Nokea
The nurse is caring for the client with a suspected DVT. For which diagnostic test should the nurse anticipate the client will need to be prepared?
- A. V/Q Scan
- B. Arteriogram
- C. Venogram
- D. Embolectomy
Correct Answer: C
Rationale: The nurse should anticipate preparing the client for a venogram, which allows visualization of veins and is used to diagnose a DVT. V/Q scans diagnose PE, arteriograms visualize arteries, and embolectomy is a treatment, not a diagnostic test.
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The client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?
- A. The client likely has peripheral arterial disease (PAD).
- B. Ticlopidine hydrochloride should be prescribed.
- C. The client’s pain is most likely psychological in origin.
- D. Medical follow-up is needed to determine the cause of pain.
Correct Answer: D
Rationale: The client requires further medical consultation because the ABI (comparison of BP in ankle to the brachial BP) is normal in each leg (1.4 and 1.3; normal is 0.9-1.3). A ratio <0.9 indicates PAD. Ticlopidine is inappropriate, and psychological pain is not supported without further evidence.
The client is hospitalized for HF secondary to alcohol-induced cardiomyopathy. The client is started on milrinone and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medications, overall care, and the need for energy conservation. Which nursing interpretation of the client’s behavior is most appropriate?
- A. The client is denying the illness.
- B. The client is experiencing fear.
- C. Alcohol abuse is affecting behavior.
- D. A reaction to milrinone is affecting behavior.
Correct Answer: B
Rationale: A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause the client to verbally attack health team members to maintain control. There’s no evidence of denial, alcohol’s neurological effects, or milrinone causing behavior changes.
The client with chronic HF tells the nurse, “I get so scared at night; I wake up and feel like I can hardly breathe.” Which is the nurse’s best response?
- A. “You are experiencing a condition called paroxysmal nocturnal dyspnea.”
- B. “Tell me if these are related to your having vivid nightmares?”
- C. “You may be experiencing this from an increased sodium intake in your diet.”
- D. “Tell me more about how often this is occurring and how you deal with it.”
Correct Answer: D
Rationale: When the client with HF expresses concerns about breathing, the nurse should further explore the comment with an open-ended statement because more information may be gained about how the client could diminish or handle the occurrence. Naming the condition (A), assuming nightmares (B), or sodium intake (C) does not facilitate further assessment.
The client with atrial flutter is receiving a continuous infusion of 25,000 units of heparin in 500 mL of 5% dextrose at a rate of 12 mL per hour. The a PTT laboratory result is 92 seconds. According to the heparin infusion protocol, the nurse should administer the heparin infusion at a rate of how many mL per hour?
Correct Answer: 11
Rationale: According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.
The nurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. Prioritize the order in which the nurse should address each client’s laboratory result.
- A. Troponin T 42 ng/mL (0.0-0.4 ng/mL)
- B. WBC 11,000/mm3
- C. Hgb 7.2 g/dL
- D. SCr 2.2 mg/dL
- E. K 2.2 mEq/L
- F. Total cholesterol 430 mg/dL
Correct Answer: A;E;C;D;F;B
Rationale: The nurse should prioritize: A) Elevated troponin indicates MI, requiring immediate action; E) Low potassium can cause dysrhythmias; C) Low hemoglobin contributes to ischemia; D) Elevated creatinine suggests renal impairment; F) High cholesterol is a long-term risk; B) Normal WBC is least urgent.