The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply:

1. Presence of cardiac pain.
2. Medications taken before hospitalizations.
3. Presence of jugular vein distention.
4. Heart sounds and apical rate.
5. Presence of diaphoresis.
6. History of difficulty breathing.

Solution

Answers: 1, 3, 4, and 5.

A focussed cardiac assessment is directed towards assessing physiologic symptoms (cardiac pain, JVD, heart sounds and rate, and presence of diaphoresis) that provide immediate information regarding the clients condition, which is appropriate for the nurse to do at the beginning of each shift. After the physiological parameters have been evaluated the nurse can determine history of SOB and meds.

The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:

1. Verify consent has been signed.
2. Explain procedure to client.
3. Provide clear liquid, no caffeine diet.
4. Evaluate peripheral pulses.
5. Obtain a 12 lead ECG
6. Obtain history of shellfish allergy.

Solution

Answers: 1, 2, 5, and 6.

In cardiac catheterization contrast dye is injected into the coronary artery and provides info on patency. Informed consent must be signed prior to any invasive procedure. The physician is responsible for explaining the procedure, the nurse can reinforce. Patient would be NPO 6-18 hours prior. An ECG would be done, but measures electrical not blood flow. Peripheral pulses is important afterwards. Shellfish is an indicator of an allergy to the medium injected.

The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:

1. Elevate the HOB.
2. Decrease intake of caffeine.
3. Discuss strategies for weight loss if overweight.
4. Increase fluid intake with meals.
5. Take ranitidine (Zantac) at hs.
6. Eat a bedtime snack of milk and protein.

Solution

Answers: 1, 2, 3, 5.

This will all help neutralize stomach acid. Drinking lots with meals and eating before bed will exacerbate the problem.

The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:

1. Decrease in pulse rate in affected leg.
2. Paresthesia distal to area of injury.
3. Toes on affected leg cool to touch and edematous.
4. Complaints that pins are hurting.
5. Complaints of leg pain unrelieved by analgesics or repositioning.
6. Client angry and calling loudly to the nurse every ten minutes.

Solution

Answers: 2, 3, 5.

Paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. With a femur fracture the will be edema, a decrease in rate is not an indication of pressure, a decrease in pulse strength is. Anger can be due to immobility, and the pins do not usually cause pain, but this may be a sign of infection.

The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:

Solution

Answers: 1, 3, 5, 6.

Indications for dialysis include volume overload, weight gain, hyperkalemia, metabolic acidosis, and rising BUN (normally 10-20 mg/dL) and Cr (normally 0.5-1.5 mg/dL) levels, along with decreased urinary creatinine clearance. The K level is hyperkalemic, the BUN is normal.

The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:

1. Serum potassium level decreases from 5.4 to 4.6 mEq/L
2. Cr decreases from 1.6 to 0.8 mg/dL
3.Hgb increases from 10-12 g/dL
4. WBC increase from 5000 to 8000/mm^3
5. BUN decreases from 110 to 90 mg/dL

Solution

Answers: 1, 2, 5.

Primary action of hemodialysis is to clear nitrogenous waste products.

A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:

1. Warming the dialysate
2. Too rapid installation
3. Infiltration of the solution into the bloodstream
4. Accumulation of dialysate solution under the diaphragm
5. Too rapid outflow of the dialysate.

Solution

Answers: 2,4.

Rapid outflow doesn’t cause pain, warming helps with discomfort and the dialysate does not infiltrate the circulation.

The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:

1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect.
2. Determine whether the client has any sudden loss of vision accompanied by pain.
3. Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision.
4. Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved.
5. Have the client demonstrate the use of eye drops.
6. Assess the client for chronic diseases such as diabetes.

Solution

Answers: 1, 5, 6.

Medications must be evaluated in terms of their potential for increasing the intraocular pressure. Ophthalmic drops are often prescribed for glaucoma and clients should know how to administer them correctly. Diabetes is a risk factor and its mgmt is important in helping slow POAG. An increase in intraocular pressure could cause further damage to a patient with POAG. The questions states the client is already diagnosed, POAG is painless and not correlated to BP.

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:

1. Position the client directly on the trochanter when side lying.
2. Avoid use of donut type devices.
3. Massage bony prominences.
4. Elevate the HOB no more than 30 degrees when possible.
5. When the client is side lying, use the 30 degree lateral inclined position.
6. Avoid uninterrupted sitting in a chair or wheelchair.

Solution

Answers: 2, 4, 5 ,6.

Elevating the head of the bed to 30 degrees or less will decrease the chance of ulcer development from shearing forces. When placing the client in a side lying position, use the 30 degree lateral inclined position. Do not place the client on their trochanter. Avoid donuts which promote ischemia. Don’t massage bony prominences as this causes capillary break down and injury leading to pressure ulcers.

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply:

1. Use active listening skills to seek information from the client.
2. Encourage the client to describe the problem as she sees it.
3. Ask the client to tell you exactly what she thinks is happening.
4. Tell the client that she is delusional and you can help her.
5. Explain to the client that most people are not investigated by the CIA.
6. Reassure the client that you are not with the CIA.

Solution

Answers: 1,2,3.

The client is displaying paranoid behaviours, which necessitates a matter of fact approach that is nonjudgmental and accepting the client’s statements and show the nurses willingness to actively listen. The last three do not contribute to a therapeutic nurse client relationship.

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