Nokea
The nurse is preparing the client for a thoracic aneurysm repair. Which assessment findings should prompt the nurse to conclude that a rupture may have occurred? Select all that apply.
- A. Oliguria
- B. Dyspnea
- C. Hypotension
- D. Abdominal distention
- E. Severe chest pain radiating to the back
Correct Answer: A;B;C;E
Rationale: A rupture may cause: A) Oliguria from decreased renal perfusion; B) Dyspnea from hemorrhage pressure; C) Hypotension from blood loss; E) Severe chest pain radiating to the back. Abdominal distention is associated with abdominal, not thoracic, aneurysms.
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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.
The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.
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 client reports pain, tenderness, and redness along the path of an arm vein where potassium chloride (KCL) is infusing IV. Which interventions should the nurse include when responding to this situation?
- A. Call the HCP immediately; administer diphenhydramine.
- B. Stop the infusion; apply a warm, moist compress to the affected area.
- C. Slow the infusion rate; teach that IV potassium is usually uncomfortable.
- D. Discontinue the potassium chloride; document the client’s allergic reaction.
Correct Answer: B
Rationale: The nurse should immediately stop the KCL infusion; signs and symptoms indicate vein inflammation, or phlebitis. After discontinuing the IV catheter, the nurse should apply a warm, moist compress and restart the IV at another location, giving the infusion at a slower rate. Other options misinterpret the situation as an allergy or fail to address the phlebitis.
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.