Nokea
A client with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. The nurse's initial action should be to:
- A. Elevate the leg above the level of the heart.
- B. Wrap the leg in a loose blanket.
- C. Notify the physician about the findings.
- D. Perform passive ROM exercises to stimulate circulation.
Correct Answer: C
Rationale: The correct initial action is to notify the physician (Choice C) about the sudden onset of leg pain, pallor, tingling, and loss of pulses, as these symptoms suggest acute arterial occlusion, a medical emergency. The physician needs to be informed immediately to assess the situation and determine the appropriate intervention, such as urgent revascularization. Elevating the leg (Choice A) may worsen the condition by reducing blood flow further. Wrapping the leg in a blanket (Choice B) is not recommended as it does not address the underlying arterial occlusion. Passive ROM exercises (Choice D) are contraindicated in this situation as they can potentially dislodge blood clots and exacerbate the blockage.
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The client has a decreased cardiac output. Which things can increase the client’s cardiac output? Select all that apply.
- A. Decreased heart rate
- B. Increased heart rate
- C. Increased blood volume
- D. Decreased venous return to the heart
Correct Answer: B
Rationale: The correct answer is B: Increased heart rate. Increasing heart rate can help increase cardiac output by pumping more blood with each heartbeat, compensating for the decreased output. Decreasing heart rate (choice A) would further reduce cardiac output. Increased blood volume (choice C) can increase preload and cardiac output, but only if the heart is able to handle the increased volume. Decreased venous return (choice D) would decrease preload and subsequently cardiac output. Therefore, choice B is the most appropriate option to increase cardiac output in this scenario.
The client has a myocardial infarction and going into shock. What might be a medication to give to counteract shock in cases of myocardial infarction?
- A. Atropine
- B. Dopamine
- C. Digoxin
- D. Adenosine
Correct Answer: B
Rationale: The correct answer is B: Dopamine. Dopamine is a medication used in cases of shock, including cardiogenic shock from a myocardial infarction. It helps to increase blood pressure and heart rate, improving cardiac output. Atropine (A) is used for bradycardia, not shock. Digoxin (C) is used for heart failure, not shock. Adenosine (D) is used for certain types of arrhythmias, not shock. Dopamine is the most appropriate choice to counteract shock in cases of myocardial infarction.
What further assessment data would suggest pulmonary embolism?
- A. Decreased urine output and elevated central venous pressure
- B. Increased heart rate and shallow painful respirations
- C. Elevated temperature and decreased skin turgor
- D. Abdominal tenderness and decreased capillary refill
Correct Answer: B
Rationale: The correct answer is B. Increased heart rate and shallow painful respirations are indicative of pulmonary embolism. Increased heart rate is a common response to decreased oxygen levels due to impaired blood flow from a clot in the pulmonary arteries. Shallow, painful respirations can occur due to chest pain and difficulty breathing associated with pulmonary embolism.
Decreased urine output and elevated central venous pressure (Choice A) are more indicative of heart failure or renal issues. Elevated temperature and decreased skin turgor (Choice C) are signs of dehydration or infection. Abdominal tenderness and decreased capillary refill (Choice D) are more suggestive of intra-abdominal issues like appendicitis or bowel obstruction.
When palpating the patient's popliteal pulse, the nurse feels a vibration at the site. How should the nurse record this finding?
- A. Thready, weak pulse
- B. Bruit at the artery site
- C. Bounding pulse volume
- D. Thrill of the popliteal artery
Correct Answer: D
Rationale: The correct answer is D: Thrill of the popliteal artery. A thrill is a vibration felt over a turbulent blood flow, indicating an abnormality like a narrowing or blockage in the artery. When palpating the popliteal pulse, feeling a vibration suggests the presence of a thrill, indicating a potential vascular issue.
A: Thready, weak pulse - This choice does not describe the sensation of vibration felt with a thrill.
B: Bruit at the artery site - A bruit is a whooshing sound heard over an artery due to turbulent blood flow, not a vibration felt during palpation.
C: Bounding pulse volume - This choice describes a strong, forceful pulse, not a vibration felt with a thrill.
In summary, the correct choice, D, is supported by the presence of a vibration indicating a thrill, while the other choices do not align with the specific finding of a vibration felt during palpation of the popliteal pulse.
You refer Joan Timmerman to the physician because you suspect she
- A. Is exhausted
- B. Has infectious mononucleosis
- C. Is emotionally upset
- D. Has a mitral valve stenosis
Correct Answer: D
Rationale: The correct answer is D: Has a mitral valve stenosis. This is because Joan Timmerman presents with symptoms that may indicate a heart condition, such as shortness of breath and fatigue. Mitral valve stenosis is a condition where the heart's mitral valve is narrowed, leading to symptoms like fatigue and shortness of breath. Infectious mononucleosis (B) typically presents with symptoms like sore throat and swollen glands, not specifically related to Joan's symptoms. Emotionally upset (C) may cause fatigue but is less likely to cause shortness of breath. Being exhausted (A) is a general symptom and does not explain the specific symptoms Joan is experiencing.