NUR 213 Health Exam

Correct Answer: Initiation of Aggressive Fluid Resuscitation

Rationale (Step-by-Step Analysis):

1. Recognizing Signs of Sepsis and Shock

The client's vital signs indicate progressive deterioration suggestive of septic shock:

Temperature: Increasing from 98.0°F to 103.1°F (Fever → Infection).

Pulse: Rising from 84 bpm to 132 bpm (Compensatory tachycardia).

Respirations: Becoming shallow and irregular (Sign of worsening perfusion).

Blood Pressure: Dropping from 146/88 to 94/52 (Hypotension → Decreased perfusion).

Mental Status Changes: From oriented to disoriented, indicating possible hypoperfusion to the brain

These findings align with severe sepsis progressing to septic shock, requiring immediate intervention.

2. Prioritizing the Most Effective Intervention

Initiation of Aggressive Fluid Resuscitation (Correct Choice)

First-line treatment for sepsis-induced hypotension.

Crystalloids (Normal Saline or Lactated Ringer’s) at 30 mL/kg bolus are recommended per the Surviving Sepsis Campaign to restore intravascular volume and improve perfusion.

 Administration of Acetaminophen (Incorrect Choice)

Helps reduce fever but does not address perfusion deficits.

Fever is secondary to sepsis; the priority is circulatory support.

 Administration of a Vasopressor (Incorrect at This Stage)

Norepinephrine or vasopressors are only given AFTER fluid resuscitation if the patient remains hypotensive.

Initiating vasopressors without fluids can worsen organ ischemia

 Initiation of a Blood Transfusion (Incorrect Choice)

Blood transfusions are not first-line treatment in sepsis unless severe anemia (Hb <7 g/dL) is present.

The primary issue here is fluid deficit and distributive shock, not blood loss.

Summary

Immediate aggressive fluid resuscitation is the priority intervention to restore perfusion and prevent septic shock from worsening.

Correct Answer:  b. Speech alterations

Explanation:

Atrial fibrillation (AFib) significantly increases the risk of thromboembolism, particularly stroke, because the irregular atrial contractions allow blood to pool in the atria, forming clots. If a clot embolizes and travels to the brain, it can cause an ischemic stroke, leading to neurological deficits such as speech alterations (dysarthria or aphasia), weakness, or facial drooping. A nurse assessing a client with AFib should be particularly vigilant for neurological symptoms such as:

Slurred speech or difficulty finding words

Unilateral weakness or numbness

Facial droop

Confusion or altered mental status

These signs may indicate a stroke, which is a life-threatening complication requiring immediate intervention.

Why the Other Options Are Incorrect:

a. Sinus tachycardia

Incorrect because sinus tachycardia is a separate rhythm from AFib and is not a direct complication. AFib itself is characterized by an irregularly irregular rhythm, not sinus tachycardia. While a rapid ventricular response (RVR) in AFib can lead to complications like hypotension or heart failure, it is not as immediately concerning as a stroke.

c. Fatigue

Incorrect because while fatigue is common in AFib due to decreased cardiac output, it is not an indication of a serious, life-threatening complication like stroke.

d. Dyspnea with activity

Incorrect because shortness of breath with exertion may indicate poor cardiac output or heart failure due to AFib, but it is not as immediately concerning as neurological deficits, which suggest a stroke. Stroke requires urgent intervention, whereas dyspnea is a more chronic symptom that can be managed.

Summary:

Among the listed options, speech alterations are the most alarming, as they may indicate a stroke—a severe, life-threatening complication of AFib. Stroke requires immediate medical intervention (e.g., thrombolysis or mechanical thrombectomy) to prevent permanent damage. Fatigue and dyspnea are common symptoms of AFib but do not signal an acute emergency like a stroke.

Correct Answer:

C) Wash hands with soap and water

Explanation:

Clostridium difficile (C. diff) is a spore-forming bacterium that causes severe diarrhea and colitis. Alcohol-based hand sanitizers are not effective against C. diff spores. The priority action after glove contamination is handwashing with soap and water, which physically removes the spores. After proper handwashing, the nurse should don a new pair of gloves before continuing care.

Why the Other Options Are Incorrect:

Don a clean pair of nonsterile gloves

Gloves should only be applied after proper hand hygiene. Putting on new gloves without washing hands first increases the risk of spreading C. diff spores.

Wash hands with alcohol-based hand sanitizer

C. diff spores are resistant to alcohol-based hand sanitizers. Only soap and water can effectively remove spores from the skin.

Wash hands with a bleach wipe from a nearby container

Bleach wipes are effective for disinfecting surfaces but are not meant for skin cleaning. Using bleach wipes on the hands can cause skin irritation and is not a CDC-recommended practice for hand hygiene.

Summary:

For C. diff infection control, handwashing with soap and water is the priority action after glove contamination. Alcohol-based sanitizers are ineffective, and proper glove use should follow hand hygiene.

Correct Answers: B, C, E. 

• Rigid abdomen


• Inability to pass stools


• Decreased urinary output

Explanation of Correct Answers:

Rigid abdomen

A rigid or board-like abdomen is a hallmark sign of peritonitis. This occurs due to inflammation and irritation of the peritoneal lining, causing involuntary muscle guarding. It is often accompanied by severe pain and tenderness.

Inability to pass stools

Peritonitis can lead to paralytic ileus, a condition where bowel motility slows or stops due to severe inflammation. As a result, patients may experience an absence of bowel movements and distension.

Decreased urinary output

Severe peritonitis can lead to hypovolemia and dehydration, reducing renal perfusion and resulting in oliguria (low urine output). This is often due to fluid shifts into the peritoneal cavity and third-spacing.

Explanation of Incorrect Answers:

Hyperactive bowel sounds

In peritonitis, bowel sounds are typically absent or hypoactive, not hyperactive, due to paralytic ileus. Hyperactive bowel sounds are more commonly seen in conditions like gastroenteritis or early bowel obstruction.

Frequent bowel movements

Patients with peritonitis usually experience constipation or complete bowel obstruction, rather than frequent bowel movements. The inflammation causes bowel paralysis, preventing normal passage of stool.

Summary:

The nurse assessing a patient with peritonitis should expect to find a rigid abdomen, inability to pass stools, and decreased urinary output due to inflammation, ileus, and fluid shifts. Hyperactive bowel sounds and frequent bowel movements are not typical findings.

Correct Answer:

d. Placement of central venous access

Explanation:

For a client scheduled for bypass surgery (such as coronary artery bypass grafting, or CABG), the nurse may need to prepare for the placement of central venous access. This allows for the administration of medications, fluids, and the monitoring of central venous pressure (CVP), which provides insight into the client’s circulatory status and fluid balance during the perioperative period. It is a common practice to have central venous access in clients undergoing major surgeries, particularly cardiac surgeries, to help manage these factors effectively.

Why the Other Choices Are Incorrect:

a. Administration of IV furosemide (Lasix) –

While furosemide (Lasix) may be used to manage fluid overload or heart failure symptoms, it is not a standard preoperative intervention specifically indicated for a client with an 80% right coronary artery blockage waiting for bypass surgery. In fact, furosemide could be used postoperatively if there is fluid accumulation or if heart failure develops, but it is not a priority intervention at this stage.

b. Initiation of an external pacemaker –

An external pacemaker is not routinely indicated for a client with coronary artery disease unless the client develops bradycardia or other specific arrhythmias that require pacing. It is not a typical preoperative intervention for a client scheduled for coronary artery bypass surgery unless there is an indication of electrical conduction problems.

c. Assistance with endotracheal intubation –

Endotracheal intubation is usually performed in the operating room during anesthesia induction, rather than being a preparation step by the nurse before surgery. The nurse may assist in preoperative assessments, but intubation is not a direct responsibility in the waiting phase before surgery unless there are specific concerns such as respiratory distress.

Summary:

The correct answer is d. Placement of central venous access because it is common practice to establish central venous access in clients undergoing major cardiac surgery to monitor fluid status and administer medications. The other interventions, such as furosemide administration, pacemaker initiation, and endotracheal intubation, are not routine preoperative interventions for this scenario.

Correct Answer:

B Pantoprazole

Explanation:

Pantoprazole is a proton pump inhibitor (PPI), a class of medications that reduce stomach acid production by blocking the H+/K+ ATPase enzyme in gastric parietal cells. PPIs are commonly prescribed for peptic ulcers, gastroesophageal reflux disease (GERD), and Zollinger-Ellison syndrome to promote healing and prevent ulcer recurrence.

Why the Other Options Are Incorrect:

1. Cimetidine – This is an H2 receptor antagonist (H2RA), not a PPI. It works by blocking histamine receptors in the stomach to reduce acid production but is less potent than PPIs.


2. Ranitidine – Another H2 receptor antagonist, previously used for acid suppression but withdrawn from many markets due to safety concerns related to contamination with NDMA, a probable carcinogen.


3. Famotidine – Also an H2 receptor antagonist, which can reduce acid production but is not as effective as PPIs in treating peptic ulcers.

Summary:

The nurse should anticipate the provider ordering Pantoprazole, as it is a proton pump inhibitor (PPI) and is more effective than H2 receptor antagonists in reducing stomach acid and promoting ulcer healing.

Correct Answer:

A. I get short of breath when I climb stairs.

Explanation:

Shortness of breath (dyspnea) is one of the most common symptoms of heart failure, particularly during physical activity like climbing stairs. This occurs because the heart is unable to pump blood efficiently, leading to fluid buildup in the lungs (pulmonary congestion) and reduced oxygen exchange, causing difficulty breathing. Exertional dyspnea, which worsens with physical activity, is a hallmark of left-sided heart failure.

Why the Other Choices Are Incorrect:

b. I see halos floating around my head –

This statement could indicate a visual disturbance associated with digoxin toxicity or other conditions, but it is not directly related to heart failure. Visual disturbances like halos are more commonly associated with medications like digoxin or issues with the eyes (e.g., cataracts or glaucoma), not heart failure itself.

c. I have trouble remembering things –

Memory problems or cognitive difficulties may occur in various conditions, including heart failure (especially in advanced stages, sometimes referred to as "cardiac encephalopathy"), but it is not a primary or early sign. Memory problems can also result from stress, medication side effects, or other illnesses.

d. I have lost weight over the past month –

Weight loss is not typically associated with heart failure in its early stages. In fact, fluid retention and weight gain are more common in heart failure due to the body holding onto excess fluid. Unexplained weight loss could indicate other conditions, such as cancer, hyperthyroidism, or malnutrition, but it is not characteristic of heart failure.

Summary:

The correct answer is a. I get short of breath when I climb stairs, as dyspnea on exertion is a classic symptom of heart failure due to fluid buildup in the lungs. The other options—visual disturbances, memory problems, and weight loss—are not directly indicative of heart failure and may signal other medical conditions.

Correct Answer: "Drink at least 8 ounces of water when you take the pyrazinamide tablet."

Why It Is Correct:

Pyrazinamide can cause hyperuricemia (elevated uric acid levels), leading to gout-like symptoms. Drinking at least 8 ounces of water helps flush out excess uric acid and reduces the risk of developing gout or kidney issues. Staying well-hydrated also supports kidney function and helps the body process the medication more efficiently.

Why the Other Choices Are Incorrect:

"Provide a sputum specimen every 2 weeks to the clinic for testing.

Incorrect because:

TB sputum testing is usually done monthly, not every 2 weeks. The frequency of testing depends on clinical progress and guidelines, but biweekly testing is not a standard recommendation.

"Take isoniazid with an antacid."

Incorrect because:

Isoniazid should be taken on an empty stomach (1 hour before or 2 hours after meals) for best absorption. Antacids, especially those containing aluminum, interfere with isoniazid absorption, making it less effective.

"Expect your sputum cultures to be negative after 6 months of therapy."

Incorrect because:

While most TB patients show negative sputum cultures after 6 months, this is not guaranteed for all patients. Some may require longer treatment, especially if they have drug-resistant TB or a weakened immune system (e.g., HIV/AIDS). The response to therapy is monitored through regular sputum cultures and clinical improvement, rather than assuming a set timeline.

Summary:

Correct Answer: Drinking at least 8 ounces of water with pyrazinamide helps prevent uric acid buildup and gout-like symptoms. Sputum testing is typically done monthly, not every 2 weeks. Isoniazid should be taken on an empty stomach, not with antacids. Sputum cultures often turn negative after 6 months, but this is not always the case for all patients.

Correct Answer:

C) Partial-thickness skin loss with red tissue in wound bed.

Explanation:

A Stage 2 pressure injury is characterized by:

• Partial-thickness skin loss involving the epidermis and/or dermis


• The wound bed appears red or pink, may be moist, and can present as an open ulcer or an intact or ruptured blister


• No slough, eschar, or exposed deeper tissues (muscle, bone, or fat)

Why the Other Options Are Incorrect:

1. Full-thickness skin loss with visible bone – Incorrect
   
   
   
   
   • This describes a Stage 4 pressure injury, which involves exposed bone, tendon, or muscle.
   
   
   
   


2. Intact skin with localized erythema – Incorrect
   
   
   
   • This describes a Stage 1 pressure injury, where the skin remains intact but is non-blanchable with redness.
   
   
   
   


3. Full-thickness skin loss with visible adipose tissue – Incorrect
   
   
   
   • This describes a Stage 3 pressure injury, which extends through the full thickness of the skin but does not expose bone or muscle.
   
   
   
   

Summary:

A Stage 2 pressure injury presents as partial-thickness skin loss with red, viable tissue in the wound bed. It does not involve full-thickness skin loss, adipose tissue, or exposed bone.