Nokea
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). What information about the balloon-tipped catheter should nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- C. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
- D. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
Correct Answer: B
Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization.
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A client is scheduled for a subtotal gastrectomy (Billroth II procedure). The nurse explains that the procedure will have which surgical results?
- A. Proximal end of the distal stomach is anastomosed to the duodenum.
- B. Entire stomach is removed and the esophagus is anastomosed to the duodenum.
- C. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum.
- D. Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum.
Correct Answer: C
Rationale: In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options 1, 2, and 4 are incorrect descriptions.
A client began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. What is the initial nursing action when the client reports itching and a tight sensation in the chest?
- A. Stop the transfusion.
- B. Check the client's temperature.
- C. Call the primary health care provider.
- D. Recheck the unit of blood for compatibility.
Correct Answer: A
Rationale: The symptoms reported by the client indicate that the client is experiencing a transfusion reaction. The first action of the nurse when a transfusion reaction is observed is to discontinue the transfusion. The IV of normal saline with new IV tubing is started and the primary health care provider is notified. The nurse then checks the client's vital signs: temperature, pulse, and respirations and then rechecks the unit of blood as appropriate for infusion into the client.
The nurse provides discharge instructions to a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply.
- A. If I am ill, I should skip my daily dose.
- B. If I overeat, I will double my dosage of medication.
- C. Oral agents are effective in managing type 2 diabetes.
- D. If I become pregnant, I will discontinue my medication.
- E. Oral hypoglycemic medications will cause my urine to turn orange.
- F. My medications are used to manage my diabetes along with diet and exercise.
Correct Answer: A,B,D,E
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes mellitus. During illness or periods of intense stress, the client should be instructed to monitor her or his blood glucose level frequently and should contact the primary health care provider if the blood glucose is elevated because insulin may be needed to prevent symptoms of acute hyperglycemia. The medication should not be skipped or the dosage should not be doubled. Taking extra medication should be avoided unless specifically prescribed by the primary health care provider. Medication should never be discontinued unless instructed to do so by the primary health care provider. However, the diabetic who becomes pregnant will need to contact her primary health care provider because the oral diabetic medication may have to be changed to insulin therapy because some oral hypoglycemics can be harmful to the fetus. These medications do not change the color of the urine.
The nurse providing diet teaching to a client experiencing heart failure instructs the client to avoid which food item?
- A. Sherbet
- B. Steak sauce
- C. Apple juice
- D. Leafy green vegetables
Correct Answer: B
Rationale: Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with heart failure should monitor sodium intake.
While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the client is exhibiting?
- A. Flaccidity
- B. Decorticate posturing
- C. Decerebrate posturing
- D. Rigidity in the upper extremities
Correct Answer: B
Rationale: Decortication is abnormal posturing seen in the client with lesions that interrupt the corticospinal pathways. In this posturing, the client's arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the feet and legs extended. Flaccidity indicates weak, soft, and flabby muscles that lack normal muscle tone. Decerebration is abnormal posturing and rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos. Decerebration is usually associated with dysfunction in the brainstem area. Rigidity indicates hardness, stiffness, or inflexibility. Decerebrate posturing is associated with rigidity.