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Acetylsalicylic acid (aspirin) is prescribed for a client diagnosed with coronary artery disease before a percutaneous transluminal coronary angioplasty (PTCA). The nurse administers the medication understanding that it is prescribed for what purpose?
- A. Relieve postprocedure pain.
- B. Prevent thrombus formation.
- C. Prevent postprocedure hyperthermia.
- D. Prevent inflammation of the puncture site.
Correct Answer: B
Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure because the aspirin inhibits platelet aggregation.
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Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?
- A. pH 7.25, PaCO2 55, HCO3 24
- B. pH 7.30, PaCO2 38, HCO3 20
- C. pH 7.48, PaCO2 30, HCO3 23
- D. pH 7.49, PaCO2 38, HCO3 30
Correct Answer: D
Rationale: Continuous nasogastric suction can lead to metabolic alkalosis due to the loss of gastric acid (hydrochloric acid), which reduces hydrogen ions and increases bicarbonate levels. The ABG values in option 4 (pH 7.49, PaCO2 38, HCO3 30) indicate metabolic alkalosis, with an elevated pH and high bicarbonate level, consistent with this condition. Option 1 suggests respiratory acidosis, option 2 suggests metabolic acidosis, and option 3 suggests respiratory alkalosis, none of which align with the expected acid-base imbalance from nasogastric suction.
During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take?
- A. Ask the client to walk and observe the gait.
- B. Lightly massage the calf area to relieve the pain.
- C. Check the calf area for temperature, color, and size.
- D. Administer PRN morphine sulfate as prescribed for postoperative pain.
Correct Answer: C
Rationale: The nurse monitors the postoperative client for complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options 1 and 2 could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client is not the appropriate nursing action since further assessment needs to take place.
A client states, 'I'm sure I have restless leg syndrome.' The nurse determines that the client is in need of further teaching on the condition when the client identifies the presence of which characteristics? Select all that apply.
- A. A heavy feeling in the legs
- B. Burning sensations in the limbs
- C. Symptom relief when lying down
- D. Decreased ability to move the legs
- E. Symptoms that are worse in the morning
- F. Feeling the need to move the limbs repeatedly
Correct Answer: A,C,D,E
Rationale: Restless leg syndrome is characterized by leg paresthesia associated with an irresistible urge to move. The client complains of intense burning or 'crawling-type' sensations in the limbs and subsequently feels the need to move the limbs repeatedly to relieve the symptoms. The symptoms are worse in the evening and night when the client is still.
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.
A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation?
- A. Radiation is the treatment of choice.
- B. The most significant symptoms are headache and vomiting.
- C. Head shaving is not required before removal of the brain tumor.
- D. Surgery is not normally performed because of the increased risk of functional deficits.
Correct Answer: B
Rationale: The classic symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor. Before surgery, the child's head will be shaved, although every effort is made to shave only as much hair as is necessary. Radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain, particularly in very young children.