2022 - 2023 NCLEX Uworld v1 - NCSBN Exam Questions and Answers Actual Latest Grade A + This client with heart failure would need to measure weight daily, restrict sodium and fluid intake, and know how to take a pulse.(Option 3) This client is not taking warfarin, so monthly testing of INR is not indicated.(Option 4) Spironolactone is a potassium-sparing diuretic, and so increasing dietary potassium is not necessary. Angiotensin-converting enzyme inhibitors such as captopril can cause hyperkalemia.(Option 6) The client's SpO2 was 96% on room air and home oxygen has not been prescribed.
Educational objective:
The client being discharged with heart failure should receive teaching related to weight monitoring, diet, medication regimen, activity, and symptoms to report.
Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a sutureless aortic graft inside the aortic aneurysm via the femoral artery. It does not require an abdominal incision. The nurse will need to monitor the puncture sites in the groin area for bleeding or hematoma formation (Option 2). Peripheral pulses should be palpated and monitored frequently in the early post-op period and routinely afterward (Option 5). Renal artery occlusion can occur due to graft migration or thrombosis so careful monitoring of urine output and kidney function should be part of nursing care (Option 4).(Option 1) No abdominal incision is required in endovascular repair.(Option 3) Chest tubes are not required in endovascular repair.
Educational objective:
The nurse needs to monitor groin puncture sites, peripheral pulses, urine output, and kidney function in the client who has had minimally invasive endovascular repair of an abdominal aneurysm.
Immunosuppressive therapy (eg, mycophenolate, tacrolimus, corticosteroids) is required after organ transplantation to prevent acute and chronic rejection of the organ. This is a lifelong drug regimen for the transplant client, and it has adverse side effects (eg, nephrotoxicity, hepatotoxicity, infection susceptibility). Prior to surgery, the client needs to fully understand the physical, psychological, and financial commitment required. It is important for the nurse at every opportunity to emphasize strict immunosuppressive therapy compliance to prevent acute transplanted organ rejection.(Option 2) Daily weight monitoring is important for identifying signs of heart failure; however, immunosuppressive therapy compliance is the priority.(Option 3) Endomyocardial biopsies are performed regularly, in addition to routine blood tests, to check for signs of rejection. This is important for the client to know; however, it is not the priority over strict immunosuppressive therapy compliance.(Option 4) Surgical incision care and signs of infection are important teaching topics; however, prior to transplantation, it is most important to ensure that the client understands and will comply with lifelong immunosuppressive therapy.
Educational objective:
Clients on the organ donation waiting list are educated regarding strict compliance with immunosuppressive therapy, which requires a lifelong commitment to prevent acute transplanted organ rejection. 1 / 3
The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of cardiopulmonary resuscitation (CPR) to provide circulation of blood to the vital organs.The nurse should implement the pulseless arrest algorithm, allowing 30-60 seconds for the ICD to complete its therapy cycle before applying external defibrillation pads/paddles.(Option 1) Epinephrine should be administered after CPR and defibrillation.(Option 2) The ICD is firing as it was programmed to do. It should not be deactivated.(Option 4) The nurse should let the ICD work but needs to implement CPR in addition.
Educational objective:
The ICD is designed to defibrillate potentially life- threatening dysrhythmias. Although the device is able to sense electrical activity of the heart and respond, it is unable to sense or treat pulselessness. CPR should be initiated in the pulseless client with an ICD.
The client with pericardial effusion should be seen first. This client is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distension) of developing cardiac tamponade, a life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart.The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Emergency pericardiocentesis is needed. Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia.(Option 1) These are symptoms typically seen in the client with endocarditis. The nurse should further assess the murmur to see if it has worsened or changed, but this should be done after the client with pericardial effusion is seen.(Option 3) The new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable; this client is not a priority over the client with possible tamponade.Atrial fibrillation is often a chronic arrhythmia and is managed with ventricular rate control and anticoagulation.(Option 4) Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic. IV diuretics can worsen the hypotension. The client is watching TV, an indication that the client is stable. The nurse can delegate to the unlicensed assistive personnel directions for the client to stay in bed due to the hypotension until the nurse can perform further assessment.
Educational objective:
Clients with pericardial effusion should be monitored and assessed closely for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular venous distension, and pulsus paradoxus.
The nurse should first ask the client if the medications are being taken as prescribed. Sudden or abrupt discontinuation of blood pressure medications can cause rebound hypertension and a possible hypertensive crisis. A major problem in the long-term management of hypertension is poor adherence to the treatment plan. Antihypertensives can have unpleasant side effects such as fatigue, dizziness, and erectile dysfunction. The medications can also be costly for the client. The nurse should assess for all of these issues, as these can contribute to poor medication adherence.(Option 1) Some over-the-counter medications such as cold medicines can increase blood pressure. This is a question the nurse should ask the client, but only after the nurse has ascertained that the prescribed blood pressure medications are being taken. 2 / 3
(Option 3) The client should be assessed for peripheral edema during the physical assessment, but this should occur after the nurse has taken a health history.(Option 4) Stress levels can elevate blood pressure. However, this question is not as high of a priority as the other assessment information.
Educational objective:
A major problem in the long-term management of hypertension is poor adherence to the treatment plan.
A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities.
Client instructions include the following:
Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances Do not bathe or shower during the test period (Option 4) Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record (Option 3) (Option 1) The data are not generally transmitted over the phone. The client simply takes the monitor back to the HCP's office.
Educational objective:
The nurse should instruct the client with a Holter monitor to keep a diary of activities and any symptoms that occur while wearing it. The client should also be taught not to bathe during the testing period but to continue all other normal activities.
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention/evaluation (eg, notify health care provider, serial CBCs, abdominal CT).(Option 1) During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant.The transplanted heart is expected to be tachycardic (eg, 90-110/min).(Option 3) Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae.(Option 4) Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms.
Educational objective:
Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention.
- / 3