a client who has been prescribed an opioid analgesic after knee replacement surgery. What teaching will the nurse provide? A. Do not take with grapefruit juice B. Eat plenty of foods that are high in fiber C. Take entire prescription even if pain is gone D. Only take 1-2 pills to avoid becoming addicted

ANS: B Opioids inhibit peristalsis in the GI tract. Patients who take opioids frequently become constipated. Interventions such as diet modifications (eating foods high in fiber) and laxative agents may be needed to prevent or minimize the problem of constipation.

The nurse on a postoperative unit is caring for four clients. Which client does the nurse discuss with the surgeon that may benefit from PCA? A. 37-year old who broke both arms in skiing accident B. 47-year old who underwent bariatric surgery for weight loss C. 59-year-old with temperature of 103° following surgery for bowel obstruction D. 66-year old with cognitive deficit who had hip replacement

ANS: B The mentally alert patient is the best candidate to receive PCA.

A 53-year-old client was admitted 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5ʹ8ʺ tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. Upon entering the room, the nurse notes the client sitting on the side of the bed, sweating, and experiencing shortness of breath. He reports just using the bathroom. His nasal cannula is on the bedside table. 1. Which action will the nurse take? A. Obtain vital signs. B. Replace the nasal cannula. C. Sit him up in a bedside chair. D. Call the Rapid Response Team.

ANS: B The patient has exerted himself in ambulating to and from the bathroom. He also has been without supplemental oxygen. The nurse will replace his nasal cannula. He has a history of heart failure and will often require supplemental oxygen. Taking his vital signs can be done once his oxygen is restored. If he wants to sit up, he should be positioned in bed, not in a bedside chair. Calling the Rapid Response Team is not necessary.

5. During the evening shift, the patient has a bedside echocardiogram, which reveals an ejection fraction of 30%.Which medication does the nurse anticipate may be prescribed by the health care provider? (Select all that apply.) A. Adenosine B. Lisinopril C. Digoxin D. Lidocaine E. Furosemide

ANS: B, C, E Commonly prescribed drug classes for patients with heart failure include ACE inhibitors (lisinopril), diuretics (furosemide), nitrates (digoxin), human B-type natriuretic peptides, inotropics, and beta-adrenergic blockers. Adenosine and lidocaine are not indicated in this scenario.

The nurse is caring for four clients with a history of hypertension. Which client will the nurse see first? A. 30-year-old with pre-eclampsia, BP 120/68 B. 41-year-old with chronic kidney disease, BP 138/80. C. 53-year-old on diuretics, BP 160/80 D. 60-year-old with LDL-C 140 mg/dL, BP 114/84

ANS: C A client on diuretics that remains hypertensive requires intervention. The other options have a blood pressure that is normal or can be addressed after the nurse sees Client C.

The nurse expects which outcome in a client who is taking a beta blocker for mild heart failure? A. Increased orthopnea B. Improved urinary output C. Improved activity tolerance D. Increased myocardial contractility

ANS: C Beta-blocker therapy for mild and moderate heart failure can lead to improvement in symptoms, including improved activity tolerance and less orthopnea.

The nurse is caring for a client with many risk factors for hypertension. A. Fainting B. Vomiting C. Headache D. Speech slurring

ANS: C Hypertension is often asymptomatic and has become known as the "silent killer" due to the lack of symptoms. Headaches may occur but not always. Hypertension does not cause slurred speech, fainting, or vomiting.

Which assessment finding does the nurse anticipate in a client with right-sided heart failure? (Select all that apply.) A. Pulmonary congestion B. Shortness of breath C. Neck vein distension D. Enlarged abdominal girth E. A third heart sound

ANS: C, D Right ventricular failure is associated with increased systemic venous pressures and congestions, which creates neck vein distension and enlarged abdominal girth. The other options are associated with left-sided heart failure.