Nokea
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.
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Upon assessing the client who has distal foot pain due to vascular insufficiency, the nurse notes the wound illustrated. When reviewing the client’s medical record, which notation is the nurse likely to find?
- A. Venous ulcer on left foot
- B. Arterial ulcer on right foot
- C. Diabetic ulcer on left foot
- D. Stress ulcer on right foot
Correct Answer: B
Rationale: The nurse should find a notation of an arterial ulcer on the right foot. Arterial ulcers typically occur on the feet; they are deep, and the ulcer bed is pale with even, defined edges and limited granulation tissue. Venous ulcers are at the ankle, diabetic ulcers are plantar, and stress ulcers are gastric.
The client who had a synthetic valve replacement a year ago is hospitalized with unstable angina. IV heparin and nitroglycerin infusions were started, but then nitroglycerin was discontinued after the client’s pain resolved. The HCP prescribes to start oral warfarin 5 mg at 1900 hours. Which is the nurse’s best action?
- A. Administer the warfarin as prescribed
- B. Call the HCP to question starting warfarin
- C. Discontinue heparin and then give warfarin
- D. Hold warfarin until heparin is discontinued
Correct Answer: A
Rationale: Both heparin and warfarin (Coumadin) are anticoagulants, but their actions are different. Oral warfarin requires 3 to 5 days to reach effective levels. It is usually begun while the client is still on heparin. Warfarin should be given as prescribed for a synthetic valve to prevent thromboembolism.
The nurse reviews symptoms of acute graft occlusion with the client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates the need for further teaching?
- A. Severe pain
- B. Paresthesia
- C. Warm and red incisions
- D. Inability to move the foot
Correct Answer: C
Rationale: Redness and warmth along the incision line are associated with inflammation or infection, not graft occlusion. Severe pain, paresthesia, and inability to move the foot are symptoms of acute arterial occlusion, indicating the client needs further teaching about incision symptoms.
At 0745 hours, the nurse is informed by the HCP that a cardiac catheterization is to be completed on the client at 1400 hours. Which intervention should be the nurse’s priority?
- A. Place the client on NPO (nothing per mouth) status.
- B. Teach the client about the cardiac catheterization.
- C. Start an intravenous (IV) infusion of 0.9% NaCl.
- D. Witness the client’s signature on the consent form.
Correct Answer: A
Rationale: A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam, during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure, making this the priority at 0745 for a 1400 procedure.
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).