MED SURG MASTERY EVOLVE
An 85-year-old client has a serum potassium level of 6.7 mEq/L. Which nursing action is a priority at this time? 1 Monitor for cardiovascular irregularities 2 Inquire about changes in bowel patterns 3 Assess client for leg muscle twitching or weakness 4 Assess client for signs and symptoms of dehydration
1 Monitor for cardiovascular irregularities Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns and leg muscle twitching and weakness are signs of hyperkalemia, but are not life threatening. Dehydration may be a cause of hyperkalemia.
A woman comes to the emergency department reporting signs and symptoms determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? (Select all that apply.) 1 Severe fatigue 2 Sense of unease 3 Choking sensation 4 Chest pain relieved by rest 5 Pain radiating down the left arm
1 Severe fatigue 2 Sense of unease A myocardial infarction in women may be asymptomatic, atypical, or mild. Unique symptoms include overwhelming fatigue, a sense of uneasiness, indigestion, and shoulder tenderness . A sense of unease is a unique characteristic of a myocardial infarction in women. The client knows something is not right but cannot identify what it is. This uneasiness often is disregarded by the client. A choking sensation occurs in both men and women with a myocardial infarction. Chest pain relieved by rest occurs in both men and women with angina; it is caused by coronary artery spasms leading to myocardial ischemia. Angina frequently is a precursor to a myocardial infarction. Pain radiating down the left arm occurs in both men and women. It can radiate also to the neck, lower jaw, left arm, left shoulder, and, less frequently, the right arm and back.
4.A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? 1 An irreversible phenomenon 2 A failure of the circulatory pump 3 Usually a fleeting reaction to tissue injury 4 Generally caused by decreased blood volume
2 A failure of the circulatory pump Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia is only one cause.
Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client? 1 4 to 5 seconds 2 1 to 3 minutes 3 30 to 45 seconds 4 20 to 45 minutes
2 1 to 3 minutes The onset of action of sublingual nitroglycerin tablets is rapid (1 to 3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.
The nurse provides medication discharge instructions to a client who received a prescription for digoxin (Lanoxin) following the client's myocardial infarction. The nurse concludes that the teaching was effective when the client says, "I should: 1 Avoid foods high in potassium." 2 Check my radial pulse rate daily." 3 Increase my intake of vitamin K." 4 Adjust the dosage according to my activities."
2 Check my radial pulse rate daily." Checking the radial pulse rate daily is necessary for monitoring cardiac function; digoxin slows and strengthens the heart rate. Digoxin should be withheld and the health care provider notified if the pulse rate falls below a predetermined rate (e.g., 60 beats per minute). Hypokalemia increases the potential for digoxin toxicity; potassium intake should be increased, not decreased. An increase in the intake of foods rich in vitamin K is unnecessary; vitamin K is not related to digoxin intake. Adjusting the dosage according to activities is not an appropriate decision for the client; the health care provider should make this decision.
A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is: 1 Oliguria 2 Dyspnea 3 Petechiae 4 Confusion
3 Petechiae At the time of a fracture or orthopedic surgery, fat globules may move from the bone marrow into the bloodstream. Also, elevated catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization of small vessels from fat globules, petechiae are noted in the buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these adaptations only occur with a fat embolism. Oliguria, dyspnea, and confusion are signs of an embolus, but are not specific to a fat embolus.
Which nursing behavior is an intentional tort? 1 Miscounting gauze pads during a client's surgery. 2 Causing a burn when applying a wet dressing to a client's extremity. 3 Divulging private information about a client's health status to the media. 4 Failing to monitor a client's blood pressure before administering an antihypertensive.
3 Divulging private information about a client's health status to the media. Divulging private information is an invasion of privacy, which is an intentional tort. Miscounting gauze pads during a client's surgery, causing a burn when applying a wet dressing to a client's extremity, and failing to monitor a client's blood pressure before administering an antihypertensive are examples of professional negligence (malpractice).
A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply, which may be diminished further by: 1 Drinking alcohol 2 Lowering the limb 3 Smoking cigarettes 4 Consuming excessive fluid
3 Smoking cigarettes Nicotine causes vasoconstriction and spasm of the peripheral arteries. Alcohol may stimulate dilation of blood vessels. Lowering the limb enhances flow of blood into the foot by gravity but does not support the return flow of blood. Consuming excessive fluid will decrease the viscosity of blood, possibly preventing the formation of thrombi.
A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is: 1 Type O positive 2 Type AB positive 3 Type A or O negative 4 Type A or AB negative
3 Type A or O negative Both A and O negative blood are compatible with the client's blood. A negative is the same as the client's blood type and preferred; in an emergency, type O negative blood also may be given. Although type O blood may be used, it will have to be Rh negative; Rh positive blood is incompatible with the client's blood and will cause hemolysis. Type AB positive blood is incompatible with the client's blood and will cause hemolysis. Type A negative blood is compatible with the client's blood, but type AB negative is incompatible and will cause hemolysis.
A health care provider prescribes a dose of medication that is much higher than is recommended for the clinical situation, and directs the nurse to give the medication immediately. Which response by the nurse is most appropriate? 1 "The dose is too high. I do not feel comfortable administering this dose." 2 "Please tell me how you arrived at this dose. I think your calculations are incorrect." 3 "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug." 4"That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself.
4 "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself. The response "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself" informs the health care provider of the nurse's dilemma and legal position without creating an adversarial professional position. A confrontational response may make the health care provider look and feel incompetent and jeopardize the collegial relationship. "The dose is too high. I do not feel comfortable administering this dose," "Please tell me how you arrived at this dose. I think your calculations are incorrect," and "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug" are confrontational responses that may make the health care provider look and feel incompetent and jeopardize the collegial relationship.
The physician prescribes one unit of packed red blood cells to be administered to a patient. To ensure the patient's safety, which measure should the nurse take during administration of blood products? 1 Discontinue the intravenous catheter if a blood transfusion reaction occurs. 2 Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle. 3 Flush packed red blood cells with 5% dextrose and 0.45% normal saline. 4 Stay with patient during first 15 minutes of infusion.
4 Stay with patient during first 15 minutes of infusion. The nurse should remain with the patient for the first 15 to 30 minutes. Any severe reaction usually occurs with the infusion of the first 50 mL of blood. Blood components are viscous, requiring a large needle to be used for venous access. A 20-gauge needle is not used to access a central catheter line. Normal saline is the solution to administer with blood products. Lactated Ringers and dextrose in water are not used for infusion because of hemolysis.
A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next? 1 Count the pulse at another site. 2 Notify the health care provider. 3 Lower the legs to increase blood flow. 4 Verify the pulse by using a Doppler.
4 Verify the pulse by using a Doppler. Clients with venous insufficiency often have edema, which may make palpation of an arterial pulse difficult. A Doppler uses sound waves so that the pulse can be heard. The quality of the pedal pulse, not the rate, is assessed to determine the adequacy of peripheral arterial circulation; the most distal site is preferred. The nurse must make other assessments of circulation before notifying the health care provider. Lowering the legs will increase edema and make palpation of pulses more difficult.