EAQ 10 Putting It All Together

Which client would the nurse care for first based on vital signs? -Client A -Client B -Client C -Client D

Client B Rationale: Client B should be given priority care, because the client's respiratory rate is high and the client's peripheral capillary oxygen saturation (Spo 2) is very low at 70%. The client requires immediate treatment. A normal respiratory rate is 12 to 20 breaths per minute. A normal Spo 2 is 92% to 100%. Client A has normal vital signs and respiratory rate, so care is not required. Client C's respiratory rate is normal at 14 breaths per minute and blood pressure is normal at 140/86 mm Hg and does not require an immediate intervention. Client D has normal vital signs and the Spo 2 of 90% is a bit lower than the normal Spo 2, but this could be a normal range for this client. Also, clients with chronic obstructive pulmonary disease (COPD) have lower than normal Spo 2, below 92%.

Which client in the emergency department would the nurse assess first? -Client with chest pressure and ST segment elevation on the electrocardiogram -Client who reports a sharp chest pain with deep inspiration for the past week -Client who has history of heart failure with ascites and bilateral 4+ ankle swelling -Client with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/minute

Client with chest pressure and ST segment elevation on the electrocardiogram Rationale: The client with chest pressure and ST segment elevation on the electrocardiogram will need emergency treatment for ST segment elevation myocardial infarction (STEMI), including transport to the cardiac catheterization laboratory for percutaneous coronary intervention within 90 minutes, and should be seen first. The client with sharp pain with deep inspiration has symptoms consistent with pericarditis or pleural effusion and does need rapid assessment and treatment, but is not at risk for life-threatening complications. The client with heart failure and ascites and ankle swelling has symptoms of right ventricular failure that are not life-threatening. The client with palpitations and rapid atrial fibrillation will need assessment and evaluation, but the client experiencing myocardial infarction has a more life-threatening diagnosis.

When a client with chronic obstructive pulmonary disease (COPD) reports a 5-1b (2.3-kg) weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication? -Polycythemia -Cor pulmonale -Compensated acidosis -Left ventricular failure

Cor pulmonale Rationale: Fluid retention and weight gain caused by right ventricular failure is a clinical manifestation of cor pulmonale, or right ventricular failure caused by pulmonary hypertension associated with COPD. Polycythemia may be caused by COPD, but it does not cause weight gain. Compensated respiratory acidosis is caused by COPD, but it would not lead to weight gain. Left ventricular failure may lead to weight gain, but it is not a complication of COPD.

Which type of lung sounds would the nurse expect to hear when caring for a client with heart failure? -Stridor -Crackles -Wheezes -Rhonchi

Crackles Rationale: Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are typically heard with airway narrowing caused by asthma. Rhonchi are heard when airways are obstructed with thick secretions caused by problems such as pneumonia.

While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis? -Gray color -Dark red color -Deep brown color -White color

Dark red color Rationale: Dark red skin coloring is identified as ecchymosis. A grayish skin color is due to cyanosis. A deep brown skin coloring is caused by erythema in dark-skinned clients. A white or ashen skin color is found in clients with pallor.

A client reports diminished sensations of pain, touch, and temperature on the skin. The nurse touches the skin and finds it cool. Which skin changes would the nurse relate to the client's findings? -Degenerated elastic fibers -Decreased blood flow to the skin -Increased melanocytes in basal layer -Decreased activity of the apocrine glands

Decreased blood flow to the skin Rationale: Decreased blood flow to the skin may cause diminished sensations of pain, touch, and temperature. The skin may also feel cold. Degeneration of elastic fibers may cause increased wrinkling and sagging of the breasts. Increased melanocytes in the basal layers may cause solar lentigines. Decreased activity of the apocrine glands may be related to uneven skin color and dry skin.

The nurse is caring for a client with emphysema. During assessment, the nurse would expect to auscultate which type of breath sounds? -Crackles -Pleural friction rub -Diminished breath sounds -Expiratory wheezes

Diminished breath sounds Rationale: Breath sounds will be decreased in clients with emphysema because of reduced airflow, pleural effusion, or lung parenchymal destruction. Crackles indicate fluid in the alveoli, which is associated with heart failure or infection. A pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Rhonchi signify airway obstruction, not emphysema. Expiratory wheezing and coughing are associated with asthma or bronchitis.

Which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma? -Cut an opening about ⅓ inch (0.85 cm) larger than the stomal pattern. -Avoid the use of soap and other irritating agents. -Eat yogurt and drink buttermilk and parsley. -Empty the pouch before it is one-third full.

Empty the pouch before it is one-third full. Rationale: The weight of drainage from the stoma pulls the wafer away from the skin, promoting skin breakdown. For this reason, ostomy bags should be emptied when one-third full. Teach the client and family caregiver to trace the pattern of the stomal area on the wafer portion of the appliance and to cut an opening about 1/8 to 1/16 inch (0.32-0.16 cm) larger than the stomal pattern to ensure that stomal tissue will not be constricted, promoting skin breakdown. Although irritating agents should not be used, soap is the agent of choice to cleanse the skin around the stoma. Yogurt, buttermilk, and parsley will help with odor but not with skin breakdown.

Which nursing intervention would the nurse consider a priority for clients with fluid overload? -Ensuring client safety -Providing medication therapy -Providing nutritional therapy -Preventing future fluid overload

Ensuring client safety Rationale: The priority nursing interventions to be followed during care for clients with fluid overload are to ensure client safety and to restore normal fluid balance to prevent complications such as pulmonary edema and heart failure. Providing medication therapy and nutritional therapy to the clients is a secondary nursing intervention. Prevention of future overload should be done after restoring the fluid levels to normal.

Which condition would be indicated by the presence of ketones in the urine of a client? -Cystitis -Heart failure -Urinary calculi -Fat metabolism

Fat metabolism Rationale: The body of a client who is ingesting fewer calories than are needed for maintenance produces ketones from fat metabolism as an alternate source of fuel for muscles and organs. Increased red blood cells in the urine indicate cystitis. Increased specific gravity of the urine indicates heart failure. The presence of casts in the urine indicates urinary calculi.

When completing a health assessment, the nurse identifies tremors of the clients hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which additional assessment finding would the nurse report immediately to the health care provider? -Increased appetite -Recent weight loss -Feelings of warmth -Fluttering in the chest

Fluttering in the chest Rationale: Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life-threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life-threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life-threatening.

Which image indicates skin atrophy? -Image 1 -Image 2 -Image 3 -Image 4

Image 2 Rationale: Image option 2 indicates atrophy of the skin, which is characterized by thinning of the skin surface with loss of skin markings. Skin depression results when the atrophy involves the dermal layer. Image option 1 indicates a wheal, which is characterized by elevated, irregularly shaped, transient areas of dermal edema. Scales such as in psoriasis, pictured in option 3, are characterized by a thickened stratum corneum. Lichenification, pictured in option 4, is characterized by thickened areas of epidermis with accentuated skin markings.

Which assessment finding in a client who had a history of chicken pox and arrived at the hospital complaining of itching and deep pain on the skin helps confirm the diagnosis? -Red, moist, irritated skin -Red-colored raised rash with pustules -Sore-looking raised bumps on the skin -Multiple lesions in a segmental distribution on the skin

Multiple lesions in a segmental distribution on the skin Rationale: The client who had a history of chicken pox may have a chance of getting herpes zoster. Multiple lesions in a segmental distribution on the skin may be a viral infection such as herpes zoster. A red, moist, irritated appearance on the skin is due to a fungal infection like Candida albicans. Red-colored raised bump appearances on the skin are due to bacterial infections such as folliculitis. Sore-looking raised bumps on the skin are due to bacterial infections like furuncles.

Which finding would the nurse expect when assessing a client who has right ventricular failure? -Slowed pulse rate -Pleural friction rub -Neck vein distention -Elevated temperature

Neck vein distention Rationale: Neck vein distention is caused by hypervolemia and pulmonary hypertension. The pulse is likely to be rapid and bounding. Pleural friction rub occurs with inflammation of the pleura, but not with heart failure. Fever occurs with infectious or inflammatory problems, but not with heart failure.

The nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. In which way would the nurse document the edema? -1+ -2+ -3+ -4+

4+ Rationale: Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse would assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8-mm depression. A grade of 1+ indicates a 2-mm depression. A grade of 2+ indicates a 4-mm depression. A grade of 3+ indicates a 6-mm depression.

Which finding would be of most concern when the nurse assesses a client with emphysema? -Barrel chest -Oral cyanosis -Pursed-lip expiration -Respirations 26 breaths per minute

Oral cyanosis Rationale: Central cyanosis indicates hypoxemia and requires further assessment and actions such as checking oxygen saturation and administration of oxygen. Clients with chronic obstructive pulmonary disease (COPD) often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity. Pursed-lip expiration is commonly used by clients with COPD to improve expiratory effort and volumes. An elevated respiratory rate is common in COPD as a compensatory mechanism to improve gas exchange.

After a thoracentesis for pleural effusion, a client returns to an outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? -"Lately I can only breathe well if I sit up." -"During the night I sometimes get the chills." -"'I get a sharp, stabbing pain when I take a deep breath." -"I'm coughing up large amounts of thicker mucus for the past several days."

"'I get a sharp, stabbing pain when I take a deep breath." Rationale: Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up large amounts of thicker mucus for the past several days" may indicate a pulmonary infection.

Which statement by a client is consistent with a diagnosis of heart failure? -"I see spots before my eyes." -"I am tired at the end of the day." -"I feel bloated when I eat a large meal." -"I have trouble breathing when I climb a flight of stairs."

"I have trouble breathing when I climb a flight of stairs." Rationale: Dyspnea on exertion occurs with heart failure because of the heart's inability to meet the oxygen needs of the body. Seeing spots before one's eyes is not a symptom associated with heart failure. Fatigue at the end of the day is common for many people, whereas fatigue that occurs all day is a symptom of heart failure. Feeling bloated after eating a large meal is not associated with heart failure, although feeling bloated constantly might be associated with fluid retention caused by heart failure.

Which statement by a client who is seen for follow-up in the heart failure clinic is most important for the nurse to communicate to the health care provider? -"I am unable to run 1 mile (1.6 km) now." -"I wake up at night short of breath." -"My spouse says I snore loudly." -"My shoes seem larger lately."

"I wake up at night short of breath." Rationale: Paroxysmal nocturnal dyspnea (awakening at night short of breath) is a symptom of poorly controlled left ventricular failure and indicates a need for a change in the client's treatment plan. The statement that the client is unable to run a mile now does indicate that the client's activity tolerance is decreasing from the baseline, but dyspnea at rest is more concerning. More information is needed about snoring, because it may indicate sleep apnea, but snoring does not indicate that the client's heart failure is worsening. Worsening heart failure typically causes ankle swelling, and the client would report that shoes were tighter fitting.

Which statement made by the nurse indicates the need for further teaching when assessing clients with dark skin? -"I will touch the skin to feel its consistency." -"I will use a fluorescent light source to assess the skin color." -"I will place my hand on the skin to assess the temperature." -"I will look for any changes in skin color darker than surrounding skin."

"I will use a fluorescent light source to assess the skin color." Rationale: The nurse would use natural light or a halogen light source to assess accurately the skin color. Fluorescent light casts a blue color, which can make skin assessment difficult, indicating the nurse needs further teaching. The nurse would touch the client's skin to feel its consistency. The nurse would assess the area for the skin temperature using the hand. The nurse would look for any changes in skin color that are darker than surrounding skin.

A registered nurse (RN) is teaching a nursing student about skin assessment. Which statement made by the nursing student is incorrect? -"Skin assessments are best performed in daylight." -"Skin assessments performed at cool room temperatures can result in cyanosis." -"Skin assessment performed at warm room temperatures can result in vasodilatation." -"In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."

"In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light." Rationale: Although skin assessments are best conducted in daylight, in the absence of sunlight, they are best performed in fluorescent lighting. Skin exposure during skin assessments in cool room temperature can result in cyanosis. Skin exposure during skin assessments made in warm room temperature can result in vasodilatation.

Which pathophysiological changes in the lungs occur with emphysema? Select all that apply. One, some, or all responses may be correct. -Collapse of alveolar walls -Trapping of air in distal lung structures -Increases in pulmonary artery pressures -Increase in surface area for gas exchange -Movement of fluid from capillaries into alveoli

-Collapse of alveolar walls -Trapping of air in distal lung structures -Increases in pulmonary artery pressures Rationale: Destruction of alveolar walls in emphysema leads to alveolar wall collapse and trapping of air in distal lung structures, leading to poor gas exchange. Chronic hypoxemia causes pulmonary hypertension. As alveolar walls collapse, less surface area is available for gas exchange. The alveoli do not become filled with fluid in emphysema. Left-sided heart failure causes pulmonary congestion with fluid-filled alveoli.

When assessing a client with right ventricular heart failure, the nurse would expect which finding? Select all that apply. One, some, or all responses may be correct. -Dependent edema -Swollen hands and fingers -Collapsed neck veins -Right upper quadrant discomfort -Oliguria

-Dependent edema -Swollen hands and fingers -Right upper quadrant discomfort Rationale: With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.

Which assessment finding is consistent with a client diagnosis of right-sided heart failure? Select all that apply. One, some, or all responses may be correct. -Collapsed neck veins -Distended abdomen -Dependent edema -Decreased appetite -Cool extremities

-Distended abdomen -Dependent edema -Decreased appetite Rationale: Right-sided heart failure is associated with increased systemic venous pressures and venous congestion, as manifested by an enlarged liver with possible ascites (distended abdomen), dependent edema, and anorexia (decreased appetite). Distended (not collapsed) neck veins occur in right-sided heart failure. Cool extremities are common in left-sided heart failure because of decreased cardiac output.

Which assessment finding would the nurse expect when a client is diagnosed with left-sided congestive heart failure? Select all that apply. One, some, or all responses may be correct. -Dyspnea -Crackles -Frequent cough -Peripheral edema -Jugular distention

-Dyspnea -Crackles -Frequent cough Rationale: With left ventricular failure, increases in left ventricular volume and pressure lead to pulmonary congestion, causing dyspnea, lung crackles, and cough. Peripheral edema occurs when right-sided heart failure causes increases in systemic venous pressure. Jugular vein distention also occurs with right-sided failure and increased systemic venous pressure.

Which clinical indicator is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply. One, some, or all responses may be correct. -Edema -Vertigo -Polyuria -Ascites -Crackles

-Edema -Ascites Rationale: Pressure in the venous system increases with right ventricular failure, leading to edema, ascites, hepatomegaly, tachycardia, and fatigue. Vertigo suggests inner ear problems and is not related to right ventricular failure. Because a diminished cardiac output decreases blood flow to the kidneys, there will be a decreased, not increased, urine output (polyuria). Crackles occur with left heart failure because of pulmonary congestion.

Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. -Fatigue -Orthopnea -Pitting edema -Dry hacking cough -4-pound weight gain

-Fatigue -Orthopnea -Pitting edema -Dry hacking cough -4-pound weight gain Rationale: Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, a dry, hacking cough, and weight gain.

Which lifestyle factor, that may have contributed to the ankle swelling, would a nurse ask about when questioning a client with heart failure and new onset ankle edema? Select all that apply. One, some, or all responses may be correct. -Intake of salty foods -Dietary fat intake -Medication compliance -Family stresses -Recent travel

-Intake of salty foods -Medication compliance -Recent travel Rationale: Fluid retention in heart failure may be caused by increased salt intake, with associated water retention. Poor adherence to medication used to treat heart failure, such as angiotensin-converting enzyme inhibitors and diuretics, may also cause fluid retention. Recent travel may cause fluid retention because of changes in environmental temperature, effects of airplane travel on fluid retention, or changes in dietary sodium intake. Increased or decreased dietary fat intake will not cause fluid retention. Stress is not a contributor to fluid retention.

The nurse is performing a skin assessment of a client. Which findings may indicate a risk of skin cancer? Select all that apply. One, some, or all responses may be correct. -Lesion -Lumps -Rashes -Bruising -Dryness

-Lesion -Lumps -Rashes Rationale: Lesions on the skin that take a long time to heal may indicate skin cancer. Lumps and rashes on the skin are characteristics of skin cancer. Bruising may indicate a bleeding disorder or injury. Dryness of the skin may be due to excessive bathing and use of harsh soaps.

Which site would the nurse prefer to assess for determining the turgor of an older adult? Select all that apply. One, some, or all responses may be correct. -Back of the neck -Back of the hand -Palm of the hand -On the sternal area -Back of the forearm

-On the sternal area -Back of the forearm Rationale: Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.

Diagnosed with chronic obstructive pulmonary disease (COPD), a 50-year-old client's clinical data after treatment is: heart rate of 100 beats/min, blood pressure of 138/82 mm Hg, respiratory rate of 32 breaths/min, tympanic temperature 98.2°F (36.8°C), and an oxygen saturation of 80%. Which vital sign obtained by the nurse indicates a positive outcome? Select all that apply. One, some, or all responses may be correct. -Radial pulse: 70 beats/min -Temperature: 98.6°F (37°C) -Respiratory rate: 14 breaths/min -Blood pressure: 110/70 mm Hg -Oxygen saturation: 92%

-Respiratory rate: 14 breaths/min -Blood pressure: 110/70 mm Hg -Oxygen saturation: 92% Rationale: The respiratory rate ranges in older adults from 12 to 20 breaths/min, and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus a blood pressure of 110/70 mm Hg obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95% to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 98.2°F (36.8°C), is considered normal and not a sign of COPD.

Which findings are expected when assessing the skin of an older adult? Select all that apply. One, some, or all responses may be correct. -Scaly skin -Tenting of skin -Transparent skin -Increased wrinkles -Pigmented lesions

-Tenting of skin -Transparent skin -Increased wrinkles -Pigmented lesions Rationale: Decreased subcutaneous fat with degeneration of elastic fibers allows tenting of the skin and increased wrinkles. Decreased dermal thickness results in paper-thin, transparent skin. Pigmented lesions (liver spots, solar lentigines) increase in number, size, and distribution with aging. Scaling of the skin is more commonly associated with psoriasis than aging.

While assessing a client's skin, the nurse notices the client's skin is dry. Which probable cause would the nurse associate with this condition? Select all that apply. One, some, or all responses may be correct. -Use of hard soap -Frequent bathing -Use of tanning pills -Presence of an allergy -Use of petroleum products

-Use of hard soap -Frequent bathing Rationale: The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

Which skin condition would the nurse expect when performing a physical assessment on a client with a new diagnosis of hyperthyroidism? Select all that apply. One, some, or all responses may be correct. -Warm -Moist -Pale -Smooth -Coarse -Dry

-Warm -Moist -Smooth Rationale: Hyperfunction of the thyroid gland causes diaphoresis, which makes the skin moist. Hyperthyroidism also causes warm and smooth skin. Pale, coarse, and dry skin is found with hypothyroidism.

Which diagnostic test is most important for the nurse to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome (ACS)? -Chest radiograph -Troponin T (cTnT) -Creatine kinase MB (CK-MB) -12-lead electrocardiogram (ECG)

12-lead electrocardiogram (ECG) Rationale: With acute coronary syndrome, ECG changes indicating myocardial injury and infarction occur within minutes. Because treatment for ACS usually involves actions to restore blood flow to the myocardium as rapidly as possible, it is essential that the ECG be done and evaluated immediately. The other tests are also appropriate but will be done after the ECG. Changes in the chest radiograph will occur if there is cardiac enlargement, pericardial effusion, or heart failure secondary to myocardial infarction. Troponin T will increase in an average of 4 to 6 hours with myocardial infarction. CK-MB starts to increase at about 6 hours after myocardial infarction.

A client receiving a blood transfusion reports itching and difficulty breathing. Upon assessment the nurse notes an increased heart rate and low blood pressure. Which type of shock would the nurse suspect the client is experiencing? -Septic shock -Cardiogenic shock -Neurogenic shock -Anaphylactic shock

Anaphylactic shock Rationale: Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage to the spinal cord.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? -Red blood cell count -Sputum culture -Arterial blood gas -Hemoglobin

Arterial blood gas Rationale: Red blood cell count, sputum culture, and hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

Which action would the nurse on the unit take first when an older client with heart failure is transferred from the emergency department to the medical service? -Interview the client for a health history. -Assess the client's heart and lung sounds. -Monitor the client's peripheral pulse quality. -Obtain the client's blood specimen for electrolytes.

Assess the client's heart and lung sounds. Rationale: The nurse's first assessments would focus on detection of signs of severely decreased cardiac output, such as tachycardia and lung crackles, which would require rapid action to correct. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although peripheral pulse quality would decrease in heart failure, this is not a life-threatening finding. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.

A client is admitted to the hospital with chronic asthma. Which complication would the nurse monitor in this client? -Atelectasis -Pneumothorax -Pulmonary edema -Respiratory alkalosis

Atelectasis Rationale: As a result of narrowed airways, adequate ventilation of lung tissue is compromised, and alveoli may collapse (atelectasis). Pneumothorax is not a common complication of asthma; a collapsed lung is referred to as a pneumothorax. Pulmonary edema is not a common complication of asthma; pulmonary edema is caused by left-sided heart failure. Respiratory alkalosis is not a common complication of asthma; with narrowed air passages, the client with asthma is at risk for hypoxia and respiratory acidosis.

Which adverse effect would a nurse monitor for when caring for a client with hypertension who is prescribed metoprolol? -Hirsutism -Bradycardia -Restlessness -Angina

Bradycardia Rationale: Beta-blockers block stimulation of beta 1 (myocardial) adrenergic receptors, which decreases the heart rate and blood pressure. The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest. Excessive growth of hair or the presence of hair in unusual places does not occur with this medication; however, absence or loss of hair (alopecia) may occur. A side effect of this medication is fatigue, not restlessness. Metoprolol is indicated for treatment of angina, so angina will be decreased.

Which laboratory result of a client with chronic bronchitis would be most important for the nurse to communicate to the health care provider? -PaO 2 75 mm Hg -PaCO 2 48 mm Hg -Hematocrit 52% (0.52) -Leukocytes 16,000 mm 3 (16 x 10 %/L)

Leukocytes 16,000 mm 3 (16 x 10 %/L) Rationale: An elevated leukocyte (white blood cell) count indicates likely infection and will require collaborative actions, such as diagnostic testing and antibiotic treatment. The PaO 2 is mildly decreased, but chronically low PaO 2 is common in clients with chronic bronchitis. The PaCO 2 is slightly elevated, but carbon dioxide retention is a common finding in clients with chronic bronchitis. The hematocrit is mildly elevated, but polycythemia is common in clients with chronic bronchitis as a compensatory mechanism for low oxygen saturation.

Which clinical manifestation would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease? -Edema of the feet and ankles -Reddened and painful areas on the calves -Pain when exercising and thickening of the toenails -Ulcers around the ankles and reports of a dull ache in the legs

Pain when exercising and thickening of the toenails Rationale: Inadequate oxygenation of tissues of the affected limb causes intermittent claudication (indicated by pain when exercising) and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these changes may also be associated with decreased cardiac output related to heart failure.

Which clinical manifestation would the nurse expect to find when a client is admitted with right ventricular failure? -Chest pain -Bradypnea -Bradycardia -Peripheral edema

Peripheral edema Rationale: Right ventricular failure causes an increase in systemic venous pressure and forces capillary fluid into interstitial spaces, causing peripheral edema. Chest pain is not typical of heart failure, but it suggests possible acute coronary syndrome. Tachypnea (not bradypnea) and dyspnea occur with right ventricular failure. Tachycardia (not bradycardia) occurs as a compensatory mechanism for heart failure.

Which type of adventitious breath sound would the nurse expect when auscultating the posterior chest of a client with pleurisy who is reporting sharp chest pain with deep breathing? -Stridor -Rhonchi -Pleural friction rub -High-pitched crackles

Pleural friction rub Rationale: Pleurisy is caused by inflammation of the pleural surfaces, and a frequent clinical manifestation is a pleural friction rub, which is a rough, scratching, grating, creaking sound caused by inflamed pleural surfaces rubbing together. It is frequently associated with chest pain. Stridor is a high-pitched, shrill, harsh sound caused by laryngeal obstruction and can be heard on auscultation over the upper airways or with the naked ear. Rhonchi are continuous, low-pitched, coarse sounds often described as having a snoring or moaning quality that occur with partial bronchial obstruction caused by mucus, bronchospasm, foreign bodies, or tumors. High-pitched crackles are fine, short, interrupted popping sounds best heard on inspiration that occur with problems such as heart failure when air passes through fluid within the alveoli.

When a client with a heart murmur reports gaining weight in spite of nausea and anorexia, which additional information would be a priority for the nurse to obtain? -Presence of a cough and exertional dyspnea -Dietary food and salt intake in the past 24 hours -Changes in voiding and bowel patterns within the past month -History of childhood streptococcal infection or rheumatic fever

Presence of a cough and exertional dyspnea Rationale: Weight gain in a client with a murmur may indicate heart failure, and the nurse would assess for other clinical manifestations of heart failure such as dyspnea and cough that may need rapid treatment. A 24-hour diet and salt intake might help in determining causes for the weight gain, but are not as important as assessment for respiratory problems that might be caused by fluid overload. Changes in elimination patterns occur with heart failure, but are not as important to assess immediately as respiratory symptoms. A history of childhood streptococcal infection or rheumatic fever would be useful in determining the cause of the murmur, but is not essential to developing any immediate interventions.

Which clinical finding is associated with a skin assessment of decreased thickness and excessive dryness of the epidermis? -Skin tears -Skin cancer -Skin fragility -Skin hyperplasia

Skin fragility Rationale: The nurse may assess excessive skin dryness due to decreased epidermal thickness. It is associated with skin transparency and fragility. Skin tears may occur due to the flattening of the dermal-epidermal junction. Decreased mitotic homeostasis in the epidermis may cause skin cancer. Skin hyperplasia may occur due to sun-induced changes that cause a decrease in mitotic homeostasis.

Which sign would indicate possible heart failure in a client with heart disease in the immediate postpartum period? -Bradycardia -Tachypnea -Hypotension -Increased vaginal bleeding

Tachypnea Rationale: Tachypnea and dyspnea are likely to be the first signs of cardiac failure in the immediate postpartum period. With the mobilization of extravascular fluid and the rapid decrease in uterine blood flow, client with a cardiac disease may begin to experience heart failure in the immediate postpartum period. Tachycardia would be a more common finding than bradycardia in this situation. Hypotension would not be a sign of heart failure. Increased vaginal bleeding is not caused by alterations in cardiac status.

Which finding in a client who has been admitted with myocardial infarction is most important to communicate to the health care provider? -High anxiety level -Elevated troponin T -Urine output 15 mL/h -Heart rate 58 beats minute

Urine output 15 mL/h Rationale: Heart failure is a common complication after myocardial infarction, and a low urine output may indicate left ventricular failure, which would require immediate collaborative actions such as administration of diuretics or diagnostic testing such as echocardiography. Anxiety is a normal response to stressful events such as myocardial infarction and does require action by the nurse, but is not life-threatening. An elevation in troponin T is expected with myocardial infarction. A heart rate of 58 beats/minute is very slightly below normal and heart rate will continue to be monitored by the nurse, but does not require immediate notification of the health care provider.

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? -Losing weight over the past week -Tingling in the upper extremities -Using several pillows at night to sleep -Wheezing when exposed to dust or pollen

Using several pillows at night to sleep Rationale: Heart failure causes pulmonary congestion, leading to orthopnea and the need to elevate the head and chest with pillows when lying down. Clients with worsening heart failure will report recent weight gain because of fluid retention. Tingling in the arms is not a clinical manifestation of heart failure or poor cardiac output. Wheezing in response to dust or pollen is typical of asthma, not heart failure.

The nurse performs a respiratory assessment and auscultates high-pitched, creaking, and accentuated breath sounds on expiration. Which term describes the findings? -Rhonchi -Wheezes -Pleural friction rub -Bronchovesicular

Wheezes Rationale: Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.