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After a client with peripheral vascular disease undergoes a right femoral-popliteal bypass graft, their blood pressure drops from 124/80 to 94/62. What should the nurse assess first?
- A. IV fluid infusion.
- B. Pedal pulses.
- C. Nasal cannula oxygen flow rate.
- D. Capillary refill time.
Correct Answer: B
Rationale: Assessing pedal pulses is crucial in this situation as it helps determine the adequacy of perfusion to the lower extremity following a bypass graft. A decrease in blood pressure postoperatively could indicate decreased perfusion, making the assessment of pedal pulses a priority to ensure proper circulation. Checking IV fluid infusion, nasal cannula oxygen flow rate, or capillary refill time are not the immediate priorities in this scenario and would not provide direct information about perfusion to the affected extremity.
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The client is scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements by the client indicates that more teaching is required?
- A. I will need to limit my intake of protein.
- B. I can skip a dialysis session if I feel tired.
- C. I should increase my intake of potassium-rich foods.
- D. I can eat whatever I want, as long as I take my medications.
Correct Answer: B
Rationale: The correct answer is B. Skipping a dialysis session can lead to serious complications as it disrupts the treatment schedule and can result in the accumulation of waste products and fluid in the body. The client must understand the importance of adhering to the prescribed dialysis regimen to maintain optimal health. Choices A, C, and D are incorrect because limiting protein intake, increasing potassium-rich foods, and taking medications do not pose the same risk as skipping dialysis sessions. These aspects are important in the management of peritoneal dialysis but do not outweigh the critical need for regular dialysis sessions to prevent complications.
A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Obtain supplies to re-dress the burn area.
- B. Verify the client's signed consent form.
- C. Give a prescribed narcotic analgesic agent.
- D. Perform active range-of-motion exercises.
Correct Answer: C
Rationale: Before transporting the client for whirlpool therapy to debride the burned area, the nurse should give a prescribed narcotic analgesic agent. This intervention is essential to manage pain effectively during the debridement process. Obtaining supplies to re-dress the burn area (Choice A) is important but not as immediate as providing pain relief. Verifying the client's signed consent form (Choice B) is necessary for procedures but does not address the client's immediate pain needs. Performing active range-of-motion exercises (Choice D) is not indicated before whirlpool therapy for debridement of burns and may cause further discomfort to the client.
Which of the following is a priority intervention for a patient with heart failure?
- A. Administering diuretics.
- B. Administering oxygen.
- C. Administering beta-blockers.
- D. Administering vasodilators.
Correct Answer: B
Rationale: Administering oxygen is a priority intervention in heart failure because it helps improve oxygenation, alleviate hypoxemia, and reduce the workload on the heart. Oxygen therapy is crucial in managing acute heart failure exacerbations. While diuretics (Choice A) are commonly used in heart failure to reduce fluid overload, administering oxygen takes precedence due to its immediate impact on oxygen delivery. Beta-blockers (Choice C) and vasodilators (Choice D) are also important in heart failure management, but in the acute setting, ensuring adequate oxygen supply is the priority.
What is a priority intervention for a patient experiencing a thyroid storm?
- A. Administering antipyretics.
- B. Cooling the patient.
- C. Administering beta-blockers.
- D. Administering antithyroid medications.
Correct Answer: D
Rationale: During a thyroid storm, the priority intervention is to administer antithyroid medications to reduce thyroid hormone levels quickly. These medications, such as propylthiouracil or methimazole, help inhibit the production of thyroid hormones. Administering antipyretics (choice A) may help reduce fever, but it does not address the underlying cause of the thyroid storm. Cooling the patient (choice B) may provide symptomatic relief but does not address the thyroid hormone dysregulation. Administering beta-blockers (choice C) can help manage symptoms like tachycardia and hypertension, but it does not target the root cause of the thyroid storm.
A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following?
- A. Cardiac output.
- B. Right atrial blood flow.
- C. Left end-diastolic pressure.
- D. Cardiac index.
Correct Answer: C
Rationale: The correct answer is C: Left end-diastolic pressure. Wedging the pulmonary artery catheter allows the nurse to obtain the pulmonary artery wedge pressure, which reflects the left end-diastolic pressure. This pressure is essential in assessing left ventricular function and diagnosing conditions like heart failure. Choices A, B, and D are incorrect because wedging the catheter does not directly provide information about cardiac output, right atrial blood flow, or cardiac index.