Nokea
After receiving normal CXR results of the client who had cardiac surgery, the nurse proceeds to remove the client’s chest tubes as prescribed. Which intervention should be the nurse’s priority?
- A. Auscultate the client’s lung sounds
- B. Administer 2 mg morphine sulfate intravenously
- C. Turn off the suction to the chest drainage system
- D. Prepare the dressing supplies at the client’s bedside
Correct Answer: B
Rationale: Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first to manage pain during chest tube removal. Auscultation, turning off suction, and preparing supplies are secondary.
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The client who had a synthetic valve replacement a year ago is hospitalized with unstable angina. IV heparin and nitroglycerin infusions were started, but then nitroglycerin was discontinued after the client’s pain resolved. The HCP prescribes to start oral warfarin 5 mg at 1900 hours. Which is the nurse’s best action?
- A. Administer the warfarin as prescribed
- B. Call the HCP to question starting warfarin
- C. Discontinue heparin and then give warfarin
- D. Hold warfarin until heparin is discontinued
Correct Answer: A
Rationale: Both heparin and warfarin (Coumadin) are anticoagulants, but their actions are different. Oral warfarin requires 3 to 5 days to reach effective levels. It is usually begun while the client is still on heparin. Warfarin should be given as prescribed for a synthetic valve to prevent thromboembolism.
The nurse is taking the BP on multiple clients. Which reading warrants the nurse notifying the HCP because the client’s MAP is abnormal?
- A. 94/60 mm Hg
- B. 98/36 mm Hg
- C. 110/50 mm Hg
- D. 140/78 mm Hg
Correct Answer: B
Rationale: The Mean Arterial Pressure (MAP) is calculated as (SBP + 2*DBP)/3. For 98/36 mm Hg: (98 + 2*36)/3 = (98 + 72)/3 = 170/3 ≈ 56.67 mm Hg, which is abnormally low (normal MAP is 70-100 mm Hg), indicating potential hypoperfusion. Other readings yield: A: (94 + 2*60)/3 ≈ 71.33 mm Hg, C: (110 + 2*50)/3 ≈ 70 mm Hg, D: (140 + 2*78)/3 ≈ 98.67 mm Hg, all within or closer to normal range.
The client asks the nurse what can be done to alleviate the pain and discomfort associated with varicose veins. Which response by the nurse is best?
- A. “Dangle your legs off the side of the bed as often as possible to alleviate the pain.”
- B. “There isn’t much you can do about the pain except have surgery to remove the veins.”
- C. “You should wear long pants to hide bulging veins; this will help your self-confidence.”
- D. “Wear elastic stockings to promote venous return; these will also help reduce discomfort.”
Correct Answer: D
Rationale: The best response to alleviate pain and discomfort associated with varicose veins includes application of elastic stockings and elevating the lower extremities. These promote venous return. Dangling legs, surgery as the only option, or wearing long pants do not address the pain effectively.
The nurse assesses the client at a vascular clinic after being treated with pentoxifylline for 6 weeks. The nurse determines that pentoxifylline has been effective when noting that the client has which finding?
- A. A decrease in lower-extremity edema
- B. No symptoms of withdrawal after quitting smoking
- C. A venous ulcer on the ankle that has decreased in size
- D. The ability to walk a longer distance without claudication
Correct Answer: D
Rationale: Pentoxifylline (Trental) is thought to act by improving capillary blood flow and is prescribed to decrease intermittent claudication. Effects are usually seen in 2 to 4 weeks. Edema, smoking withdrawal, and venous ulcers are not treated by pentoxifylline.
The client calls for the nurse after experiencing sharp chest pains that radiate to the left shoulder. All of the following interventions were prescribed on admission for treating chest pain. Which intervention should the nurse implement first?
- A. STAT 12-lead electrocardiogram (ECG)
- B. Oxygen 4 liters by nasal cannula
- C. Nitroglycerin 0.4 mg sublingual
- D. Morphine sulfate 2-4 mg IV prn
Correct Answer: B
Rationale: Oxygen should be available in the room and should be initiated first to enhance oxygen flow to the myocardium. ECG, nitroglycerin, and morphine are important but secondary to improving oxygenation in acute chest pain.