Nokea
The nurse is caring for a client scheduled to undergo a cardiac catheterization for the first time. Which information should the nurse share with the client regarding the procedure?
- A. The procedure is performed in the operating room.
- B. The initial catheter insertion is quite painful; after that, there is little or no pain.
- C. You may feel fatigue and have various aches because it is necessary to lie quietly on a stationary x-ray table for about 4 hours.
- D. You may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations.
Correct Answer: D
Rationale: Cardiac catheterization is an invasive test that involves the insertion of a catheter and the injection of dye into the heart and surrounding vessels to obtain information about the structure and function of the heart chambers and valves and the coronary circulation. Access is made by the insertion of a needle in either side of the groin into an artery and the catheter is advanced up to the heart through the abdomen and chest. Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so that there is little to no pain with catheter insertion. The x-ray table is hard but can be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.
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The nurse in the mental health unit is preparing to admit a severely depressed client. Which findings on assessment support the diagnosis of this client? Select all that apply.
- A. Insomnia
- B. Flat affect
- C. Hypersomnia
- D. Substantial weight loss
- E. Weight gain since onset of depression
- F. Reports, 'I don't have any more tears to cry.'
Correct Answer: A,B,D,F
Rationale: In the severely depressed client, loss of weight is typical, whereas the mildly depressed client may experience a gain in weight. Sleep is generally affected in a similar way, with hypersomnia in the mildly depressed client and insomnia in the severely depressed client. The severely depressed client may report that no tears are left for crying. A flat affect may be associated with depression.
A primary health care provider is inserting a chest tube. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site?
- A. Petrolatum jelly gauze
- B. Sterile 4 x 4 gauze pad
- C. Absorbent gauze dressing
- D. Gauze impregnated with povidone-iodine
Correct Answer: A
Rationale: The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. The items in the remaining options would not be selected as the first protective layer.
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
- A. Presence of a cephalhematoma
- B. Infant blood type of O negative
- C. Birth weight of 8 pounds 6 ounces
- D. A negative direct Coombs' test result
Correct Answer: A
Rationale: A cephalhematoma is swelling caused by bleeding into an area between the bone and its periosteum (does not cross over the suture line). Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves (usually within 6 weeks) and is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus/newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that there are no maternal antibodies on fetal erythrocytes.
A client who has experienced an acute kidney injury is prescribed a fluid restriction of 1500 mL per day. Which interventions will the nurse implement to assist the client in maintaining this restriction? Select all that apply.
- A. Removing the water pitcher from the bedside
- B. Using mouthwash with alcohol for mouth care
- C. Prohibiting beverages with sugar to minimize thirst
- D. Providing the client with lip balm to keep lips moist
- E. Offering the client ice chips at intervals during the day
Correct Answer: A,D,E
Rationale: The nurse can help the client maintain fluid restriction through a variety of means. The water pitcher should be removed from the bedside to aid in compliance. The use of ice chips and lip ointments is another intervention that may be helpful to the client on fluid restriction. Frequent mouth care is important; however, alcohol-based products should be avoided because they are drying to mucous membranes. Beverages that the client enjoys are provided and are not restricted based on sugar content.
The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses
- B. Drainage at the pin sites
- C. Complaints of leg discomfort
- D. Toes demonstrating a brisk capillary refill
Correct Answer: A
Rationale: Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.