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The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired.
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A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
- A. The development of chronic obstructive pulmonary disease (COPD)
- B. The development of left-sided heart failure
- C. The development of right-sided heart failure
- D. The development of cor pulmonale
Correct Answer: B
Rationale: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of/left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.
A client with heart failure reports not having had a bowel movement in 2 days. Why would it be important for the nurse to obtain a prescription for a stool softener?
- A. Straining engages the Valsalva maneuver, which can cause dangerous effects.
- B. The client should not develop hemorrhoids.
- C. The client can develop a rectal fissure, which will increase pain levels.
- D. The client should have a bowel movement every day to avoid development of an intestinal obstruction.
Correct Answer: A
Rationale: Avoid activities that engage the Valsalva maneuver, such as straining with bowel elimination or using the arms to pull and reposition oneself. The Valsalva maneuver increases intrathoracic pressure, reduces right atrial filling, triggers tachycardia, and increases blood pressure. The client's discomfort would be increased if hemorrhoids or a rectal fissure developed but would not engage the Valsalva maneuver. It is not necessary for the client to have a bowel movement on a daily basis.
The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?
- A. Avoid any activity at least 2 hours before the test.
- B. Drink plenty of fluids during the test.
- C. Avoid dairy products a day before and a day after the test.
- D. Lie very still at intermittent times during the test.
Correct Answer: D
Rationale: The nurse should instruct the client, who is to undergo a MUGA scan, to lie very still at intermittent times during the 45-minute test. The client need not drink plenty of fluids, avoid activities before/after the test, or avoid dairy products during the test.
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
- A. Intubation of the airway
- B. BP and pulse measurements every 15 to 30 minutes
- C. Insertion of a central venous catheter
- D. Hourly administration of a fluid bolus
Correct Answer: B
Rationale: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
A client is scheduled for a multiple gated acquisition (MUGA) scan the following day. What medication is contraindicated for the nurse to administer the morning of the procedure?
- A. Furosemide
- B. Acetaminophen
- C. Morphine sulfate
- D. Guaifenesin
Correct Answer: A
Rationale: Diuretics are contraindicated the morning of a test to avoid any interruptions for urination. Clients are also medicated to relieve a cough that may cause movement during the test so administration of guaifenesin is not contraindicated. Acetaminophen and morphine sulfate are not contraindicated the morning of the test.