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The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?
- A. Facial flushing
- B. A complaint of chest heaviness
- C. Heart rate increase of 10 beats/min
- D. Systolic blood pressure increase of 10 mm Hg
Correct Answer: B
Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.
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How can a nurse recognize that a chronic renal failure client's AV shunt is patent?
- A. Absence of a bruit
- B. Presence of a thrill
- C. Blood return from the shunt
- D. Urine output greater than 30 ml/hr
Correct Answer: B
Rationale: The correct assessment to determine the patency of an AV shunt in a chronic renal failure client is the presence of a thrill. A thrill is a vibration or buzzing sensation felt over the shunt site, indicating good blood flow through the shunt. While the presence of a bruit is also important for assessing an AV shunt, a thrill is a more specific indicator of patency. Blood return from the shunt is related to cannulation and not necessarily an indicator of patency. Urine output greater than 30 ml/hr is not directly related to the assessment of an AV shunt's patency.
A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis. Therefore, the correct answer is Respiratory acidosis.
Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.
The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice until the client regains full consciousness?
- A. Supine
- B. Fowlers
- C. Lateral
- D. High Fowlers
Correct Answer: C
Rationale: The correct answer is 'Lateral.' When a client is very drowsy or sedated, placing them in the lateral position is important to maintain an open airway and allow for drainage of secretions. This position helps prevent airway obstruction and aspiration.
Choice A, 'Supine,' is lying flat on the back and may not be ideal for a drowsy client due to the risk of airway compromise.
Choice B, 'Fowlers,' is a semi-sitting position that is beneficial for clients with respiratory distress, but it may not be the best choice for a very drowsy individual.
Choice D, 'High Fowlers,' is a more upright sitting position, which again may not be suitable for a drowsy client as it does not facilitate airway patency as effectively as the lateral position.
The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?
- A. Client with irritable bowel syndrome
- B. Family history of colon polyps
- C. Client with cirrhosis of the liver
- D. History of colon surgery
Correct Answer: B
Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.
When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
- A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
- B. Risk for injury related to active loss of blood from the vascular space
- C. Deficient knowledge related to the client's lack of understanding of the disease process
- D. Impaired skin integrity related to the development of bruises and/or hematoma
Correct Answer: B
Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.