Nokea
The nurse is applying electrocardiogram (ECG) electrodes to a diaphoretic client. Which intervention should the nurse take to keep the electrodes securely in place?
- A. Secure the electrodes with adhesive tape.
- B. Place clear, transparent dressings over the electrodes.
- C. Apply lanolin to the skin before applying the electrodes.
- D. Cleanse the skin with alcohol before applying the electrodes.
Correct Answer: D
Rationale: Alcohol defats the skin and helps the electrodes adhere to the skin. Placing adhesive tape or a clear dressing over the electrodes will not help the adhesive gel of the actual electrode make better contact with the diaphoretic skin. Lanolin or any other lotion makes the skin slippery and prevents good initial adherence.
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The nurse reviews the client's most recent blood gas results that include a pH of 7.43, PCO2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid-base imbalance is present?
- A. Compensated metabolic acidosis
- B. Compensated respiratory alkalosis
- C. Uncompensated respiratory acidosis
- D. Uncompensated metabolic alkalosis
Correct Answer: B
Rationale: The normal pH is 7.35 to 7.45, the normal PCO2 is 35 to 45 mm Hg, and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, the pH and the PCO2 move in opposite directions; that is, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).
A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply.
- A. Fever
- B. Leukopenia
- C. Bradycardia
- D. Pericardial friction rub
- E. Decreased erythrocyte sedimentation rate
- F. Precordial chest pain that intensifies by the supine position
Correct Answer: A,D,F
Rationale: In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common.
A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention should the nurse plan to implement to safely administer the medication?
- A. Infuse over 1 hour and allow the client to ambulate.
- B. Infuse over 1 hour with the client in a supine position.
- C. Administer over 30 minutes with the client in a reclining position.
- D. Administer by IV push over 15 minutes with the client in a supine position.
Correct Answer: B
Rationale: IV pentamidine is an antifungal medication infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias. Options 1, 3, and 4 are inaccurate in either the length of time that pentamidine is administered or the client's position.
A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action should the nurse take?
- A. Start the client on sips of water.
- B. Remove the nasogastric (NG) tube.
- C. Call the primary health care provider immediately.
- D. Document the finding and continue to assess for bowel sounds.
Correct Answer: D
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days because of bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to do so. There is no need to call the primary health care provider immediately at this time.
A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.