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A client has driven himself to the emergency department. He is 50
years old, has a history of hypertension, and informs the nurse that his
father died from a heart attack at age 60. The client has indigestion.
The nurse connects him to an electrocardiogram monitor and begins
administering oxygen at 2 L/min per nasal cannula. The nurse's next
action should be to:
1. Call for the physician.
2. Start an IV infusion.
3. Obtain a portable chest radiograph.
4. Draw blood for laboratory studies. - ANSWER 2. Start an IV infusion.
Advanced cardiac life support recommends that at least one or two IV
lines
be inserted in one or both of the antecubital spaces. Calling the
physician, obtaining a portable chest radiograph, and drawing blood for
the laboratory are important but secondary to starting the IV line.
CN: Physiological adaptation; CL: Synthesize
,Which is a priority assessment for the client in shock who is receiving an
IV infusion of packed red blood cells and normal saline solution?
1. Fluid balance.
2. Anaphylactic reaction.
3. Pain.
4. Altered level of consciousness. - ANSWER 2. Anaphylactic reaction.
Crackles heard on lung auscultation indicate which of the following?
1. Cyanosis.
2. Bronchospasm.
3. Airway narrowing.
4. Fluid-filled alveoli. - ANSWER 4. Fluid-filled alveoli.
Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung
auscultation do not have to be associated with cyanosis. Bronchospasm
and airway narrowing generally are associated with wheezing sounds.
CN: Physiological adaptation; CL: Analyze
A 68-year-old client on day 2 after hip surgery has no cardiac history
but reports having chest heaviness. The first nursing action should be
to:
,1. Inquire about the onset, duration, severity, and precipitating factors
of the heaviness.
2. Administer oxygen via nasal cannula.
3. Offer pain medication for the chest heaviness.
4. Inform the physician of the chest heaviness. - ANSWER 1. Inquire
about the onset, duration, severity, and precipitating factors of the
heaviness.
Further assessment is needed in this situation. It is premature to
initiate other actions until further data have been gathered. Inquiring
about the onset, duration, location, severity, and precipitating factors
of the chest heaviness will provide pertinent information to convey to
the physician.
CN: Reduction of risk potential; CL: Synthesize
The nurse is assessing an older adult with a pacemaker who leads a
sedentary lifestyle. The client reports being unable to perform activities
that require physical exertion. The nurse should further assess the
client for which of the following?
1. Left ventricular atrophy.
2. Irregular heartbeats.
3. Peripheral vascular occlusion.
4. Pacemaker placement. - ANSWER 1. Left ventricular atrophy.
, In older adults who are less active and do not exercise the heart
muscle, atrophy can result. Disuse or deconditioning can lead to
abnormal changes in the myocardium of the older adult. As a result,
under sudden emotional or physical stress, the left ventricle is less able
to respond to the increased demands on the myocardial muscle.
Decreased cardiac output, cardiac hypertrophy, and heart failure are
examples of the chronic conditions that may develop in response to
inactivity, rather than in response to the aging process. Irregular
heartbeats are generally not associated with an older sedentary adult's
lifestyle. Peripheral vascular occlusion or pacemaker placement should
not affect response to stress.
Following diagnosis of angina pectoris, a client reports being unable to
walk up two flights of stairs without pain. Which of the following
measures would most likely help the client prevent this problem?
1. Climb the steps early in the day.
2. Rest for at least an hour before climbing the stairs.
3. Take a nitroglycerin tablet before climbing the stairs.
4. Lie down after climbing the stairs. - ANSWER 3. Take a nitroglycerin
tablet before climbing the stairs.
Nitroglycerin may be used prophylactically before stressful physical
activities such as stair climbing to help the client remain pain free.
Climbing the stairs early in the day would have no impact on decreasing