Nokea
The nurse fails to obtain scheduled VS at 0200 hours for the client who had cardiac surgery 2 days ago. After assessing the client at 0600 hours, the nurse documents the 0600 HR for both the 0200 and 0600 VS. Which conclusion should a supervising charge nurse make about the nurse’s actions? Select all that apply.
- A. The nurse’s action was acceptable; neither complications nor harmful effects occurred.
- B. The nurse’s action is concerning legally; the nurse fraudulently falsified documentation.
- C. The nurse’s action demonstrates beneficence; the nurse decided what was best for the client.
- D. The nurse’s action is extremely concerning; it involves the ethical issue of veracity.
- E. The nurse’s action demonstrates distributive justice; other clients’ needs were priority.
Correct Answer: B;D
Rationale: The charge nurse should conclude: B) Falsifying documentation is a legal concern; D) The action involves the ethical issue of veracity (truthfulness). The action is not acceptable (A), does not show beneficence (C), and there’s no evidence of distributive justice (E).
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After receiving normal CXR results of the client who had cardiac surgery, the nurse proceeds to remove the client’s chest tubes as prescribed. Which intervention should be the nurse’s priority?
- A. Auscultate the client’s lung sounds
- B. Administer 2 mg morphine sulfate intravenously
- C. Turn off the suction to the chest drainage system
- D. Prepare the dressing supplies at the client’s bedside
Correct Answer: B
Rationale: Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first to manage pain during chest tube removal. Auscultation, turning off suction, and preparing supplies are secondary.
The client with a left anterior descending (LAD) 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitroglycerin. Which ECG finding is most concerning and should alert the nurse to immediately notify the HCP?
- A. Q waves
- B. Flipped T waves
- C. Peaked T waves
- D. ST segment elevation
Correct Answer: D
Rationale: The nurse should be most concerned about ST elevation because it indicates an evolving MI. Q waves suggest a previous MI, flipped T waves indicate ischemia, and peaked T waves may indicate hyperkalemia, but ST elevation is the most acute and critical finding.
The nurse is assessing the client with an 8-centimeter AAA. Which finding should the nurse expect?
- A. Report of persistent nagging pain in the upper anterior chest
- B. Systolic bruit palpated over the upper abdomen
- C. Edema of the face and neck with distended neck veins
- D. A pulsating mass in the mid to upper abdomen
Correct Answer: D
Rationale: Throbbing or pulsating in the abdomen is the sign most indicative of an AAA. Chest pain, edema, and neck vein distention are associated with thoracic aneurysms, and a bruit is auscultated, not palpated.
The clinic nurse is teaching the client at risk for developing arteriosclerosis. The nurse should teach the client that the dietary therapy to decrease homo-cysteine levels includes eating foods rich in which nutrient?
- A. Monosaturated fats
- B. B complex Vitamins
- C. Vitamin C
- D. Calcium
Correct Answer: B
Rationale: Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich in B-complex vitamins, especially folic acid, have been found to lower serum homocysteine levels. Monosaturated fats, Vitamin C, and Calcium do not have a direct effect on homocysteine levels.
The client asks the nurse what can be done to alleviate the pain and discomfort associated with varicose veins. Which response by the nurse is best?
- A. “Dangle your legs off the side of the bed as often as possible to alleviate the pain.”
- B. “There isn’t much you can do about the pain except have surgery to remove the veins.”
- C. “You should wear long pants to hide bulging veins; this will help your self-confidence.”
- D. “Wear elastic stockings to promote venous return; these will also help reduce discomfort.”
Correct Answer: D
Rationale: The best response to alleviate pain and discomfort associated with varicose veins includes application of elastic stockings and elevating the lower extremities. These promote venous return. Dangling legs, surgery as the only option, or wearing long pants do not address the pain effectively.