Nokea
The client with Raynaud’s disease is seen in a vascular clinic 6 weeks after nifedipine has been prescribed. The nurse evaluates that the medication has been effective when which findings are noted?
- A. The client’s blood pressure is 110/68 mm Hg.
- B. The client states experiencing less pain and numbness.
- C. The client states that tolerance to heat is improved.
- D. The client walks without intermittent claudication
Correct Answer: B
Rationale: Raynaud’s disease is a disease in which cutaneous arteries in the extremities have recurrent episodes of vasospasm that result in pain and numbness. Nifedipine (Procardia), a calcium-channel blocker, causes vasodilation, thus reducing pain and numbness. BP changes, heat tolerance, and claudication are not primary indicators.
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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.
The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.
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 client with atrial flutter is receiving a continuous infusion of 25,000 units of heparin in 500 mL of 5% dextrose at a rate of 12 mL per hour. The a PTT laboratory result is 92 seconds. According to the heparin infusion protocol, the nurse should administer the heparin infusion at a rate of how many mL per hour?
Correct Answer: 11
Rationale: According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.
The male client states to the nurse, “I’ve recovered after having my new artificial heart valve inserted. Now I want to have a vasectomy so I don’t get my wife pregnant.” What is the nurse’s best response?
- A. “That’s probably not a good idea. You could get an infection and damage the new valve.”
- B. “You seem relieved that surgery was successful and that you can enjoy a normal life again.”
- C. “Be sure to take a nitroglycerin tablet before sexual intercourse to prevent any chest pain.”
- D. “Inform your surgeon about the new valve so antibiotics are prescribed before the procedure.”
Correct Answer: D
Rationale: The surgeon should be aware of the artificial heart valve because antibiotics are required prior to invasive procedures to prevent complications such as endocarditis. The client is also taking an anticoagulant and would be at risk for bleeding. Other responses are incorrect or irrelevant.