Nokea
In preparing the patient for insertion of a pulmonary artery catheter, the nurse
- A. Obtains informed consent
- B. Places the patient in a high Fowler's position
- C. Ensures that the patient has continuous ECG monitoring
- D. Performs an Allen test to confirm adequate ulnar circulation
Correct Answer: C
Rationale: The correct answer is C because continuous ECG monitoring is crucial during pulmonary artery catheter insertion to detect any arrhythmias or changes in cardiac status promptly. This ensures the patient's safety and allows for immediate intervention if needed. Obtaining informed consent (choice A) is important but not specific to this procedure. Placing the patient in a high Fowler's position (choice B) may be necessary for comfort but is not directly related to the insertion process. Performing an Allen test (choice D) is not typically required for pulmonary artery catheter insertion.
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A nurse is caring for a child with a cyanotic heart defect. Which signs should the nurse expect to observe?
- A. Cyanosis, hypertension, clubbing, and lethargy.
- B. Cyanosis, hypotension, crouching, and lethargy.
- C. Cyanosis, irritability, clubbing, and crouching.
- D. Cyanosis, confusiion, clonus, and crouching.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: In a child with a cyanotic heart defect, the deoxygenated blood mixes with oxygenated blood, resulting in cyanosis (bluish skin). Hypertension can occur due to increased workload on the heart. Clubbing indicates chronic hypoxia. Lethargy is a common symptom of decreased oxygen levels.
Summary of Other Choices:
B: Hypotension is less likely due to increased workload on the heart. Crouching may be seen in some cases but is not a typical sign. Lethargy is common.
C: Irritability is less common compared to lethargy. Clubbing is a common sign. Crouching may be seen but is not specific.
D: Confusion and clonus are not typical signs of cyanotic heart defects. Crouching may occur, but it is not specific.
Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes?
- A. Inform the patient about a diet containing no saturated fat and minimal salt.
- B. Help the patient modify favorite high-fat recipes by using monounsaturated oils.
- C. Emphasize the increased risk for heart problems unless the patient makes the dietary changes.
- D. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.
Correct Answer: B
Rationale: The correct answer is B: Help the patient modify favorite high-fat recipes by using monounsaturated oils. This answer is correct because it focuses on practical and sustainable dietary changes by modifying existing favorite recipes to make them healthier. By using monounsaturated oils instead of saturated fats, the patient can still enjoy their favorite foods while making positive changes to their diet.
Option A is too restrictive in eliminating all saturated fats and may not be sustainable for the patient in the long term. Option C focuses on fear-based motivation, which is not always effective in promoting behavior change. Option D gives a list of foods without addressing how the patient can make practical changes in their meal preparation. Overall, option B is the most effective as it encourages gradual and realistic changes in the patient's diet.
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.
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 vasopressor that helps increase blood pressure and cardiac output, which can counteract shock in cases of myocardial infarction. It improves blood flow to vital organs. Atropine (A) is used for bradycardia, not shock. Digoxin (C) and Adenosine (D) are not indicated for treating shock in myocardial infarction as they have different mechanisms of action.
The client has been prescribed gemfibrozil. The nurse explains the function of the drug as what?
- A. It reduces cholesterol levels
- B. It destabilizes cholesterol plaques.
- C. It prevents a recurrent MI.
- D. It lowers triglyceride levels.
Correct Answer: D
Rationale: The correct answer is D: It lowers triglyceride levels. Gemfibrozil is a fibric acid derivative that primarily works by decreasing triglyceride levels. It does not directly reduce cholesterol levels (A), destabilize cholesterol plaques (B), or prevent a recurrent MI (C). Lowering triglyceride levels helps reduce the risk of cardiovascular events such as heart attacks and strokes. Therefore, the explanation that gemfibrozil lowers triglyceride levels aligns with its mechanism of action and therapeutic effects.