Exam 3 Prep

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

• Call the nursing supervisor to initiate a court order for the surgical procedure.

• Try calling the client's spouse to obtain telephone consent before the surgical procedure.

• Ask the friend who accompanied the client to the emergency department to sign the consent form.

• Transport the client to the operating department immediately without obtaining an informed consent.

Answer explanation

Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

• "This diet will help lower my blood pressure."

• "Fresh foods such as fruits and vegetables are high in sodium."

• "This diet is not a replacement for my antihypertensive medications."

• "The reason I need to lower my salt intake is to reduce fluid retention."

Answer explanation

A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Fresh foods such as fruits and vegetables are low in sodium.

A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a beta blocker, digoxin, and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which assessment data supports this diagnosis?

• Dyspnea, edema, and palpitations

• Chest pain, hypotension, and paresthesia

• Double vision, loss of appetite, and nausea

• Constipation, dry mouth, and sleep disorder

The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action would the nurse take first?

• Check the hourly urine output.

• Check the client's pulse oximetry.

• Check the intravenous (IV) site for infiltration.

• Place the client in the modified Trendelenburg's position.

Answer explanation

The client is exhibiting signs of shock and requires emergency intervention. Placing the client in the modified Trendelenburg's position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's blood volume status by assessing the urine output and ensuring that the IV is infusing without complications. The nurse should also check the client's pulse oximetry and notify the registered nurse.

The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition?

• Shock

• Kidney dysfunction

• Respiratory Insufficiency

• Increased intracranial pressure

Answer explanation

A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat and slightly elevating the head and shoulders. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, which is vital to the treatment of shock. The remaining conditions would not benefit from and in some cases would be worsened by this position.

The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication?

• Cold skin, drowsiness, and hypertension

• Fever, irritability, and rapid respirations

• Tachycardia, cold skin, and hypotension

• Slow pulse, warm skin, and restlessness

Answer explanation

Postoperative hypotension or shock can have numerous causes such as inadequate ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood loss. The symptoms of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and apprehension

The nurse is reinforcing discharge teaching to a client who was given a prescription for nifedipine for blood pressure management. Which instructions would the nurse reinforce? Select all that apply.

• "Palpitations may occur early in therapy."

• "Increase calcium intake."

• "Take pulse rate each day."

• "Weigh at the same time each day."

• "Be careful when rising from sitting to standing."

Answer explanation

Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.

A client taking an angiotensin-converting enzyme (ACE) inhibitor reviewed the medication information sheet and notes that the medication is used to treat hypertension. He states, "I have heart failure. Why am I taking this medicine?" The nurse responds by making which statement?

• "There must be some mistake; I will check the medication prescriptions."

• "The medication causes relaxation in your arteries and veins and decreases the heart's work."

• "The medication makes your heart beat faster, and this improves blood flow to your tissues."

• "An additional medication will be added to the ACE inhibitor to strengthen your heart muscle."

Answer explanation

ACE inhibitors produce multiple benefits in heart failure. By lowering arteriolar tone, these medications improve regional blood flow, and by reducing cardiac afterload, they increase cardiac output. By causing venous dilation, they reduce pulmonary congestion and peripheral edema. By dilating blood vessels in the kidney, they increase renal blood flow and thereby promote excretion of sodium and water. This loss of fluid has two beneficial effects: (1) it helps reduce edema and (2) by lowering blood volume, it decreases venous return to the heart thereby reducing right-heart size. Also by suppressing aldosterone and by reducing local production of angiotensin II in the heart, ACE inhibitors may prevent or reverse pathological changes in cardiac structure. Therefore, options 1, 3, and 4 are incorrect.

The nurse is attending an in-service education session on the therapeutic use of calcium-channel blockers. The instructor of the session determines that teaching has been effective when the nurse correctly identifies that these medications are used for which disorders? Select all that apply.

• Angina

• Glaucoma

• Hypertension

• Dysrhythmias

• Glomerulonephritis

Answer explanation

Calcium-channel blockers are medications that prevent calcium ions from entering cells. These agents have their greatest effects on the heart and blood vessels. They are used widely to treat hypertension, angina pectoris, and cardiac dysrhythmias. They are not used to treat glaucoma, acute kidney injury, or glomerulonephritis.

The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.

• Increasing restlessness

• Capillary refill of 3 seconds in all extremities

• Hypoactive bowel sounds in all four quadrants

• White blood cell (WBC) count 9,500 mm3 (9.5 × 109/L)

• Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

Answer explanation

Hypovolemia is decreased circulating blood volume. In a postoperative client, this often is associated with inadequate fluid replacement or hemorrhage. Increasing restlessness is a sign that requires continuous and close monitoring because it could forecast a complication such as shock. A low and dropping BP with an increased pulse rate could be early compensation for a decrease in circulating blood volume. The WBC count is normal at 5000 to 10,000 mm3 (5 to 10 × 109/L). Hearing hypoactive bowel sounds in all four quadrants is a normal occurrence, as is a capillary refill of 3 seconds in all extremities.