NUR 155 Test 2 - Answered with Rationales (Complete Solutions) The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which pa
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NUR 155 Test 2 - Answered with Rationales (Complete Solutions) The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A. Urine output of 20ml/hour B. Temperature of 37.6 C C. Blood pressure of 114/70 D. Serous drainage on the surgical dressing Rationale: Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for each of 2 consecutive hours should be reported to the health care provider. A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? A. Pneumonia B. Hypoxemia C. Fluid imbalance D. Pulmonary embolism Rationale: Postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by the retention of pulmonary secretions. The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? A. Avoid oral hygiene and rinsing with mouthwash B. Verify that the client has not eaten for the last 24 hours C. Have the client void immediately before going into surgery D. Report immediately any slight increase in BP or pulse Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in BP and pulse is common during the preoperative period due to anxiety. A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? A. Obtain a court order for the surgery. B. Have the charge nurse sign the informed consent immediately C. Send the client to surgery without the consent form being signed D. Obtain a telephone consent from a family member, following agency policy Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency the client may not be able to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but tin this case it is not an emergency. Agency policies regarding informed consent should always be followed. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? A. "If it's any help, everyone is nervous before surgery." B. "I will be happy to explain the entire surgical procedure with you." C. "Can you share with me what you've been told about your surgery?" D. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate". Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible B. Keep a loose seal between the lips and the mouthpiece C. After maximum inspiration, hold the breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowlers or high fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? A. "Aspirin can cause bleeding after surgery." B. "Aspirin can cause my ability to clot blood to be abnormal." C. "I need to continue to take the aspirin until the day of surgery." D. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery." Rationale: Anticoagulants altered normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm tender skin Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Wound infection usually appears 3 to 6 days after surgery. (SATA)A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? 1. Contact the surgeon 2. Instruct the client to try not to cough 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and icepacks over the wound 6. Place the client in a prone position without a pillow under the head. A. 1,3,4 B. 1,2,3,4 C. 5 D. 1,6,3,4 E. All F. None Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowler's position and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken. A client who has undergone preadmission testing, has had blood drawn for serum lab studies, including a complete blood count, coagulation studies and electrolytes and creatinine levels. Which lab result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? A. Sodium, 141mEq/L B. Hemoglobin, 8.0 g/dL C. Platelets, 210,000/mm3 D. Serum creatine, 0.8 mg/dL Rationale: The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway B. Check tubes or drains for patency C. Check the dressing to assess for bleeding D. Assess the vital signs to compare with preoperative measurements Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking of the dressing and tubes or drains. A patient is being discharged home on Hydrochlorothiazide (HCTZ) for treatment of hypertension. Which of the following statements by the patient indicates they understood your discharge teaching about this medication? A. I will make sure I consume foods high in potassium. B. I will only take this medication if my blood pressure is high. C. I understand a dry cough is a common side effect with this medication. D. I will monitor my glucose levels closely because this medication may mask symptoms of hypoglycemia. Which of the following patients does not have a risk factor for hypertension? A. A 25 year old male with a BMI of 35. B. A 35 year old female with a total cholesterol level of 100. C. A 68 year old male who reports smoking 2 packs of cigarettes a day. D. A 40 year old female with a family history of hypertension and diabetes. A patient with hypertension is started on a new medication for treatment and is reporting a continuous dry cough. Which of the following medications do you suspect is causing this problem? A. Lisinopril B. Labetalol C. Losartan D. Hydrochlorothiazide Which of the following patients is not a candidate for a beta blocker medication? A. A 45 year old male with angina. B. A 39 year old female with asthma. C. A 25 year old female with migraines. D. A 55 year old male with a history of two heart attacks. Which family of drugs are the following medications considered: Amlodipine, Verapamil, Diltiazem? A. Beta blockers (BB) B. ACE Inhibitors (ACEI) C. Angiotensin Receptor Blockers (ARBs) D. Calcium Channel Blockers (CCBs) Which of the following systems of the body are affected by hypertension? A. Cardiovascular, brain, kidney, eyes B. Cardiovascular, gastrointestinal, reproductive, and kidney C. Brain, respiratory, kidney, cardiovascular D. None of the options are correct Non-pharmacological techniques can help lower blood pressure. Which of the following is not considered one of these types of techniques? A. Dietary changes B. Multivitamins C. Smoking cessation D. Limiting caffeine Which of the following drugs is NOT considered an Angiotensin Receptor Blocker (ARBs) medication used in hypertension? A. Catapres B. Losartan C. Benicar D. Valsartan A patient is scheduled to take Captopril. When is the best time to administer this medication? A. 30 minutes after a meal B. At bedtime C. In the morning D. 1 hour before a meal (T or F) Most patients with hypertension are asymptomatic. True False (SATA)Which of the following patients are MOST at risk for developing heart failure? 1. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction. 2. A 55 year old female with a health history of asthma and hypoparathyroidism. 3. A 30 year old male with a history of endocarditis and has severe mitral stenosis. 4. A 45 year old female with lung cancer stage 2. 5. A 58 year old female with uncontrolled hypertension and is being treated for influenza. A. 1,3,4 B. 1,2,3,4 C. 1,3,5 D. 1,2,4 E. All F. None Rationale: These patients are at most risk for heart failure. Remember risks factor for developing heart failure include: remember the mnemonic FAILURE: Faulty heart valves ( Option 3 mitral stenosis in this case), Arrhythmias, Infarction (Option 1), Lineage, Uncontrolled hypertension (Option 5), Recreational drug usage, Evaders (Option 5 with influenza) A patient is being discharged home after hospitalization of left ventricular systolic dysfunction. As the nurse providing discharge teaching to the patient, which statement is NOT a correct statement about this condition? A. "Signs and symptoms of this type of heart failure can include: dyspnea, persistent cough, difficulty breathing while lying down, and weight gain." B. "It is important to monitor your daily weights, fluid and salt intake." C. "Left-sided heart failure can lead to right-sided heart failure, if left untreated." D. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema." Rationale: This is a description of right-sided heart failure NOT left ventricular systolic dysfunction. Left-sided systolic dysfunction is where the left side of the heart is unable to CONTRACT efficiently which causes blood to back-up into the lungs...leading to pulmonary edema. (SATA)Which of the following are NOT typical signs and symptoms of right-sided heart failure? 1. Jugular venous distention 2. Persistent cough 3. Weight gain 4. Crackles 5. Nocturia 6. Orthopnea A. 1,3,4 B. 1,2,3,4 C. 2,4,6 D. 1,6,3,4 E. All F. None Rationale: Persistent cough, crackles (also called rales), and orthopnea are signs and symptoms of LEFT-sided heart failure...not right-sided heart failure. A patient is diagnosed with left-sided systolic dysfunction heart failure. Which of the following are expected findings with this condition? A. Echocardiogram shows an ejection fraction of 38%. B. Heart catheterization shows an ejection fraction of 65%. C. Patient has frequent episodes of nocturnal paroxysmal dyspnea. D. Options A and C are both expected findings with left-sided systolic dysfunction heart failure. Rationale: Both Options A and C are correct. Option B is a finding expected in left-sided DIASTOLIC dysfunction heart failure because the issue is with the ability of the ventricle to FILL properly...therefore a patient usually has a normal ejection fraction. Remember a normal EF is >60% in a healthy heart. (T or F)Patients with left-sided diastolic dysfunction heart failure usually have a normal ejection fraction. True False Rationale: Patient with left-sided DIASTOLIC dysfunction heart failure normally have a normal ejection fraction. However, patients with left-sided SYSTOLIC dysfunction heart failure usually do not because the heart is unable to CONTRACT efficiently rather than fill properly as with diastolic dysfunction. A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation? A) "I've noticed that I've gain 6 lbs in one week." B) "While I sleep I have to prop myself up with a pillow so I can breathe." C) "I haven't noticed any swelling in my feet or hands lately." D) Options B and C are correct. E) Options A and B are correct. F) All are correct. Rationale: Options A and B are classic signs and symptoms a patient may experience with heart failure exacerbation. Patients with heart failure can experience episodes of exacerbation. All of the patients below have a history of heart failure. Which of the following patients are at MOST risk for heart failure exacerbation? A. A 55 year old female who limits sodium and fluid intake regularly. B. A 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation. C. A 67 year old female who is being discharged home from heart valve replacement surgery. D. A 78 year old male who has a health history of eczema and cystic fibrosis. Rationale: Patients who are in an arrhythmia (especially a-fib) are at risk for developing heart failure because the heart is not contracting properly and blood is pooling in the chambers. A 74 year old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure? A. K+ 5.6 B. BNP 820 C. BUN 9 D. Troponin <0.02 Rationale: BNP (b-type natriuretic peptide) is a biomarker released by the ventricles when there is excessive pressure in the heart due to heart failure. <100 no failure, 100-300 present, >300 pg/mL mild, >600 pg/mL >moderate, 900 pg/mL severe Which of the following tests/procedures are NOT used to diagnose heart failure? A. Echocardiogram B. Brain natriuretic peptide blood test C. Nuclear stress test D. Holter monitoring Rationale: Options A, B, and C are all used to diagnose heart failure...however a holter monitor is not. A holter monitor is used to monitor a patient's heart rate and rhythm. What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath. A. Left ventricular systolic dysfunction B. Left ventricular ride-sided dysfunction C. Right ventricular diastolic dysfunction D. Left ventricular diastolic dysfunction A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention? A. Encourage the patient to cough and deep breathe. B. Place the patient in Semi-Fowler's position. C. Assist the patient into High Fowler's position. D. Perform chest percussion therapy. Rationale: Due to the patient being in fluid overload (especially with left-sided heart failure...remember the lungs are majorly affected in this type of heart failure), it is most appropriate to place the patient in High Fowler's position to help make breathing easier. You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching? A. "I will limit my sodium intake to 5-6 grams a day." B. "I will be sure to incorporate canned vegetables and fish into my diet." C. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches." D. "I will limit my consumption of frozen meals." Rationale: Patients with heart failure should limit sodium intake to 2 to 3 grams per day (not 5-6 grams), avoid canned vegetable/fish, and avoid sandwich meats and cheeses because of their high sodium content. Frozen meals are high in sodium, therefore the patient is correct in saying they should limit their consumption of them. (SATA)Select all the correct statements about educating the patient with heart failure: 1. It is important patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week. 2. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine. 3. Heart failure patients should limit sodium intake to 2-3 grams per day. 4. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias. 5. Patients with heart failure should limit exercise because of the risks. A. 1,3,4 B. 1,2,3,4 C. 2,3,4
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