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The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's blood pressure and apical rate every four (4) hours.
- B. Place the client on intake and output every shift.
- C. Require the client to sleep with the head of the bed elevated.
- D. Teach the patient to perform Buerger Allen exercises daily.
- E. Determine if the client is on an antiplatelet or anticoagulant medication.
- F. Assess the client's neurological status every shift and prn.
Correct Answer: A,E,F
Rationale: Monitoring BP/apical rate (A), anticoagulation status (E), and neurological status (F) address AF-related perfusion risks (clots, stroke). I/O (B) is for fluid status, HOB elevation (C) is for CHF, and Buerger Allen (D) is for PAD.
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The nurse is administering morning medications. Which medication should be administered first?
- A. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet.
- B. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast.
- C. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL.
- D. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.
Correct Answer: B
Rationale: Fasting glucose of 345 mg/dL (B) requires immediate insulin to prevent complications, especially before eating. Digoxin (A), furosemide (C), and ARB (D) are less urgent.
The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?
- A. The client takes prophylactic antibiotics.
- B. The client uses a soft-bristle toothbrush.
- C. The client takes an enteric-coated aspirin daily.
- D. The client alternates rest with activity.
Correct Answer: C
Rationale: Aspirin (C) is not routinely required post-mechanical valve; warfarin is standard. Antibiotics (A), soft toothbrush (B), and rest/activity (D) are appropriate.
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?
- A. The client's BP is 110/70 and pulse is 90.
- B. The client's groin dressing is dry and intact.
- C. The client refuses to keep the leg straight.
- D. The client denies any numbness and tingling.
Correct Answer: C
Rationale: Refusing to keep the leg straight (C) risks bleeding from the femoral site, requiring immediate intervention. Normal BP/pulse (A), intact dressing (B), and no numbness (D) are expected.
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?
- A. Medicate the client with intravenous morphine.
- B. Assess the client's chest dressing and vital signs.
- C. Encourage the client to turn from side to side.
- D. Check the client's telemetry monitor.
Correct Answer: B
Rationale: Chest pain post-CABG may indicate complications. Assessing the dressing and vital signs (B) identifies bleeding or instability. Morphine (A), repositioning (C), and telemetry (D) follow.
The nurse is working with a group of new graduates on a medical-surgical unit. Which should the nurse explain about completing first morning rounds on clients?
- A. Perform a 'down and dirty' assessment on each client soon after receiving report.
- B. Determine which client should have a bath and inform the unlicensed assistive personnel.
- C. Give all the clients a wet wash to wash the face and a toothbrush and toothpaste.
- D. Pick up any paper on the floor and get the room ready for morning physician rounds.
Correct Answer: A
Rationale: A quick 'down and dirty' assessment (A) prioritizes client stability post-report. Bathing (B), hygiene (C), and room prep (D) are secondary to safety.