Nokea
The client reports pain, tenderness, and redness along the path of an arm vein where potassium chloride (KCL) is infusing IV. Which interventions should the nurse include when responding to this situation?
- A. Call the HCP immediately; administer diphenhydramine.
- B. Stop the infusion; apply a warm, moist compress to the affected area.
- C. Slow the infusion rate; teach that IV potassium is usually uncomfortable.
- D. Discontinue the potassium chloride; document the client’s allergic reaction.
Correct Answer: B
Rationale: The nurse should immediately stop the KCL infusion; signs and symptoms indicate vein inflammation, or phlebitis. After discontinuing the IV catheter, the nurse should apply a warm, moist compress and restart the IV at another location, giving the infusion at a slower rate. Other options misinterpret the situation as an allergy or fail to address the phlebitis.
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The nurse is caring for the client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse?
- A. Copious chest tube output; now none for 1 hour
- B. Current core temperature of 101.3°F (38.5°C)
- C. pH 7.32; Paco2 48; HCO3 28; Pao2 80
- D. Urine output 160 mL in the last 4 hours
Correct Answer: A
Rationale: A copiously draining chest tube that is no longer draining indicates an obstruction. It should be most concerning because there is an increased risk for cardiac tamponade or pleural effusion. Slight fever, compensated respiratory acidosis, and adequate urine output are less urgent.
The client is hospitalized for HF secondary to alcohol-induced cardiomyopathy. The client is started on milrinone and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medications, overall care, and the need for energy conservation. Which nursing interpretation of the client’s behavior is most appropriate?
- A. The client is denying the illness.
- B. The client is experiencing fear.
- C. Alcohol abuse is affecting behavior.
- D. A reaction to milrinone is affecting behavior.
Correct Answer: B
Rationale: A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause the client to verbally attack health team members to maintain control. There’s no evidence of denial, alcohol’s neurological effects, or milrinone causing behavior changes.
Two days ago the client underwent femoral popliteal artery bypass graft surgery. What should be the nurse’s priority at this time?
- A. Monitor intake and output every four hours.
- B. Report any edema that develops in the operative leg.
- C. Place the client in a 60-degree sitting position when in bed.
- D. Check pedal and post tibial pulses bilaterally every 4 hours.
Correct Answer: D
Rationale: The priority nursing action should be to monitor the pulses in the feet to detect graft occlusion. Checking both sides allows for comparison. I&O, edema, and positioning are secondary.
While the nurse is assessing the client, the client says, “I had an endovascular repair of an AAA that was found 1 month ago during a routine physical.” The nurse’s assessment of the client should be based on understanding that this procedure involves which action?
- A. Excision to remove the aneurysm and place a graft percutaneously
- B. An angioplasty with placement of a stent around the outside of the aorta
- C. Placement of a filter within the aneurysm to block clots from becoming emboli
- D. Placement of a stent graft inside the aorta that excludes the aneurysm from circulation
Correct Answer: D
Rationale: The endovascular repair consists of placement of the endovascular stent graft inside the aorta, extending above and below the aneurysmal area to seal it off from the circulation. Excision, external stents, and filters are not involved.
The nurse, caring for the client following an anterior MI, obtains the assessment findings illustrated. Based on these findings, the nurse should immediately notify the HCP and plan which intervention?
- A. Administer an IV fluid bolus of 0.9% NaCl; the client is in right heart failure.
- B. Initiate an IV infusion of dopamine; the client is in cardiogenic shock.
- C. Prepare the client for pericardiocentesis; the findings support cardiac tamponade.
- D. Notify radiology for a STAT chest x-ray to rule out pulmonary embolism (PE).
Correct Answer: B
Rationale: Complications of an anterior MI are left ventricular failure, reduced cardiac output, and cardiogenic shock. The client’s MAP is 55, with hypotension, tachycardia, tachypnea, and low urine output, indicating cardiogenic shock. Dopamine is administered to increase cardiac output. Right HF, tamponade, and PE are less likely based on the findings.