230 Med Surg Final Review 3/4

What motor function is affected by a C7 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

triceps

Ch. 34: Care of Patients with Dysrhythmias

Ch. 34: Care of Patients with Dysrhythmias

identify the arrhythmia

PVC (Premature Ventricular Contraction)

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow."

d. "Tighten your abdominal muscles to stimulate urine flow." (In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.)

When caring for a patient with premature ventricular contractions (PVCs), which electrolyte imbalances will contribute to this dysrhythmia and should therefore be monitored? Select all that apply. Hypokalemia Hyponatremia Hypocalcemia Hypomagnesemia Hypophosphatemia

Hypokalemia Hypomagnesemia (Low serum levels of potassium and magnesium predispose the patient to PVCs. The other electrolyte imbalances may cause ECG changes but do not increase the risk for PVCs.)

The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education? "I will be able to shower again soon." "I need to take my pulse every day." "I might trigger airport security metal detectors." "I no longer need my heart pills."

"I no longer need my heart pills." (All prescribed medications, including heart medications, are still needed after the pacemaker is implanted.Once the wound from the surgery heals, the patient will be able to shower. The patient's pulse will have to be taken and recorded for 1 full minute at the same time each day. The metal in the pacemaker will trigger the alarm in metal detector devices. A card can be shown to authorities to indicate that the patient has a pacemaker.)

A client has been diagnosed with Primary Progressive MS (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for more teaching? "I can alternate wearing my eye patch between eyes for double vision." "I should keep my home clutter free so I don't fall." "It's important I work out in the afternoon so my muscles are warmed up." "I always keep my medications in the same place."

"It's important I work out in the afternoon so my muscles are warmed up." (More teaching is needed for the client with PPMS when the client says, "It's important I work out in the afternoon so my muscles are warmed up." Working out in the afternoon will increase body temperature and lead to fatigue. Fatigue is a key feature of MS. Working with a physical therapist to develop an appropriate exercise program tailored to the client's condition will be beneficial.If a client has diplopia, wearing an eye patch and alternating it between eyes every few hours may relieve the symptoms. Keeping the home organized and clutter free will decrease the risk of falls. Keeping medications and other important belongings in the same place and maintaining a routine may help with memory deficits that may occur with MS.)

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Avoid using a pillow under the head while sleeping." "Begin driving 1 week after discharge." "Keep straws available for drinking fluids." "Swimming is recommended to keep active."

"Keep straws available for drinking fluids." (The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth.The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.)

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."

"Parts of my nervous system have plaques." (The statement that demonstrates that the newly diagnosed client with MS correctly understands the pathophysiology of the disease is "parts of my nervous system have plaques." MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system.The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.)

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider. I will help set that up."

"Please request a meeting with the health care provider. I will help set that up." (The nurse's best response to a family member of a client with a recent spinal cord injury is, "Please request a meeting with the primary health care provider. I will set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting however.The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.)

What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin? "It is important to consume a diet high in green leafy vegetables." "You would take aspirin or ibuprofen for headache." "Report nosebleeds to your provider immediately." "Avoid caffeinated beverages."

"Report nosebleeds to your provider immediately." (A nosebleed could be indicative of excessive dosing of warfarin. Warfarin is an anticoagulant and causes decreased ability for blood to clot.Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; these vegetables would be eaten in moderate amounts. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time and the international normalized ratio, causing predisposition to bleeding. These agents would be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin.)

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? "This way you will not need to have a leg incision." "The surgeon prefers this approach because it is easier." "These arteries remain open longer." "The surgeon has chosen this approach because of your age."

"These arteries remain open longer." (The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts.Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.)

A patient with atrial fibrillation (AF) with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? Synchronized cardioversion Electrophysiology studies (EPS) Anticoagulation Radiofrequency ablation therapy

Anticoagulation (The patient's rhythm has stabilized but because of the risk for thromboembolism related to AF, anticoagulation is necessary.Cardioversion is not needed at this time. EPS are indicated for recurring, symptomatic dysrhythmia. Ablation therapy is ordered for recurring and symptomatic atrial fibrillation.)

A patient is admitted to the intensive care unit with an acute pulmonary embolism. What dysrhythmia would most likely contribute to this condition? Atrial fibrillation Sinus bradycardia Ventricular tachycardia Premature atrial contractions

Atrial fibrillation (Because the atria are not fully contracting in atrial fibrillation, there is stagnation of blood flow resulting in formation of thrombi in the atria. A thrombus can be dislodged from the right atrium and travel to the lung, causing a pulmonary embolus. There is not a risk of thrombus formation with sinus bradycardia, premature atrial contractions, or ventricular tachycardia.)

Which teaching is essential for a patient who has had a permanent pacemaker inserted? Avoid talking on a cell phone. Avoid operating electrical appliances over the pacemaker. Avoid sexual activity. Do not take tub baths.

Avoid operating electrical appliances over the pacemaker. (The patient needs to avoid operating electrical appliances directly over the pacemaker site because this may cause the pacemaker to malfunction.It is not necessary to avoid a telephone or a cell phone, but the patient would keep cellular phones at least six inches (15 centimetres) away from the generator and with the handset on the ear opposite the side of the generator. Radio transmitter towers, arc welding, and strong electromagnetic fields may pose a hazard. No hazard exists with sexual activity. Bathing and showering are permitted.)

Which statement correctly differentiates cardioversion from defibrillation? Defibrillation is a synchronized shock delivered to depolarize the myocardium simultaneously in atrial fibrillation. Cardioversion is an asynchronous shock to the patient to convert ventricular tachycardia or ventricular fibrillation. Defibrillation delivers an electrical shock to the heart; cardioversion involves use of a temporary pacemaker to deliver the shock. Cardioversion delivers a synchronized shock for ventricular tachycardia or supraventricular tachycardia.

Cardioversion delivers a synchronized shock for ventricular tachycardia or supraventricular tachycardia. (Cardioversion involves the delivery of a synchronized electric shock to terminate unstable ventricular or supraventricular rhythms. It is not useful in ventricular fibrillation because all electrical activity is disorganized with no ability to synchronize. Defibrillation delivers an asynchronous countershock, depolarizing a critical mass of the myocardium to stop the re-entry circuit in ventricular fibrillation or pulseless ventricular tachycardia, allowing the sinus node to regain control of the heart.)

Ch. 43: Care of Patients with Problems of the Central Nervous System: The Spinal Cord

Ch. 43: Care of Patients with Problems of the Central Nervous System: The Spinal Cord

Before administering a dose of an antidysrhythmic drug to a patient, what is the priority nursing assessment? Measure urine output and specific gravity. Check apical pulse and blood pressure. Evaluate peripheral pulses and level of consciousness. Obtain temperature and pulse oximetry on room air.

Check apical pulse and blood pressure. (Antidysrhythmic drugs can cause both hypotension and bradycardia; therefore, it is important to assess blood pressure and apical pulse before administration.)

The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? Defibrillate the patient at 200 joules. Check the patient for a pulse. Cardiovert the patient at 50 joules. Give the patient IV lidocaine.

Check the patient for a pulse. (The nurse needs to first assess the patient to determine stability before proceeding with further interventions. If the patient has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular tachycardia with a pulse is amiodarone.If the patient is pulseless or nonresponsive, the patient is unstable and defibrillation is used and not cardioversion. Also, if the patient is pulseless, lidocaine may be given after defibrillation.)

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? Temperature 98.2°F (36.8°C) Chest tube drainage 175 mL last hour Serum potassium 3.9 mEq/L (3.9 mmol/L) Incisional pain 6 on a scale of 0 to 10

Chest tube drainage 175 mL last hour (The nurse needs to report chest drainage over 150 mL/hr to the surgeon. Although some bleeding is expected after surgery, 175 mL per hour is excessive.Although hypothermia is a common problem after surgery, a temperature of 98.2°F (36.8°C) is a normal finding. Serum potassium of 3.9 mEq/L (3.9 mmol/L) is a normal finding. Incisional pain of 6 on a scale of 0-10 is expected immediately after major surgery; the nurse would administer prescribed analgesics.)

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? Select all that apply. Bradycardia Cool, diaphoretic skin Crackles in the lung fields Respiratory rate of 12 breaths/min Anxiety and restlessness Temperature of 100.4°F (38.0°C)

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness (The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/minute is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.)

Calcium channel blockers have which pharmacodynamic effect? Positive chronotropic Shortened refractory period Positive inotropic Coronary vasodilation

Coronary vasodilation (Calcium channel blockers cause coronary vasodilation, a negative inotropic effect, a negative chronotropic effect, and a negative dromotropic effect.)

The nurse is preparing to administer digoxin (Lanoxin) 0.25mg intravenous push to a patient. Which is an expected patient outcomerelated to the administration of digoxin? Low serum potassium Reduction in urine output Increase in blood pressure Decrease in the heart rate

Decrease in the heart rate (Digoxin has a negative chronotropic effect (decreased heart rate).)

The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? Defibrillation Cardiopulmonary resuscitation (CPR) Administration of epinephrine Administration of oxygen

Defibrillation (Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over. In asystole, there is no rhythm to interrupt. Therefore, this intervention is not used.If drug therapy fails to restore effective rhythm, CPR is initiated. Epinephrine is used to increase heart rate in asystole. Hypoxia may be a cause of cardiac arrest, so the administration of oxygen would be appropriate.)

Which risk factors are known to contribute to atrial fibrillation? Select all that apply. Use of beta-adrenergic blockers Excessive alcohol use Advancing age High blood pressure Palpitations

Excessive alcohol use Advancing age High blood pressure (Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and African Americans. Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.)

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? ST segment Heart rate Troponin Myoglobin

Heart rate (The monitoring of the patient's heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.)

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Help the client sit up. Insert a straight catheter. Loosen the client's clothing.

Help the client sit up. (The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.)

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse plan to administer? Heparin Atropine Dobutamine Magnesium sulfate

Heparin (The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin [Lovenox], warfarin [Coumadin], and novel oral anticoagualants, when nonvalvular, such as dabigatran [Pradaxa], rivaroxaban [Xarelto], apixaban [Eliquis], or edoxaban [Savaysa]) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.)

What training does an Advanced Cardiac Life Support (ACLS) certification offer? Neonatal and pediatric resuscitation Validation of core emergency nursing knowledge base Noninvasive assessment skills for airway maintenance Invasive airway management skills and electrical therapies

Invasive airway management skills and electrical therapies (An ACLS certification provides training in invasive airway management skills, pharmacology, special therapies, and electrical therapies. A Basic Life Support (BLS) certification provides training in noninvasive assessment skills for airway maintenance and cardiopulmonary resuscitation. A Pediatric Advanced Life Support certification (PALS) provides training in neonatal and pediatric resuscitation. A Certified Emergency Nurse (CEN) certification validates the core emergency nursing knowledge base.)

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action would be performed first? Assess coping skills. Assess for postoperative pain at the client's incision site. Monitor the heart rate for dysrhythmias. Monitor mental status.

Monitor the heart rate for dysrhythmias. (The nurse would monitor the client's heart rate for dysrhythmias. Dysrhythmias are the leading cause of prehospital death. Assessing mental status, coping skills, or postoperative pain is not the priority for this client.)

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

b. Methylprednisolone (Medrol) (Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.)

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Indication of allergies Level of consciousness Loss of sensation Patent airway

Patent airway (The nursing priority when assessing a client with a spinal cord injury is a patent airway. Clients with injuries at or above T6 are at risk for respiratory complications. Assessing for a patent airway is essential.Asking the client about current medications and allergies is part of every trauma assessment. Assessing the level of consciousness utilizing the Glasgow Coma Score (GCS) is an important part of the trauma assessment. Determining the level of loss of sensation will be included in the neurological evaluation.)

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

Positioning the client to maximize ventilation potential (The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm.Auscultating bowel sounds is important since paralytic ileus can develop from a SCI; however this is not the priority intervention. Beginning bladder retraining and monitoring the nutritional status will be important for adequate healing and progress to rehabilitation. However, these interventions can be delayed until major life threats are addressed.)

Which are therapeutic effects of digoxin (Lanoxin)? Positive inotropic, negative chronotropic, and negative dromotropic Negative inotropic, negative chronotropic, and negative dromotropic Positive inotropic, positive chronotropic, and negative dromotropic Positive inotropic, negative chronotropic, and positive dromotropic

Positive inotropic, negative chronotropic, and negative dromotropic (Digoxin increases cardiac contractility (positive inotropic effect), decreases heart rate (negative chronotropic effect), and decreases conductivity (negative dromotropic effect).)

A patient admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? Prepare for defibrillation. Establish IV access. Place an oral airway and ventilate. Start cardiopulmonary resuscitation (CPR).

Prepare for defibrillation. (Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols.After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.)

The nurse administers amiodarone (Cordarone) to a patient with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. Respiratory rate QT interval Heart rate Heart rhythm Urine output

QT interval Heart rate Heart rhythm (Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed.Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.)

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Encouraging nutrition Frequent ambulation Regular turning and repositioning Special pressure-relief devices

Regular turning and repositioning (Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.)

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? Pulse 60 beats/min and regular Urinary frequency Incisional discomfort Respiratory rate 28 breaths/min

Respiratory rate 28 breaths/min (The activity should be terminated when the nurse notices the client's respiration rate of 28 breaths per minute. This indicates tachypnea and possibly tachycardia due to activity intolerance.Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.)

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy

Respiratory therapy (To help prevent death for a client with spinal cord injury, collaboration with the Respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with Respiratory therapy is crucial. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.)

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

Sensation (The nurse uses a paper clip bilaterally on each limb of the client with back pain to assess sensation. Both extremities may be checked for sensation by using a paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side. Gait is assessed by having the client walk. Mobility is assessed by determining the client's ability to move on his/her own, turn or perform ADLs. Strength is measured by having the client perform bilateral grips.

Which intervention provides safety during cardioversion? Setting the defibrillator at 220 joules Obtaining informed consent Setting the defibrillator to the synchronized mode Removing oxygen

Setting the defibrillator to the synchronized mode (Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation. Cardioversion is usually performed starting at a lower rate of 120-200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.)

Which precaution should the nurse follow when providing cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) to a patient? Protective Isolation Standard Precautions Surgical asepsis with defibrillator Respiratory isolation during intubation

Standard Precautions (Standard Precautions and personal protective equipment must be used when there is risk of contact with blood and body fluids. Protective isolation is designed to protect the patient from pathogens in the environment. Surgical asepsis involves ridding an item of all pathogens, such as in the operating room, with sterilization procedures. A defibrillator is a "clean," not sterile, item. Respiratory isolation is used to prevent transmission of organisms by droplets, such as chickenpox or meningitis. The nurse may choose to use protective eyewear or a face shield during intubation or suctioning of the airway to protect from spraying blood and body fluids.)

The nurse is caring for a client in the emergency department (ED) whose spinal cord was injured at the level of C7 1 hour prior to arrival. Which assessment finding requires the most rapid action? After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg. Cardiac monitor shows a sinus bradycardia at a rate of 50 beats/min. The client's chest moves very little with each respiration. The client demonstrates flaccid paralysis below the level of injury.

The client's chest moves very little with each respiration. (The most rapid action is needed for a spinal cord injury client injured one hour prior to arrival whose chest moves very little with each respiration. Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm.Bradycardia and hypotension are indications neurogenic shock due to disruption of autonomic pathways. This will need to be addressed rapidly however airway and breathing are always the top priority. Flaccid paralysis below the level of the injury is to be expected.)

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

b. Turn off oxygen therapy. (For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.)

A patient is receiving lidocaine (Xylocaine) by continuous intravenous (IV) infusion. The nurse understands this medication is prescribed for what condition? Ventricular dysrhythmias Sinus bradycardia Atrial fibrillation First-degree heart block

Ventricular dysrhythmias (Lidocaine is a sodium channel blocker drug used specifically to treat ventricular dysrhythmias.)

identify the arrhythmia

Ventricular tachycardia (V-tach)

Which patient-teaching instructions are appropriate for a patient taking an antidysrhythmic drug? (Select all that apply.) a. "Do not chew or crush extended-release forms of medication." b. "Take the medication with food if gastrointestinal distress occurs." c. "If a dose is missed, the missed dose should be taken along with the next dose that is due to be taken." d. "Take the medications with an antacid if gastrointestinal distress occurs." e. "Limit or avoid the use of caffeine." f. "The presence of a capsule in the stool should be reported to the physician immediately."

a. "Do not chew or crush extended-release forms of medication." b. "Take the medication with food if gastrointestinal distress occurs." e. "Limit or avoid the use of caffeine." (Appropriate teaching instructions for a patient taking an antidysrhythmic drug include: do not chew or crush extended-release forms; if gastrointestinal distress occurs, take the drug with food; and limit or avoid the use of caffeine. Do not double medication doses or take medications with an antacid. The presence of a portion of a capsule or tablet in the stool is actually the wax matrix that carried the medication, which has been absorbed. The physician does not need to be notified.)

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

a. "High glucose is common in shock and needs to be treated." (High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.)

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

a. "I'll use my incentive spirometer every 2 hours while I'm awake." (Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.)

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." e. "Do not lift your left arm above the level of your shoulder for 8 weeks." (The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.)

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

a. Assist the client to the chair for meals and to the bathroom. c. Ensure the client wears TED hose or sequential compression devices. e. Take and record a full set of vital signs per hospital protocol. (The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.)

A patient is in the emergency department with a new onset of rapid-rate atrial fibrillation, and the nurse is preparing a continuous infusion. Which drug is most appropriate for this dysrhythmia? a. Diltiazem (Cardizem) b. Atenolol (Tenormin) c. Lidocaine d. Adenosine (Adenocard)

a. Diltiazem (Cardizem) (Diltiazem (Cardizem) is indicated for the temporary control of a rapid ventricular response in a patient with atrial fibrillation or flutter and paroxysmal supraventricular tachycardia. It is given by continuous infusion after a loading dose given by IV bolus. The other options are incorrect.)

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mmHg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness (Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.)

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

a. Medication reconciliation (The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.)

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

a. Smoking cessation b. Stress reduction and management d. Adverse effects of medications (A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.)

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

a. Spiritual beliefs c. Family support d. Level of independence f. Previous coping strategies (Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.)

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown

a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. e. Assess the chest and back for skin breakdown (A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.)

What motor function is affected by a T7-T11 injury? chest muscles abdominal muscles

abdominal muscles

Identify the arrhythmia

atrial fibrillation

identify the arrhythmia

atrial flutter

A nurse is teaching a client with multiple sclerosis who is prescribed methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Relying on a walker will weaken your gait." d. "Take prescribed medications when symptoms occur."

b. "Avoid crowds and people with colds." (The client should be taught to avoid people with any type of upper respiratory illness because this medication is immunosuppressive. Warm baths will exacerbate the client's symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.)

A patient has a digoxin level of 1.1 ng/mL. Which interpretation by the nurse is correct? a. It is below the therapeutic level. b. It is within the therapeutic range. c. It is above the therapeutic level. d. It is at a toxic level.

b. It is within the therapeutic range. (The normal therapeutic drug level of digoxin is between 0.5 and 2 ng/mL. The other options are incorrect.)

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"

b. "I hope I can get my water turned back on when I get home." (All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.)

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

b. A 50-year-old who is post coronary artery bypass graft surgery (Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.)

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

b. Assess vital signs and level of consciousness. (In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.)

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

b. Assist the client into a position of comfort in bed. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing. (Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.)

When monitoring a patient's response to interferon therapy, the nurse notes that the major dose-limiting factor for interferon therapy is which condition? a. Diarrhea b. Fatigue c. Anxiety d. Nausea and vomiting

b. Fatigue (Patients who receive interferon therapy may experience flu-like symptoms: fever, chills, headache, malaise, myalgia, and fatigue. Fatigue is the major dose-limiting factor for interferon therapy. Patients taking high dosages become so exhausted that they are commonly confined to bed.)

A patient with multiple sclerosis will be starting therapy with an immunosuppressant drug. The nurse expects that which drug will be used? a. Azathioprine (Imuran) b. Glatiramer (Copaxone) c. Daclizumab (Zenapax) d. Sirolimus (Rapamune)

b. Glatiramer (Copaxone) (Glatiramer and fingolimod are the only immunosuppressants currently indicated for reduction of the frequency of relapses (exacerbations) in a type of multiple sclerosis known as relapsing-remitting multiple sclerosis.)

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

b. Notify the provider immediately. (If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.)

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

b. Provide a diet high in fluids and fiber. d. Implement a consistent daily time for elimination. f. Perform manual disimpaction. (For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.)

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Time: 0800 Vital Signs: Temperature: 98°F Heart rate: 68 beats/min Blood pressure: 135/60 mmHg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2L nasal cannula Time: 1000 Vital Signs: Temperature: 98.2°F Heart rate: 50 beats/min Blood pressure: 132/57 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2L nasal cannula Time: 0800 Nursing Assessment: Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Nursing Assessment: Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

b. Slow the amiodarone infusion rate. (IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the client's heart rate.)

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

b. Speech alterations (Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.)

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

b. Warfarin (Coumadin) (Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.)

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

c. "Clients who use cocaine are at risk for fatal dysrhythmias." (Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.)

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation." (Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.)

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." (Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.)

A patient is in the intensive care unit and receiving an infusion of milrinone (Primacor) for severe heart failure. The prescriber has written an order for an intravenous dose of furosemide (Lasix). How will the nurse give this drug? a. Infuse the drug into the same intravenous line as the milrinone. b. Stop the milrinone, flush the line, and then administer the furosemide. c. Administer the furosemide in a separate intravenous line. d. Notify the prescriber that the furosemide cannot be given at this time.

c. Administer the furosemide in a separate intravenous line. (Furosemide must not be injected into an intravenous line with milrinone because it will precipitate immediately. The infusion must not be stopped because of the patient's condition. A separate line will be needed. The other options are incorrect.)

A patient is in the intensive care unit because of an acute myocardial infarction. He is experiencing severe ventricular dysrhythmias. The nurse will prepare to give which drug of choice for this dysrhythmia? a. Diltiazem (Cardizem) b. Verapamil (Calan) c. Amiodarone (Cordarone) d. Adenosine (Adenocard)

c. Amiodarone (Cordarone) (Amiodarone (Cordarone) is the drug of choice for ventricular dysrhythmias according to the Advanced Cardiac Life Support guidelines. The other drugs are not used for acute ventricular dysrhythmias.)

The nurse administering the phosphodiesterase inhibitor milrinone (Primacor) recognizes that this drug will have a positive inotropic effect. Which result reflects this effect? a. Increased heart rate b. Increased blood vessel dilation c. Increased force of cardiac contractions d. Increased conduction of electrical impulses across the heart

c. Increased force of cardiac contractions (Positive inotropic drugs increase myocardial contractility, thus increasing the force of cardiac conduction. Positive chronotropic drugs increase the heart rate. Positive dromotropic drugs increase the conduction of electrical impulses across the heart. Blood vessel dilation is not affected.)

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus (involuntary eye movement) d. Heat intolerance

c. Nystagmus (involuntary eye movement) (Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.)

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

c. Occupational therapist (The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.)

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

c. Palpate the bladder for distention. (The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.)

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

c. Re-position the client off of the reddened areas. e. Obtain a low-air-loss mattress to minimize pressure. (Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.)

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

c. Schedule periods of exercise and rest during the day. (Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.)

What motor function is affected by a T2-T6 injury? chest muscles abdominal muscles

chest muscles

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a. "You should discuss this with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "Using the incentive spirometer each hour will delay the need for a ventilator." d. "What would you like to be done if you begin to have difficulty breathing?"

d. "What would you like to be done if you begin to have difficulty breathing?" (ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.)

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

d. Ensure that everyone is clear of contact with the client and the bed. (To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.)

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

d. Evaluate respiratory status. (The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.)

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

d. Impairment of respiratory muscles (In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.)

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

d. Methylprednisolone (Medrol) (Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.)

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

d. Perform hand hygiene. (To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.)

A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.

d. Place the client in a gown that has cloth ties instead of metal snaps. (Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.)

The nurse is administering an interferon and will implement which intervention? a. Giving the medication with meals b. Monitoring daily weights c. Limiting fluids while the patient is taking this medication d. Rotating sites if administered subcutaneously

d. Rotating sites if administered subcutaneously (Interferon is given parenterally (not orally), and injection sites need to be rotated. Fluids need to be increased during interferon therapy. The other options are incorrect.)

A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next? a. Administer the dose. b. Administer the dose, and notify the prescriber. c. Check the radial pulse for 1 full minute. d. Withhold the dose, and notify the prescriber.

d. Withhold the dose, and notify the prescriber. (Digoxin doses are held and the prescriber notified if the apical pulse is 60 beats/min or lower or is higher than 100 beats/min. The other options are incorrect.)

What motor function is affected by a C4 or C5 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

deltoids & biceps

What motor function is affected by a C3 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

diaphragm

What motor function is affected by a C8 or T1 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

hands

What motor function is affected by a C1 or C2 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

head & neck

What motor function is affected by a T12-L4 injury? leg muscles bowel & bladder sexual function

leg muscles

What motor function is affected by a C6 injury? head & neck diaphragm deltoids & biceps wrist extenders triceps hands

wrist extenders