Nokea
A client returns to the Cardiovascular Intensive Care Unit following a coronary artery bypass graft (CABG). In planning the client's care, the most important electrolyte to monitor is:
- A. chloride.
- B. bicarbonate.
- C. potassium.
- D. sodium.
Correct Answer: C
Rationale: Chloride, bicarbonate, and sodium will need to be monitored, but they are not as important as potassium. Potassium will need to be closely monitored, because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias.
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Trevor Gilbert, 59, arrives at the ambulatory surgery department as instructed prior to his back surgery. The baseline history taken on Mr. Gilbert should include:
- A. experiences he's had with hospitalizations.
- B. reactions to his childhood immunizations.
- C. what type of diet he's on and his compliance with it.
- D. what he believes will happen as a result of the surgery.
Correct Answer: D
Rationale: A preoperative assessment should include the patient's history, but the focus should be particularly on his expectations of this particular hospitalization. Knowledge about whether he received his childhood immunizations is important, but his reactions to those, even if he knows what they were, is not the most important information to gain today. The type of diet he's on is good information, but again not the most important information listed here. It is vital to determine the patient's expectations of his surgery, in order to correct any misperceptions he may have about the outcome, or reason, for this invasive treatment.
A patient with chronic cancer-related pain has started using MS Contin for pain control and has developed common side effects of the drug. The nurse reassures the patient that tolerance will develop to most of these side effects but that continued treatment will most likely be required for what?
- A. Pruritus
- B. Constipation
- C. Dizziness
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B. Constipation is a persistent side effect of opioids.
During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow to normal breaths alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems.
Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations.
Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations.
Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.
A 29-year-old client is admitted for a hysterectomy and is expressing concern regarding the procedure. Shortly into the preoperative teaching, the client complains of a tightness in the chest, feelings of suffocation, light-headedness, and tingling in the hands. The client's respirations are rapid and deep. The nursing assessment reveals that this client is:
- A. having a heart attack.
- B. wanting attention from the nurses.
- C. suffering from complete upper airway obstruction.
- D. hyperventilating.
Correct Answer: D
Rationale: Classic symptoms of a heart attack include a heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may also be present. However, the client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, lack of airflow between the nose and mouth, and absent breath sounds. A tightness in the chest, feelings of suffocation, light-headedness, tingling in the hands, and rapid deep respirations are signs and symptoms of hyperventilation, which is almost always a manifestation of anxiety.
A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?
- A. Prepare for mechanical ventilation.
- B. Administer oxygen via face mask.
- C. Prepare to administer a sedative.
- D. Assess for indications of pulmonary embolism.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen via face mask. Given the client's symptoms and ABG results showing respiratory alkalosis and hypoxemia, the priority is to improve oxygenation. Administering oxygen via face mask will help increase the oxygenation levels and alleviate the hypoxemia. Mechanical ventilation (A) is not indicated as the client is able to maintain their own ventilation. Administering a sedative (C) is not appropriate without addressing the underlying respiratory issue. Assessing for pulmonary embolism (D) may be important but not the immediate priority in this case.