Nokea
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.
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The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication?
- A. Pulmonary embolism
- B. Cardiac tamponade
- C. Cardiomyopathy
- D. Cardiogenic shock
Correct Answer: D
Rationale: The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism and tamponade could cause shock but are less likely post-MI, and cardiomyopathy is not an acute complication.
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.
The client, who is a 15-pack-year cigarette smoker, has painful fingers and toes and is diagnosed with Buerger’s disease (thromboangiitis obliterans). Which measure to prevent disease progression should be the nurse’s initial focus when teaching the client?
- A. Avoid exposure to cold temperatures
- B. Maintain meticulous hygiene
- C. Abstain from all tobacco products
- D. Follow a low-saturated-fat diet
Correct Answer: C
Rationale: Buerger’s disease is an uncommon vascular occlusive disease that affects the medial and small arteries and veins, initially in the distal limbs. It is strongly associated with tobacco use, which causes vasoconstriction. The most important action to communicate to the client is that he must abstain from tobacco in all forms to prevent progression of the disease.
The client is scheduled for a coronary artery bypass graft in one week. Which instructions should the nurse provide to the client? Select all that apply.
- A. Stop taking aspirin now and any products containing aspirin.
- B. Do perform aerobic exercises 30 minutes daily before surgery.
- C. Use the prescribed antimicrobial soap before hospital arrival.
- D. Shave your chest and legs and then shower to remove the hair.
- E. Resume normal activities when discharged from the hospital.
Correct Answer: A;C
Rationale: The nurse should instruct: A) Stop aspirin to reduce bleeding risk; C) Use antimicrobial soap to decrease infection risk. Aerobic exercises (B) may be too strenuous, shaving (D) is done just before surgery, and normal activities (E) are restricted post-surgery.
The client returns to a hospital unit after undergoing placement of a vena cava filter. Which intervention should the nurse implement?
- A. Restart heparin therapy as soon as possible.
- B. Reinforce the abdominal incision dressing.
- C. Inspect the groin insertion site for bleeding.
- D. Increase fluids to promote excretion of the dye.
Correct Answer: C
Rationale: The procedure for placement of a vena cava filter is done percutaneously, usually through the subclavian or femoral vein approach. The nurse should check the groin insertion site for bleeding. Heparin is unnecessary, there’s no abdominal incision, and dye is not used.