LMJ Cardio Endo Detailed Answer Key Graded A

1. A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend? A. Peanut butter and jelly with enriched bread Rationale: The client who does not substitute protein-rich beans for meat protein should select a peanut butter sandwich, which is an excellent source of protein. A peanut butter and jelly sandwich, if prepared on protein-enriched bread, can provide almost 20 g of protein, called a complementary protein. A complementary protein is when two incomplete proteins are the equivalent of a complete protein and provides all the essential amino acids. B. Baked potato with sour cream Rationale: Baked potato with sour cream provides the client with a small amount of protein; however, it is not a complementary protein source. C. Bagel with cream cheese Rationale: A bagel with cream cheese provides the client with one incomplete protein; however, it is not a complementary protein source. D. Fruit salad and carrot sticks Rationale: Fruit salad and carrot sticks contain no protein; therefore, this recommendation is not a complementary protein source. 2. A nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily at home. Which of the following instructions should the nurse give the client? A. Fold used patch with medication area to the inside and discard in a closed receptacle. Rationale: It is important to prevent pets, children, and others in the client’s home from coming into contact with the medication on the nitroglycerin patch. Therefore, the client should be instructed to fold the patch in half with the medication area to the inside and to discard the patch in a closed receptacle rather than in an open trash can. B. Put a second patch in place if angina pain occurs. Rationale: Nitroglycerin transdermal patches are designed for prophylaxis of angina pain and are not to be used to stop an existing angina attack. Adding a second patch is not appropriate and could cause adverse effects, such as hypotension. The client should discuss strategies for treating an angina attack with the provider. C. Keep a nitroglycerin patch in place 24 hr per day. Rationale: Since clients can develop tolerance to nitroglycerin, the transdermal patch should be removed after 12 to 14 hr each day, and the client should have 10 to 12 hr of time without a patch during the evening and nighttime hours. D. Shave excess hair from skin before applying a nitroglycerin patch. Rationale: The client should be instructed to apply the patch to a different hairless area each day. If it is necessary to apply the patch to an area with hair, the hair should be clipped, not shaved, to avoid irritation to the skin. 3. A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A. Remove the window and view the incision. Rationale: The incision should be viewed regularly for signs of infection; however, this is not the first action the nurse should take. B. Turn the client so the cast will dry on all sides. Rationale: The client should be turned regularly to ensure that all sides of the cast are allowed to dry; however, this is not the first action the nurse should take. C. Medicate the client for pain. Rationale: Medicating the client for pain is an important nursing action; however, this is not the first action the nurse should take. D. Perform neurovascular checks of the affected extremity. Rationale: The greatest risk to this client is injury from impaired circulation due to constriction. Therefore, the first action the nurse should take is to perform neurovascular checks. 4. A nurse is caring for a client who has a deep vein thrombosis, who received IV heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the heparin. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse? A. "Heparin enhances the effects of the warfarin." Rationale: Neither medication enhances the effects of the other. B. "I will ask the charge nurse to call your provider and get an explanation." Rationale: The charge nurse does not need to call the provider for an explanation at this time. C. "Both heparin and warfarin work together to dissolve the clots." Rationale: Neither heparin nor warfarin dissolves clots that have already formed. D. "Heparin will be continued until the warfarin reaches a therapeutic level." Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, they work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which usually takes about 3 days. Oral warfarin therapy may continue for several months following discharge. 5. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? A. Suggest that the client rests before eating the meal. Rationale: The nurse should encourage frequent rest periods for the client who has heart failure, as dyspnea and fluid overload increases the workload to consume adequate nutrition; however, another action is the priority. B. Request a dietary consult. Rationale: The nurse should consider obtaining a dietary consult for the client who has heart failure to provide nutritional evaluation and counseling; however, another action is the priority. C. Check the client's vital signs. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with other manifestations such as muscle weakness, confusion, abdominal cramping, and changes in vision. D. Request an order for an antiemetic. Rationale: The nurse should request antiemetics for the client who is experiencing nausea in order to maintain client comfort and nutritional intake; however, another action is the priority. 6. A nurse is collecting data from a client who takes several daily medications and states that he wants to ask the provider for a prescription for sildenafil. The nurse knows that sildenafil is contraindicated due to an interaction with which of the following client’s medications? A. Isosorbide Rationale: Sildenafil, a medication used to treat impotence in men, increases the body's ability to achieve and maintain an erection during sexual stimulation. Isosorbide is a nitrate medication used to prevent or treat angina. Clients who are taking nitrates, including isosorbide and nitroglycerin preparations, should not take sildenafil due to the potential for severe hypotension. B. Cefuroxime Rationale: Cefuroxime, a second-generation cephalosporin antibiotic, is not contraindicated for use with sildenafil. C. Metformin Rationale: Metformin, an antidiabetic medication, is not contraindicated for use with sildenafil. D. Naproxen Rationale: Naproxen, an NSAID medication, is not contraindicated for use with sildenafil. 7. A nurse is caring for a client who is receiving IV dextrose 5% in 0.9% sodium chloride at 75 mL/hr. When the nurse checks the client’s IV bag at 0700, 300 mL remain in the bag. At what time should the nurse hang a new bag of IV fluid? (Use the military format, four-digit number to enter the time.) 1100 24hr time Correct Rationale: STEP 1: What is the unit of measurement the nurse should calculate? time STEP 2: What is the volume yet to infuse? 300 mL STEP 3: What is the rate of infusion? 75 mL/hr STEP 4: Set up an equation and solve for X. Volume (mL)/Rate (mL/hr) = X mL/hr 300 mL/75 mL/hr = X hr remaining X = 4 STEP 5: Calculate the time 0700 + 4 hr = 1100 Step 6: Reassess to determine whether the time to hang the next IV fluid bag makes sense. If 300 mL remain in the bag to infuse at 75 mL/hr, then it makes sense that it will take 4 hr for the remaining fluid to infuse. The nurse should hang the next IV fluid bag at 1100. InCorrect Rationale: STEP 1: What is the unit of measurement the nurse should calculate? time STEP 2: What is the volume yet to infuse? 300 mL STEP 3: What is the rate of infusion? 75 mL/hr STEP 4: Set up an equation and solve for X. Volume (mL)/Rate (mL/hr) = X mL/hr 300 mL/75 mL/hr = X hr remaining X = 4 STEP 5: Calculate the time 0700 + 4 hr = 1100 Step 6: Reassess to determine whether the time to hang the next IV fluid bag makes sense. If 300 mL remain in the bag to infuse at 75 mL/hr, then it makes sense that it will take 4 hr for the remaining fluid to infuse. The nurse should hang the next IV fluid bag at 1100. 8. A nurse is caring for a child who has disseminated intravascular coagulation and is experiencing epistaxis. Which of the following actions should the nurse take? A. Insert cotton into both of the child's nostrils. Rationale: The nurse should insert cotton into both the child's nostrils and apply continuous pressure to reduce bleeding. B. Apply a warm cloth to the bridge of the child's nose. Rationale: The nurse should apply an ice pack to the bridge of the child's nose in order to decrease bleeding and improve clot formation. C. Ask the child to gently blow his nose. Rationale: The nurse should tell the child avoid blowing his nose, as this could delay clot formation and result in additional bleeding time. D. Place the child in a supine position. Rationale: The nurse should have the child sit up and tilt his head forward in order to reduce blood pressure in the nasal vessels and to prevent blood from entering the nasopharynx. 9. A nurse is collecting data from a client who has hypertension and a prescription for propranolol. A history of which of the following conditions should be reported to the provider? A. Migraine Rationale: The use of propranolol is not contraindicated for a client who has a history of migraines. B. Glaucoma Rationale: Beta-blockers, such as propranolol, can be safely used by a client who has glaucoma. C. Depression Rationale: Depression is not a contraindication for the use of propranolol, a beta-blocker. D. Heart failure Rationale: Propranolol is used with caution in clients who have heart failure due to the depressive effect on myocardial contractility; therefore, the nurse should report this finding to the provider. 10. During a change-of-shirt report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take? A. Elevate the head of the bed to high Fowler's. Rationale: Unless the client is showing visible signs of dyspnea, positioning the client upright will not help resolve receiving an excessive amount of IV fluid. B. Request NPO status for the client. Rationale: There is no rationale for restricting oral fluids completely if the client has received an excess of IV fluids. C. Check the client's respiratory rate and lung sounds. Rationale: The nurse should collect data immediately to identify any indications of fluid-volume excess. To do so, the nurse should listen to the client's lungs for dyspnea and rales. D. Measure the client's temperature. Rationale: Receiving 900 mL of fluid in 30 min is unlikely to change the client’s temperature. It could help lower a fever, but there is no indication that the client had one.