Nokea
A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following?
- A. Cardiac output.
- B. Right atrial blood flow.
- C. Left end-diastolic pressure.
- D. Cardiac index.
Correct Answer: C
Rationale: The correct answer is C: Left end-diastolic pressure. Wedging the pulmonary artery catheter allows the nurse to obtain the pulmonary artery wedge pressure, which reflects the left end-diastolic pressure. This pressure is essential in assessing left ventricular function and diagnosing conditions like heart failure. Choices A, B, and D are incorrect because wedging the catheter does not directly provide information about cardiac output, right atrial blood flow, or cardiac index.
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What is the primary nursing intervention for a patient experiencing an acute asthma attack?
- A. Administering bronchodilators.
- B. Administering antibiotics.
- C. Administering IV fluids.
- D. Administering corticosteroids.
Correct Answer: A
Rationale: The correct answer is administering bronchodilators. During an acute asthma attack, the primary goal is to relieve airway constriction and bronchospasm to improve breathing. Bronchodilators, such as short-acting beta-agonists, are the cornerstone of treatment as they help dilate the airways quickly. Administering antibiotics (choice B) is not indicated unless there is an underlying bacterial infection. Administering IV fluids (choice C) may be necessary in some cases, but it is not the primary intervention for an acute asthma attack. Administering corticosteroids (choice D) is often used as an adjunct therapy to reduce airway inflammation, but it is not the primary intervention during the acute phase of an asthma attack.
A client with chronic heart failure is being taught by a nurse about the importance of daily weights. Which of the following instructions should the nurse include?
- A. Weigh yourself at the same time every day.
- B. Use the same scale for weighing each time.
- C. Record your weight in a journal or log.
- D. Report any weight gain of more than 2 to 3 pounds in a day.
Correct Answer: D
Rationale: The correct instruction for a client with chronic heart failure is to report any weight gain of more than 2 to 3 pounds in a day. This weight gain may indicate fluid retention, which is a critical sign of worsening heart failure. Weighing at the same time every day and using the same scale for consistency are good practices, but the crucial action is to promptly report significant weight gain, as stated in option D. Recording the weight in a journal or log can be helpful for tracking trends, but immediate reporting of weight gain is essential for timely intervention in heart failure management. Therefore, option D is the most appropriate instruction for this client.
The client with peripheral vascular disease (PVD) and a history of heart failure may have a low tolerance for exercise due to:
- A. Decreased blood flow.
- B. Increased blood flow.
- C. Decreased pain.
- D. Increased blood viscosity.
Correct Answer: A
Rationale: The correct answer is A: Decreased blood flow. In clients with peripheral vascular disease (PVD) and a history of heart failure, decreased blood flow due to heart failure can result in reduced oxygen delivery to tissues. This reduced oxygen supply can lead to low exercise tolerance. Increased blood flow (Choice B) is not typically associated with reduced exercise tolerance in these clients. Decreased pain (Choice C) and increased blood viscosity (Choice D) are not the primary factors contributing to low exercise tolerance in this scenario.
The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?
- A. Protect the skin of the radiation portal site from sunlight exposure
- B. Apply moisturizing lotions daily to the radiation portal site
- C. Avoid washing the skin inside the radiation portal site
- D. Remove the ink marks of the portal after each radiation treatment
Correct Answer: A
Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.
A young adult client, admitted to the Emergency Department following a motor vehicle collision, is transfused with 4 units of PRBCs (packed red blood cells). The client's pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all the PRBCs have been transfused?
- A. 0.19
- B. 0.09
- C. 0.39
- D. 0.29
Correct Answer: D
Rationale: The expected increase in hematocrit after transfusion is approximately 3% per unit of PRBCs. Since the client received 4 units, the expected increase would be 4 x 3% = 12%. Therefore, adding this to the pretransfusion hematocrit of 17% would result in an expected post-transfusion hematocrit of 29%. Choice A (0.19) is incorrect as it doesn't consider the incremental increase per unit of PRBCs. Choices B (0.09) and C (0.39) are also incorrect as they do not align with the expected increase in hematocrit following the transfusion of 4 units of PRBCs.