CV
A nurse is caring for a client with a history of congestive heart failure at risk for the development of fluid volume excess. The nurse should monitor for which of the following is a manifestation of left-sided heart failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night
Dyspnea with a cough that is worse at night
Dyspnea with a cough that is worse at night is an indication of left-sided heart failure. Left-sided heart failure causes blood to back up in the heart and lungs with decreased distribution of blood throughout the body.
Which client problem should receive highest priority when a client is admitted with an acute exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety
Impaired physical mobility
When setting priorities for nursing care, physiological needs should be addressed first according to Maslow's Hierarchy of Needs. Reducing the client's pain will help with other needs, such as hygiene and grooming.
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss
Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased serum calcium levels), which may cause tetany. Involuntary muscle spasms are a common symptom associated with hypothyroidism.
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead.
Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds after instillation.
Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to the puncta for 1 to 2 min to prevent loss of medication into the nasal lacrimal duct and into the systemic circulation.
"Did you flush your eye out at work?"
The first action to decrease additional risk of injury is to flush out the eye as soon as possible after entry by a foreign body. If this was not done at the worksite, it needs to be done immediately.
Following a transient ischemic attack (TIA), a client is alert, slightly confused, and has a blood pressure of 204/102 mm Hg. The client is also incontinent of urine. When contributing to the client's plan of care, which nursing action would be appropriate?
Offer the client a bedpan every 2 hr.
Place an adult diaper on the client and check every 2 hr.
Request a prescription for an indwelling urinary catheter from the client's provider.
Ambulate the client to the bathroom every 4 hr.
Offer the client a bedpan every 2 hr.
The effects of a TIA are usually temporary, and the nurse should try to help the client regain bladder control. This option helps the client regain bladder control, uses an appropriate time interval (2 hr) for bladder training, and keeps the client safe by maintaining bed rest.
A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the nurse should instruct the client to do which of the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures.
Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
Keep ice on the ankle to prevent edema.
Keep ice on the ankle to prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve impulse transmission will also be reduced, resulting in analgesia to the injured area and a reduction of muscle spasms. Ice applications should not exceed 20 to 30 min per application.
A nurse is assisting with the discharge of a client newly diagnosed with diabetes. When reviewing information about proper foot care, which of the following would be appropriate to include?
Soak feet every night in warm water.
Wear clean cotton socks daily.
Walk barefoot at home when possible.
Get fitted for shoes in the morning.
Wear clean cotton socks daily.
Cotton socks should be worn by clients who are diabetic. They are soft and will wick excess moisture away from the foot.
A nurse is reinforcing teaching to a client recently diagnosed with systemic lupus erythematosus (SLE). Which statement made by the client indicates to the nurse an accurate understanding of the home management of SLE?
"I will need to take prednisone when I am having an exacerbation of the disease."
"I'm thankful this condition only affects the skin because I will just need to stay out of the sun."
"A warm shower for 10 to 15 minutes every evening will really help to loosen up my joints."
"A mild fever is common with SLE and usually does not require medical intervention."
"I will need to take prednisone when I am having an exacerbation of the disease."
SLE is an autoimmune disorder characterized by flares or exacerbations with periodic remissions. It affects the skin as well as joints, organs, and any structure in the body that contains connective tissue. Prednisone (Deltasone) is the medication most commonly given to decrease the body's inflammatory response and subsequently decrease pain in affected joints/organs/tissues and fatigue. Long-term therapy with corticosteroids pose significant side effects so clients are usually weaned off these medications when the exacerbation has subsided.
A client has a platelet count of 18,000 cells/mL. An appropriate nursing intervention is to do which of the following?
Avoid intramuscular injections (IM).
Administer oxygen via nasal cannula.
Maintain a no visitors policy.
Provide meticulous oral hygiene every 3 to 4 hr.
Avoid intramuscular injections (IM).
The platelet count is dangerously low indicating thrombocytopenia (decreased platelet count). Any invasive procedure, such as an IM injection, can precipitate hemorrhage that may be difficult to stop. Bleeding precautions are necessary for this client.
"I will force fluids to prevent dehydration."
"I will notify my doctor before I have invasive surgery or dental procedures."
"I will stay on a low-protein and low-potassium diet."
"I will wear a mask when I go out into crowds."
"I will notify my doctor before I have invasive surgery or dental procedures."
Preventing a reoccurrence of rheumatic endocarditis is the goal of notifying the provider prior to invasive surgical or dental procedures. The client will need prophylactic antibiotic therapy prior to any invasive procedure that can result in risk for a streptococcal infection.
A nurse is caring for a client who has undergone a hip arthroplasty. The nurse reminds the client that the purpose of an abduction pillow following arthroplasty is to do which of the following?
Raise the bed linens off the client's feet preventing plantar flexion.
Keep the client's heels off the bed to prevent pressure ulcers.
Position the client off of the operative site while in bed.
Prevent dislocation of the hip during position changes or movement.
Prevent dislocation of the hip during position changes or movement.
Total hip arthroplasty is a surgical procedure to reconstruct a diseased hip joint. The head of the femur is removed, along with the lining of the acetabulum (hip socket). The head of the femur is replaced with a metal ball and stem, and the acetabulum is replaced with a plastic or metal cup. Following surgery, the client must be on "hip precautions" to prevent dislocation of the new hip joint. The abduction pillow is a wedge-shaped pillow that is placed between the legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body following total hip replacement during position changes or client movement.
A client with type 1 diabetes mellitus has a capillary blood glucose reading of 48 mg/dL. Which of the following should the nurse expect to find?
Kussmaul respirations
Diaphoresis
Decreased skin turgor
Ketonuria
Diaphoresis
Hypoglycemia is a complication that occurs in clients with insulin-dependent diabetes mellitus. Hypoglycemia develops when the client's blood glucose level is below 70 mg/dL and can occur secondary to a precipitous decrease in blood glucose that is still within the expected reference range. Common symptoms of hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion.
A client who is admitted to the hospital after experiencing a tonic clonic seizure is scheduled for a routine electroencephalogram (EEG). In preparing the client for the EEG, the nurse should explain that the client will undergo which of the following?
Remain NPO 6 to 8 hr prior to the EEG.
Receive a sedative the night prior to the EEG.
Receive a thorough shampoo prior to the EEG.
Have no dietary restrictions prior to the test.
Receive a thorough shampoo prior to the EEG.
The client's hair must be washed thoroughly prior to the EEG. Hairsprays, oils, and other hair preparations interfere with recording results of the EEG.
A nurse asks a client who is diagnosed with asthma about the pathophysiology of the disorder. Further reinforcement of teaching is indicated when the client states that the cause of airway obstruction is due to which of the following?
Edema of the bronchial membranes
Collapse of the alveoli
Constriction of the bronchioles
Excessive production of mucus
Collapse of the alveoli
Alveolar collapse does not contribute to an acute asthma attack.
A client has just received a cardiac pacemaker. Which statement by the client demonstrates to the nurse an understanding of the pacemaker's purpose?
"The pacemaker will help stimulate my heart to beat when my heart rate is slow or irregular."
"I don't have to take my antihypertensive medications since my pacemaker will regulate my body's blood flow."
"Having a pacemaker means that I will never have a heart attack."
"I cannot stand in front of our new microwave oven when it is on."
"The pacemaker will help stimulate my heart to beat when my heart rate is slow or irregular."
Maintaining a regular heartbeat at a predetermined rate is the primary purpose of a cardiac pacemaker.
Administer prescribed dose of gabapentin (Neurontin).
Administer prescribed dose of hydrocodone (Vicodin).
Contact the provider for a change in the antibiotic prescribed.
Increase the frequency of the dressing changes.
Administer prescribed dose of gabapentin (Neurontin).
This client is experiencing phantom limb pain. Even though amputated limbs are no longer attached to the body, a client can feel pain in the amputated limb, especially after a traumatic amputation. Opiates are not effective for this type of pain. Beta-blockers, antispasmodics and anticonvulsants such as gabapentin, are more effective for treating this type of pain.
A nurse making rounds finds a client in the waiting room who is confused, has clammy skin, and his hands are tremoring. The nurse should do which of the following?
Check the client's blood glucose using a glucometer.
Check the client's oxygen level using a pulse oximeter.
Call a code blue.
Implement seizure precautions.
These are manifestations of hypoglycemia that are consistent with diabetes and a blood glucose level should be done to validate this suspicion. This client needs to be assessed for the presence of ketones in the urine, a blood sugar, and arterial blood gases to determine the degree of acidosis and elevation of the blood sugar.
Provide oxygen.
Turn the client onto his side.
Provide privacy.
Lower the client to the floor.
When a client begins to have a seizure while sitting or standing, the nurse should gently lower the client to the floor to protect the client from injury; therefore, this intervention has the highest priority.
A client with chronic renal failure is undergoing peritoneal dialysis. Which nursing measure will be helpful in promoting outflow drainage of the dialyzing solution?
Turn the client from side to side.
Elevate the height of the dialysate bag.
Apply manual pressure to the client's lower abdomen.
Push the peritoneal catheter in approximately 1 inch further.
Turn the client from side to side.
Sometimes the peritoneal catheter is buried in the omentum, which will slow or stop the outflow drainage. If the fluid is not draining properly, it is helpful to move the client from side to side to facilitate removal of peritoneal drainage.
A client diagnosed with emphysema is being prepared for discharge. Which instruction reinforced by the nurse would be beneficial for improving the client's gas exchange?
Reinforcing teaching for the client to use pursed-lip breathing
Encouraging the client to limit fluids to 1,500 mL per day
Demonstrating the proper technique for chest breathing
Reinforcing teaching about home oxygen therapy at 5 L/min
Reinforcing teaching for the client to use pursed-lip breathing
Pursed-lip breathing slows expiration, prevents collapse of lung units, and facilitates effective gas exchange.
A client is brought to the emergency department following a fall. The nurse, suspecting a basilar skull fracture, should check the client for which of the following signs specific to a basilar skull fracture?
A depressed fracture of the forehead
Clear fluid coming from the nares
Black-and-blue discoloration around the eyes
A superficial hematoma on the skull
Clear fluid coming from the nares
Clear fluid coming from the nares is associated with a basal skull fracture.
A nurse is caring for a client admitted with a diagnosis of hyperthyroidism caused by an adenoma of the thyroid gland. Twelve hours following the thyroidectomy, which of the following findings should the nurse report to the charge nurse? (Select all that apply.)
Tachycardia and hypertension
Respiratory rate of 16/min
Negative Chvostek's sign
Laryngeal stridor and a hoarse voice
Positive Trousseau's sign
Tachycardia and hypertension are correct.
Tachycardia and hypertension are unexpected findings and may indicate the occurrence of thyroid storm, which can occur after removal of the thyroid gland, especially if the client was in a hyperthyroid state prior to the surgery. Thyrotoxic, or thyroid, storm is a life-threatening condition that develops in cases of thyrotoxicosis (hyperthyroidism) or following acute stress, such as trauma or infection. Onset is sudden with a tachycardia, fever, sweating, restlessness, and tremors. Congestive heart failure and pulmonary edema can develop rapidly and lead to death.
A respiratory rate of 16/min is incorrect. This is an expected finding and is within the normal reference range.
A negative Chvostek's sign is incorrect. This is an expected finding. A Positive Chvostek's sign (facial muscle spasm after tapping the facial nerve in front of the ear) would be an indication of hypocalcemia, a complication of thyroid removal. This occurs when the parathyroid glands are also removed and regulation of serum calcium is impaired.
Laryngeal stridor and a hoarse voice are correct. Laryngeal stridor and a hoarse voice are unexpected findings and may be an indication of swelling in the area of the surgery or damage to the laryngeal nerve. This should be reported to the provider before respiratory distress develops.
A positive Trousseau's sign is correct. A Positive Trousseau's sign is an indication of hypocalcemia, a complication of thyroid removal. This occurs when the parathyroid glands are also removed and regulation of serum calcium is impaired
At the start of the night shift, an assistive personnel (AP) brings the nurse a list of client reports. Which client does the nurse need to check first?
The client with emphysema who is reporting dyspnea
The client with ulcerative colitis who is reporting diarrhea
The client with benign prostate hypertrophy (BPH) who is reporting dysuria
The client with laryngeal cancer who is reporting dysphagia
The client with emphysema who is reporting dyspnea
Using the airway, breathing, and circulation (ABC) priority framework, the nurse should check the client who is having difficulty breathing first. Dyspnea is a common report from clients with emphysema, but the nurse realizes that this is the client with the greatest physiologic risk.
A nurse is caring for a client in acute renal failure. Which of the following manifestations should the nurse expect the client to exhibit?
Anuria
Polyphagia
Weight loss
Bradycardia
Anuria
Anuria (no urine output) occurs during acute renal failure.