NUR 213 Health Exam

Correct Answer: A. "I will wake my child for feeding every 2 hours so he can get enough calories to gain weight."

Explanation

Waking the child every 2 hours for feeding increases cardiac demands, leading to fatigue and excessive energy expenditure. Infants with congenital heart defects (CHDs) already have compromised cardiac function, and frequent feeding may worsen their condition by causing increased metabolic stress. Instead, parents should focus on feeding techniques that conserve energy, such as feeding in a semi-upright position, using a high-calorie formula, or considering supplemental tube feedings if necessary.

Explanation of Incorrect Options:

B. "When I give the digoxin, I will listen to the pulse for 1 full minute."

This is correct teaching. Digoxin slows the heart rate and improves cardiac efficiency, so the pulse must be monitored for a full minute before administration. If the heart rate is too low, the dose may need to be held to prevent bradycardia.

C. "I should protect my child from people who have respiratory infections."

This is correct teaching. Children with CHDs are more prone to respiratory infections, which can worsen their condition by increasing cardiac workload and oxygen demand. Avoiding exposure to infections is essential to prevent complications.

D. "I will count the number of wet diapers to be sure my child is not getting too much or too little fluid."

This is correct teaching. Monitoring urine output helps assess hydration and fluid balance, which is crucial in managing heart failure and preventing fluid overload or dehydration.

Summary:

The parent needs more teaching because waking the child every 2 hours for feeding increases cardiac demands, leading to fatigue and worsening heart function. Instead, high-calorie feedings and energy conservation strategies should be used. Monitoring pulse with digoxin, preventing infections, and tracking urine output are all appropriate actions for managing a child with CHD.

Correct Answer:

B) The patient is infected with HIV but lacks HIV-specific antibodies.

Explanation:

The primary infection stage of HIV, also called acute HIV infection or acute retroviral syndrome, occurs 2 to 4 weeks after exposure to the virus. During this time:

• The virus rapidly replicates in the body.


• The immune system has not yet produced detectable HIV-specific antibodies, meaning standard HIV antibody tests (such as ELISA) may not detect the infection.


• Some patients experience flu-like symptoms (fever, swollen lymph nodes, rash, sore throat), while others remain asymptomatic.


• The viral load is very high, making the person highly infectious even if they feel well.

This stage progresses into the chronic (latent) phase once the immune system begins producing antibodies.

Why the Other Choices Are Incorrect:

• A) "The patient's HIV antibodies are successfully, but temporarily, killing the virus."
  
  
  
  
  • Incorrect. The immune system has not yet produced HIV-specific antibodies during the primary infection stage. Antibody production occurs weeks later in the chronic phase. Additionally, while the immune system fights the virus, it cannot eliminate HIV completely.
  
  
  
  


• C) "The patient's risk for opportunistic infections is at its peak."
  
  
  
  • Incorrect. Opportunistic infections (e.g., Pneumocystis pneumonia, Kaposi’s sarcoma) occur in late-stage HIV/AIDS, when the CD4+ T-cell count falls below 200 cells/mm³. In the primary infection stage, the immune system is still functioning relatively well, so the risk for opportunistic infections is low.
  
  
  
  


• D) "The patient may or may not develop long-standing HIV infection."
  
  
  
  • Incorrect. Once infected, a person will have HIV for life unless they receive an extremely rare, complete HIV cure (e.g., through experimental treatments like bone marrow transplants). The infection does not "go away", though antiretroviral therapy (ART) can control it.
  
  
  
  

Summary:

In the primary infection stage of HIV, the virus is actively replicating, but HIV-specific antibodies are not yet detectable (B is correct). Opportunistic infections are not a concern at this stage, and HIV infection is lifelong once acquired.

Correct Answer: A. "Avoid using salt substitutes."

Explanation:

Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor used to treat heart failure (HF) and hypertension by lowering blood pressure and reducing cardiac workload. ACE inhibitors can cause potassium retention, leading to hyperkalemia (high potassium levels). Many salt substitutes contain potassium chloride, which can increase potassium levels dangerously, potentially leading to arrhythmias or cardiac complications.

Why the Other Options Are Incorrect:

B. "Take your medication with food." – While some medications should be taken with food, enalapril does not require food for absorption and can be taken with or without meals.

C. "Avoid using aspirin-containing products." – Low-dose aspirin (81 mg) is generally safe for heart failure patients. However, high doses of NSAIDs (like ibuprofen or full-dose aspirin) should be avoided because they can cause fluid retention and worsen heart failure.

D. "Check your pulse daily." – While some heart medications (e.g., beta-blockers, digoxin) require pulse monitoring, ACE inhibitors do not directly affect heart rate, so routine pulse checks are unnecessary.

Summary:

Clients taking enalapril should avoid salt substitutes because of the risk of hyperkalemia, which can cause dangerous cardiac complications.

Correct Answers: A, B, E, F. 

✅ (a) Hematocrit: 32.8%

✅ (b) Serum sodium: 130 mEq/L

✅ (e) Proteinuria

✅ (f) Microalbuminuria

Explanation:

Heart failure (HF) leads to fluid retention, kidney dysfunction, and poor tissue perfusion, which can cause various laboratory abnormalities.

• (a) Hematocrit: 32.8% – Correct
  
  
  
  
  • Anemia is common in HF due to dilutional effects from fluid retention and decreased erythropoietin production. Normal hematocrit is around 37-52%, so 32.8% is low.
  
  
  
  


• (b) Serum sodium: 130 mEq/L – Correct
  
  
  
  • Hyponatremia occurs due to fluid retention and dilutional effects from excessive antidiuretic hormone (ADH) secretion.
  
  
  • Normal serum sodium is 135-145 mEq/L; 130 mEq/L is low, indicating fluid overload.
  
  
  
  


• (e) Proteinuria – Correct
  
  
  
  • Heart failure affects kidney perfusion, leading to kidney dysfunction and protein leakage into the urine.
  
  
  
  


• (f) Microalbuminuria – Correct
  
  
  
  • Early kidney damage in HF leads to albumin leakage, which is an early marker of worsening heart failure.
  
  
  
  

Why the Other Options Are Wrong:

• (c) Serum potassium: 4.0 mEq/L – Incorrect
  
  
  
  
  • Normal potassium is 3.5-5.0 mEq/L. A level of 4.0 mEq/L is within the normal range, so this is not expected to be abnormal in heart failure.
  
  
  • Potassium abnormalities may occur if the patient is taking diuretics (low K⁺) or ACE inhibitors (high K⁺), but this specific value is normal.
  
  
  
  


• (d) Serum creatinine: 1.0 mg/dL – Incorrect
  
  
  
  • Normal creatinine is 0.6-1.2 mg/dL. A level of 1.0 mg/dL is within normal limits, meaning no significant kidney dysfunction is present.
  
  
  • In severe heart failure, creatinine may rise due to poor kidney perfusion, but this particular value is not abnormal.
  
  
  
  

Summary:

Expected abnormal lab findings in heart failure include low hematocrit (a), low serum sodium (b), proteinuria (e), and microalbuminuria (f). Potassium (c) and creatinine (d) are normal in this case but may become abnormal depending on the severity of heart failure and medications used.

Correct Answer

a. Assess the client's blood pressure and level of consciousness.

Explanation:

Inferior wall myocardial infarctions (MI) are often associated with conduction abnormalities, particularly bradyarrhythmias such as sinus bradycardia, first-degree AV block, second-degree AV block (Mobitz I), or complete heart block.

The priority action is to assess the client's hemodynamic stability, which includes:

• Blood pressure (BP) – to determine if cardiac output is sufficient


• Level of consciousness (LOC) – to assess cerebral perfusion


• Other signs of poor perfusion, such as cool, clammy skin or decreased urine output

If the client is hemodynamically unstable (e.g., low BP, altered LOC, symptoms of shock), immediate intervention such as IV atropine or temporary pacing may be required.

Why the other options are incorrect:

• b. Call the health care provider or the Rapid Response Team.
  
  
  
  
  • Incorrect—Although calling for help is important, assessment must come first to determine the severity of the situation. If the client is stable, immediate escalation may not be necessary.
  
  
  
  


• c. Obtain a permit for an emergency temporary pacemaker insertion.
  
  
  
  • Incorrect—A temporary pacemaker is not always required unless the client is unstable or has a high-degree AV block.
  
  
  
  


• d. Prepare to administer antidysrhythmic medication.
  
  
  
  • Incorrect—Antidysrhythmic medications are not the first-line treatment for bradycardia due to an inferior MI. Atropine is typically used first if the patient is symptomatic.
  
  
  
  

Summary:

For a client with an inferior wall MI and bradyarrhythmia, the first action is to assess blood pressure and level of consciousness to determine hemodynamic stability before escalating care.

Correct Answers:

 (a) "Reposition the client every 2 hours."

 (c) "Accurately record intake and output."

 (d) "Use the same scale to weigh the client each morning."

Explanation:

When delegating tasks to an unlicensed assistive personnel (UAP), the nurse must ensure that the tasks fall within their scope of practice. UAPs can assist with routine, non-clinical, and repetitive tasks but cannot perform assessments, provide education, or make clinical decisions.

(a) "Reposition the client every 2 hours." 

UAPs can reposition clients to prevent skin breakdown and improve circulation. This is essential for CHF patients who may have reduced mobility and increased risk of pressure ulcers.

(c) "Accurately record intake and output." 

Monitoring fluid intake and output (I&O) is critical for CHF clients to assess fluid balance and prevent fluid overload. UAPs can document intake (food, fluids) and output (urine, stool, drainage) as directed.

(d) "Use the same scale to weigh the client each morning." 

Daily weight monitoring is vital for CHF clients to detect early signs of fluid retention. Using the same scale at the same time each day ensures accurate trends in weight changes. A weight gain of 2–3 lbs in a day or 5 lbs in a week may indicate worsening heart failure.

Why the Other Options Are Wrong:

(b) "Teach the client to perform deep-breathing exercises." 

Teaching is a nursing responsibility and cannot be delegated to a UAP. The nurse should provide education on breathing techniques to improve oxygenation.

(e) "Place the client on oxygen if the client becomes short of breath."

Applying oxygen requires assessment and a provider's order. The UAP should report changes in breathing, but the nurse is responsible for assessing oxygen needs and initiating oxygen therapy.

Summary:

When delegating to a UAP, the nurse should assign non-clinical, repetitive tasks that do not require assessment, education, or critical decision-making. The correct answers are (a), (c), and (d).

Correct Answer:

b. "Avoid straining while having a bowel movement."

Explanation:

The client's heart rate is 56 beats per minute, which is considered bradycardia (HR < 60 bpm). However, since the client has no adverse symptoms (such as dizziness, fatigue, or syncope), this bradycardia may be a normal variation, especially in athletes or those with good cardiovascular conditioning.

Straining during a bowel movement (Valsalva maneuver) increases vagal tone, which can further slow the heart rate by stimulating the parasympathetic nervous system (via the vagus nerve). In individuals with bradycardia, excessive vagal stimulation can lead to a more profound decrease in heart rate, potentially causing dizziness or fainting. Therefore, avoiding straining is the best modification to prevent further heart rate reduction.

Why the Other Options Are Incorrect:

a. "Make certain that your bath water is warm."

• Incorrect because cold water exposure can trigger the diving reflex, which slows the heart rate, but warm water does not have the same effect. While extremely hot water may cause vasodilation and hypotension, it does not significantly impact heart rate in a way relevant to this scenario.

c. "Limit your intake of caffeinated drinks to one a day."

• Incorrect because caffeine is a stimulant that increases heart rate rather than decreasing it. If anything, reducing caffeine intake would be more relevant in cases of tachycardia rather than bradycardia.

d. "Avoid strenuous exercise such as running."

• Incorrect because exercise actually increases heart rate and can improve cardiovascular fitness. Individuals with resting bradycardia (especially if they are asymptomatic) often have well-conditioned hearts, and avoiding exercise is unnecessary unless the client has symptoms like dizziness or fatigue.

Summary:

The Valsalva maneuver (straining during a bowel movement) stimulates the vagus nerve, further slowing the heart rate. Since the client already has bradycardia, they should avoid this activity to prevent excessive heart rate reduction. Thus, option b is the best choice. The other options either do not significantly impact heart rate or are irrelevant in this context.

Correct Answer: (b) "The heparin keeps that artery from getting blocked again."

Explanation:

Tissue plasminogen activator (t-PA) is a thrombolytic medication used to dissolve clots during a myocardial infarction (MI, heart attack) by breaking down fibrin. However, once the clot is dissolved, the client remains at risk for re-occlusion (another clot forming in the same artery).

Heparin is an anticoagulant that helps prevent new clot formation in the recently opened artery. Heparin does not dissolve existing clots but prevents the fibrin formation that can lead to clot recurrence. Administering heparin after t-PA is standard practice to maintain blood flow and prevent another blockage.

Why the Other Options Are Incorrect:

(a) "The t-PA didn't dissolve the entire coronary clot."

t-PA is highly effective in breaking down clots. If the clot wasn't fully dissolved, further intervention (e.g., PCI, stenting) would be required, not just heparin.

(c) "Heparin keeps the blood as thin as possible for a longer time."

Heparin does not "thin the blood" permanently. Instead, it prevents clot formation by inhibiting fibrin.

(d) "The heparin prevents a stroke from occurring as the t-PA wears off."

Heparin is used after an MI to prevent another clot, not specifically to prevent a stroke. Stroke prevention with anticoagulants is more common in conditions like atrial fibrillation.

Key Takeaway:

After receiving t-PA for an MI, heparin is given to prevent re-occlusion of the coronary artery. The nurse should explain this clearly to the client’s spouse to provide reassurance and understanding.

Correct Answer: B) Start infusion of Norepinephrine 4 mg/250 mL D5W

Why This Answer Is Correct:

The client is in septic shock with persistent hypotension (78/50 mmHg) and tachycardia (HR 136) despite fluid resuscitation. Norepinephrine is the first-line vasopressor for septic shock. It acts as a potent vasoconstrictor, increasing systemic vascular resistance (SVR) and improving blood pressure. It also helps maintain organ perfusion and prevents progression to multi-organ failure.

Why the Other Choices Are Incorrect:

Nitroprusside (100 mg/250 mL D5W)

Nitroprusside is a potent vasodilator used to treat hypertensive crisis and heart failure, not septic shock. In septic shock, vasodilation is already a problem, and further vasodilation would worsen hypotension and compromise organ perfusion.

Nitroglycerin (50 mg/250 mL 0.9% NS)

Nitroglycerin is a vasodilator used for angina and acute coronary syndromes. It reduces preload and myocardial oxygen demand but would further lower blood pressure in a patient with septic shock, worsening perfusion.

Dobutamine (500 mg/250 mL D5W)

Dobutamine is an inotropic agent used to improve cardiac output in heart failure and cardiogenic shock. While it may be used in septic shock with severe myocardial dysfunction, it is not the first-line treatment for hypotension. It primarily increases contractility rather than providing vasoconstriction.

Summary:

Norepinephrine is the preferred vasopressor for septic shock as it increases blood pressure through vasoconstriction, improving perfusion to vital organs. The other medications are vasodilators or inotropes, which would not adequately address hypotension in septic shock.