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A client is brought to the emergency department reporting chest pain. Assessment shows vital signs that include a blood pressure (BP) of 150/90 mm Hg, pulse (P) 88 beats per minute (BPM), and respirations (R) 20 breaths per minute. The nurse administers nitroglycerin 0.4 mg sublingually. The treatment is found to be effective when the reassessment of vital signs shows which data?
- A. BP 150/90 mm Hg, P 70 BPM, R 24 breaths per minute
- B. BP 100/60 mm Hg, P 96 BPM, R 20 breaths per minute
- C. BP 100/60 mm Hg, P 70 BPM, R 24 breaths per minute
- D. BP 160/100 mm Hg, P 120 BPM, R 16 breaths per minute
Correct Answer: B
Rationale: Nitroglycerin dilates both arteries and veins, causing blood to pool in the periphery. This causes a reduced preload and therefore a drop in cardiac output. This vasodilation causes the blood pressure to fall. The drop in cardiac output causes the sympathetic nervous system to respond and attempt to maintain cardiac output by increasing the pulse. Beta blockers, such as propranolol, are often used in conjunction with nitroglycerin to prevent this rise in heart rate. If chest pain is reduced and cardiac workload is reduced, the client will be more comfortable; therefore, a rise in respirations should not be seen.
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After a cervical spine fracture, this device (refer to figure) is placed on the client. The nurse creates a discharge plan for the client to ensure safety and includes which measures? Select all that apply.
- A. Teach the client how to ambulate with a walker.
- B. Instruct the client to bend at the waist to pick up needed items.
- C. Demonstrate the procedure for scanning the environment for vision.
- D. Inform the client about the importance of wearing rubber-soled shoes.
- E. Teach the spouse to use the metal frame to assist the client to turn in bed.
Correct Answer: A,C,D
Rationale: The client with a halo fixation device should be taught that the use of a walker and rubber-soled shoes may help prevent falls and injury and are therefore also helpful. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. The client with a halo fixation device should avoid bending at the waist because the halo vest is heavy, and the client's trunk is limited in flexibility. The nurse instructs the client and family that the metal frame on the device is never used to move or lift the client because this will disrupt the attachment to the client's skull, which is stabilizing the fracture.
The client states that he has smoked three-fourths of a pack per day over the last 10 years. The nurse calculates that the client has a smoking history of how many pack-years?
Correct Answer: 7.5
Rationale: The standard method for quantifying smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The number is recorded as the number of pack-years. The calculation for the number of pack-years for the client who has smoked three-fourths of a pack per day for 10 years is 0.75 pack × 10 years = 7.5 pack-years.
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
- A. Assess peripheral circulation.
- B. Monitor for abdominal distention.
- C. Educate the client that abdominal pain is to be expected.
- D. Assess the client for observable ecchymoses on the lower back.
- E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
Correct Answer: A,B,D
Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.
The nurse is analyzing an electrocardiogram (ECG) rhythm strip on an assigned client. What should the nurse record as the client's PR interval?
- A. 0.12 second
- B. 0.20 second
- C. 0.24 second
- D. 0.40 second
Correct Answer: A
Rationale: Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.