Nokea
The nurse is to administer 40 mg of furosemide to the client in HF. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, how many milliliters should the nurse administer to the client?
Correct Answer: 0.4
Rationale: Use a proportion formula: 100 mg: 1 mL :: 40 mg: X mL; 100X = 40; X = 0.4. The nurse should administer 0.4 mL of furosemide.
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The nurse is admitting the client with a thoracic aortic aneurysm. Which intervention should the nurse plan to include?
- A. Administering antihypertensive medications
- B. Palpating the abdomen to determine the aneurysm’s size
- C. Inserting a nasogastric tube set to moderate suction
- D. Teaching about a diet high in potassium and low in sodium
Correct Answer: A
Rationale: The nurse should include administering antihypertensive medications to the client with a thoracic aortic aneurysm; controlling HR and BP is important to decrease the risk of aneurysm rupture. Palpation is contraindicated, and NG tubes or specific diets are not indicated.
The nurse is assessing the client with an anterior-lateral MI. The nurse should add decreased cardiac output to the client’s plan of care when which finding is noted?
- A. Pain radiates up left arm to neck
- B. Presence of an S4 heart sound
- C. Crackles auscultated in both lung bases
- D. Vesicular breath sounds over lung lobes
Correct Answer: C
Rationale: An anterior-lateral MI can produce left ventricular dysfunction and low cardiac output. With decreased cardiac output, blood accumulates in the heart and backs up into the pulmonary system, causing fluid to move into interstitial spaces and alveoli, resulting in crackles. Pain radiation, S4 sounds, and vesicular breath sounds do not directly indicate decreased cardiac output.
The nurse obtains the client’s cardiac monitor print-out illustrated. What should be the nurse’s interpretation of the client’s rhythm?
- A. Atrial flutter
- B. Atrial fibrillation
- C. Sinus bradycardia
- D. Sinus rhythm with premature atrial contractions (PACs)
Correct Answer: C
Rationale: Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 bpm and one discernable P wave prior to each QRS. Atrial flutter and fibrillation have multiple or nondiscernible P waves, and PACs include premature atrial beats, which are not described in the image.
The nurse is caring for multiple clients. Which client should the nurse identify as having the greatest risk for developing a DVT?
- A. The client with an area of slight inflammation at the peripheral IV site with a PT of 25 seconds, INR of 2.5.
- B. The client postoperative hip arthroplasty who has venous insufficiency and is immobile; platelet count = 550,000/mm3.
- C. The client with a history of DVT admitted with chest pain and has a continuous intravenous heparin drip; PTT of 55 seconds.
- D. The client with dependent rubor, pallor upon lower-extremity elevation, and absent peripheral pulses; platelet count of 350,000/mm3.
Correct Answer: B
Rationale: Blood stasis (immobility), endothelial injury (postoperative client), and hypercoagulability (platelet count increased) suggest Virchow’s triad, which is associated with an increased risk of DVT. Other clients have prolonged coagulation times or arterial issues, reducing DVT risk.
The nurse who is beginning a shift on a cardiac step-down unit receives shift report for four clients. Prioritize the order, from most urgent to least urgent, that the nurse should assess the clients.
- A. The 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes
- B. The 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a “Do Not Resuscitate” order; whose family has just arrived
- C. The 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new-onset atrial fibrillation with rapid ventricular response
- D. The 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C)
Correct Answer: C;D;A;B
Rationale: The nurse should assess: C) Atrial fibrillation with rapid ventricular response is life-threatening; D) Elevated temperature and vital signs suggest infection; A) Heparin adjustment is pending but less urgent; B) End-stage cardiomyopathy with DNR is stable and family support is secondary.