Cardiovascular/Respiratory
A client is scheduled for a cardiac catheterization. The nurse should do which preprocedure tasks? Select all that apply. 1. Verify the client has stopped taking anticoagulants if instructed by the health care provider. 2. Check for iodine sensitivity. 3. Verify that written consent has been obtained. 4. Withhold food and oral fluids before the procedure. 5. Insert a urinary drainage catheter.
1, 2, 3, 4 1. Verify the client has stopped taking anticogulants if instructed by the health care provider. 2. Check for iodine sensitivity. 3. Verify that written consent has been obtained. 4. Withhold food and oral fluids before the procedure. Rationale: For clients scheduled for a cardiac catheterization, it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. If the client is taking anticoagulant drugs, the nurse should ask the client if the HCP has given instructions to withhold these medications. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.
The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on the finding, what should the nurse do FIRST? 1. Assess respiratory status 2. Draw blood for laboratory studies 3. Insert a Foley catheter 4. Weigh the client
1. Assess the respiratory status Rationale: The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weight the client.
A client comes into the ER with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and respiratory rate of 38 breaths/min. The client's medical history included DM, HTN, and heart failure. Which of the following disorders should the nurse suspect? 1. Pulmonary edema 2. Pneumothorax 3.Cardiac tamponade 4. Pulmonary embolism
1. Pulmonary edema Rationale: SOB, tachypnea, low BP, tachycardia, crackles, and a cough producing pink, frothy sputum are late signs of pulmonary edema. Progressively worsening dyspnea, tachypnea, and rales (or crackles) on examination with associated hypoxia are the clinical features common to both cardiogenic and noncardiogenic pulmonary edema. Cough with pink, frothy sputum noted due to hypoxemia from alveolar flooding and auscultation of an S3 gallop could suggest cardiogenic edema. Similarily, the presence of murmurs, elevated jugular veinous pressure, and peripheral edema may point towards a cardiac etiology.
A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
1. Respiratory acidosis Rationale: Respiratory acidosis is most often due to hypoventilation. Chronic respiratory acidosis is most commonly caused by COPD. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships. Respiratory acidosis is a state in which there is usually a failure of ventilation and an accumulation of carbon dioxide. The primary disturbance of elevated arterial PCO2 is the decreased ration of arterial bicarbonate to arterial PCO2, which leads to a lowering of the pH.
Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision. The nurse's response should reflect the understanding that the client may be experiencing: 1. anxiety related to altered body image. 2. depression related to altered health status. 3. altered tissue perfusion. 4. lack of knowledge regarding the postoperative course.
1. anxiety related to altered body image. Rationale: Verbalized concerns from this client may stem from anxiety over the changes in the body after open-heart surgery. Although the client may experience depression related to altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in the body image. The client is not concerned about altered tissue perfusion.
A client, diagnoses with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the healthcare provider (HCP)? 1. arterial oxygen level of 46 mmHG 2. respirations of 12 breaths/min 3. lack of adventitious lung sounds 4. oxygen saturation of 96% on room air
1. arterial oxygen level of 46 mmHg Rationale: Manifestations of ARDS secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen below 50 mmHg. The nurse should report the arterial oxygen level of 46 mmHg to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.
An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. During admission, what should the nurse assess FIRST? 1. blood pressure 2. skin breakdown 3. serum potassium level 4. urine output
1. blood pressure Rationale: It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.
Which complication is associated with mechanical ventilation? 1. gastrointestinal hemorrhage 2. immunosuppression 3. increased cardiac output 4. pulmonary emboli
1. gastrointestinal bleeding Rationale: Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.
A client with ARDS is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR technique for communication, the nurse calls the healthcare provider (HCP) with the recommendation for: 1. initiating IV sedation. 2. starting a high-protein diet. 3. providing pain medication. 4. increasing the ventilator rate.
1. initiating IV sedation. Rationale: The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.
A client has mitral stenosis and will have a valve replacement. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which prescription would pose the GREATEST health hazard to this client at this time? 1. medication therapy 2. diet modification 3. activity restrictions 4. dental care
1. medication therapy Rationale: Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprosthesis are maintained on lifelong anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.
Which condition can place a client at risk for acute ARDS? 1. septic shock 2. chronic obstructive pulmonary disease 3. asthma 4. heart failure
1. septic shock Rationale: The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.
A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. 1. Administer warfarin. 2. Check the postoperative CBC, INR, PTT, and platelet levels. 3. Confirm availability of blood products. 4. Monitor the mediastinal chest tube drainage. 5. Start a dopamine drop for a systolic blood pressure <100 mmHg.
2, 3, 4 2. Check the postoperative CBC, INR, PTT, and platelet levels. 3. Confirm availability of blood products. 4. Monitor the mediastinal chest tube drainage. Rationale: The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding; therefore, availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.
A nurse is caring for a client who in on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PCO2 of 30 mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 2.0 mg/L 4. Phosphorus level of 4.0 mg/dL
2. Potassium level of 3.0 mEq/L Rationale: Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Since the primary cause of all respiratory alkalosis etiologies is hyperventilation, many patients present complaints of SOB. The exact history and physical exam findings are highly variable as there are many pathologies that induce the pH disturbance. A potassium level of 3.0 mEq/L identifies the presence of hypokalemia.
The nurse has received a change of shift report on clients. Which client should the nurse assess FIRST? 1. a client with COPD with a PaO2 of 56 mmHg who is being discharged home on oxygen 2. a client with asthma with respirations of 36 breaths/min whose wheezing has diminished 3. a client with asthma who has a heart rate of 90 bpm and whose beta-blocker is scheduled to be administered 4. a client who is scheduled for an angiogram now and is ready to be transported
2. a client with asthma with respirations of 36 breaths/min whose wheezing has diminished Rationale: Respirations of 36 breaths/min and diminished wheezing are indicative of respiratory distress. This finding take precedence over a client scheduled for an angiogram, a client with a heart rate of 90 bpm needing a scheduled beta-blocker, or a client with a PaO2 of 56 mmHg, which is indicated for a client being discharged home on oxygen.
The nurse is assessing a client with a known history of chronic heart failure. Which finding indicates poor perfusion to the tissues? 1. blood pressure 102/64 mmHg 2. cool, pale extremities 3. heart rate 104 bpm 4. shortness of breath when supine
2. cool, pale extremities Rationale: In heart failure, the heart is unable to adequately meet the body's metabolic demands; in an attempt to supply major organs, less blood is circulated to extremities, leaving them cool, pale and potentially cyanotic. A blood pressure of 102/64 mmHg is lower than average, but it may be normal for this client and would not indicate poor perfusion to tissues. It is not unusual for the client with heart failure to have a slightly elevated heart rate (unless taking medications to lower the heart rate) because the increased rate may help compensate for reduces stroke volume (and therefore, decreased cardiac output). Shortness of breath may occur with heart failure as a result of poor pumping action of the heart that allows fluid to accumulate in the lungs, however, it is not an indicator of peripheral perfusion.
A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. What other signs should the nurse assess NEXT? 1. hyperkalemia 2. digoxin toxicity 3. fluid deficit 4. pulmonary edema
2. digoxin toxicity Rationale: Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
The primary reason for infusing blood at a rate of 60 mL/hr is to help prevent: 1. emboli formation. 2. fluid overload. 3. red blood cell hemolysis. 4. allergic reaction.
2. fluid overload. Rationale: Too rapid infusion of blood, or any intravenous fluid, can cause fluid overload and related problems such as pulmonary edema. Emboli formation, red blood cell hemolysis, and allergic reaction are not related to rapid infusion.
The nurse interprets which finding as an early sign as an early of ARDS in a client at risk? 1. elevated carbon dioxide level 2. hypoxia not responsive to oxygen therapy 3. metabolic acidosis 4. severe, unexplained electrolyte imbalance
2. hypoxia not responsive to oxygen therapy Rationale: A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.
What information should the nurse provide to the client who is receiving warfarin? 1. Partial thromboplastin time values determine the dosage of warfarin sodium. 2. Protamine sulfate is used to reverse the effects of warfarin sodium. 3. International normalized ratio (INR) is used to assess effectiveness. 4. Warfarin sodium will facilitate clotting of the blood.
3. International normalized ratio (INR) is used to assess effectiveness. Raitonale: INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.
Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mmHg, and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the following lab tests (see below). What should the nurse do FIRST? Sodium: 140 mEq/L Potassium: 6.8 mEq/L BUN: 18 md/dL Creatinine: 1.0 mg/dL Hemoglobin: 12 g/dL Hematocrit: 37% 1. Administer the medications. 2. Call the health care provider (HCP). 3. Withhold the captopril. 4. Question the metoprolol dose.
3. Withhold the captopril. Rationale: The nurse should withhold the dose of captopril; captopril is an ACE inhibitor, and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.
Which of the following cardiac conditions does a fourth heart sound (S4) indicate? 1. Dilated aorta 2. Normally functioning heart 3. Decreased myocardial contractility 4. Failure of the ventricle to eject all of the blood during systole
4. Failure of the ventricle to eject all of the blood during systole Rationale: An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. The increased resistance is related to decreased resistance to filling of the left or right ventricle because of a reduction in ventricular wall compliance, and it is accompanied by a disproportionate rise in ventricular end-diastolic pressure.
Which of the following blood gas abnormalities is initially MOST suggestive of pulmonary edema? 1. Anoxia 2. Hypercapnia 3. Hyperoxygenation 4. Hypocapnia
4. Hypocapnia Rationale: In an attempt to compensate for increased work of breathing due to hyperventilation, carbon dioxide decreases, causing hypocapnia. If the condition persists, CO2 retention occurs and hypercapnia results. Hypoxemia and hypocapnia occurs in stages 1 and 2 of pulmonary edema, right-to-left ventilation/perfusion (V/Q) mismatch. In stage 3 of pulmonary edema, right-to-left intrapulmonary shunt develops secondary to alveolar flooding and further contributes to hypoxemia.
In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open-heart surgery, what should the nurse tell the family? 1. The client will remain in the ICU for 5 days. 2. The client will sleep most of the time while in the ICU. 3. Noise and activity within the ICU are minimal. 4. The client will receive medication to relive pain.
4. The client will receive medication to relieve pain. Rationale: Management of postoperative pain is a priority for the client after surgery., including valve replacement surgery. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.
Which assessment is MOST appropriate for determining the correct placement of an endotracheal tube in the mechanically ventilated client? 1. assessing the client's skin color 2. monitoring the respiratory rate 3. verifying the amount of cuff inflation 4. auscultating breath sounds bilaterally
4. auscultating breath sounds bilaterally Rationale: Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, ad the amount of cuff inflation cannot validate the placement of the endotracheal tube.
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position? 1. supine 2. semi-Fowler's 3. lateral side 4. prone
4. prone Rationale: Prone positioning is used to improve oxygenation in client with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, and reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head on the bead elevated at least 30 degrees.
A client is undergoing a thoracentesis. What should the nurse monitor the client for during and immediately after the procedure? Select all that apply. 1. pneumothorax 2. subcutaneous emphysema 3. tension pneumothorax 4. pulmonary edema 5. infection
1, 2, 3, 4 1. pneumothorax 2. subcutaneous emphysema 3. tension pneumothorax 4. pulmonary edema Rationale: Following a thoracentesis, the nurse should assess the client for possible complications of the procedure such as pneumothorax, tension pneumothorax, and subcutaneous emphysema, which can occur because of the needle entering the chest cavity. Pulmonary edema could occur if a large volume was aspirated causing a significant mediastinal shift. Although infection is a possible complication, signs of infection will not be evident immediately after the procedure.
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which are expected findings on assessment? Select all that apply. 1. decreased cardiac output 2. increased heart rate 3. vasoconstriction in skin, GI tract, and kidneys 4. decreased pulmonary perfusion 5. fluid overload
1, 2, 3, 5 1. decreased cardiac output 2. increased heart rate 3. vasoconstriction in skin, GI tract, and kidneys 5. fluid overload Rationale: Heart failure can be a result of several cardiovascular conditions, which will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure and, therefore, cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease.
The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The client has understood the instruction when the client identifies which potential complications? Select all that apply. 1. becoming increasingly short of breath at rest 2. weight gain of 2 lb (0.9 kg) or more in 1 day 3. high intake of sodium for breakfast 4. having to sleep sitting up in a reclining chair 5. weight loss of 2 lb (0.9 kg) in 1 day
1, 2, 4 1. becoming increasingly short of breath at rest 2. weight gain of 2 lb (0.9 kg) or more in 1 day 4. having to sleep sitting up in a reclining chair Rationale: If the client will call the HCP when there is increasing shortness of breath, weight gain over 2 lb in 1 day, and need to sleep sitting up, this indicates an understanding of the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the HCP if he or she had consumed a high-sodium breakfast. Instead, the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of the day and in the future.
The nurse should assess the client with left-sided heart failure for which findings? Select all that apply. 1. dyspnea 2. jugular vein distention (JVD) 3. crackles 4. right upper quadrant pain 5. oliguria decreased oxygen saturation levels
1, 3, 5, 6 1. dyspnea 3. crackles 5. oliguria 6. decreased oxygen saturation levels Rationale: Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure.
Good dental care is an important measure in reducing the risk of endocarditis. What information about dental care should the nurse include in the teaching plan for a client with mitral stenosis? Select all that apply. 1. Brush the teeth at least twice a day. 2. Avoid use of an electric toothbrush. 3. Take an antibiotic prior to oral surgery. 4. Floss the teeth at least once a day. 5. Have regular dental checkups. 6. Rinse the mouth with an antibiotic mouthwash once a day.
1, 4, 5 1. Brush the teeth at least twice a day. 4. Floss the teeth at least once a day. 5. Have regular dental checkups. Rationale: Daily dental care including brushing the teeth twice a day and flossing once a day and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. The client can use a regular toothbrush; it is not necessary to avoid use of an electric toothbrush. Taking antibiotics prior to dental procedures is recommended only is the client has a prothetic valve or a heart transplant. It is not necessary to use an antibiotic mouthwash.
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. 1. Monitor serum creatinine and blood urea nitrogen levels. 2. Administer a sedative. 3. Keep the head of the bed flat. 4. Administer humidified oxygen. 5. Auscultate the lungs.
1, 4, 5 1. Monitor serum creatinine and blood urea nitrogen levels. 4. Administer humidified oxygen. 5. Auscultate the lungs. Rationale: ARDS may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackled in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used in caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.
The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply. 1. Reorient frequently to time, place, and situation. 2. Put the client in a quiet room furthest from the nursing station. 3. Perform necessary procedures quickly. 4. Arrange for familiar pictures or special items at bedside. 5. Limit the client's visitors. 6. Spend time with the client, establishing a trusting relationship.
1, 4, 6 1. Reorient frequently to time, place, and situation. 4. Arrange for familiar pictures or special items at bedside. 6. Spend time with the client, establishing a trusting relationship. Rationale: It is not unusual for the elderly client to become somewhat confused when "relocated" to the hospital, and this may be more difficult for those with known dementia. Frequent reorientation delivered patiently and calmly along with placing familiar items nearby so the client can see them may help decrease confusion related to hospitalization. Establishing a trusting relationship is important with every client but may be more so with this client. Putting the client in a room further from the nursing station may decrease extra noise for the client but will also make it more difficult to observe the client and maintain a safe environment. Procedures should be explained to the client prior to proceeding and should not be rushed. Visits by family and friends may help to keep the client oriented.
In which of the following types of cardiomyopathy does cardiac output remain normal? 1. Dilated 2. Hypertrophic 3. Obliterative 4. Restrictive
2. Hypertrophic Rationale: Cardiac output isn't affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. All other choices cause decreased cardiac output. During the cardiac cycle, the mitral valve is pulled towards the septum by several proposed mechanisms: contraction of the papillary muscles, abnormal location in the outflow tract, and low pressure that occurs as blood is ejected at high velocity through a narrowed outflow tract (Venturi effect).
When developing a teaching plan for a client with endocarditis, which of the following points is MOST essential for the nurse to include? 1. "Report fever, anorexia, and night sweats to the physician." 2. "Take prophylactic antibiotics after dental work and invasive procedures." 3. "Include potassium rich foods in your diet." 4. "Monitor your pulse regularly."
1. "Report fever, anorexia, and night sweats to the physician." Rationale: An essential teaching point is to report signs of relapse, such as fever, anorexia, or night sweats, to the physician. An early manifestation of the disease is mild. Prolonged duration of fever that persists for several months without other manifestation may be the only symptom. On the other hand, the onset can be acute and severe with high, intermittent fever.
Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? 1. 5 to 10 minutes 2. 30 to 60 minutes 3. 2 to 4 hours 4. 6 to 8 hours
1. 5 to 10 minutes Rationale: After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.
Which of the following terms describes the force against which the ventricle must expel blood? 1. Afterload 2. Cardiac output 3. Overload 4. Preload
1. Afterload Rationale: Afterload refers to the resistance maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. The afterload of any contracting muscle is defined as the total force that opposes sarcomere shortening minus the stretching force that existed before contraction. Applying this definition to the heart, afterload can be most easily describes as the "load" against which the heart ejects blood.
A client with aortic stenosis has increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis. 1. Aoritc valve 2. Pulmonary valve 3. Erb's Point 4. Tricuspid valve 5. Mitral valve
1. Aortic valve Rationale: To assess a murmur from aortic stenosis, the stethoscope is placed at the second intercostal space right of sternum; (1) location (aortic valve), (2) the pulmonic valve area, (3) Erb's point, (4) tricuspid valve area, and (5) mitral valve area.
The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to the unlicensed assistive personnel (UAP)? 1. Assisting a client with adjusting his or her nasal cannula 2. Making adjustments to flow rates based on client resources 3. Monitoring a client for adverse effects of oxygen therapy 4. Assessing a client for the best method of oxygen therapy
1. Assisting a client with adjusting his or her nasal cannula Rationale: UAP can assist a client with the adjustment of his or her oxygen delivery device. Making adjustments based on client responses, monitoring for adverse effects, and assessing for the best methods of oxygen delivery are skills that require nursing judgments and can only be performed by a nurse.
Which of the following actions is the appropriate response to a client coughing up pink, frothy sputum? 1. Call for help. 2. Call the physician. 3. Start an IV line. 4. Suction the client.
1. Call for help. Rationale: Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. Fluid shifts may cause cerebral edema and changes in mentation, especially in the geriatric population. The other three interventions would immediately follow.
When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as: 1. Cheyne-Stokes respiration. 2. hyperventilation. 3. obstructive sleep apnea. 4. Biot's respirations.
1. Cheyne-Stokes respiration. Rationale: Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also know as "cluster breathing", is periods of normal respirations followed by varying periods of apnea.
An 18-year-old client who recently had an URI is admitted with suspected rheumatic fever. Which assessment findings confirm this diagnosis? 1. Erythema marginatum, subcutaneous nodules, and fever 2. Tachycardia, finger clubbing, and a load S3 3. Dyspnea, cough, and palpitations 4. Dyspnea, fatigue, and syncope
1. Erythema marginatum, subcutaneous nodules, and fever Rationale: Diagnosis for rheumatic fever requires that the client either have two major Jones' criteria or one minor Jones' criterion plus evidence of a previous streptococcal infection. Major criteria include carditis, polyarthritis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum (transient, non pruritic macules on the trunk or inner aspects of the upper arms or thighs). Minor criteria include fever, arthralgia, elevated levels of acute phase reactants, and a prolonged PR-interval on ECG.
What is the major goal of nursing care for a client with heart failure and pulmonary edema? 1. Increase cardiac output 2. Improve respiratory status 3. Decrease peripheral edema 4. Enhance comfort
1. Increase cardiac output Rationale: Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.
A client has the following arterial blood gas values: pH 7.52, PaO2 50 mmHg, PaCO2 28 mmHg, HCO3 24 mEq/L. Based upon the client's PaO2, which conclusion would be accurate? 1. The client is severely hypoxic. 2. The oxygen level is low but poses no risk for the client. 3. The client's PaO2 level is within normal range. 4. The client requires oxygen therapy with very low oxygen concentrations.
1. The client is severely hypoxic. Rationale: Normal PaO2 level ranges from 80 to 100 mmHg. When PaO2 falls to 50 mmHg, the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mmHg.
What measure should the nurse take that will be MOST helpful in preventing would infection when changing a client's dressing after coronary artery bypass surgery? 1. Wash hands before changing the dressing. 2. Clean the incisional area with an antiseptic. 3. Use prepackaged sterile dressings to cover the incision. 4. Place soiled dressings in a hazardous waste container.
1. Wash hands before changing the dressing. Rationale: Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
A client receiving a loop diuretic should be encouraged to eat which foods to prevent potassium loss? Select all that apply. 1. angel food cake 2. banana 3. dried fruit 4. orange juice 5. peppers
2, 3, 4 2. banana 3. dried fruit 4. orange juice Rationale: Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake and peppers are low in potassium.
Which of the following classes of drugs is MOST widely used in the treatment of cardiomyopathy? 1. Antihypertensives 2. Beta-adrenergic blockers 3. Calcium channel blockers 4. Nitrates
2. Beta-adrenergic blockers Rationale: By decreasing the heart rate and contractility, beta-blockers improve myocardial fillings and cardiac output, which are primary goals in the treatment of cardiomyopathy. Therefore, the chronotropic and inotropic effects on the heart undergo inhibition, and the heart rate slows down as a result. Beta-blockers also decrease blood pressure via several mechanisms, including decreased renin and reduced cardiac output.
A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician's office. The nurse would plan on having which of the following medications readily available for use? 1. Diltiazem (Cardizem) 2. Digoxin (Lanoxin) 3. Propranolol (Inderal) 4. Metoprolol (Lopressor)
2. Digoxin (Lanoxin) Rationale: Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Digoxin is beneficial in patients with systolic heart failure, better known as heart failure with reduces ejection fraction (HRrEF), with an ejection fraction below 40%. It is used for rate control in atrial fibrillation or atrial flutter when conventional therapies have not achieved the goal heart rate.
A client with ARDS is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived. Laboratory Results pH: 7.35 PaCO2: 25 mmHg HCO3: 22 mEq/L PaO2: 95 mmHg Which finding is abnormal? 1. pH 2. PaCO2 3. HCO3 4. PaO2
2. PaCO2 Rationale: The normal range for PaCO2 is 35 to 45 mmHg. Thus, the client's PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid deficit) due to hyperventilation. The nurse should report this finding to the health care provider because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is > 7.45.
An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written which prescription for takin the metformin before the procedure? 1. Increase the amount of protein in the diet the day before. 2. Withhold the metformin. 3. Administer the metformin with only a sip of water. 4. Give the metformin before breakfast.
2. Withhold the metformin. Rationale: The nurse should verify that the HCP has requested to withhold the metformin prior to any procedure requiring dye such as cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while clears the client's system. The HCP may prescribe sliding scale insulin during this time if needed. Regardless of how or when the medication is administered, the medication should be withheld. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide and nitroprusside as prescribed. The nurse notices a sudden drop in the pulmonary wedge pressure and pulmonary artery wedge pressure. What should the nurse assess NEXT? 1. 12-lead EKG 2. blood pressure 3. lung sounds 4. urine output
2. blood pressure Rationale: The nurse should immediately assess the blood pressure since nitroprusside and furosemide can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the nitroprusside dose should be reduces or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.
The nurse is preparing the client for discharge after mitral valve replacement surgery. Which activity should the client avoid until after the 1-month postdischarge appointment with the surgeon? 1. showering 2. lifting anything heavier than 10 lb (4.5 kg) 3. a program of gradually progressive walking 4. light housework
2. lifting anything heavier than 10 lb (4.5 kg) Rationale: Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle recondisitoning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.
A client experiences initial indications of dizziness after having an IV infusion of lidocaine hydrochloride started. The nurse should further assess the client for which symptoms? 1. palpitations 2. tinnitus 3. urinary frequency 4. lethargy
2. tinnitus Rationale: Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.
The nurse has placed the intubated client with ARDS in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. 1. The family is coming in to visit. 2. The client has increased secretions requiring frequent suctioning. 3. The SpO2 and PO2 have decreased. 4. The client is tachycardic with drop in blood pressure. 5. The face has increased skin breakdown and edema.
3, 4, 5 3. The SpO2 and PO2 have decreased. 4. The client is tachycardic with drop in blood pressure. 5. The face has increased skin breakdown and edema. Rationale: The prone position is used to Improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions, and the nurse can provide suctioning. Clinical judgment must be used to determine the length in time in the prone position. If the client is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern.
A client with chronic heart failure has atrial fibrillation and is taking warfarin. What should the nurse tell the client about the expected outcome of this drug? 1. "This medication will decrease the extra fluid your heart is circulating." 2. "This medication will improve the work of your heart." 3. "This medication will prevent a clot from forming." 4. "This medication will regulate the rhythm of your heart."
3. "This medication will prevent a clot from forming." Rationale: Warfarin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (<20%) to prevent thrombus formation and release of emboli into the circulation. The client ,ay also take other medications as needed to manage the heart failure. Warfarin does not reduce circulatory load or improve myocardial workload. Warfarin does not affect cardiac rhythm.
A client's ABG results are as follows: pH 7.16, PaCO2 80 mmHg, PaO2 46 mmHg, HCO3 24 mEq/L, SaO2 81%. This ABG result represents which of the following conditions? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
3. Respiratory acidosis Rationale: PaCO2 >40 with a pH <7.4 indicates a respiratory acidosis. If the pH is in the normal range (7.35-7.45), use a pH of 7.40 as a cutoff point. In other words, a pH of 7.37 would be categorized as acidosis. Arterial blood gas interpretation is best approached systematically. Interpretation leads to an understanding of the degree or severity of abnormalities, whether the abnormalities are cute or chronic, and if the primary disorder is metabolic or respiratory in origin.
If medical treatments fail, which of the following invasive procedures is necessary for treating cardiomyopathy? 1. Cardiac catheterization 2. Coronary artery bypass graft (CABG) 3. Heart transplantation 4. Intra-aortic balloon pump (IABP)
3. Heart transplantation Rationale: The only definitive treatment for cardiomyopathy that can't be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.
Which of the following positions would BEST aid breathing for a client with acute pulmonary edema? 1. Lying flat in bed 2. Left side-lying 3. In high Fowler's position 4. In semi-Fowler's position
3. In high Fowler's position Rationale: A high Fowler's position promotes ventilation and facilitates breathing by reducing venous return. Gravity improves lung expansion by lowering diaphragm and shifting fluid to the lower abdominal cavity. Turn or reposition and provide skin care at regular intervals to decrease pressure and friction on edematous tissue, which is more prone to breakdown than normal tissue.
Acute pulmonary edema caused by heart failure is usually a result of damage to which of the following areas of the heart? 1. Left atrium 2. Right atrium 3. Left ventricle 4. Right ventricle
3. Left ventricle Rationale: The left ventricle is responsible for the majority of force for the cardiac output. If the left ventricle is damaged, the output decreases and fluid accumulates in the interstitial and alveolar spaces, causing pulmonary edema. The resultant pathology of increased extravascular fluid content in the lung remains common to all forms of pulmonary edema. However, the underlying mechanism leading to the edema arises from the disruption of various complex physiologic processes, maintaining a delicate balance of filtration of fluid and solute across the pulmonary capillary membrane.
Which is the MOST important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? 1. Monitor the laboratory values. 2. Observe neurologic function every 15 minutes. 3. Observe the puncture site for swelling and bleeding. 4. Monitor the skin warmth and turgor.
3. Observe the puncture site for swelling and bleeding. Rationale: Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.
Myocardial oxygen consumption increases as which of the following parameters increase? 1. Preload, afterload, and cerebral blood flow 2. Preload, afterload, and renal blood flow 3. Preload, afterload, contractility, and heart rate 4. Preload, afterload, cerebral blood flow, and heart rate
3. Preload, afterload, contractility, and heart rate Rationale: Myocardial oxygen consumption increases as preload, afterload, contractility, and heart rate increase. Cerebral blood flow doesn't directly affect myocardial oxygen consumption. Myocardial oxygen consumption is equal to coronary blood flow multiplied by the arterial-venous oxygen difference. During diastole, the ventricles are receiving blood before systolic contraction. This filling phase of the cardiac cycle allows the coronary arteries to provide maximum blood flow to the heart.
A client has returned from the cardiac cath lab after a balloon valvuloplasty for mitral stenosis. Which finding requires IMMEDIATE nursing action? 1. There is a low, grade 1 intensity mitral regurgitation murmur. 2. SpO2 is 94% on 2 L of oxygen via nasal cannula. 3. The client has become more somnolent. 4. Urine output decreased from 60 mL/hr to 40 mL over the last hour.
3. The client has become more somnolent. Rationale: A complication of balloon valvuloplasty is emboli resulting in a stroke. The client's increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely but do not warrant concern.
Which action should the nurse anticipate in a client who has been diagnosed with ARDS? 1. tracheostomy 2. use of a nasal cannula 3. mechanical ventilation 4. insertion of a chest tube
3. mechanical ventilation Rationale: Endotracheal intubation and mechanical ventilation are required in ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation; nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or fluid from intrapleural spaces.
What instruction should the nurse's discharge teaching plan for the client with heart failure include? 1. maintaining a high-fiber diet 2. walking 2 miles every day 3. obtaining daily weights at the same time each day 4. remaining sedentary for most of the day
3. obtaining daily weights at the same time each day Rationale: Heart failure is a complex and chronic condition. Education should focus on health promotion and preventative care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the HCP if there has been a weight gain of 2 lb or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles every day, would not be appropriate at discharge. The clients exercise program would need to be planned in consultation with the HCP and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.
While making rounds, the nurse finds a client with COPD sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, the nurse's FIRST action should be to: 1. push the "code blue" (emergency response) button. 2. call the rapid response team. 3. open the client's airway. 4. call for a defibrillator.
3. open the client's airway. Rationale: The nurse has already called for help and established unresponsiveness, so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine is the rapid response team is needed. Calling for a defibrillator may not be the necessary or appropriate action once the client's airway has been opened.
Which position is BEST for a client with heart failure who has orthopnea? 1. semisitting (low Fowler's position) with legs elevated on pillows 2. lying on the right side (Sims' position) with a pillow between the legs 3. sitting upright (high Fowler's position) with legs resting on the mattress 4. lying on the back with the head lowered (Trendelenburg's position) and legs elevated
3. sitting upright (high Fowler's position) with legs resting on the mattress Rationale: Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg's position.
Which are indications that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply. 1. distended jugular veins 2. dependent edema 3. anorexia 4. coarse crackles 5. tachycardia
4, 5 4. coarse crackles 5. tachycardia Rationale: Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to symptomatic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.
Which of the following is a compensatory response to decreased cardiac output? 1. Decreased BP 2. Alteration in LOC 3. Decreased BP and diuresis 4. Increased BP and fluid retention
4. Increased BP and fluid retention Rationale: The body compensates for a decrease in cardiac output with a rise in BP, due to the stimulation of the sympathetic NS and an increase in blood volume as the kidneys retain sodium and water. Compensation may help the body adjust to the effects of heart failure in the short term, but over time it can make heart failure worse by further enlarging the heart and reducing the pumping ability of the heart.
The nurse teaches a client with heart failure to take oral furosemide in the morning. What is the expected outcome for taking this drug in the morning? The client will: 1. Avoid concentrated urine. 2. Prevent the risk of falling. 3. Limit the excretion of electrolytes. 4. Obtain more sleep more.
4. Obtain more sleep more. Rationale: When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's will be able to sleep more. The client may be at risk for falling, and the nurse should instruct all clients to rise from a sitting or lying position slowly, but the primary reason for taking the drug in the morning is to limit the number of times the client would need to void during the night if the drug were taken at bedtime. Taking furosemide in the morning has no effect on concentrating the urine or preventing electrolyte imbalances.
To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? 1. Administer oxygen every 2 hours. 2. Turn the client every 4 hours. 3. Administer sedatives to promote rest. 4. Suction if cough is ineffective.
4. Suction if cough is ineffective. Rationale: The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives to promote rest is contraindicated in acute respiratory distress because sedatives can depress respirations.
Which nursing interventions would be MOST likely to prevent the development of acute respiratory distress syndrome (ARDS)? 1. teaching cigarette smoking cessation 2. maintaining adequate serum potassium levels 3. monitoring clients for signs of hypercapnia 4. replacing fluids adequately during hypovolemic states
4. replacing fluids adequately during hypovolemic states Rationale: One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.
A client was admitted with an exacerbation of heart failure breath at 0200. At 0700, which information is MOST important for the nurse who admitted the client to communicate during the hand-off of care report to the nurse who will next care of the client? 1. admission weight of 210 lb (95 kg) 2. elevated B-type natriuretic peptide of 600 mg/mL 3. reaching 250 mL by incentive spirometer 4. urinary output of 120 mL
4. urinary output of 120 mL Rationale: The urinary output is less than the expected minimum of 30 mL/hr, and is the urinary output does nor increase, the nurse who will next care for the client should report the decreased urinary output to the HCP. An elevated B-type natriuretic peptide level is expected with acute heart failure. The level that the client can reach with incentive spirometer is good to know, but it is not the most essential finding to report at this time. The admission weight is helpful only if a prior or baseline weight is provided.
The nurse should teach the client that signs of digoxin toxicity include: 1. rash over the chest and back. 2. increased appetite. 3. visual disturbances such as seeing yellow spots. 4. elevated blood pressure.
4. visual disturbances such as seeing yellow spots. Rationale: Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increase appetite, and elevated blood pressure are not associated with digoxin toxicity.
