NUR 213 Health Exam

Correct Answer:

d. Allergies to iodine-based agents

Explanation:

Cardiac catheterization often involves the use of contrast dye (iodine-based agents) to visualize the coronary arteries and assess heart function. Before the procedure, it is critical to assess for any allergies to iodine or contrast agents, as reactions can range from mild (e.g., rash, itching) to severe (e.g., anaphylaxis). If the client has an allergy to iodine, the healthcare provider may need to choose an alternative contrast agent or take other precautions to prevent a reaction.

Why the Other Choices Are Incorrect:

a. Client's level of anxiety –

While anxiety is common before procedures like cardiac catheterization, it is not as immediately critical as identifying allergies to contrast dye. However, assessing and addressing anxiety is important for providing support and may help improve the overall experience for the client, but it is secondary to confirming allergies.

b. Ability to turn self in bed –

While mobility might be relevant after the procedure (since clients are typically restricted from moving the affected leg post-catheterization), the ability to turn in bed is not a priority assessment before the procedure. The nurse should be more concerned with ensuring the client is prepared for the procedure itself.

c. Cardiac rhythm and heart rate –

Cardiac rhythm and heart rate should indeed be assessed before the procedure, but it is not as urgent as confirming allergies to iodine-based contrast agents. The nurse can monitor the client's rhythm during the procedure, but knowledge of any iodine allergies is more critical to prevent a potentially life-threatening reaction.

Summary:

The correct answer is d. Allergies to iodine-based agents, as knowing if the client has an allergy to iodine is essential to avoid a severe allergic reaction during the cardiac catheterization. While assessing anxiety, mobility, and cardiac rhythm are important, identifying any allergy to contrast agents is the highest priority before proceeding with the procedure.

Priority Orders (Select 4)

1️⃣ Cefepime 2 grams IV every 12 hours ✅

• Rationale: Broad-spectrum IV antibiotics should be initiated as soon as sepsis is suspected. Early antibiotic administration is critical in preventing worsening infection and sepsis-related complications.

2️⃣ Stat lactate level ✅

• Rationale: Elevated lactate levels indicate tissue hypoxia and worsening sepsis. A lactate level >2 mmol/L suggests possible sepsis, and >4 mmol/L indicates septic shock, requiring immediate intervention.

3️⃣ Obtain a set of blood cultures ✅

• Rationale: Before starting antibiotics, blood cultures must be obtained to identify the causative organism and ensure appropriate antibiotic therapy.

4️⃣ Discontinue indwelling catheter ✅

• Rationale: The catheter is a likely source of infection, and removal helps reduce bacterial colonization and prevent further complications.

Non-Priority Orders (Not Selected)

Fingerstick glucose every 6 hours

• Rationale: Hyperglycemia can occur in stress responses, but glucose monitoring is not a primary intervention in suspected sepsis.

Discontinue Furosemide

• Rationale: Stopping diuretics abruptly in a CHF patient could lead to fluid overload. The provider should reassess fluid balance first.

1000mL Lactated Ringer's at 170mL/hr

• Rationale: Aggressive fluid resuscitation must be carefully considered in a CHF patient, as excess fluids may worsen heart failure. A more cautious approach with monitoring would be preferred.

Final Priorities

✅ Administer IV Cefepime

✅ Obtain stat lactate level

✅ Draw blood cultures

✅ Discontinue the indwelling catheter

💡 These actions align with the Surviving Sepsis Campaign and focus on infection control, identifying severity, and initiating treatment

Correct Answer:

A) Hemorrhage and shock

Explanation:

• Restlessness, cold/clammy skin, pallor, and moist skin are early signs of hemorrhage and shock, particularly hypovolemic shock due to blood loss.


• Hypovolemic shock occurs when there is inadequate blood volume, leading to decreased oxygen delivery to tissues and organs.


• As blood loss progresses, other signs may include tachycardia, hypotension, weak pulse, decreased urine output, and altered mental status.

Why the Other Choices Are Incorrect:

B) Aspiration

• While restlessness can be a sign of hypoxia or airway obstruction, the patient’s symptoms (cold, moist, pale skin) are more indicative of circulatory compromise rather than respiratory distress.


• Aspiration typically presents with coughing, wheezing, respiratory distress, or decreased oxygen saturation.

C) Postoperative infection

• Infection does not typically present immediately in the PACU.


• Signs of infection (fever, warmth, redness, purulent drainage) take hours to days to develop, not immediately after surgery.


• Restlessness and pallor are not classic signs of infection.

D) Hypertension and dysrhythmias

• While hypertension and dysrhythmias can cause restlessness, they are not usually associated with cold, moist, and pale skin.


• Hypertension is more likely to present with warm, flushed skin, headaches, and possibly dizziness.

Summary:

Restlessness, cold/clammy skin, and pallor are early signs of hemorrhage and hypovolemic shock, which is a medical emergency. The nurse should immediately assess vital signs, check for active bleeding, notify the provider, and prepare for possible interventions such as fluid resuscitation and blood transfusion.

Correct Answer:  A. Oliguria

Explanation:

Hypovolemic shock occurs when there is a significant loss of blood or fluids, leading to decreased perfusion to organs and tissues. The body compensates by redirecting blood to vital organs (brain and heart), reducing blood flow to the kidneys, which results in oliguria (low urine output, typically <30 mL/hr).

Decreased renal perfusion → Activation of the renin-angiotensin-aldosterone system (RAAS) → Water and sodium retention → Reduced urine output

A key sign of worsening shock is progressive oliguria or anuria (complete lack of urine output).

Why the Other Choices Are Incorrect:

Flushing of the skin

Hypovolemic shock typically causes cool, pale, and clammy skin due to peripheral vasoconstriction as the body tries to maintain blood flow to vital organs. Flushed skin is more characteristic of early septic shock, not hypovolemic shock.

Hypertension

Hypovolemic shock causes hypotension, NOT hypertension. Loss of blood volume reduces cardiac output, leading to low blood pressure. If shock progresses, hypotension worsens, leading to organ failure and death if untreated.

Bradypnea

Hypovolemic shock initially causes tachypnea (rapid breathing) as the body attempts to increase oxygen delivery and compensate for decreased blood volume. Bradypnea (slow breathing) occurs in later stages when shock progresses to respiratory failure but is not an expected early finding.

Summary:

The expected finding in hypovolemic shock is oliguria (low urine output) due to decreased kidney perfusion. Other signs include hypotension, tachypnea, pale/cool skin, and tachycardia. Flushed skin, hypertension, and bradypnea are NOT typical findings.

Correct Answer: 

D) Heart rate

Why It Is Correct:

• A decrease in heart rate is a key sign of adequate fluid resuscitation.


• In severe burns, hypovolemia causes tachycardia (increased heart rate) as a compensatory response to maintain cardiac output.


• When fluid resuscitation is effective, intravascular volume is restored, tissue perfusion improves, and heart rate decreases to a normal range.

Why the Other Choices Are Incorrect:

1. Blood Pressure (BP)
   
   
   
   
   • Incorrect because:
     
     
     
     
     • Blood pressure may not decrease as an early indicator of fluid resuscitation effectiveness.
     
     
     • BP is often maintained due to compensatory vasoconstriction, even when hypovolemia is present.
     
     
     • A stable or increasing BP may indicate improving fluid status, but a decrease would suggest worsening shock.
     
     
     
     
   
   
   
   


2. Weight
   
   
   
   • Incorrect because:
     
     
     
     • Weight may initially increase due to large volumes of IV fluids administered for resuscitation.
     
     
     • Burn patients experience fluid shifts (third-spacing), so weight changes are not an immediate indicator of adequate resuscitation.
     
     
     • Fluid retention in tissues makes weight unreliable for early assessment.
     
     
     
     
   
   
   
   


3. Urine Output
   
   
   
   • Incorrect because:
     
     
     
     • Urine output should increase with adequate fluid resuscitation, not decrease.
     
     
     • Oliguria (low urine output) is a sign of inadequate perfusion and ongoing shock.
     
     
     • Adequate resuscitation is confirmed when urine output reaches at least 30-50 mL/hr in adults.
     
     
     
     
   
   
   
   

Summary:

• Correct Answer: Heart rate—a decrease in HR signals improved circulatory status and effective fluid resuscitation.


• BP changes are not the best early indicator of resuscitation effectiveness.


• Weight can fluctuate due to fluid shifts and resuscitation.


• Urine output should increase, not decrease, with proper fluid replacement.

Correct Answers: B, C, D, E. 

✅ Inspect the sacrum for blanching

✅ Frequent turning and positioning

✅ Optimizing nutrition

✅ Frequent skin assessments

Correct Answers and Explanations:

Inspect the sacrum for blanching

Inspecting the sacrum for blanching is crucial in the early detection of pressure injuries. Blanching refers to the temporary whitening of the skin when pressure is applied, indicating adequate blood flow. If an area does not blanch, it may suggest the beginning of a pressure injury. Early identification allows for timely intervention, such as repositioning and pressure relief, to prevent further skin breakdown.

Frequent turning and positioning

Regular repositioning, ideally every two hours, helps redistribute pressure and reduce prolonged compression on bony prominences such as the sacrum, heels, and elbows. This prevents ischemia, which can lead to tissue damage and ulcer formation. Additionally, using pillows or foam wedges to offload pressure points can further reduce the risk of pressure injuries.

Optimizing nutrition

Proper nutrition plays a significant role in skin integrity and wound healing. Protein is essential for tissue repair, while adequate calorie intake ensures that the body has enough energy to maintain healthy skin. Hydration is also critical, as dehydrated skin is more prone to breakdown. Vitamins such as vitamin C and zinc support collagen formation and wound healing, reducing the risk of pressure injuries.

Frequent skin assessments

Regular skin assessments allow early identification of redness, non-blanching areas, or open wounds before they progress into more severe pressure injuries. These assessments should be done at least once per shift, focusing on areas at high risk, such as the sacrum, heels, elbows, and back of the head. If any signs of skin breakdown are noted, immediate interventions such as repositioning, use of barrier creams, and pressure-relieving devices should be implemented.

Incorrect Answer and Explanation:

Maintaining the head of the bed at a 45-degree angle

Keeping the head of the bed at a 45-degree angle increases shear and friction forces, especially on the sacrum and lower back. This can contribute to skin breakdown and pressure injury formation. Instead, the head of the bed should be kept at 30 degrees or lower whenever possible to reduce these forces while still maintaining comfort and preventing aspiration, especially in patients at risk for aspiration pneumonia.

Summary:

To effectively reduce the incidence of pressure injuries in hospitalized clients, nurses should conduct frequent skin assessments, inspect for blanching, reposition the patient regularly, and ensure optimal nutrition and hydration. The head of the bed should not be elevated beyond 30 degrees to prevent increased shear and friction, which can accelerate skin breakdown.

Correct Answer: A) Administer antidiarrheal medications on a scheduled basis, as ordered.

Explanation:

Severe diarrhea in HIV/AIDS patients can be caused by opportunistic infections (e.g., Cryptosporidium, CMV, Mycobacterium avium complex), medication side effects, or HIV enteropathy. Uncontrolled diarrhea can lead to dehydration, malnutrition, and electrolyte imbalances, making its management a priority. Administering antidiarrheal medications (e.g., loperamide, diphenoxylate/atropine) on a scheduled basis, as prescribed, is the most effective way to manage persistent diarrhea and improve the patient’s quality of life.

Why the Other Choices Are Incorrect:

B) Encourage the patient to eat three balanced meals and a snack at bedtime:

 While proper nutrition is important, small, frequent meals with bland, low-fiber foods (such as bananas, rice, applesauce, and toast) are better tolerated than large meals in patients with severe diarrhea.

C) Increase the patient's oral fluid intake:

Partially correct but not the best choice. Hydration is important to replace fluid losses, but without addressing the cause of diarrhea, the patient will continue losing fluids. Fluid replacement should be combined with antidiarrheal medications for effective management.

D) Encourage the patient to increase his or her activity level:

Increasing activity can worsen fatigue and fluid loss, leading to further dehydration in a patient with severe diarrhea. Rest and proper management of symptoms are more appropriate.

Summary:

For HIV/AIDS patients with severe diarrhea, administering antidiarrheal medications on a scheduled basis (A) is the most appropriate nursing intervention. Hydration and dietary adjustments are helpful but should not replace medication management. Increased activity is not recommended as it may exacerbate dehydration and fatigue.

Correct Answer: D) Pain, hypoxia, or bladder distention

Explanation:

Postoperative hypertension is common and can be caused by pain, hypoxia (low oxygen levels), or bladder distention due to urinary retention. The patient’s significant increase in blood pressure (from 112/68 mm Hg pre-op to 164/92 mm Hg post-op) suggests a stress response, likely due to unrelieved pain, inadequate oxygenation, or an overfilled bladder. Pain activates the sympathetic nervous system (SNS), leading to vasoconstriction and increased blood pressure. Hypoxia (low oxygen) can trigger a similar SNS response, leading to hypertension. Bladder distention increases sympathetic nervous activity, causing elevated blood pressure and discomfort.

Why the Other Choices Are Incorrect:

A) Dysrhythmias, blood loss, and hyperthermia

Incorrect because while dysrhythmias and blood loss can impact blood pressure, they usually cause hypotension (low blood pressure), not hypertension. Hyperthermia can cause tachycardia but is not a primary cause of hypertension in a PACU patient.

B) Electrolyte imbalances and neurologic change

Incorrect because while electrolyte imbalances (e.g., hyperkalemia, hypocalcemia) can cause cardiac arrhythmias, they are not the main cause of sudden postoperative hypertension. Neurologic changes (e.g., stroke or brain injury) could lead to hypertension, but there is no evidence of these conditions in this scenario.

C) A parasympathetic reaction and low blood volumes

Incorrect because a parasympathetic reaction (vagal response) typically lowers blood pressure, not raises it. Low blood volume (hypovolemia) leads to hypotension, not hypertension.

Summary:

The most likely cause of postoperative hypertension in this patient is pain, hypoxia, or bladder distention. The nurse should assess pain levels, ensure adequate oxygenation, and check for urinary retention to determine the primary cause and intervene appropriately.

Correct Answer:

A. A 36-year-old woman with aortic stenosis

Explanation:

Left-sided heart failure (HF) occurs when the left ventricle cannot pump blood effectively to the body, leading to pulmonary congestion. Aortic stenosis causes increased afterload on the left ventricle, leading to hypertrophy, decreased cardiac output, and eventual failure of the left side of the heart. This makes the 36-year-old woman with aortic stenosis the highest-risk client.

Why the Other Options Are Incorrect:

• B. A 42-year-old man with pulmonary hypertension – Pulmonary hypertension primarily leads to right-sided heart failure due to increased resistance in the pulmonary vasculature, making it less likely to cause left-sided HF.


• C. A 59-year-old woman who smokes cigarettes daily – While smoking increases the risk of cardiovascular disease and can contribute to HF, it is not an immediate or direct cause of left-sided HF like aortic stenosis.


• D. A 70-year-old man who had a cerebral vascular accident (CVA) – A CVA (stroke) is related to vascular conditions like hypertension or embolism but does not directly cause left-sided HF.

Summary:

The client at greatest risk for left-sided heart failure is the one with aortic stenosis, as the narrowing of the aortic valve increases left ventricular workload, leading to hypertrophy and heart failure. Other options either relate more to right-sided HF or do not directly contribute to left ventricular dysfunction.