The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate:
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Solution
Answer B is correct. The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect.
A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should:
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Solution
Answer A is correct. The normal central venous pressure is 5–10cm of water. A reading of 2cm is low and should be reported. Answers B, C, and D indicate that the nurse believes that the reading is too high and is incorrect.
The nurse identifies ventricular tachycardia on the heart monitor. Which action should the nurse prepare to take?
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Solution
Answer C is correct. The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes successful in slowing the rate, but this should be done only if a defibrillator is available. In answer A, atropine sulfate will speed the rate further; in answer B, checking the potassium is indicated but is not the priority; and in answer D, defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Also, defibrillation should begin at 200 joules and be increased to 360 joules.
The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurse should instruct the client to:
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Solution
Answer B is correct. The client should be asked to perform Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied. Answers A and C are not recommended, and sneezing is difficult to perform on command.
The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:
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Solution
Answer D is correct. The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor’s order, as stated in answer B, and answer C will not help with this situation.
Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)?
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Solution
Answer A is correct. An occult blood test should be done periodically to detect any intestinal bleeding on the client with coumadin therapy. Answers B, C, and D are not directly related to the question.
The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:
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Solution
Answer D is correct. After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.
The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture:
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Solution
Answer C is correct. Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse should question this treatment. Answer A describes acupressure, and answers B and D describe massage therapy with the use of oils.
The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:
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Solution
Answer B is correct. The fifth vital sign is pain. Nurses should assess and record pain just as they would temperature, respirations, pulse, and blood pressure. Answers A, C, and D are included in the charting but are not considered to be the fifth vital sign and are, therefore, incorrect.
The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated by morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opoid analgesics?
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Solution
Answer A is correct. Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a nonopoid analgesic; aspirin (answer C) is an analgesic, anticoagulant, and antipyretic; and atropine (answer D) is an anticholengergic.