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The client newly diagnosed with HF has an ejection fraction of 20%. Which criteria should the nurse use to evaluate the client’s readiness for discharge to home? Select all that apply.
- A. There is a scale in the client’s home
- B. The client started ambulating 24 hours ago
- C. The client is receiving furosemide IV 20 mg bid
- D. A smoking cessation consult is scheduled for 2 days after discharge
- E. A home-care nurse is scheduled to see the client 3 days after discharge
Correct Answer: A;B;E
Rationale: The nurse should evaluate: A) A scale to monitor fluid status; B) Ambulation to confirm functional capability; E) Home-care nurse visit within 3 days for support. IV furosemide (C) should be oral before discharge, and smoking cessation (D) should start before discharge.
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The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse?
- A. Jugular vein distention, muffled heart sounds, and BP 84/48
- B. Temperature 96.4°F (35.8°C), heart rate 58 bpm, and shivering
- C. Increased heart rate, audible S1 and S2, and pain rated at a 5
- D. Central venous pressure (CVP) 4 mm Hg, urine output 30 mL/hr, and sinus rhythm with a few PVCs
Correct Answer: A
Rationale: The nurse should be most concerned with JVD, muffled heart sounds, and hypotension (Beck’s Triad). This is a life-threatening event suggesting cardiac tamponade. Other findings are expected post-surgery or less critical.
The cardiac monitor of the client diagnosed with Prinzmetal’s angina shows a prolonged PR interval of 0.32 seconds. Which prescribed medication should the nurse question administering to the client?
- A. Isosorbide mononitrate 20 mg oral daily
- B. Amlodipine 10 mg oral daily
- C. Nitroglycerin 0.4 mg sublingual prn
- D. Atenolol 50 mg oral daily
Correct Answer: D
Rationale: Atenolol (Tenormin), a beta blocker, blocks stimulation of beta1 (myocardial)-adrenergic receptors, causing a reduction in BP and HR. A side effect of the medication is a prolongation of the PR interval (normal PR interval is 0.12 to 0.20 second). Continued use of the drug can result in heart block. The nurse should question administering atenolol. Other medications do not prolong the PR interval.
The nurse is caring for the client with varicose veins. Which action should indicate to the nurse that an expected outcome has been met?
- A. States will walk daily to promote venous return
- B. Reports decreased need for compression stockings
- C. States can finally stand for prolonged periods of time
- D. Chooses diet high in potassium and low in magnesium
Correct Answer: A
Rationale: Walking promotes venous return; verbalizing intent to increase activity indicates an expected outcome has been met for the client with varicose veins. Decreased stocking use, prolonged standing, and specific diets are not beneficial.
The nurse fails to obtain scheduled VS at 0200 hours for the client who had cardiac surgery 2 days ago. After assessing the client at 0600 hours, the nurse documents the 0600 HR for both the 0200 and 0600 VS. Which conclusion should a supervising charge nurse make about the nurse’s actions? Select all that apply.
- A. The nurse’s action was acceptable; neither complications nor harmful effects occurred.
- B. The nurse’s action is concerning legally; the nurse fraudulently falsified documentation.
- C. The nurse’s action demonstrates beneficence; the nurse decided what was best for the client.
- D. The nurse’s action is extremely concerning; it involves the ethical issue of veracity.
- E. The nurse’s action demonstrates distributive justice; other clients’ needs were priority.
Correct Answer: B;D
Rationale: The charge nurse should conclude: B) Falsifying documentation is a legal concern; D) The action involves the ethical issue of veracity (truthfulness). The action is not acceptable (A), does not show beneficence (C), and there’s no evidence of distributive justice (E).
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.