Choice A rationale

Acetaminophen is an appropriate analgesic for managing headaches, a common side effect of nitroglycerin due to vasodilation. It does not interfere with the therapeutic effects of nitroglycerin and provides symptomatic relief. Other non-steroidal anti-inflammatory drugs (NSAIDs) might be contraindicated in some cardiac patients, making acetaminophen a safer initial choice for headache management in this context.

Choice B rationale

Touching the medication portion of the transdermal patch can lead to unintended absorption of the nitroglycerin by the person applying it. This could result in side effects such as headache or hypotension in the caregiver. Maintaining the integrity of the dosage and preventing accidental exposure are crucial for safe medication administration.

Choice C rationale

Applying the nitroglycerin patch to a different site each day helps prevent skin irritation and sensitization at the application site. Consistent use on the same area can lead to local reactions, reduced absorption, and potential skin breakdown. Rotating sites ensures optimal drug absorption and minimizes dermatological complications.

Choice D rationale

Applying the nitroglycerin patch to hairy areas can impede proper adhesion to the skin, potentially affecting the absorption and efficacy of the medication. Hair can create a barrier, preventing consistent contact between the patch and the skin's surface, thus reducing the intended therapeutic effect.

Choice D rationale

Spironolactone is a potassium-sparing diuretic that works by antagonizing aldosterone in the distal tubules of the kidneys. Aldosterone normally promotes sodium reabsorption and potassium excretion. By blocking aldosterone, spironolactone increases sodium and water excretion (leading to hyponatremia) while simultaneously reducing potassium excretion (leading to hyperkalemia). Normal serum sodium levels range from 135 to 145 mEq/L, and normal serum potassium levels range from 3.5 to 5.0 mEq/L.

Choice A rationale

Early ambulation encourages deep breathing and lung expansion. Movement and changes in position help to mobilize secretions in the lungs, preventing them from accumulating and causing alveolar collapse, which is the underlying mechanism of atelectasis.

Choice B rationale

An incentive spirometer provides visual feedback to the patient, encouraging slow, deep inhalations. These deep breaths help to inflate the alveoli fully, counteracting the shallow breathing often seen postoperatively due to pain or anesthesia, thus preventing atelectasis.

Choice D rationale

Turning and repositioning the patient every 2 hours helps to prevent the pooling of secretions in dependent lung areas. Regular changes in position promote lung expansion in different segments, reducing the risk of alveolar collapse and improving overall ventilation and perfusion.

Choice A rationale

Headache is a common and expected adverse effect of nitroglycerin. Nitroglycerin causes vasodilation, including dilation of the cerebral blood vessels. This increased blood flow to the head is the primary physiological mechanism responsible for nitroglycerin-induced headaches.

Choice A rationale

Cloudy and odorous urine suggests a urinary tract infection. While important to address, it is not the priority in a client receiving heparin for atrial fibrillation, as it does not directly indicate an immediate, life-threatening complication related to anticoagulation. Normal urine is typically clear and has a mild odor.

Choice B rationale

An aPTT of 80 seconds indicates that the client's blood is anticoagulated. The therapeutic range for aPTT in a client receiving heparin is typically 1.5 to 2.5 times the control value (usually 25-35 seconds), so 80 seconds is within a therapeutic to slightly elevated range. While it requires monitoring, it is not the immediate priority compared to signs of bleeding or thromboembolism.

Choice C rationale

Sudden weakness of one arm and leg is a classic sign of a stroke, which could be an embolic event related to atrial fibrillation despite heparin therapy. This requires immediate attention as it indicates a potentially life-threatening complication. Rapid intervention is crucial to minimize neurological damage.

Choice D rationale

An irregular heart rate without P waves on the ECG is characteristic of atrial fibrillation, the underlying condition for which the client is receiving heparin. While this confirms the diagnosis, it is not a new or acute finding requiring immediate action in the same way as a potential stroke.

Choice A rationale

Encouraging early ambulation helps to mobilize secretions in the lungs and promote lung expansion. Gravity assists in the drainage of mucus, and physical activity increases tidal volume and improves ventilation, reducing the risk of alveolar collapse and atelectasis.

Choice B rationale

Educating the patient on the proper use of an incentive spirometer encourages deep, slow inhalations, which help to expand the alveoli and prevent their collapse. Sustained maximal inspiration increases transpulmonary pressure, promoting lung inflation and reducing the risk of atelectasis.

Choice C rationale

Obtaining an order for daily chest x-rays is a diagnostic measure to identify atelectasis, not a preventative intervention. While it can help in the management of atelectasis if it develops, it does not actively prevent its occurrence.

Choice D rationale

Turning and repositioning the patient every 2 hours helps to prevent stasis of secretions in the lungs. Regular changes in position promote drainage of mucus from different lung segments, improving ventilation and reducing the likelihood of alveolar collapse and atelectasis.

Choice A rationale

Active tuberculosis is an airborne infection transmitted through droplet nuclei that can remain suspended in the air for extended periods. Placing the client in a private room with a special ventilation system, such as negative pressure with high-efficiency particulate air (HEPA) filtration and air exchange directly to the outside, prevents the spread of these infectious particles to other areas and individuals.

Choice B rationale

Assigning the client to a room with other clients who require droplet precautions is inappropriate for tuberculosis. Droplet precautions are used for infections transmitted by larger respiratory droplets that travel short distances (e.g., influenza), while airborne precautions with a negative pressure room are necessary for tuberculosis.

Choice C rationale

Modifying the protocol for donning and removing personal protective equipment (PPE) before entering or leaving the client's room is unsafe. Strict adherence to established airborne precautions, including wearing an N95 respirator, is crucial to protect healthcare workers from tuberculosis transmission. Modifying the protocol could compromise their safety.

Choice D rationale

Ensuring the client wears a surgical mask during all interactions with healthcare providers helps to contain respiratory secretions at the source. However, this is a source control measure and does not protect healthcare providers from inhaling airborne droplet nuclei. Healthcare providers must wear an N95 respirator for respiratory protection when in the same room as a client with active tuberculosis.

Choice A rationale

Nausea, vomiting, and weakness are potential signs of digoxin toxicity, especially when coupled with a refusal to eat, which could indicate electrolyte imbalances exacerbating the toxicity. Digoxin has a narrow therapeutic index (0.5-2.0 ng/mL), and these symptoms warrant immediate notification of the provider for potential medication adjustment and further evaluation, including checking digoxin levels and electrolytes.

Choice B rationale

Checking vital signs is a necessary step in assessing the client's overall condition. However, in the context of potential digoxin toxicity, this action alone does not address the underlying concern. Notifying the provider to order relevant tests and potential medication changes takes priority.

Choice C rationale

Suggesting rest before eating does not address the potential underlying cause of the nausea and weakness, which could be digoxin toxicity. Delaying appropriate intervention could lead to worsening toxicity and adverse effects.

Choice D rationale

Requesting an order for an antiemetic might alleviate the nausea, but it does not address the potential digoxin toxicity causing the symptom. Masking the symptom without identifying and treating the underlying cause could be harmful. .

Choice A rationale

Chronic obstructive pulmonary disease (COPD) significantly increases the risk of postoperative complications following coronary artery bypass graft (CABG) surgery due to impaired respiratory function. COPD is characterized by airflow limitation and inflammation, which can lead to difficulties with ventilation and oxygenation after surgery. Patients with COPD have reduced lung capacity and increased mucus production, making them more susceptible to atelectasis, pneumonia, and prolonged intubation. These pulmonary complications can further strain the cardiovascular system and increase the risk of mortality and morbidity following CABG.

Choice B rationale

Bell's palsy, a temporary facial nerve paralysis, does not directly impact the cardiovascular or respiratory systems in a way that would significantly increase the risk of complications following CABG. While it can cause discomfort and functional limitations, it does not have a direct pathophysiological link to increased surgical risks associated with CABG. The primary concerns after CABG relate to cardiac function, bleeding, infection, and respiratory compromise, none of which are directly exacerbated by Bell's palsy.

Choice C rationale

Chronic diverticulitis, an inflammatory condition of the colon, primarily affects the gastrointestinal system. While it can cause pain, inflammation, and potential for infection, it does not directly increase the risks associated with CABG surgery. The physiological stressors of CABG mainly involve the cardiovascular and respiratory systems. Although systemic inflammation can have indirect effects, chronic diverticulitis is not a primary risk factor for complications following this specific cardiac surgery compared to a respiratory condition like COPD.

Choice D rationale

Chronic allergies, while causing inflammation and potential respiratory symptoms like asthma in some cases, do not inherently pose as high a risk for complications following CABG as COPD. Allergic reactions during or after surgery can occur, but well-managed allergies are less likely to lead to severe postoperative pulmonary or cardiovascular complications compared to the chronic and progressive lung damage seen in COPD. The primary risks in CABG are related to the heart and lungs, making a pre-existing chronic lung condition a major concern.

Choice A rationale

First-degree heart block is characterized by a prolonged PR interval (greater than 0.20 seconds) due to a delay in the conduction of the electrical impulse from the atria to the ventricles. The ECG strip described lacks identifiable P waves and a measurable PR interval, thus ruling out first-degree heart block. The QRS duration is within the normal range (0.06-0.10 seconds), which is also inconsistent with higher-degree AV blocks that might show a widened QRS complex if a ventricular escape rhythm is present.

Choice B rationale

Supraventricular tachycardia (SVT) is characterized by a rapid heart rate (typically greater than 150 beats per minute) originating above the ventricles. While the rhythm might be regular or slightly irregular depending on the specific type of SVT, P waves are usually present, although they may be abnormal in morphology or hidden within the T wave. The ECG description indicates an irregular rhythm and the absence of identifiable P waves, making SVT an unlikely diagnosis.

Choice C rationale

Sinus bradycardia is defined by a slow heart rate (less than 60 beats per minute) originating from the sinoatrial (SA) node. The rhythm is regular, and P waves are present, preceding each QRS complex with a normal PR interval (0.12-0.20 seconds). The client's heart rate is 92 beats per minute, which is within the normal range (60-100 beats per minute), and the rhythm is irregular with no discernible P waves, thus excluding sinus bradycardia.

Choice D rationale

Atrial fibrillation (A-fib) is a common arrhythmia characterized by rapid, disorganized electrical activity in the atria, leading to an irregularly irregular ventricular response. The ECG findings of an irregular rhythm, the absence of identifiable P waves (replaced by fibrillatory waves, which are not explicitly mentioned but implied by the lack of P waves), and a normal QRS duration (indicating normal ventricular depolarization) are classic characteristics of atrial fibrillation. The heart rate can vary in A-fib; a rate of 92 beats per minute falls within a controlled ventricular response in the context of this arrhythmia.