Nokea
The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
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The nurse has just finished assisting the primary health care provider in placing a central intravenous (IV) line. Which is a priority intervention to assure the client's safety?
- A. Assessing the client's pain level
- B. Assessing the client's temperature
- C. Preparing the client for a chest x-ray
- D. Monitoring the client's blood pressure (BP)
Correct Answer: C
Rationale: A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and verify catheter tip placement before initiating IV therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Pain management is important but is not the priority at this point. Although BP assessment is always important in assessing a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.
A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention should the nurse plan to implement to prevent complications associated with the use of this catheter?
- A. Monitor urine output every shift.
- B. Measure specific gravity once a shift.
- C. Encourage a high intake of oral fluids.
- D. Avoid kinking of the catheter tubing.
Correct Answer: D
Rationale: A complication after surgical repair of the bladder is disruption of sutures caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care, including keeping the tubing free from kinks, keeping the tubing below the level of the bladder, and monitoring the flow of urine frequently. Monitoring urine output every shift is insufficient to detect decreased flow from catheter kinking. Measurement of urine specific gravity and a high oral fluid intake do not prevent complications of bladder surgery.
The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When should the nurse plan to administer the client's daily dose of enalapril to ensure its effectiveness?
- A. During dialysis
- B. Just before dialysis
- C. The day after dialysis
- D. Upon return from dialysis
Correct Answer: D
Rationale: Antihypertensive medications, such as enalapril, are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.
An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Using the rule of nines, the nurse should determine that approximately what percentage of the client's body surface has been burned? Fill in the blank.
Correct Answer: 37%
Rationale: The most rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the rule of nines. This method divides the body into areas that are multiples of 9%, except for the perineum. Each entire leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36%, and the perineal area is 1%. Both legs and perineal area equal 37%.
A client hospitalized with a diagnosis of thrombophlebitis is being treated with heparin infusion therapy. About 24 hours after the infusion has begun, the nurse notes that the client's partial thromboplastin time (PTT) is 65 seconds with a control of 30 seconds. What nursing action should the nurse implement?
- A. Discontinue the heparin infusion.
- B. Prepare to administer protamine sulfate.
- C. Notify the primary health care provider of the laboratory results.
- D. Include in report that the client is adequately anticoagulated.
Correct Answer: D
Rationale: The effectiveness of heparin therapy is monitored by the results of the PTT. Desired range for therapeutic anticoagulation is 1.5 to 2.5 times the control. A PTT of 65 seconds is within the therapeutic range. Therefore, options 1, 2, and 3 are incorrect actions.