Receiving a report that Mr. K.'s prothrombin time (PT) is 4-4.5 times normal, your nursing action would be to

Correct Answer: A

Rationale: In this scenario, the correct nursing action is to choose option A) call Mr. K.'s physician to report the PT result. A significantly elevated prothrombin time indicates a prolonged clotting time, which may lead to an increased risk of bleeding. Therefore, it is crucial to inform the physician promptly to ensure appropriate management. Option B) stopping the heparin infusion is incorrect because heparin is an anticoagulant used to prevent blood clots, and abruptly discontinuing it can lead to an increased risk of clot formation. Option C) increasing the heparin infusion is also incorrect as it would further exacerbate the anticoagulation effect, potentially leading to serious bleeding complications. Option D) doing nothing is not the appropriate course of action when faced with a critical lab result that can impact patient safety. Educationally, understanding the significance of prothrombin time values is vital for nurses caring for patients on anticoagulant therapy. This knowledge helps in recognizing abnormal results, taking appropriate actions, and collaborating effectively with the healthcare team to ensure patient safety and optimal outcomes.

Correct Answer: C

Rationale: The correct answer is C) left ventricular failure. Pulmonary capillary wedge pressure (PCWP) is a measure of the pressure in the left side of the heart and reflects left ventricular function. When PCWP rises above normal values, it indicates increased pressure in the left side of the heart, which commonly occurs in left ventricular failure. This can lead to symptoms of pulmonary congestion and edema due to the backflow of blood into the lungs. Option A) right ventricular failure is incorrect because PCWP specifically reflects left ventricular function, not right ventricular function. Right ventricular failure would manifest with other signs and symptoms. Option B) hypovolemia is incorrect because in hypovolemia, the PCWP would be low rather than high. Hypovolemia indicates a decreased blood volume, leading to reduced filling pressures in the heart. Option D) ventricular irritability is incorrect as this term refers to abnormal electrical activity in the heart, such as arrhythmias, and is not directly related to PCWP levels. In an educational context, understanding the significance of monitoring PCWP is crucial in assessing cardiac function and guiding treatment in patients with heart failure. This question highlights the importance of recognizing the implications of changes in PCWP values and their correlation with specific cardiac conditions, aiding in clinical decision-making and patient management.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) 1-lb weight gain in 2 days. This is a crucial symptom that clients taking diuretics for chronic congestive heart failure need to report promptly. This rapid weight gain can indicate fluid retention, a sign that the heart failure is worsening, and immediate medical intervention may be necessary. Option B) Seeing yellow hazes around bright lights is not directly related to the management of congestive heart failure or diuretic therapy. This symptom could be indicative of other health issues but is not a typical concern for clients in this specific context. Option C) Change in the heart rate is a common symptom in heart-related conditions, but for clients taking diuretics for heart failure, changes in heart rate may not always be a primary indicator of worsening condition compared to sudden weight gain. Option D) Change in activity tolerance is a general symptom that can be seen in various health conditions. While it is important for clients with heart failure to monitor their activity tolerance, sudden weight gain is a more specific and critical indicator that requires immediate attention in this context. Educational context: It is essential for healthcare providers to educate clients with chronic congestive heart failure about the importance of monitoring their weight regularly, as it can be an early sign of fluid retention and worsening heart failure. Recognizing and reporting such changes promptly can help prevent complications and improve outcomes for individuals with heart failure.

Correct Answer: C

Rationale: In third-degree atrioventricular block (complete heart block), there is a complete dissociation between the atria and ventricles, leading to an independent rhythm of both. The correct answer is C) A slow heart rate because in this condition, the ventricles are activated by an escape rhythm originating from a lower pacemaker site, resulting in a slower heart rate. Option A) A highly variable PR interval is incorrect because in third-degree AV block, there is no relationship between the P waves and QRS complexes, so PR intervals are not applicable. Option B) Regular PP intervals are incorrect because PP intervals refer to the atrial activity, which may be regular in this condition but do not reflect the lack of conduction to the ventricles. Option D) Regular RR intervals are incorrect because RR intervals measure the ventricular rate, and in third-degree AV block, the ventricular rate is typically slower and irregular due to the escape rhythm. Educationally, understanding the different degrees of heart block is crucial for healthcare professionals as it impacts patient management and treatment decisions. Recognizing the characteristic features of each degree of heart block, like the specific ECG findings in third-degree AV block, is essential for providing appropriate care to patients with cardiac conduction abnormalities.

Correct Answer: C

Rationale: In Mrs. Jones' discharge teaching with a permanent pacemaker, covering the point that she can return to the degree of sexual activity that is desired and tolerable for her is crucial. This information is important as it addresses a common concern among patients with pacemakers and promotes a holistic approach to her quality of life post-implantation. Educating Mrs. Jones about resuming sexual activity helps address her emotional and psychological well-being, enhancing her overall recovery process. Option A is incorrect because having a pacemaker does not necessarily mean one cannot get pregnant; however, it is important to consult with her healthcare provider. Option B is incorrect as regular exercise is generally encouraged for patients with pacemakers to maintain cardiovascular health. Option D is incorrect as regular follow-up visits with her physician are essential to monitor the pacemaker's function and her overall cardiac health. By explaining the importance of sexual activity in the context of pacemaker management, healthcare providers can empower patients like Mrs. Jones to make informed decisions about their lifestyle and well-being, fostering a collaborative and patient-centered approach to care.