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The client, who is a 15-pack-year cigarette smoker, has painful fingers and toes and is diagnosed with Buerger’s disease (thromboangiitis obliterans). Which measure to prevent disease progression should be the nurse’s initial focus when teaching the client?
- A. Avoid exposure to cold temperatures
- B. Maintain meticulous hygiene
- C. Abstain from all tobacco products
- D. Follow a low-saturated-fat diet
Correct Answer: C
Rationale: Buerger’s disease is an uncommon vascular occlusive disease that affects the medial and small arteries and veins, initially in the distal limbs. It is strongly associated with tobacco use, which causes vasoconstriction. The most important action to communicate to the client is that he must abstain from tobacco in all forms to prevent progression of the disease.
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The nurse obtains the client’s cardiac monitor print-out illustrated. What should be the nurse’s interpretation of the client’s rhythm?
- A. Atrial flutter
- B. Atrial fibrillation
- C. Sinus bradycardia
- D. Sinus rhythm with premature atrial contractions (PACs)
Correct Answer: C
Rationale: Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 bpm and one discernable P wave prior to each QRS. Atrial flutter and fibrillation have multiple or nondiscernible P waves, and PACs include premature atrial beats, which are not described in the image.
The nurse is completing a home visit with the client who has an arterial ulcer secondary to PAD. Which statement by the client warrants immediate intervention by the nurse?
- A. “I soak my feet daily to warm them and keep them soft.”
- B. “I cover the sore on my foot with sterile gauze to protect it.”
- C. “I use a pillow under my calves to keep my heels off the bed.”
- D. “I lubricate my feet daily to prevent them from cracking.”
Correct Answer: A
Rationale: The nurse should immediately intervene when the client states soaking feet daily; foot soaks when the client has PAD can cause maceration (tissue breakdown). Covering with gauze, using a pillow, and lubricating are appropriate actions.
While preparing the client for a computed tomography angiography (CTA), the client asks the nurse what the test Will entail. Which should be the nurse’s correct response?
- A. “A CTA uses magnetic fields to visualize the major vessels Within your body.”
- B. “A CTA is an invasive procedure that requires a small incision into an artery.”
- C. “A CTA is a quick procedure that requires anesthesia for about 20 minutes.”
- D. “A CTA is a scan that includes a contrast dye injection to visualize your arteries.”
Correct Answer: D
Rationale: The correct response should explain CTA. CTA is a noninvasive spiral CT scan using contrast dye to yield a 3-dimensional image of the arteries. It does not use magnetic fields (A), require incisions (B), or anesthesia (C).
The nurse who is beginning a shift on a cardiac step-down unit receives shift report for four clients. Prioritize the order, from most urgent to least urgent, that the nurse should assess the clients.
- A. The 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes
- B. The 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a “Do Not Resuscitate” order; whose family has just arrived
- C. The 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new-onset atrial fibrillation with rapid ventricular response
- D. The 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C)
Correct Answer: C;D;A;B
Rationale: The nurse should assess: C) Atrial fibrillation with rapid ventricular response is life-threatening; D) Elevated temperature and vital signs suggest infection; A) Heparin adjustment is pending but less urgent; B) End-stage cardiomyopathy with DNR is stable and family support is secondary.
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.