Aortic Regurgitation

65% Correct Let's review your results from 12/23/2021 at 10:59 pm PST Correct Incorrect Question 1 of 23 Which intervention should the nurse initiate first? Apply an oxygen mask on the client at 6 liters per minute. The client may need oxygen but getting the client's airway open is priority. Place the client on a stretcher and open airway. The nurse needs to place the client on a solid, flat surface to align his airway in a neutral position to open his airway for a visual inspection to assess for an airway obstruction. Check the client’s oxygen saturation level. Knowing the client's oxygen saturation will provide the information needed to determine how much supplemental oxygen the client needs, however getting the client's airway open is priority. Auscultate the client’s lung sounds. Lung sounds are important to determine the movement of air, however getting the client's airway open is priority. Question 2 of 23 As the client is transferred to a stretcher the nurse notices the use of accessory muscles of the chest and neck and an exaggerated effort to breathe. Which intervention should the nurse implement first? Raise the head of the stretcher to a semi-Fowler's position. The first intervention is to raise the head of the stretcher to a semiFowler’s position, allowing for full expansion of the client’s lungs and taking pressure off his diaphragm, enhancing the delivery of oxygen to the lungs. Apply a partial rebreather mask with oxygen at 10 liters per minute. Once positoned so the airway is open and the client is able to breathe easier, oxygen should be applied. Auscultate the client's lungs bilaterally to assess for diminished breath sounds. Equal breath sounds are important; however, airway patency is priority. Monitor the client's oxygen saturation level. Knowing the level of oxygen will help the nurse titrate oxygen once airway is patent. Question 5 of 23 The ED nurse looks up the prescribed medications and notes that the recommended dosage for losartan is 50 mg PO daily, or 25 mg PO daily in combination with a diuretic. A precaution listed for this medication is increased risk of hypotension and syncope with concurrent use of ACE inhibitors. What action should the nurse implement? Acknowledge the losartan medication prescription. Acknowledging prescriptions only verifies the nurse is aware of what has been prescribed. It does not address the issue. A medication that needs to be clarified should not be acknowledged until clarified to prevent the client from receiving an incorrect dose. Contact the HCP to clarify medication prescriptions. The nurse is responsible for researching potential drug interactions and verifying that the prescribed medication is the appropriate dose and route, prior to administering it to the client. Adminster medications after pharmacy verifies orders. Pharmacy may review the medications and seek clarification; however, it is the nurse's primary responsibility to clarify with the HCP. Prepare first dose of losartan to be administered. The medication should not be administered until the dosage has been clarified. Question 6 of 23 The HCP plans to keep the client in the hospital for a few days. The ED nurse is preparing to transfer the client to a medical unit. Which intervention should the nurse implement first? Call to provide a report to the receiving nurse. Notifiying the receiving nurse of readiness to transfer will alert all the nurses to obtain any needed equipment prior to the client's arrival on the medical unit. Handoff communication is priority. Document the transfer in the medical record. Documentation of transfer should be done when client is leaving the ED. Obtain and apply portable oxygen. Oxygen will be needed for transport but should not be discontinued from the wall oxygen until the client is ready to leave the room. Administer first dose of prescribed medications. First doses may not all be due or ready for administration. This should not delay transfer to the medical unit. Question 8 of 23 The severity of the client's pleural effusions are confirmed with the enlarged cardiac silhouette on the chest x-ray. The client is having difficulty taking deep breaths and is short of breath when speaking. Which intervention is most important for the nurse to include in the client's plan of care? Daily weights Daily weights will help monitor fluid retention but will not improve the client's symptoms. Sodium restricted diet Diet restrictions will decrease complications of further fluid retention due to diet; however, this intervention is not immediately helpful. Daily fluid restrictions Fluid restrictions will decrease complications of further fluid retention due to diet; however, this intervention is not immediately helpful. High Fowler's positon. Positioning the client to promote ease of breathing is immediately effective and a priority while treating the underlying cause. Question 9 of 23 The client is having periods of confusion and appears weak and fatigued. The client tells the nurse they feel like their heart is fluttering at times. Which laboratory value(s) could be related to the client's symptoms? (Select all that apply. One, some, or all options may be correct.) Sodium. Common symptoms of low sodium (hyponatremia) include confusion, lethargy, headache, and dizziness. Potassium. Common symptoms of low potassium (hypokalemia) include weakness, fatigue, and palpitations. Chloride. The chloride level is within normal limits. Blood urea nitrogen. Common symptoms of high blood urea nitrogen (BUN) levels include fatigue, edema, shortness of breath, confusion, and dehydration. Phosphorus. Common symptoms of high phosphorus (hyperphosphatemia) include fatigue, shortness of breath, anorexia, nausea, vomiting, and sleep disturbances. Question 10 of 23 The nurse notices that the client's urine is greenish in appearance when a urine sample is collected. Which intervention(s) should the nurse implement? (Select all that apply. One, some, or all options may be correct.) Notify the HCP. Some infectious processes such as urinary tract infections (UTIs) caused by pseudomonas can cause the urine to turn green, but this is not indicated at this time. Recollect the urine sample to be analyzed again. The urine specimen was properly collected; therefore, it is not necessary to collect another sample. Ask the client to list the food he has eaten in the last 24 hours. Certain foods, such as asparagus and black licorice, as well as medications such as cimetidine and indomethacin can cause urine to appear green. Record the color and amount of urine in the medical record. The appearance of the urine needs to be documented, along with information the client provides about oral intake from the previous 24 hours. Prepare to place a urinary catheter. The presence of a urinary catheter is the most important risk factor for bacteriuria. The nurse cannot place a urinary catheter without a prescription from the HCP. A urinary catheter would exacerbate an infection which has not been confirmed at this point. Question 11 of 23 The client is transferred from the ED to the medical unit. The ED nurse gives the admitting nurse a hand-off report. Which nursing intervention best promotes effective communication? Relay a complete review of the client's past medical history. Handoff communication should be problem focused. A complete history may not be appropriate at handoff. Report off on all abnormal laboratory and diagnostic procedure results. Handoff of abnormal results can be limited to critical values and results that require nursing intervention. Use SBAR (Situation-Background-AssessmentRecommendation) when reporting to receiving nurse. SBAR (Situation-Background-Assessment-Recommendation) technique provides a systematic, effective way to report off when a client is moving within units of the hospital. SBAR is a way to communicate the client's condition among members of the healthcare team that is predictable and structured. Elaborate on the history of smoking and alcohol consumption. Smoking and alcohol consumption can be included in the SBAR if it is immediatly necessary . Question 12 of 23 he client is settled in and the the nurse is planning the client's care. Based on the prescriptions provided, which actions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply. One, some, or all options may be correct.) Weigh the client on the medical unit’s scale. This is within the scope of responsibility for the UAP. Place the cardiac monitor on the client. This is within the scope of responsibility for the UAP. Put a fluid restriction sign at the head of bed. This is within the scope of responsibility for the UAP. Set up the oxygen delivery system at 10 liters/minute. This is not within the scope of responsibility for the UAP. Adjust oxygen rate if oxygen saturations decrease while ambulating. This is not within the scope of responsibility for the UAP. Question 16 of 23 It is important for the nurse to develop a therapeutic relationship with the client. When conducting the admission interview, what actions best facilitate the process? (Select all that apply. One, some, or all options may be correct.) Clarify information by questioning the client to verify information. Accepting information without questioning and/or clarifying could lead to misunderstanding and lack of pertinent information. The nurse needs to clarify information with the client by asking additional questions when necessary. Stand at the foot of the client’s bed to conduct the interview. Standing at the foot of the client's bed is an intimidating posture that insinuates the nurse is in a hurry. Sitting in a chair by the bedside will place the nurse at eye level with the client, which helps facilitate conversation and sends the message that the nurse is there to communicate. Reassure the client that everything will be alright and that he is going to get better. The nurse should not give the client false reassurance. Giving false reassurance could lead to feelings of mistrust and anger. Let the client do most of the talking and actively listen. The most important element of effective communication is active listening. Watching, observing, and listening to the client’s verbal and non-verbal language are very important. Use closed-ended questions to keep the client from straying from the topic. Using closed-ended questions will elicit minimal information from the client. Open-ended questions requires the client to provide more details and may provide additional insight regarding the client’s situation and circumstances. Additionally, summarizing the client’s responses gives the client an opportunity to reflect and verify the context of his answers. Question 17 of 23 Therapeutic communication involves listening and analyzing what the client is conveying. Based on the information provided by the client, which nursing interventions best promotes effective communication? (Select all that apply. One, some, or all options may be correct.) Inquire about the client's work history including specific job duties. Individuals who had worked in naval and civilian shipyards were exposed to asbestos in the construction of naval ships, which is known to cause mesothelioma. Asbestos was also used in construction material for buildings. Studies have suggested that individuals who worked in the farming industry and were exposed to pesticides are at increased risk of developing cancers, especially prostate cancer. Ask the client to elaborate on his son's line of work. The client’s son’s employment and location should not have a direct impact on the client developing cancer and/or blood anomalies. Assist the client in recalling his diet intake over the last few weeks. Because of his anemia, it is important to ask about protein intake. Iron deficiency anemia is the most common nutritional disorder in the world and adequate protein intake can prevent this condition. Review with the client any family history of cancer. It is important to ask about family history of cancer because of the risk factor for some cancers. Question the client regarding history of military enlistments. Studies have shown that some individuals who served in Vietnam were exposed to Agent Orange (herbicide). Those individuals are more likely to develop a precursor disease to multiple myelomas. Question 19 of 23 The nurse teaches the client about their medications prior to administering them. Which intervention is most important for the nurse to include regarding the amlodipine and diltiazem which are both calcium-channel blockers? Report any episodes of dizziness. Combination calcium channel blocker therapy is prescribed to better control the client's blood pressure. Since amlodipine and diltiazem are both calcium-channel blockers, it is important for the client to report side effects such as dizziness, which may be a sign of low blood pressure. A very low heart rate may also occur which will require an adjustment in the client's medications and/or dosages. While in the hospital and on a cardiac monitor, the nurse should monitor for a low, irregular heart rate. Avoid drinking grapefruit juice. While this may cause an increase in the serum blood levels of calcium chanel blockers, a low blood pressure requires immediate intervention. Tell HCP of daily weight gain. Weighing daily is important to evaluate the amount of fluid retention that may increase as heart failure worsens. The HCP may need to change the medications and/or dosages to better manage these symptoms. Weight gain does not require an immediate intervention. Keep a blood pressure diary. It will be important for the HCP to evaluate the effectiveness of this combination therapy; however, reporting serious side effects is priority. Question 21 of 23 During client education, the client reports to the nurse that even though breathing is easier, they do not like the dizzy feeling they experience when changing positions or when getting out of bed. Which nursing intervention best promotes effective communication? Tell the client to get into position quickly to minimize the dizziness. Rising quickly may cause syncope. Explain to the client that the symptoms should start to decrease as the body gets used to the medications. This is not a symptom that gets better. It is a side effect of the medication. The orthostatic hypotension remains a risk for the client and he should be instructed to slowly change positions. Have the client hold the medications and ask his HCP decrease to dose of the medications to lessen the effect. This is a common side effect of the medications due to the mechanism of the medications. Medication should not be held unless instructed to do so by the HCP first. Decreasing the medications can cause the client’s blood pressure to increase. Instruct the client to change positions and stand slowly. This is a common side effect of the medications. The client needs to be aware of the orthostatic hypotension and be aware to slowly change his position and to rise slowly to a sitting and/or standing position. Question 22 of 23 Later that day, the client reports to the nurse less abdominal pain and nausea, a severe headache, blurry vision, and feels really tired. The nurse assesses the client and notes an irregular heart rate of 56 bpm. Which laboratory tests does the nurse anticipate the HCP will prescribe for the client? (Select all that apply. One, some, or all options may be correct.) Digoxin serum level. The client is prescribed digoxin and is congruently taking captopril and diltiazem which has the potential to increase the levels of the digoxin, leading to toxic levels. Sodium level. Sodium levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to digoxin and the other medications that increase the potential for digoxin toxicity. Potassium serum level. Low potassium levels increase the chance of digoxin toxicity. Furosemide may cause hypokalemia which increases the potential of the occurrence of digoxin toxicity. Phosphorus serum level. Phosphorus levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to the prescribed digoxin and other medications that increase the potential for digoxin toxicity. Calcium serum level. Calcium levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to the prescribed digoxin and other medications that increase the potential for digoxin toxicity. Question 23 of 23 The nurse assesses the client's fall risk factors and determines they score a moderate fall risk. What change(s) in the client's care should the nurse tell him to expect? (Select all that apply. One, some, or all options may be correct.) Two side rails up while in bed. For a low to high fall risk only two side rails should be up as a reminder to call for assistance unless the client is in the intensive care unit. Four side rails up at all times. Only two side rails should be up. Clients can get wedged between rails while trying to get out of bed if they do not call for help. Soft wrist restraints tied loosely. Restraints are not indicated unless the client is at risk of harming self or others. Not to be used as a reminder to call for help. A UAP will assist with trips to the bathroom. Supervision and assistance to the bathroom is required while on moderate fall risk precautions. Non-skid footwear to be worn while out of bed. Use of properly fitting nonskid footwear decreases the risk of falling when the client is walking, especially when unsteady. Previous Section