Nokea
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
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A client with heart failure has a prescription for Digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication
- A. can predispose to dysrhythmias
- B. may lead to oliguria
- C. may cause irritability and anxiety
- D. sometimes alters consciousness
Correct Answer: A
Rationale: can predispose to dysrhythmias. The nurse should be aware of a decrease in the client's potassium levels because low potassium enhances the effects of Digoxin and predisposes the client to dysrhythmias. The other options are seen in hyperkalemia. Muscle weakness occurs in both hyperkalemia and hypokalemia.
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct Answer: C
Rationale: accept the client's report of pain. Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain -- 'the client's report.'
The nurse assesses a 72 year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
- A. Decreased urinary output
- B. Jugular vein distention
- C. Pleural effusion
- D. Bibasilar crackles
Correct Answer: B
Rationale: Signs of right-sided heart failure include jugular vein distention, ascites, nausea, and vomiting.
The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?
- A. Prepare a statement for the hospital spokesperson to release to the news agencies
- B. Recommend that only staff with recent negative tuberculin skin tests provide care
- C. Implement measures to notify the local or state health department about the case
- D. Notify the nearest infectious disease facility and prepare the client for transfer
Correct Answer: C
Rationale: C: TB is a reportable disease, requiring health department notification. A: Media release is inappropriate. B: All staff can provide care with precautions. D: Transfer is unnecessary.