aortic regurgitation HESI

Which intervention should the nurse initiate first?

1. Apply an oxygen mask on the client at 6 liters per minute.

2. Place the client on a stretcher and open the client's airway.

3. Check the client's oxygen saturation level.

4. Auscultate the client's lung sounds

ans: 2

The nurse needs to place the client on a solid, flat surface to align the client's airway to a neutral position. This will allow for visual inspection to assess for obstruction.

As the client is transferred to a stretcher the nurse notices the use of accessory muscles of the chest and neck and an exaggerated effort to breathe. Which intervention should the nurse implement first?

1. Raise the head of the stretcher to semi-Fowler's position.

2. Apply a partial rebreather mask with oxygen at 10 liters per minute.

3. Auscultate the client's lungs bilaterally to assess for diminished breath sounds.

4. Monitor the client's oxygen saturation level.

ans: 1

The first intervention is to raise the head of the stretcher to semi-Fowler's position, which allows for full expansion of the client's lungs. It also takes pressure off the diaphragm, enhancing the delivery of oxygen to the lungs.

Which intervention is most important for the nurse to include in the client's plan of care to decrease the risk for myocardial infarction?

1. Arrange a follow-up appointment with a healthcare provider.

2. Obtain a consult for a social worker to provide community resources.

3. Call the local pharmacy to identify the antihypertensive that the client was prescribed.

4. Identify the client's risk factors for having an acute myocardial infarction.

ans: 4

Identifying and informing the client of the risk factors that can be modified is priority. Smoking, drinking, and hypertension are modifiable and/or controllable risk factors. Family history will also increase the client's risks.

The nurse completes a problem-focused assessment. Which finding warrants immediate intervention by the nurse?

1. Irregularly irregular atrial dysrhythmia.

2. Progressive weight gain.

3. Fatigue with usual activities.

4. Dyspnea with mild excretion

ans: 1

An irregularly irregular atrial dysrhythmia, known as atrial fibrillation, is a complication of heart failure. Atrial fibrillation increases as the severity of heart failure increases. It also promotes thrombus formation within the atria, which can break loose and place the client at risk for a life-threatening stroke.

The ED nurse looks up the prescribed medications and notes that the recommended dosage for losartan is 50 mg PO daily or 25 mg PO daily in combination with a diuretic. A precaution listed for this medication is increased risk of hypotension and syncope with concurrent use of angiotensin-converting enzyme (ACE) inhibitors. What action should the nurse implement?

1- Acknowledge the losartan medication prescription.

2- Contact the HCP to clarify the medication prescriptions.

3- Administer the medications after the pharmacy verifies the orders.

4- Prepare the first dose of losartan to be administered.

ans: 2

The nurse is responsible for researching potential drug interactions and verifying that the prescribed medication reflects the appropriate dose and route prior to administering it to the client.

The HCP plans to keep the client in the hospital for a few days. The ED nurse is preparing to transfer the client to a medical unit. Which intervention should the nurse implement first?

1. Call to provide a report to the receiving nurse.

2. Document the transfer in the medical record.

3. Obtain and apply portable oxygen.

4. Administer the first dose of prescribed medications.

ans: 1

Notifying the receiving nurse of readiness to transfer will alert all the nurses to obtain any needed equipment prior to the client's arrival on the medical unit. Hand-off communication is priority.

Based on the diagnostic findings with the physical assessment of dullness with percussion, which assessment finding warrants immediate intervention by the nurse?

1. Progressive dry cough.

2. Decreased breath sounds.

3. Use of accessory muscles.

4.Dyspnea on exertion.

ans: 3

Use of accessory muscles is a sign that the client is failing to compensate and may require life-saving measures.

The severity of the client's pleural effusions are confirmed with the enlarged cardiac silhouette on the chest x-ray. The client is having difficulty taking deep breaths and is short of breath when speaking. Which intervention is most important for the nurse to include in the client's plan of care?

1. Daily weights.

2. Sodium restricted diet.

3. Daily fluid restrictions.

4. High Fowler's position.

ans: 4

Positioning the client to promote ease of breathing is immediately effective and a priority while treating the underlying cause.

The client is having periods of confusion and appears weak and fatigued. The client tells the nurse they feel like their heart is fluttering at times. Which laboratory value could be related to the client's symptoms? (Select all that apply.)

Select all that apply

1. Sodium.

2. Potassium.

3. Chloride.

4. Blood urea nitrogen (BUN).

5. Phosphorus.

ans: 1,2,4,5

Common symptoms of low sodium (hyponatremia) include confusion, lethargy, headache, and dizziness. Common symptoms of low potassium (hypokalemia) include weakness, fatigue, and palpitations. Common symptoms of high BUN levels include fatigue, edema, shortness of breath, confusion, and dehydration. Common symptoms of high phosphorus (hyperphosphatemia) include fatigue, shortness of breath, anorexia, nausea, vomiting, and sleep disturbances.

The nurse notices that the client's urine is green in appearance when a urine sample is collected. Which intervention should the nurse implement? (Select all that apply.)

Select all that apply

1. Notify the HCP.

2. Recollect the urine sample to be analyzed again.

3. Ask the client to list the food he has eaten in the last 24 hours.

4. Record the color and amount of urine in the medical record.

5. Prepare to place a urinary catheter.

ans: 3,4

Certain foods, such as asparagus and black licorice, as well as medications, such as cimetidine and indomethacin, can cause urine to appear green. The appearance of the urine needs to be documented, along with information the client provides about oral intake from the previous 24 hours.

The client is transferred from the ED to the medical unit. The ED nurse gives the admitting nurse a hand-off report. Which nursing intervention best promotes effective communication?

1. Relay a complete review of the client's past medical history.

2. Report on all abnormal laboratory and diagnostic procedure results.

3. Use the SBAR (Situation-Background-Assessment-Recommendation) technique when reporting to the receiving nurse.

4. Elaborate on the history of smoking and alcohol consumption.

ans: 3

The SBAR (Situation-Background-Assessment-Recommendation) technique provides a systematic, effective way to provide information when a client is moving within units of the hospital. SBAR is a way to communicate the client's condition among members of the healthcare team that is predictable and structured.

The client is settled in and the nurse is planning the client's care. Based on the prescriptions provided, which action should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) Select all that apply

1- Weigh the client on the medical unit's scale.

2- Place the cardiac monitor on the client.

3- Put a fluid restriction sign at the head of bed.

4- Set up the oxygen delivery system at 10 L/minute.

5- Adjust the oxygen rate if oxygen saturation decreases while ambulating.

ans: 1,2,3

This is within the scope of responsibility for the UAP. Delegation standards and scope of practice may vary by state and country.

After reviewing the prescriptions and laboratory results, which intervention should the nurse include in the client's plan of care? (Select all that apply.) Select all that apply

1. Keep the client on bed rest until oxygen can be weaned.

2. Ensure NPO instructions are clarified with the HCP.

3. Discuss a plan to correct abnormal laboratory values with HCP.

4. Increase the frequency of vital signs.

5. Clarify the rate of IV fluids while NPO

ans: 2,3

The client should be NPO for a minimum of 8 hours for the fasting glucose and 12 hours for the lipid profile. The client's abnormal sodium, potassium, and phosphorus need to be addressed. Abnormalities can cause cardiac irritability and lethal arrhythmias.

The nurse administered the first doses of digoxin and furosemide at 0800. What is the earliest time the second dose of digoxin can be given?

1. In the morning with breakfast.

2. 0815 as instructed.

3. 1400 as instructed.

4. 0900 as instructed.

ans: 3

Pay attention to order details. First and second doses of the digoxin prescription are loading doses. The second dose should be administered 6 hours after the first dose at 1400

The nurse verified the prescriptions and the dose to be given to the client. When preparing to administer the furosemide, which assessment finding warrants intervention by the nurse? (Select all that apply.) Select all that apply

1. Tenderness at the IV insertion site.

2. Blood pressure 160/90 mmHg.

3. Occasional premature ventricular complexes (PVCs).

4. The client's bladder.

5. The client's potassium level for any preexisting hypokalemia.

ans: 1,3,5

The IV site should be assessed a minimum of every two hours and whenever the nurse is getting ready to initiate an IV medication. Tenderness may be a sign of infection or infiltration and requires further assessment. Occasional PVCs are a sign of cardiac muscle irritability. The client has low potassium and sodium levels. Administering a diuretic will increase the urine output and may lower the value of the electrolytes more. PVCs should be reported and electrolytes assessed before administering a diuretic. Electrolytes, particularly potassium, should be monitoring before and during therapy.

It is important for the nurse to develop a therapeutic relationship with the client. When conducting the admission interview, what action best facilitates the process? (Select all that apply.) Select all that apply.

1- Clarify information by asking the client more focused questions.

2- Stand at the foot of the client's bed to conduct the interview.

3- Reassure the client that everything will be alright and that he is going to get better.

4- Let the client do most of the talking and actively listen.

5- Use open-ended questions that will allow the client to "lead" the conversation.

ans: 1,4,5

Accepting information without questioning and/or clarifying could lead to a misunderstanding and lack of pertinent information. Focused questions should we used when more specific information is needed. The most important element of effective communication is active listening. Watching, observing, and listening to the client's verbal and nonverbal commuications are very important. Open-ended questions allow the client to take the conversational lead and introduce pertinent information about a topic. Focused questions should be used when more specific information is needed in an area

Therapeutic communication involves listening and analyzing what the client is conveying. Based on the information provided by the client, which nursing intervention best promotes effective communication? (Select all that apply.) Select all that apply

1- Inquire about the client's work history and specific job duties.

2- Ask the client to elaborate on his son's line of work.

3- Assist the client in recalling his diet intake over the last few weeks.

4- Review with the client any family history of cancer.

5- Question the client regarding history of military enlistments.

ans: 1,3,4,5

Individuals who worked in naval and civilian shipyards were exposed to asbestos in the construction of naval ships, which is known to cause mesothelioma. Asbestos was also used in construction material for buildings. Studies have suggested that individuals who worked in the farming industry and were exposed to pesticides are at increased risk of developing cancers, especially prostate cancer. Because of the client's anemia, it is important to ask about protein intake. Iron deficiency anemia is the most common nutritional disorder in the world and adequate protein intake can prevent this condition. It is important to ask about the client's family history of cancer because of the risk factor for some cancers. Studies have shown that some individuals who served in Vietnam were exposed to Agent Orange (herbicide). Those individuals are more likely to develop a precursor disease to multiple myelomas.

Discharge planning starts with the admission process. With the information that the nurse has gathered, which intervention is most important for the nurse to include in the client's discharge plan?

1. Identify available community resources.

2. Ensure the client that they will have a room at the homeless shelter.

3. Teach the client about foods high in protein.

4. Schedule follow-up appointments.

ans: 1

Once the client is discharged, community resources can address his healthcare, financial, and transportation needs. The resources will be key in the client's overall well-being.

The nurse teaches the client about the medications prior to administering them. Which intervention is most important for the nurse to include regarding amlodipine and diltiazem, which are both calcium channel blockers?

1. Report any episodes of dizziness.

2. Avoid drinking grapefruit juice.

3. Tell the HCP of daily weight gain.

4. Keep a blood pressure diary.

ans: 1

Combination calcium channel blocker therapy is prescribed to better control the client's blood pressure. Since amlodipine and diltiazem are both calcium channel blockers, it is important for the client to report side effects such as dizziness, which may be a sign of low blood pressure. A very low heart rate may also occur, which will require an adjustment in the client's medications and/or dosages. While in the hospital and on a cardiac monitor, the nurse should monitor for a low, irregular heart rate.

Calcium channel blockers enhance the action of digoxin by increasing the serum digoxin levels. Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?

1. Low potassium level.

2. Yellow halos around lights.

3. Slow heart rate.

4. Increased liver function tests.

ans: 2

Early signs of toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and visual changes.

During client education, the client reports to the nurse that though breathing is easier, they do not like the dizzy feeling they experience when changing positions or getting out of bed. Which nursing intervention best addresses this issue?

1- Tell the client to change positions quickly to minimize the dizziness.

2- Explain to the client that the symptoms should start to decrease as the body gets used to the medications.

3- Hold the medications and ask the HCP to decrease the dose of the medications to lessen the effect.

4- Instruct the client to change positions, sit up, and stand slowly.

ans: 4

This is a common side effect of the medications. The client needs to be educated about orthostatic hypotension. The client should be taught to change positions slowly

Later that day, the client reports to the nurse less abdominal pain and nausea, a severe headache, blurry vision, and feeling really tired. The nurse assesses the client and notes an irregular heart rate of 56 bpm. Which laboratory test does the nurse anticipate the HCP will prescribe for the client? (Select all that apply.) Select all that apply

1. Digoxin serum level.

2. Sodium level.

3. Potassium serum level.

4. Phosphorus serum level.

5. Calcium serum level.

ans: 1,3

The client is prescribed digoxin and is concurrently taking captopril and diltiazem, which has the potential to increase the levels of the digoxin, leading to toxic levels. Low potassium levels increase the chance of digoxin toxicity. Furosemide may cause hypokalemia, which increases the potential of the occurrence of digoxin toxicity.

The nurse assesses the client's fall risk factors and determines a moderate fall risk. What change in the client's care should the nurse tell him to expect? (Select all that apply.) Select all that apply

1. Two side rails up while in bed.

2. Four side rails up at all times.

3. Soft wrist restraints tied loosely.

4. A UAP will assist with trips to the bathroom.

5. Non-skid footwear to be worn while out of bed.

ans: 1,4,5

For a low to high fall risk, two side rails should be up as a reminder to call for assistance unless the client is in the intensive care unit. Supervision and assistance to the bathroom is required while on moderate fall risk precautions. Use of properly fitting nonskid footwear decreases the risk of falling when the client is walking, especially when unsteady.