Nokea
The client returns to a hospital unit after undergoing placement of a vena cava filter. Which intervention should the nurse implement?
- A. Restart heparin therapy as soon as possible.
- B. Reinforce the abdominal incision dressing.
- C. Inspect the groin insertion site for bleeding.
- D. Increase fluids to promote excretion of the dye.
Correct Answer: C
Rationale: The procedure for placement of a vena cava filter is done percutaneously, usually through the subclavian or femoral vein approach. The nurse should check the groin insertion site for bleeding. Heparin is unnecessary, there’s no abdominal incision, and dye is not used.
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The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication?
- A. Pulmonary embolism
- B. Cardiac tamponade
- C. Cardiomyopathy
- D. Cardiogenic shock
Correct Answer: D
Rationale: The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism and tamponade could cause shock but are less likely post-MI, and cardiomyopathy is not an acute complication.
The client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. Which statements, if made by the client, support the home-care nurse’s conclusion that the client is making lifestyle changes to decrease the likelihood of restenosis and arterial occlusion? Select all that apply.
- A. “I have been doing exercises twice daily.”
- B. “All nicotine products were thrown away.”
- C. “These support hose keep my legs warm.”
- D. “I see a podiatrist tomorrow for foot care.”
- E. “I'm following a low-saturated-fat diet”
- F. “I now take rosuvastatin calcium.”
Correct Answer: A;B;E;F
Rationale: The client’s statements indicating lifestyle changes are: A) Exercising to promote collateral circulation; B) Discontinuing nicotine to deter atherosclerosis; E) Following a low-saturated-fat diet to reduce atherosclerosis; F) Taking rosuvastatin to lower cholesterol. Support hose and podiatry care do not directly prevent restenosis.
The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?
- A. A low-calorie regular diet
- B. A statin antilipidemic medication
- C. A thiazide diuretic medication
- D. Low-salt, low-saturated-fat, low-potassium diet
Correct Answer: B
Rationale: A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will lower the LDL cholesterol and triglycerides and increase the HDL cholesterol. A low-calorie diet is unnecessary with a normal BMI, a diuretic is not indicated for slightly elevated BP, and a low-potassium diet is not needed with normal potassium levels.
The nurse is to administer 40 mg of furosemide to the client in HF. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, how many milliliters should the nurse administer to the client?
Correct Answer: 0.4
Rationale: Use a proportion formula: 100 mg: 1 mL :: 40 mg: X mL; 100X = 40; X = 0.4. The nurse should administer 0.4 mL of furosemide.
The nurse is caring for the client immediately following insertion of a permanent pacemaker via the right subclavian vein approach. Which intervention should the nurse include in the client’s plan of care to best prevent pacemaker lead dislodgement?
- A. Inspect the incision for approximation and bleeding
- B. Prevent the right arm from going above shoulder level
- C. Assist the client with using a walker when out of bed
- D. Request a STAT chest x-ray upon return from the procedure
Correct Answer: B
Rationale: Limiting arm and shoulder activity initially and up to 24 hours after the pacing leads are implanted helps prevent lead dislodgement. Often an arm sling is used as a reminder to the client to limit arm activity. Inspecting the incision, using a walker, and chest x-ray do not directly prevent lead dislodgement.