Nokea
The nurse is preparing to initiate an intravenous nitroglycerin drip on a client who has experienced an acute myocardial infarction. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside to help assure the client's safety?
- A. Defibrillator
- B. Pulse oximeter
- C. Central venous pressure (CVP) tray
- D. Noninvasive blood pressure monitor
Correct Answer: D
Rationale: Nitroglycerin dilates arteries and veins (vasodilator), causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.
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As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?
- A. At the left midclavicular line at the fifth intercostal space
- B. At the left midclavicular line at the third intercostal space
- C. To the right of the left midclavicular line at the fifth intercostal space
- D. To the right of the left midclavicular line at the third intercostal space
Correct Answer: A
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. Options 2, 3, and 4 are not descriptions of the location for palpation of the apical pulse.
To ensure client safety, which assessment is most important for the nurse to make before advancing a client from liquid to solid food?
- A. Bowel sounds
- B. Chewing ability
- C. Current appetite
- D. Food preferences
Correct Answer: B
Rationale: The nurse needs to assess the client's chewing ability before advancing a client from liquid to solid food. It may be necessary to modify a client's diet to a soft or mechanical chopped diet if the client has difficulty chewing because of the risk of aspiration. Bowel sounds should be present before introducing any diet, including liquids. Appetite will affect the amount of food eaten, but not the type of diet prescribed. Food preferences should be ascertained on admission assessment.
The nurse hangs an intravenous (IV) bag of 1000 mL of 5% dextrose in water (D5W) at 3 pm and sets the flow rate to infuse at 75 mL/hour. At 11 pm, the nurse should expect the fluid remaining in the IV bag to be at approximately which level?
Correct Answer: 400 mL
Rationale: In an 8-hour period, 600 mL would infuse if an IV is set to infuse at 75 mL/hour. Therefore, 400 mL would remain in the IV bag.
A client who undergoes a gastric resection is at risk for developing dumping syndrome. Which manifestation should the nurse monitor the client for? Select all that apply.
- A. Pallor
- B. Dizziness
- C. Diaphoresis
- D. Bradycardia
- E. Constipation
- F. Extreme thirst
Correct Answer: A,B,C
Rationale: Dumping syndrome is the rapid emptying of the gastric contents into the small intestine that occurs after gastric resection. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Manifestations also include vasomotor disturbances such as dizziness, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
A child diagnosed with rheumatic fever is admitted to the hospital. The nurse prepares to manage which clinical manifestations of this disorder? Select all that apply.
- A. Cardiac murmur
- B. Cardiac enlargement
- C. Cool pale skin over the joints
- D. White painful skin lesions on the trunk
- E. Small nontender lumps on bony prominences
- F. Purposeless jerky movements of the extremities and face
Correct Answer: A,B,E,F
Rationale: Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; arthritis manifested as tender, warm erythematous skin over the joints; and erythema marginatum, manifested as red, painless skin lesions usually over the trunk.