Nokea
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.
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While the nurse is assessing the client, the client says, “I had an endovascular repair of an AAA that was found 1 month ago during a routine physical.” The nurse’s assessment of the client should be based on understanding that this procedure involves which action?
- A. Excision to remove the aneurysm and place a graft percutaneously
- B. An angioplasty with placement of a stent around the outside of the aorta
- C. Placement of a filter within the aneurysm to block clots from becoming emboli
- D. Placement of a stent graft inside the aorta that excludes the aneurysm from circulation
Correct Answer: D
Rationale: The endovascular repair consists of placement of the endovascular stent graft inside the aorta, extending above and below the aneurysmal area to seal it off from the circulation. Excision, external stents, and filters are not involved.
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 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 admitted with an ACS. Which should be the nurse’s priority assessment?
- A. Pain
- B. Blood pressure
- C. Heart rate
- D. Respiratory rate
Correct Answer: A
Rationale: The nurse’s priority assessment in ACS is the client’s pain; pain indicates that the heart is not receiving adequate oxygen and blood flow (perfusion). BP, HR, and RR are secondary as they stem from the lack of perfusion.
The RN and the NA are caring for four clients, all in need of immediate attention. The NA is a senior nursing student who has been giving medications and performing procedures on clients as a student nurse. The unit charge nurse determines that care is appropriate when the RN working with the NA delegates which actions? Select all that apply.
- A. Give acetaminophen to the client with a high temperature.
- B. Take vital signs on the client newly admitted with heart failure.
- C. Discuss the pacemaker discharge handout so this client can go home.
- D. Change this client’s chest tube dressing; it got wet with drinking water.
- E. Provide a sponge bath for the client with the increased temperature.
Correct Answer: B;E
Rationale: The RN delegates appropriately when having the NA: B) Take vital signs; E) Perform a sponge bath. Administering medication (A), teaching (C), and changing chest tube dressings (D) are outside the NA’s scope of practice.