ATI NUR 213 Midpoint Assessment

Correct Answer:

b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg

Explanation:

This client requires immediate attention due to the critically elevated blood pressure so soon after a coronary artery bypass graft (CABG). Hypertension in the immediate postoperative period places significant strain on the new grafts and suture lines, increasing the risk of bleeding, graft rupture, myocardial infarction, or cerebrovascular accident (stroke). The nurse must act swiftly to bring the blood pressure under control and prevent these life-threatening complications. Post-CABG patients are often kept within a tightly controlled blood pressure range for exactly this reason. Prompt intervention—such as administering antihypertensives and alerting the provider—is warranted.

Why the Other Options Are Wrong:

Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours

This client appears stable. Nitroglycerin infusions are commonly used for angina or blood pressure control, and if the dose has not required titration for several hours, it suggests that the client's condition is currently well-managed. There is no indication of active symptoms or deterioration, so this client is not the highest priority.

Client who is 1 day post percutaneous coronary intervention (PCI), going home this morning

This client is preparing for discharge, indicating clinical stability. While the nurse must ensure discharge instructions are complete and the patient is safe to go home, there is no acute concern or urgent intervention required at this moment. They are appropriately addressed after more critical patients.

Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

Dizziness is a concerning symptom and warrants assessment—possible causes include hypotension, anemia, or arrhythmia—but it is not as acutely dangerous as uncontrolled hypertension in a patient only one day post-CABG. The hypertensive crisis presents a more immediate threat to life or graft integrity, so it takes precedence.

Summary:

The client with severe hypertension after CABG is the top priority because of the immediate risk to the graft and cardiovascular system. The other clients are stable or have less acute issues that can be addressed after stabilizing the post-CABG patient.

Correct Answer:

C) Red, warm, tender incision

Explanation:

A red, warm, and tender incision is a localized sign of infection at the surgical site. These symptoms suggest inflammation, possible pus formation, and bacterial presence, which are key indicators of surgical site infection (SSI). Other signs of infection at an incision site may include purulent drainage, swelling, and increasing pain.

Why the Other Choices Are Incorrect:

A) Presence of an indwelling urinary catheter

The presence of an indwelling urinary catheter increases the risk of infection (CAUTI) but does not necessarily mean an infection is present. The nurse should monitor for symptoms like fever, dysuria, cloudy urine, or foul odor to determine if an infection is developing.

B) Rectal temperature of 99.5°F (37.5°C)

A temperature of 99.5°F is slightly elevated but not a definitive sign of infection. Postoperative patients may have mild temperature increases due to inflammation, anesthesia effects, or dehydration. A more concerning sign would be a temperature above 100.4°F (38°C), along with other infection symptoms.

D) White blood cell (WBC) count of 8,000/mL

A WBC count of 8,000/mL is within the normal range (4,000–11,000/mL) and does not indicate an active infection. In an infection, WBC counts are often elevated due to the body’s immune response to pathogens.

Summary:

The most indicative sign of infection is a red, warm, and tender incision, as it directly suggests inflammation and possible bacterial presence at the surgical site.

Correct Answer:

Tachypnea and restlessness

Explanation:

Tachypnea and restlessness are signs of hypoxia, which is a critical and potentially life-threatening complication in a patient with pneumonia. These symptoms suggest that the patient is not adequately oxygenating, which requires immediate intervention to prevent further respiratory compromise or failure. In the context of HIV, where patients may have compromised immune function, even a mild respiratory infection can rapidly escalate, making early recognition of hypoxia essential. Restlessness is an early neurological sign of inadequate oxygen delivery to the brain.

Why the Other Options Are Wrong:

Oral temperature of 100°F is only slightly elevated and is not uncommon in patients with infection. It does not indicate immediate deterioration and does not take priority over signs of respiratory distress.

Frequent loose stools can contribute to dehydration and electrolyte imbalances but are not life-threatening in the short term and do not pose the same immediate threat as respiratory compromise.

Weight loss of 1 pound since yesterday is concerning over time, especially in patients with HIV who are at risk for wasting syndrome, but a single day of minor weight loss is not an urgent issue and does not require immediate action.

Correct Answer:

Multiple pregnancy (twins or more)

Explanation:

Clomiphene (Clomid) is a selective estrogen receptor modulator used to induce ovulation in women with ovulatory dysfunction, making it a common treatment for infertility. It works by stimulating the release of hormones (FSH and LH) that trigger ovulation. Because it often leads to the development of more than one mature ovarian follicle, there is a significantly increased chance of multiple ovulation events, which raises the risk of multiple gestations, such as twins or triplets. Couples considering clomiphene therapy must be counseled on this possibility, as multiple pregnancies carry increased risks for both the mother and the fetuses, including preterm labor, low birth weight, and complications during delivery.

Why the Other Options Are Incorrect:

Increased menstrual flow

This is not a typical or expected effect of clomiphene. The drug primarily affects ovulation, not the volume of menstrual bleeding.

Increased menstrual cramping

While some women may experience mild abdominal or pelvic discomfort (especially around ovulation), increased cramping is not a prominent or widely reported effect of clomiphene.

Sedation

Clomiphene does not cause sedation. Its side effect profile is more likely to include hot flashes, mood swings, breast tenderness, or visual disturbances, but not central nervous system depression or drowsiness.

Summary:

Couples starting clomiphene should be aware that a higher likelihood of multiple pregnancies is a significant potential effect. This distinguishes it from other infertility treatments and underscores the need for close medical monitoring during its use.

Correct Answer:

Clients who use cocaine are at risk for fatal dysrhythmias.

Explanation:

Cocaine is a powerful sympathomimetic agent that significantly increases the risk of serious cardiovascular complications, including ventricular dysrhythmias, myocardial infarction, and sudden cardiac death. It acts by inhibiting the reuptake of norepinephrine, dopamine, and serotonin, leading to heightened adrenergic stimulation. This excessive stimulation can trigger arrhythmias by increasing myocardial oxygen demand, promoting vasoconstriction, and altering the electrical conduction system of the heart. Educating the client about this specific risk helps build understanding and trust while directly linking their substance use to the current health issue being assessed.

Why Other Options Are Wrong:

Substance abuse puts clients at risk for many health issues

While this statement is true, it is too broad and does not specifically answer the client’s question about cocaine in the context of their ventricular dysrhythmia. Providing a direct and relevant explanation is more effective in clinical communication.

The hospital requires that I ask you about cocaine use

This response is procedural and impersonal, and it misses an opportunity for patient education. It may make the client feel interrogated rather than cared for and does not clarify the clinical relevance of the question.

We can provide services for cessation of substance abuse

Although offering support services is important, this answer does not address the client’s immediate concern about why the nurse is asking specifically about cocaine use. It shifts the focus to treatment rather than providing necessary clinical insight.

Correct Answer: The patient is in pain.

Explanation:

In the PACU, a patient exhibiting restlessness and increased blood pressure after abdominal surgery is most likely experiencing pain. Postoperative pain is a common cause of sympathetic nervous system activation, leading to elevated blood pressure and behavioral changes such as restlessness. The patient’s oxygen saturation of 97% indicates adequate oxygenation, ruling out hypoxia as a primary cause. Pain assessment and management are critical in the immediate postoperative period, as untreated pain can exacerbate physiological stress and delay recovery. Addressing pain promptly with analgesics or other interventions can stabilize the patient’s vital signs and improve comfort.

Why Other Options Are Wrong:

The patient is hypothermic. Hypothermia can occur post-surgery due to anesthesia or environmental factors, but it typically causes vasoconstriction and may lead to bradycardia or hypotension rather than hypertension and restlessness. Restlessness is more commonly associated with discomfort or pain rather than hypothermia, which may cause shivering or lethargy. In the absence of specific signs like low body temperature or shivering, hypothermia is not the primary concern. This option does not align with the patient’s presentation of restlessness and elevated blood pressure.

The patient is in shock. Shock, such as hypovolemic or septic shock, typically presents with hypotension, tachycardia, and signs of poor perfusion, not hypertension. Restlessness may occur in early shock due to anxiety or hypoperfusion, but the patient’s elevated blood pressure and normal oxygen saturation (97%) make shock unlikely. Without additional signs like pallor, clammy skin, or decreased urine output, shock is not the most immediate concern. This option is inconsistent with the clinical picture described.

The patient is hypoxic. Hypoxia could cause restlessness and hypertension by triggering a stress response or vasoconstriction, but the patient’s oxygen saturation of 97% indicates normal oxygenation. Hypoxia is typically associated with saturations below 90–92%, and the absence of this finding rules it out as the primary cause. Restlessness and hypertension in the presence of normal oxygen levels point more directly to pain as the underlying issue. This option is incorrect given the patient’s stable oxygen saturation.

Correct Answer:

Nausea

Explanation:

Nausea is one of the most commonly reported side effects of oral contraceptive therapy (OCT), especially during the initial weeks of use. This is primarily due to the estrogen component of the pill, which can irritate the gastrointestinal lining. Although the symptom often resolves over time, taking the pill with food or before bed can help reduce this discomfort. Mild nausea is usually benign but should be monitored if it persists.

Why the Other Options Are Incorrect:

Dizziness

Dizziness is not a common or expected side effect of oral contraceptives. If it occurs, it may be due to other causes such as dehydration, anemia, or blood pressure fluctuations, rather than a direct effect of OCT. It is not routinely listed among the frequent adverse effects and would warrant further investigation if persistent.

Tingling in the extremities

Paresthesia (tingling or numbness) is not typical of oral contraceptive use. When it does occur, it may suggest a serious adverse event such as a blood clot, particularly in the presence of other symptoms like swelling, pain, or shortness of breath. While blood clots are a rare but serious complication of OCT, especially in smokers and those over 35, tingling alone is not a common or early warning sign.

Polyuria

Polyuria (excessive urination) is not associated with oral contraceptives. In fact, hormonal contraceptives are more likely to cause fluid retention than increased urination. If polyuria is reported, other causes such as uncontrolled diabetes mellitus or diuretic use should be considered.

Summary:

Nausea is a common and expected side effect of oral contraceptives due to the estrogen component. The other symptoms—dizziness, tingling, and polyuria—are not typical of OCT and may indicate unrelated or more serious conditions requiring further evaluation.

Correct Answer:

b. Notify the provider immediately.

Explanation:

After a coronary artery bypass graft (CABG), a sudden decrease in chest tube output can indicate a critical complication such as cardiac tamponade or chest tube obstruction. Cardiac tamponade involves the accumulation of blood or fluid in the pericardial sac, compressing the heart and severely impairing cardiac output. This condition is life-threatening and demands immediate intervention. Promptly notifying the provider allows for rapid assessment, diagnosis (often via echocardiogram), and emergency management, such as return to surgery or pericardiocentesis.

Why the Other Options Are Incorrect:

Increase the setting on the suction

Chest tube suction settings should not be changed without a provider's order. Increasing suction will not correct mechanical obstruction or tamponade and could damage tissue or exacerbate the problem if misapplied.

Re-position the chest tube

Nurses are not authorized to reposition a chest tube. Doing so could inadvertently dislodge the tube or worsen complications. Proper evaluation and manipulation of chest tubes must be done under direct provider supervision or by a trained surgical team.

Take the tubing apart to assess for clots

Opening the closed chest tube system introduces a high risk for infection and pneumothorax. Nurses should inspect the tubing externally for kinks, dependent loops, or visible clots, but must not break the system's sterility by disconnecting components.

Summary:

In post-CABG patients, a sudden drop in chest tube drainage is a red flag for possible tamponade or tube malfunction. The nurse's role is to immediately notify the provider and continue monitoring for signs of hemodynamic compromise while avoiding unsafe interventions.

Correct Answer: (d) Sit the client up with a pillow to lean forward on.

Explanation:

Acute pericarditis is characterized by inflammation of the pericardium, leading to sharp, substernal precordial pain that often worsens with lying flat and deep inspiration. Sitting up and leaning forward relieves pericardial pain by reducing pressure on the inflamed pericardium, making (d) the best choice.

Why the Other Options Are Wrong:

(a) Apply an ice pack to the client's chest.

Pericarditis pain is inflammatory, not musculoskeletal, so ice will not provide relief. Instead, anti-inflammatory medications (e.g., NSAIDs) are used for pain management.

(b) Provide a neck rub, especially on the left side.

Pericarditis pain is not due to muscle tension in the neck. A neck rub won't relieve the inflammation-related pain.

(c) Allow the client to lie in bed with the lights down.

Lying flat can worsen pericarditis pain, making this an incorrect intervention. While a calm environment is beneficial, it does not address the underlying pain.

Summary:

For clients with acute pericarditis, sitting upright and leaning forward reduces pericardial friction and pain, making (d) the correct answer.