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The nurse has entered a patients room and found the patient unresponsive and not breathing. What is the nurses next appropriate action?
- A. Palpate the patients carotid pulse
- B. Illuminate the patients call light
- C. Begin performing chest compressions
- D. Activate the Emergency Response System (ERS)
Correct Answer: D
Rationale: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
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Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
- A. Monitor liver function studies
- B. Monitor for hypotension
- C. Assess the patients vitamin D intake
- D. Assess the patient for hyperkalemia
Correct Answer: B
Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
Diagnostic imaging reveals that the quantity of fluid in a clients pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication?
- A. Pulmonary edema
- B. Pericardiocentesis
- C. Cardiac tamponade
- D. Pericarditis
Correct Answer: C
Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiological process.
A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurses nutritional teaching plan has been effective?
- A. I will have a ham and cheese sandwich for lunch
- B. I will have a baked potato with broiled chicken for dinner
- C. I will have a tossed salad with cheese and croutons for lunch
- D. I will have chicken noodle soup with crackers and an apple for lunch
Correct Answer: B
Rationale: The patients choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care?
- A. Improve functional status
- B. Prevent endocarditis
- C. Extend survival
- D. Limit physical activity
- E. Relieve patient symptoms
Correct Answer: A,C,E
Rationale: The overall goals of management of HF are to relieve the patients symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.
The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?
- A. Check for a carotid pulse
- B. Apply supplemental oxygen
- C. Give two full breaths
- D. Gently shake and shout, Are you OK?
Correct Answer: D
Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.