Nokea
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.
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The client with class II HF according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes which component?
- A. Diuretics
- B. A low-sodium diet
- C. Home oxygen therapy
- D. Angiotensin-converting enzyme (ACE) inhibitors
Correct Answer: C
Rationale: In class II HF, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain, but symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics, low-sodium diet, and ACE inhibitors are standard treatments.
The nurse is admitting the client experiencing dyspnea from HF and COPD with high CO2 levels. Which interventions should the nurse plan? Select all that apply.
- A. Apply oxygen 6 liters per nasal cannula.
- B. Elevate the head of the bed 30 to 40 degrees.
- C. Weigh daily in the am. after the client voids.
- D. Teach client pursed-lip breathing techniques.
- E. Turn and reposition the client every 1 to 2 hours.
Correct Answer: B;C;D
Rationale: The nurse should plan: B) Elevating the head of the bed to promote lung expansion; C) Daily weights to assess fluid retention; D) Pursed-lip breathing to conserve energy and slow breathing. High oxygen flow (A) may depress hypoxic drive in COPD, and repositioning (E) is less specific to dyspnea management.
The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?
- A. Recheck the pulse in 5 minutes.
- B. Reposition the affected leg.
- C. Notify the surgeon of the finding.
- D. Document that the pulse is absent.
Correct Answer: C
Rationale: The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse could signify graft occlusion or embolization. Rechecking, repositioning, or documenting delays critical intervention.
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.