NG 306 EAQ’s
A 50-year-old client who has aortic stenosis and is scheduled for a valve replacement
tells the nurse, "I gave my spouse all my financial records in case I don't make it."
Which response by the nurse is best?
A. "Your surgeon is very experienced."
B. "People your age generally do very well."
C. "Are you concerned that you may die during surgery?"
D. "Would you like medication to help you sleep at night?"
(Asking if the client is concerned about dying is reflective and encourages further
communication. A statement that the surgeon is experienced may be true, but is not
specific to the client's statement and cuts off further communication. Telling the client
that other people generally do well is nonspecific and provides false reassurance that is
unlikely to decrease anxiety. Asking about whether the client would like sleep
medication evades the client's concerns and cuts off more communication about the
client's concerns.)
Which foods would the nurse recommend for a client who is to begin a 2-g sodium diet?
Select all that apply. One, some, or all responses may be correct.
A. Beef steaks
B. Mushrooms
C. Aged cheeses
D. Luncheon meats
E. Cooked broccoli
(Beef is low in sodium. Broccoli and mushrooms do not have significant sodium levels.
Aged cheeses are high in sodium and saturated fat. Luncheon meat is processed and
has high sodium levels to help with its preservation.)
After the nurse has completed teaching about sclerotherapy for a client with varicose
veins, which client statement indicates that more teaching is needed?
A. "I can eat and drink normally in the hours before the procedure."
B. "I will still need to wear compression stockings after the procedure."
C. "I can plan to take acetaminophen or ibuprofen for pain after the procedure."
D. "I should return to the clinic immediately if there is any swelling at the procedure
site."
(Because sclerotherapy causes inflammation of the affected vein, swelling is expected
and not a reason to return to the clinic. No general anesthesia is used for sclerotherapy,
so clients may eat and drink normally. Ongoing use of compression stockings is
,recommended to prevent more varicosities from developing. There is usually minimal
pain after sclerotherapy and mild analgesics such as acetaminophen or ibuprofen are
adequate for pain control.)
A client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a
thyroidectomy is scheduled. What is important for the nurse to consider when caring for
this client during the postoperative period?
A. Hypercalcemia may result from parathyroid damage.
B. Hypotension and bradycardia may result from thyroid storm.
C. Tetany may result from underdosage of thyroid hormone replacement.
D. Hoarseness and airway obstruction may result from laryngeal nerve damage
(Laryngeal nerve injury can cause laryngeal spasms, resulting in airway obstruction.
Parathyroid damage results in hypocalcemia, not hypercalcemia. Thyroid storm (thyroid
crisis) is characterized by the release of excessive levels of thyroid hormone, which
increases the metabolic rate. An increase in the metabolic rate increases vital signs,
resulting in hypertension, not hypotension, and tachycardia, not bradycardia. Tetany is
caused by a decrease in parathormone, a parathyroid hormone, not a thyroid hormone.)
Which clinical manifestations would the nurse expect when assessing a client who is
diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses
may be correct.
a. Tachycardia
b. Restlessness
c. Warm, moist skin
d. Decreased urinary output
e. Bradypnea
(The heart rate increases (tachycardia) and the respiratory rate increases (tachypnea,
not bradypnea) in an attempt to meet the oxygen demands of the body. Restlessness
occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/h
because of decreased arterial perfusion to the kidneys and the compensatory
mechanism of reabsorbing fluid to increase the circulating blood volume. The skin
becomes cool and pale as blood shunts from the peripheral blood vessels to the vital
organs.)
A client on a telemetry unit demonstrates a sinus rhythm with an occasional premature
atrial contraction (PAC). Which action would the nurse take?
a. Continue to monitor the client.
b. Ensure that a defibrillator is available close by.
c. Activate the Rapid Response Team.
d. Give lidocaine intravenously as per protocol.
,(Occasional PACs (premature atrial contractions) are benign and will not affect cardiac
output, but the nurse will continue to monitor the client for increased numbers of PACs
or other dysrhythmias. Activation of the Rapid Response Team is inappropriate,
because there is no indication that the client is unstable. No defibrillator is needed for
this benign atrial dysrhythmia. Lidocaine is specific for ventricular, not atrial, irritability.)
When teaching a client who has a new prescription for antihypertensive medication,
which suggestion will the nurse make to minimize orthostatic hypotension?
a. Wear support hose continuously.
b. Lie down for 30 minutes after taking medication.
c. Avoid tasks that require high-energy expenditure.
d. Change position slowly when going from lying to standing.
(Changing position slowly when going from lying to sitting to standing gives the body a
chance to adjust to the effects of gravity on circulation in the upright position. Support
hose may help prevent orthostatic hypotension by increasing venous return. However,
they must be applied before getting out of bed and should not be worn continuously.
Lying down for 30 minutes after taking medication will not prevent episodes of
orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase
hypotension.)
A client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a
screening session at a health fair asks the nurse what to do in light of this result. How
would the nurse respond?
a. "Your cholesterol is high, and you may need medication."
b. "This is within the acceptable range, and no action is required."
c. "Your level is low; you should eat more foods that"
d. "Your cholesterol is elevated slightly. A diet low in saturated fats should be followed."
(A level more than 200 mg/dL (5 mmol/L) is considered elevated. This client's total
cholesterol is mildly elevated and the initial intervention would be making changes in
diet and activity level. The client's cholesterol is not elevated enough to require
medication as an initial intervention. The client's cholesterol is elevated and action is
advised to lower total cholesterol level and cardiac risk. A low level is less than 140
mg/dL (2.0 mmol/L). Medical attention should be sought, because low cholesterol levels
are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and
myeloproliferative disease.)
When discharging a client who has had insertion of a coronary artery stent, the nurse
will instruct the client to seek immediate medical attention for which signs and
symptoms? Select all that apply. One, some, or all responses may be correct.
a. Dyspnea with vigorous exertion
b. Unexplainable profuse diaphoresis
, c. Indigestion not relieved by antacids
d. Fatigue the day after a rigorous walk
e. Acute chest pain after rigorous exercise
f. Continued chest pain after nitroglycerin use
(Unexplainable profuse diaphoresis, indigestion not relieved by antacids, acute chest
pain after rigorous exercise, and continued chest pain after use of nitroglycerin are
clinical indicators of inadequate oxygen to the heart. The client should be instructed to
seek immediate medical intervention. Dyspnea on vigorous exertion and fatigue the day
after a rigorous walk are expected.)
Which action by a client who requires an above-the-knee amputation for peripheral
arterial disease best indicates emotional readiness for the surgery?
a. Explains the goals of the procedure
b. Displays few signs of anticipatory grief
c. Participates in learning perioperative care
d. Verbalizes acceptance of permanent dependency needs
(Active participation in learning self-care indicates emotional acceptance of the need for
surgery and planning for the future after surgery. Explaining the goals of the procedure
may indicate intellectual readiness but not necessarily emotional readiness. A client
who displays no signs of grief with a loss like amputation may be in denial. The client
need not be dependent permanently; verbalizing acceptance of permanent dependency
needs indicates the need for more teaching and emotional support.)
When preparing to give medications to a client, the nurse notes a prescription for
digoxin 2.5 mg by mouth daily. The digoxin is supplied as 0.125 mg tablets. Which
action would the nurse take?
a. Give two tablets.
b. Administer 20 tablets.
c. Clarify why the client is taking digoxin.
d. Consult with the primary health care provider.
(The usual dose of digoxin is 0.125 mg to 0.25 mg daily. A dose of 2.5 mg is excessive,
and the prescription should be questioned. Two tablets would equal 0.25 mg, which
may be the correct prescription, but this will need to be clarified with the primary health
care provider. Twenty tablets would equal 2.5 mg, but this would be a toxic dose of
digoxin. Clarifying why the digoxin is prescribed would not be useful, because the dose
is inappropriate for any diagnosis.)
When caring for a client who is in the postanesthesia care unit after receiving general
anesthesia, which assessment finding would be most important for the nurse to report to
the health care provider?
