Nokea
The client with chronic HF tells the nurse, “I get so scared at night; I wake up and feel like I can hardly breathe.” Which is the nurse’s best response?
- A. “You are experiencing a condition called paroxysmal nocturnal dyspnea.”
- B. “Tell me if these are related to your having vivid nightmares?”
- C. “You may be experiencing this from an increased sodium intake in your diet.”
- D. “Tell me more about how often this is occurring and how you deal with it.”
Correct Answer: D
Rationale: When the client with HF expresses concerns about breathing, the nurse should further explore the comment with an open-ended statement because more information may be gained about how the client could diminish or handle the occurrence. Naming the condition (A), assuming nightmares (B), or sodium intake (C) does not facilitate further assessment.
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The nurse completes teaching the client with a newly inserted ICD. Which statement, if made by the client, indicates that further teaching is needed?
- A. “The ICD will give me a shock if my heart goes into ventricular fibrillation again.”
- B. “When I feel the first shock, my family should start CPR immediately and call 911.”
- C. “I’m afraid of my first shock; my friend stated his shock felt like a blow to the chest.”
- D. “Some states do not allow driving until there is a 6-month discharge-free period.”
Correct Answer: B
Rationale: CPR should only be initiated if the client is unresponsive and pulseless. EMS should be called if there is more than one shock. This statement indicates further teaching is needed. The other statements are correct regarding ICD function, shock sensation, and driving restrictions.
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 increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity?
- A. Pulse rate increased by 15 beats per minute during activity
- B. BP 130/86 mm Hg before activity; 108/66 mm Hg during activity
- C. Increased dyspnea and diaphoresis relieved when sitting in a chair
- D. A mean arterial pressure (MAP) of 80 following activity
Correct Answer: B
Rationale: A drop in BP of 20 mm Hg from the baseline indicates that the client’s heart is unable to adapt to the increased energy and oxygen demands of the activity. The client is not tolerating the activity; the length of time or the intensity should be reduced. A modest pulse increase, relieved symptoms, and normal MAP are less concerning.
The nurse is preparing the client for a thoracic aneurysm repair. Which assessment findings should prompt the nurse to conclude that a rupture may have occurred? Select all that apply.
- A. Oliguria
- B. Dyspnea
- C. Hypotension
- D. Abdominal distention
- E. Severe chest pain radiating to the back
Correct Answer: A;B;C;E
Rationale: A rupture may cause: A) Oliguria from decreased renal perfusion; B) Dyspnea from hemorrhage pressure; C) Hypotension from blood loss; E) Severe chest pain radiating to the back. Abdominal distention is associated with abdominal, not thoracic, aneurysms.
The RN and the NA are caring for four clients, all in need of immediate attention. The NA is a senior nursing student who has been giving medications and performing procedures on clients as a student nurse. The unit charge nurse determines that care is appropriate when the RN working with the NA delegates which actions? Select all that apply.
- A. Give acetaminophen to the client with a high temperature.
- B. Take vital signs on the client newly admitted with heart failure.
- C. Discuss the pacemaker discharge handout so this client can go home.
- D. Change this client’s chest tube dressing; it got wet with drinking water.
- E. Provide a sponge bath for the client with the increased temperature.
Correct Answer: B;E
Rationale: The RN delegates appropriately when having the NA: B) Take vital signs; E) Perform a sponge bath. Administering medication (A), teaching (C), and changing chest tube dressings (D) are outside the NA’s scope of practice.