ATI NUR 213 Midpoint Assessment

Correct Answer:

b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety

Explanation:

This client is exhibiting signs of a potential anaphylactic reaction, likely caused by an allergy to the contrast dye used during angioplasty. Tongue swelling is a red flag for airway obstruction, which can rapidly become life-threatening. Anxiety in this context may signal hypoxia or the onset of respiratory distress. Immediate assessment and intervention are crucial to prevent airway compromise, shock, and possible death. Prompt treatment typically includes administering epinephrine, ensuring airway patency, and providing supportive care.

Why the Other Options Are Incorrect:

Client with an acute myocardial infarction, pulse 102 beats/min

Although an MI is serious, a pulse of 102 beats per minute is only mildly elevated and does not indicate immediate instability. This client is less urgent compared to one with airway swelling.

Client who is post coronary artery bypass, chest tube drained 100 mL/hr

Chest tube drainage of 100 mL/hr is within acceptable limits after surgery. Continuous monitoring is necessary, but this does not constitute an immediate emergency.

Client who is post coronary artery bypass, potassium 4.2 mEq/L

A potassium level of 4.2 mEq/L is within the normal range, requiring no urgent action.

Summary:

The priority is always to address airway emergencies first. Tongue swelling post-angioplasty signals a possible anaphylactic reaction that can quickly lead to airway obstruction, making this client the highest priority for immediate assessment and intervention.

Correct Answer:

"You should balance weight loss with consuming necessary nutrients."

Explanation:

For clients with diabetes and a high body mass index, effective weight management requires a balanced approach that includes adequate nutrition to maintain metabolic health while promoting gradual weight loss. Nutrient-dense foods provide essential vitamins, minerals, and macronutrients necessary for overall health, energy, and glycemic control. Focusing solely on calorie restriction without ensuring proper nutrition can lead to deficiencies, muscle loss, and poor blood sugar management. Educating clients about balanced diets encourages sustainable lifestyle changes that support both weight loss and diabetes management.

Why Other Options Are Wrong:

"The best way to lose weight is a high-protein, low-carbohydrate diet."

Although low-carbohydrate diets can be effective for some people, recommending a high-protein, low-carbohydrate diet as the “best way” oversimplifies weight loss strategies and may not be appropriate for everyone. Such diets can lead to kidney strain, nutrient imbalances, or unsustainable eating patterns. Individualized plans that consider personal preferences, medical conditions, and long-term sustainability are more appropriate than rigid diets.

"A nutritionist will provide you with information about your new diet."

While referral to a nutritionist or dietitian is beneficial, simply stating this to the client without providing initial education limits their understanding and motivation. The nurse's role includes delivering foundational knowledge to empower the client before or alongside specialist input. Relying solely on the nutritionist to provide all information may delay the client’s engagement and readiness for change.

"If you exercise more frequently, you won't need to change your diet."

Exercise alone is insufficient for effective weight loss and diabetes management. Without dietary modifications, increased physical activity may not produce the desired weight loss or glycemic control. Combining both exercise and healthy eating habits is essential. This statement can mislead clients into neglecting critical dietary changes necessary for improving health outcomes.

Correct Answer: b. Cool, clammy skin

Explanation:

Hypotension after a myocardial infarction (MI) is a sign of decreased cardiac output and poor perfusion. When blood pressure drops, the body compensates by activating the sympathetic nervous system (SNS), which causes vasoconstriction to maintain blood flow to vital organs. This vasoconstriction leads to cool, clammy skin, a classic sign of poor perfusion and shock.

Why the Other Choices Are Incorrect:

a. Heart rate of 120 beats/min –

While tachycardia (HR > 100 bpm) can occur as a compensatory response to hypotension, it is not the most definitive sign of poor perfusion. Some patients with severe heart damage may not mount a strong tachycardic response due to heart failure.

c. Oxygen saturation of 90% –

An oxygen saturation of 90% is mildly low, but it is not a direct or consistent finding in hypotensive patients after an MI. Oxygen levels may decrease if there is pulmonary congestion or heart failure, but the skin findings (cool and clammy) are more directly associated with hypotension.

d. Respiratory rate of 8 breaths/min –

A low respiratory rate (bradypnea) is not an expected response to hypotension. In fact, hypotensive patients are more likely to have an increased respiratory rate (tachypnea) as the body tries to compensate for low oxygen delivery. A depressed respiratory rate (RR < 10) may indicate central nervous system depression, narcotic overdose, or impending respiratory failure, which is not a direct result of MI-induced hypotension.

Summary:

The correct answer is b. Cool, clammy skin because hypotension leads to poor tissue perfusion, triggering vasoconstriction and activation of the sympathetic nervous system, which results in pale, cool, and clammy skin. The other options—tachycardia, mild oxygen desaturation, and bradypnea—may be present in some cases but are not as directly linked to hypotensive shock after an MI.

Correct Answer: A. Assess the client's respiratory status.

Explanation:

In a client experiencing heart failure exacerbation, the priority concern is airway and breathing. Pulmonary congestion and fluid overload can lead to respiratory distress, hypoxia, or pulmonary edema, making respiratory assessment the first action.

Why the Other Options Are Incorrect:

B. Draw blood to assess the client's serum electrolytes.

Important, but not the priority. Electrolyte imbalances (e.g., potassium, sodium) are common in heart failure but do not require immediate action before assessing breathing.

C. Administer intravenous furosemide (Lasix).

IV diuretics help reduce fluid overload, but the nurse must first assess respiratory status to determine how urgent the intervention is. Also, a provider's order is required before administration.

D. Ask the client about current medications.

Medication history is important but not the first priority in an acute exacerbation. The nurse should stabilize the patient before gathering background information.

Correct Answer:

Perform hand hygiene.

Explanation:

Before any sterile or clean procedure—especially one involving a post-surgical sternal wound—performing hand hygiene is the first and most critical action. This step significantly reduces the risk of introducing harmful microorganisms that could cause infection, particularly in a vulnerable area like the sternum. Sternal wound infections can result in severe complications such as mediastinitis, which is life-threatening and difficult to treat. Hand hygiene ensures that subsequent actions, including the use of gloves, gowns, or masks, do not become compromised by contaminated hands. It is a foundational element of infection control and patient safety.

Why Other Options Are Wrong:

Assess vital signs

While assessing vital signs is a routine nursing responsibility and provides important information about the patient’s status, it is not the first action when preparing for a dressing change. Infection prevention takes precedence at this stage. Moreover, vital signs are typically assessed before the decision to change a dressing, not at the moment of setting up the procedure.

Don a mask and gown

Using personal protective equipment may be indicated based on the patient’s condition or hospital protocol. However, donning a mask and gown before performing hand hygiene undermines the protective function of that equipment. Contaminated hands can transfer pathogens to the PPE during application, defeating its purpose.

Gather needed supplies

Gathering supplies is a necessary part of preparing for a dressing change, but it should never be done with unclean hands. Handling sterile or clean items with contaminated hands increases the risk of wound infection. Supplies should be handled only after performing hand hygiene to ensure their sterility is maintained.

Summary:

Hand hygiene is the first and most essential step in preparing for a sternal wound dressing change. It serves as the foundation for all other infection control practices and is key to ensuring patient safety.

Correct Answer:

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

Explanation:

During the primary infection stage of HIV—also known as acute HIV infection or seroconversion illness—the virus is rapidly replicating in the body. Although the individual is infected, the immune system has not yet produced detectable levels of HIV-specific antibodies, which is why early HIV tests (particularly antibody-based tests) may return false-negative results during this window period. Despite the lack of antibodies, the patient is highly infectious due to the high viral load present in the blood and other bodily fluids.

Why the Other Options Are Wrong:

"The patient's HIV antibodies are successfully, but temporarily, killing the virus.":

This is incorrect because during the primary infection phase, HIV-specific antibodies have not yet been produced in significant amounts. The immune system is beginning to respond, but it is not capable of “killing” the virus—especially not temporarily or completely. The virus continues to replicate aggressively.

"The patient's risk for opportunistic infections is at its peak.":

This is not accurate for the primary stage. Opportunistic infections are most common in the later stages of HIV, particularly during AIDS, when the immune system is severely compromised. In the primary stage, while the viral load is high, CD4+ T-cell counts are not yet critically low.

"The patient may or may not develop long-standing HIV infection.":

This is misleading. Once infected with HIV, the person will have a lifelong infection unless a cure is found. The term "long-standing HIV infection" applies to the chronic nature of the disease post-primary phase. The infection does not resolve or go away on its own; without treatment, it progresses over time.

Correct Answers:

(a) A 36-year-old woman with systemic lupus erythematosus (SLE)

(b) A 42-year-old man recovering from coronary artery bypass graft surgery

(d) An 80-year-old man with a bacterial infection of the respiratory tract

Explanation:

Acute pericarditis is inflammation of the pericardial sac, which can result from autoimmune diseases, recent cardiac surgery, infections, or post-myocardial infarction syndrome (Dressler’s syndrome).

(a) A 36-year-old woman with systemic lupus erythematosus (SLE) – Correct

Autoimmune diseases, such as SLE and rheumatoid arthritis, are known risk factors for pericarditis.

In SLE, autoimmune-mediated inflammation can affect the pericardium, leading to pericarditis.

(b) A 42-year-old man recovering from coronary artery bypass graft (CABG) surgery – Correct

Cardiac surgery, including CABG and valve replacement, is a major risk factor for pericarditis due to surgical trauma to the pericardium.

This can lead to post-pericardiotomy syndrome, an inflammatory reaction that occurs days to weeks after heart surgery.

(d) An 80-year-old man with a bacterial infection of the respiratory tract – Correct

Infectious pericarditis can develop from bacterial, viral, or fungal infections, especially in elderly or immunocompromised patients.

Pneumonia or other respiratory infections can spread to the pericardium, causing pericarditis.

Why the Other Options Are Wrong:

(c) A 59-year-old woman recovering from a hysterectomy – Incorrect

A hysterectomy (surgical removal of the uterus) is not a direct risk factor for pericarditis.

While postoperative infections or complications could indirectly contribute, they are not common causes of pericarditis.

(e) An 88-year-old woman with a stage III sacral ulcer – Incorrect

Pressure ulcers indicate poor circulation and prolonged immobility, but they are not strongly linked to pericarditis.

Infection from a deep ulcer could potentially spread to the bloodstream, but this is not a common cause of pericarditis compared to bacterial respiratory infections.

Summary:

The greatest risk factors for acute pericarditis include autoimmune diseases (SLE), recent heart surgery (CABG), and bacterial infections (especially respiratory infections). Therefore, the correct choices are (a), (b), and (d).

Correct Answer: B. Dyspnea on exertion

Explanation:

Mitral valve stenosis leads to narrowing of the mitral valve, causing impaired blood flow from the left atrium to the left ventricle. As the stenosis worsens, pressure increases in the left atrium, leading to pulmonary congestion and dyspnea on exertion (DOE). DOE is one of the earliest and most significant signs of progression.

Why the Other Options Are Incorrect:

A. Oxygen saturation of 92%

A slightly decreased O₂ saturation is not a primary indicator of progression. It can occur due to other factors, and more severe mitral stenosis would lead to lower oxygen levels with worsening pulmonary congestion.

C. Muted systolic murmur

Mitral stenosis produces a diastolic murmur, not a systolic murmur. Additionally, as stenosis progresses, the murmur often becomes louder, not muted.

D. Upper extremity weakness

Weakness in the upper extremities is not a classic symptom of mitral stenosis progression. It would be more concerning for neurological issues (e.g., stroke, embolism) rather than valve disease itself.

Correct Answer:

Avoid straining while having a bowel movement.

Explanation:

A heart rate of 56 beats per minute in the absence of symptoms can be normal, particularly in well-conditioned individuals or during rest. However, straining during bowel movements (Valsalva maneuver) triggers vagal stimulation, which can further slow the heart rate through parasympathetic activation of the sinoatrial (SA) node. For clients with already slow heart rates, minimizing vagal stimulation is important to prevent further bradycardia that could result in symptoms such as dizziness, syncope, or hypotension. Therefore, the nurse should recommend avoiding straining by promoting hydration, dietary fiber, or use of stool softeners if needed.

Why Other Options Are Wrong:

"Make certain that your bath water is warm."

While extremely cold water can provoke a vagal response and warm water is generally soothing, the temperature of bathwater is not a significant contributor to heart rate changes in the context of bradycardia. This recommendation is not as relevant or impactful as avoiding maneuvers known to trigger vagal stimulation.

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

Caffeine is a stimulant that can increase heart rate, not decrease it. While excessive caffeine has other health risks, limiting it would not help prevent bradycardia and could theoretically reduce a mild compensatory mechanism in this individual. This advice doesn’t directly address the concern of avoiding further heart rate slowing.

"Avoid strenuous exercise such as running."

Strenuous exercise is not contraindicated for someone with a heart rate of 56 bpm and no symptoms—especially if the bradycardia is due to high physical conditioning. Regular aerobic exercise is often associated with resting bradycardia in healthy individuals. Avoiding exercise is not necessary or advised in the absence of adverse symptoms.