NUR 213 Health Exam

Correct Answers: C, D, F. 

Inspect urine for color, odor, and consistency

Maintain a closed drainage system

Secure the catheter to prevent movement

Why These Answers Are Correct:

Inspect urine for color, odor, and consistency

• Regular assessment of urine helps detect early signs of infection, such as cloudiness, foul odor, or sediment. Early identification allows prompt intervention to prevent complications.

Maintain a closed drainage system

• Keeping the system closed reduces the risk of introducing bacteria into the urinary tract. Opening the system increases the chance of contamination and infection.

Secure the catheter to prevent movement

• Securing the catheter prevents unnecessary friction and movement, which can cause urethral trauma and introduce bacteria into the bladder.

Why the Other Choices Are Incorrect:

Begin antibiotics

• Antibiotics are not used prophylactically for catheter-associated infections. They should only be given if an infection is confirmed through clinical symptoms and a urine culture.

Obtain a urine specimen for culture every 24 hours

• Routine urine cultures are not necessary unless there are signs of infection (e.g., fever, dysuria, foul-smelling urine). Frequent cultures increase the risk of contamination and unnecessary antibiotic use.

Flush catheter system daily

• Flushing is not recommended unless there is a blockage. Routine flushing can introduce bacteria and increase the risk of infection.

Summary:

To prevent catheter-associated urinary tract infections (CAUTIs), the nurse should inspect urine, maintain a closed drainage system, and secure the catheter. Routine antibiotic use, frequent urine cultures, and daily flushing are not recommended.

Correct Answer: D. Administer PRN acetaminophen.

Explanation:

Isosorbide mononitrate (Imdur) is a nitrate used for angina prophylaxis. Headache is a common side effect because nitrates cause vasodilation, leading to increased blood flow to the brain, which can trigger headaches. The appropriate action is to administer PRN acetaminophen (Tylenol) to relieve the headache, as this is a well-known and expected side effect of Imdur. Over time, the body develops tolerance to this effect, and headaches usually become less severe.

Why the Other Options Are Incorrect:

A. Initiate oxygen therapy.

Oxygen is not necessary for nitrate-induced headaches. It is used for clients with hypoxia or acute chest pain.

B. Hold the next dose of Imdur.

The medication should not be held unless the headache is severe and unrelieved by pain management. Stopping nitrates abruptly can cause rebound angina.

C. Instruct the client to drink water.

Hydration does not directly relieve nitrate-induced headaches. While staying hydrated is important, it will not resolve this issue.

Summary:

Since headaches are a common side effect of Isosorbide Mononitrate (Imdur) due to vasodilation, the best action is to give PRN acetaminophen (Tylenol) for symptom relief.

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 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:

(c) Stop the infusion and call the provider.

Explanation:

Tissue plasminogen activator (t-PA) is a clot-busting medication used to treat ischemic strokes, myocardial infarctions, and pulmonary embolisms by dissolving blood clots. However, it carries a major risk of intracranial hemorrhage (brain bleed).

• New-onset disorientation (confusion to person, place, and time) is a critical sign of a possible hemorrhagic stroke or bleeding in the brain.


• The priority action is to STOP the infusion immediately to prevent further bleeding.


• The next step is to call the provider STAT for urgent evaluation and possible reversal of t-PA effects.

Why the Other Options Are Incorrect:

• (a) Assess the client's pupillary responses – Incorrect
  
  
  
  
  • While assessing pupils is important, it is not the priority.
  
  
  • The first action must be to stop the t-PA to prevent worsening bleeding.
  
  
  
  


• (b) Request a neurologic consultation – Incorrect
  
  
  
  • A neurology consult may be needed, but it delays immediate intervention.
  
  
  • Stopping the infusion takes priority.
  
  
  
  


• (d) Take and document a full set of vital signs – Incorrect
  
  
  
  • Vital signs are important, but stopping t-PA must come first.
  
  
  • Bleeding can progress rapidly, so the infusion must be stopped immediately.
  
  
  
  

Key Takeaway:

Any sudden neurologic change in a client receiving t-PA is a medical emergency. The nurse must immediately stop the infusion and call the provider to prevent further complications.

Correct Answer:

B) Notify the physician and continue to monitor the hourly urine output closely.

Explanation:

• Normal urine output is at least 30 mL/hour. A urine output of 10 mL/hour is critically low and could indicate acute kidney injury, hypovolemia, or decreased renal perfusion.


• Notifying the physician is crucial because this could indicate postoperative complications, including shock, dehydration, or renal impairment.


• Continuing to monitor the hourly urine output is necessary to track any worsening condition or improvement after medical intervention.

Why the Other Choices Are Incorrect:

A) Irrigate the Foley with 30 mL normal saline.

• Incorrect because the catheter is already patent (unobstructed). Bladder obstruction is not the issue, so irrigation is unnecessary and could introduce bacteria, increasing the risk of infection.

C) Decrease the IV fluid rate and massage the patient’s abdomen.

• Incorrect because reducing IV fluids could worsen low urine output if the issue is hypovolemia or dehydration.


• Massaging the abdomen does not directly address decreased urine production unless there is bladder retention, which is not indicated here.

D) Have the patient sit in high-Fowler’s position.

• Incorrect because positioning does not directly affect renal perfusion or urine output.


• If hypotension or poor renal perfusion is suspected, fluid resuscitation and medical intervention are needed rather than simply changing position.

Summary:

A postoperative urine output of 10 mL/hour is dangerously low and could indicate renal dysfunction or hypoperfusion. The nurse should immediately notify the physician and continue monitoring to prevent complications such as acute kidney injury or shock.

Correct Answer: d. Pulse decreased from 100 beats/min to 80 beats/min

Explanation:

Beta blockers (e.g., metoprolol, atenolol, propranolol) block the beta-adrenergic receptors in the heart, leading to decreased heart rate (negative chronotropic effect) and reduced myocardial contractility (negative inotropic effect). These effects help reduce the workload on the heart, lower blood pressure, and control arrhythmias. A decrease in pulse rate is an expected response because beta blockers slow conduction through the AV node, reducing sympathetic nervous system stimulation.

Why the Other Choices Are Incorrect:

a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg –

Beta blockers typically lower blood pressure by reducing cardiac output and blocking vasoconstriction, not increasing it. An increase in BP after administration would be unexpected.

b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min –

Beta blockers do not have a direct effect on respiratory rate unless a non-selective beta blocker (e.g., propranolol) is given, which may cause bronchoconstriction in patients with respiratory conditions like asthma or COPD. However, a decrease in respiratory rate from 25 to 14 is not a primary expected effect of beta blockers.

c. Oxygen saturation increased from 88% to 96% –

Beta blockers do not directly improve oxygen saturation. If oxygen saturation increases, it is likely due to another factor, such as improved ventilation or oxygen therapy. While beta blockers reduce myocardial oxygen demand, they do not directly affect oxygenation levels in the lungs.

Summary:

The correct answer is d. Pulse decreased from 100 beats/min to 80 beats/min, as beta blockers work by slowing the heart rate. The other options—increased blood pressure, decreased respiratory rate, and improved oxygen saturation—are not primary expected effects of beta blocker administration.

Correct Answer:

b. "My shoes fit tighter by the end of the day."

Explanation:

Edema refers to the accumulation of excess fluid in the tissues, and it often becomes more noticeable by the end of the day due to gravitational pooling of fluid in the lower extremities. When a client reports that their shoes fit tighter by the end of the day, this is a classic sign of peripheral edema, where fluid builds up in the legs and feet due to standing or sitting for extended periods. This could be indicative of heart failure, kidney disease, or venous insufficiency.

Why the Other Choices Are Incorrect:

a. "I wake up to go to the bathroom at night." –

This statement is indicative of nocturia, which refers to frequent urination at night. While nocturia can be associated with heart failure due to fluid redistribution when lying down, it does not directly suggest the presence of edema.

c. "I seem to be feeling more anxious lately." –

Anxiety can be related to many conditions, but it does not directly point to the presence of edema. Anxiety might be a symptom of other health issues, including heart disease, but it is not a primary indicator of fluid accumulation in the tissues.

d. "I drink at least eight glasses of water a day." –

Drinking an adequate amount of water is generally healthy and not a sign of edema. While excessive fluid intake could potentially contribute to fluid retention in some circumstances, this statement does not suggest that the client is experiencing the fluid retention characteristic of edema.

Summary:

The correct answer is b. "My shoes fit tighter by the end of the day." because tight-fitting shoes by day's end are a typical sign of peripheral edema, where fluid accumulates in the lower extremities. The other statements—nocturia, anxiety, and fluid intake—do not directly indicate the presence of edema.

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.