Nokea
The nurse suspecting that a client is developing cardiogenic shock should assess for which peripheral vascular manifestation of this complication? Select all that apply.
- A. Warm, moist skin
- B. Flushed, dry skin
- C. Cool, clammy skin
- D. Irregular pedal pulses
- E. Bounding pedal pulses
- F. Weak or thready pedal pulses
Correct Answer: C,F
Rationale: Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin. None of the remaining options are associated with the peripheral vascular aspects of cardiogenic shock.
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A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks' gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information?
- A. Identify mitral valve prolapse.
- B. Identify cardiac dysrhythmias.
- C. Rule out the possibility of pneumonia.
- D. Assess for early signs of heart failure (HF).
Correct Answer: D
Rationale: Fluid volume during pregnancy peaks between 18 and 32 weeks' gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or HF in the pregnant client with cardiac disease. By assessing lung sounds, the nurse may identify early symptoms of diminished oxygen exchange and potential HF. Options 1, 2, and 3 are not related to the data in the question.
An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. After reviewing the results of the analysis, the nurse recognizes that the CSF is normal when which element is negative?
- A. Protein
- B. Glucose
- C. Red blood cells
- D. White blood cells
Correct Answer: C
Rationale: The adult with a normal CSF has no red blood cells in the CSF. Protein (15-45 mg/dL [0.15-0.45 g/L]) and glucose (50-75 mg/dL [2.8-4.2 mmol/L]) are normally present in CSF. The client may have small levels of white blood cells (0-5 cells/mcL [0-5 × 10^6/L]).
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.
The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position?
- A. High Fowler's
- B. Trendelenburg's
- C. Lateral recumbent
- D. Reverse Trendelenburg's
Correct Answer: B
Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.