138: EAQs: Perfusion
A client with hypertension has received a prescription for metoprolol. Which information should the nurse include when teaching this client about metoprolol? 1 Do not abruptly discontinue the medication. 2 Consume alcoholic beverages in moderation. 3 Report a heart rate of less than 70 beats per minute. 4 Increase the medication dosage if chest pain occurs.
1 Abrupt discontinuation of metoprolol may cause rebound hypertension and an acute myocardial infarction. Alcohol is contraindicated for clients taking beta-adrenergic blockers such as metoprolol. Clients should never increase medications without medical direction. The pulse rate can go lower than 70 beats per minute as long as the client feels well and is not dizzy.
A nurse is caring for a client who had a splenectomy. Which complication in the immediate postoperative period is priority for the nurse to assess for in this client? 1 Infection 2 Peritonitis 3 Hemorrhage 4 Intestinal obstruction
3 Because the spleen is highly vascular, hemorrhage may occur, and abdominal distention results. Although an elevated temperature is common, usually it is not the result of infection; the incidence of infection is higher after a splenectomy, but it does not occur in the immediate postoperative period. The incidence of intestinal obstruction is not higher than for other abdominal surgery and does not take priority over hemorrhage. Topics
A nurse is reviewing the laboratory report of an infant with tetralogy of Fallot that indicates an increased red blood cell (RBC) count. What does the nurse identify as the cause of the polycythemia? 1 Low blood pressure 2 Diminished iron level 3 Tissue oxygen needs 4 Hypertrophic cardiac muscle
3 Decreased tissue oxygenation stimulates erythropoiesis, resulting in excessive production of RBCs. Low blood pressure and hypertrophic cardiac muscle are not direct causes of polycythemia. Diminished iron level may or may not affect the production of RBCs.
A client with a history of gastrointestinal varices develops severe hematemesis, and insertion of a Sengstaken-Blakemore tube has been scheduled. What information about the design and purpose of the tube does the nurse provide the client? 1 Single-lumen for gastric lavage 2 Double-lumen for intestinal decompression 3 Triple-lumen to compress the esophagus 4 Multilumen for gastric and intestinal decompression
3 One lumen inflates the esophageal balloon, the second inflates the gastric balloon, and the third decompresses the stomach. It is a triple-lumen, not single-lumen, tube. It is a triple-lumen, not double-lumen, tube; the stomach, not the intestine, is decompressed. The stomach, but not the intestine, is decompressed.
A client who is receiving atenolol for hypertension frequently reports feeling dizzy. What effect of atenolol should the nurse consider may be responsible this response? 1 Depleting acetylcholine 2 Stimulating histamine release 3 Blocking the adrenergic response 4 Decreasing adrenal release of epinephrine
3 The beta adrenergic blocking effect of atenolol decreases the heart's rate and contractility; it may result in orthostatic hypotension and decreased cerebral perfusion, causing dizziness. Depleting acetylcholine is not an action of atenolol. Stimulating histamine release is not an action of atenolol. Decreasing adrenal release of epinephrine is not an action of atenolol.
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings? 1 Cardiogenic shock 2 Hypervolemic shock 3 Hemorrhagic shock 4 Septic shock
3 The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.
A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? 1 Decreased tremors 2 Increased hours of sleep 3 Weight loss during next 2 days 4 More rapid heart rate within 2 days
3 Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failure. Tremors are not typical in infants with heart disease. Tremors are related to central nervous system irritability. If the infant's condition improved, energy would increase and sleeping needs would decrease. Tachycardia is a sign of congestive heart failure. The purpose of the cardiotonic is to slow the heart rate.
Which anatomic changes result in thermodysregulation in elderly people? Select all that apply. 1 Increased metabolic rate 2 Increased shivering response 3 Decreased circulation of blood 4 Decreased number of sweat glands 5 Decreased vasoconstrictive response
3,4,5 As aging occurs, body temperature tends to fluctuate because of the body's decreased ability to regulate its temperature. These fluctuations in temperature occur because of decreased blood circulation, decreased number and efficiency of the sweat glands, and decreased vasoconstrictive response. Increased metabolic rate and shivering response do not result in thermodysregulation; they contribute to fluctuations in the body temperature.
A client with the diagnosis of primary hypertension is started on a regimen of hydrochlorothiazide. The nurse is providing instructions regarding this medication. What information should the nurse include? 1 A common side effect is decreased sexual libido. 2 One dose should be omitted if dizziness occurs when standing up. 3 The client should adjust the dosage daily based on his blood pressure. 4 An antihypertensive medication will likely be required for the remainder of life
4 If medication is necessary to control primary hypertension, usually it is a lifetime requirement. The client should not adjust the dosage without the healthcare provider's direction. Impotence may occur with some antihypertensive medications but not with hydrochlorothiazide. The drug should not be stopped; orthostatic hypotension can be controlled by a slow change of body position.
A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client? 1 Obstructive 2 Neurogenic 3 Cardiogenic 4 Hypovolemic
4 Hypovolemic shock occurs when an abdominal aneurysm ruptures. Shock ensues because fluid volume becomes depleted as the heart continues to pump blood out of the ruptured vessel. Obstructive shock occurs from physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism. Neurogenic shock results from decreased neuromuscular tone, which reduces vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.
An electrocardiogram is prescribed for a client complaining of chest pain. The nurse recognizes which as an early finding of an infarcted area of the heart? 1 Flattened T waves 2 Absence of P waves 3 Elevated ST segments 4 Disappearance of Q waves
3 Elevated ST segments are an early typical finding after a myocardial infarct because of the altered contractility of the heart. Flattened or depressed T waves indicate hypokalemia. Absence of P waves occurs in atrial and ventricular fibrillation. Q waves may become distorted with conduction or rhythm problems, but they do not disappear unless there is cardiac standstill.
When a client has a myocardial infarction, one of the major manifestations is a decrease in the conductive energy provided to the heart. When assessing this client, the nurse is aware that the existing action potential is in direct relationship to what? 1 Heart rate 2 Refractory period 3 Pulmonary pressure 4 Strength of contraction
4 A direct relationship exists between the strength of cardiac contractions and the electrical conductions through the myocardium. The heart rate is related to factors such as sinoatrial (SA) node function, partial pressures of oxygen and carbon dioxide, and emotions. The refractory period is when the heart is at rest, not when it is contracting. Pulmonary pressure does not influence action potential; it becomes elevated in the presence of left ventricular failure.
A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response? 1 Respirations are enhanced. 2 Bladder tonicity is increased. 3 Abdominal muscles are strengthened. 4 Peripheral vasomotor activity is promoted
4 There is extensive activation of the blood-clotting factors after a birth; this, together with immobility, trauma, or sepsis, encourages thromboembolization, which can be limited through activity. Respirations are enhanced by encouraging the client to turn from side to side and deep-breathe and cough. Bladder tone is improved by regular voiding and filling of the bladder. Exercise during the next 6 weeks can strengthen the abdominal muscles.
A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1 A 59-year-old who had a knee replacement 2 A 60-year-old who has bacterial pneumonia 3 A 68-year-old who had emergency dental surgery 4 A 76-year-old who has a history of thrombocytopenia
1 Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
Within the first 2.5 hours after a radical neck dissection, 40 mL of medium red, bloody fluid is collected in the portable wound drainage system. What should the nurse do first? 1 Obtain the client's vital signs. 2 Notify the primary healthcare provider. 3 Document the amount in the medical record. 4 Continue to monitor the amount for another 2.5 hours
1 The client shows an excessive amount of drainage in 2.5 hours; 80 to 120 mL of drainage is expected within the first 24 postoperative hours. The client's status should be assessed first, then the primary healthcare provider should be notified. Charting the amount on the I&O record should be done eventually, but it is not the priority at this time. Continuing to monitor the amount for another 2.5 hours is unsafe; the client is bleeding excessively.
A client develops gastric bleeding and is hospitalized. Which area should the nurse assess most closely during the history? 1 Usual dietary pattern 2 Recent travel to other countries 3 Medications taken routinely or recently 4 A change in the status of family relationships
3 Some medications, such as aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and prednisone, irritate the stomach lining and may cause bleeding with prolonged use. The client's usual dietary pattern is not the cause of gastric bleeding; it is important to ascertain dietary habits when teaching about diet therapy. Travel to other countries may be related to intestinal irritation, causing diarrhea and intestinal bleeding, not gastric bleeding. Although stress related to family relationships may play a part in the need for treatment, the use of some medications has a more direct relationship.
A client with a history of type 1 diabetes is experiencing progressive problems with venous stasis. The client tells the nurse, "I bumped my leg a week ago, and now it has an open draining area just above the ankle." Which information is most important for the nurse to explore when collecting the client's health history? 1 The type of treatment and care the client is receiving 2 What dosage and type of insulin the client is taking and how often 3 The number of family members that are experiencing similar problems 4 How many times a day the client voids and the frequency of bowel movements
1 Asking what type of treatment the client is receiving and how the client is managing care will elicit a variety of data such as medications, diet, and other aspects of care and even includes the care of the new wound. Although it is important to know about the client's insulin use, the information is too limited and does not include how the client is caring for the new wound or for the diabetes itself. Although information about a client's bowel and bladder habits is important, it is not the priority. Although information about the client's children is important, determining the number of family members the client has and whether they are having similar problems is not the priority.
A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment? 1 "Does walking for long periods of time increase your pain?" 2 "Does standing without moving decrease your pain?" 3 "Have you had your potassium level checked recently?" 4 "Have you had any broken bones in your lower extremities?"
1 Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular-related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.
Late in the postoperative period after resection of an aldosterone-secreting adenoma, what would the nurse expect the client's blood pressure to do? 1 Gradually return to near normal levels 2 Rise quickly above the preoperative level 3 Fluctuate greatly during this entire period 4 Drop very low, then increase rapidly to normal levels
1 Once the excessive secretion of aldosterone is stopped, the blood pressure gradually drops to a near normal level. The blood pressure drops gradually; it does not rise. Blood pressure will fluctuate if the hypervolemia is overcorrected; this is not expected. The blood pressure drops gradually in response to decreasing serum corticosteroid levels; a rapid drop immediately after surgery may indicate hemorrhage.
A client is admitted to the hospital with pancytopenia as a result of chemotherapy. What should the nurse plan to teach this client in an effort to minimize the risk of complications as a result of pancytopenia? 1 Avoid traumatic injuries and exposure to infection. 2 Perform frequent mouth care with a firm toothbrush. 3 Increase oral fluid intake to a minimum of 3 L daily. 4 Report any unusual muscle cramps or tingling sensations in the extremities
1 Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase susceptibility to infection. Aggressive oral hygiene can precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic by-products of chemotherapy, this has no effect on pancytopenia. Muscle cramps or tingling sensations in the extremities are adaptations to hypocalcemia; hypocalcemia is unrelated to pancytopenia.
The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively? 1 Administering supplemental oxygen 2 Maintaining a reduced blood pressure 3 Keeping the client in a supine position 4 Monitoring the peripheral vascular status
2 Maintaining a low blood pressure reduces the risk of aortic rupture. Administering supplemental oxygen may or may not be necessary. Keeping the client in a supine position may or may not be necessary. Monitoring will help identify whether an aneurysm has ruptured, but it will not prevent rupture.
A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin? 1 Headaches 2 Bradycardia 3 Hypertension 4 Junctional tachycardia
2 Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate. Metoprolol reduces, not produces, headaches. These drugs may cause hypotension, not hypertension. These drugs may depress nodal conduction; therefore, junctional tachycardia would be less likely to occur.
A client is prescribed prolonged bed rest after surgery. The nurse expects which complication to possibly occur secondary to a compromised circulation from the calf veins? 1 Cerebral embolism 2 Pulmonary embolism 3 Dry gangrene of a limb 4 Coronary vessel occlusion
2 The pulmonary capillary beds are the first small vessels that the embolus encounters once it is released from the calf veins. Pressure on the popliteal space causes venous stasis, promoting thrombus formation. Dry gangrene occurs when the arterial rather than the venous circulation is compromised. The other complications (cerebral embolism and coronary vessel occlusion) will not occur because the embolus will enter the pulmonary system first.
The nurse is caring for a client with a distal femoral shaft fracture. For which clinical indicator unique to a fat embolus should the nurse assess the client? 1 Oliguria 2 Dyspnea 3 Petechiae 4 Confusion
3 At the time of fracture or orthopedic surgery, fat globules may move from bone marrow into the bloodstream; also, increased catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization from fat globules, petechiae are noted in buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these indicators occur only with fat embolism. Oliguria is a clinical finding of an embolus but is not specific to a fat embolus. Dyspnea is not a clinical manifestation of a fat embolus, but an embolus. Confusion is a clinical manifestation of an embolus but is not specific to a fat embolus.
During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? 1 Abdominal girth decrease 2 Mucous membranes becoming drier 3 Heart rate increases from 80 to 135 4 Blood pressure rises from 130/70 to 190/80
3 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.
Which finding is inferred from a grade 4 intensity of heart murmurs? 1 Thrill is easily palpable 2 Quiet and clearly audible thrill 3 Loud murmur associated with thrill 4 Moderately loud murmur without thrill
3 Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.
A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response? 1 Blood loss 2 Tissue death 3 Vascular spasms 4 Electrolyte imbalance
3 In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in turn contributes to the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure diminishes, and there may be no permanent damage. Severe electrolyte imbalance may cause generalized weakness; however, hemiparesis and aphasia are not the result of electrolyte loss.
A client with intermittent claudication has been instructed to stop smoking and doesn't understand why this is necessary. Which is the nurse's best response? 1 "The policy states that the hospital is a smoke-free environment." 2 "Nicotine thins the blood and should be avoided in clients that take anticoagulants." 3 "Nicotine is a vasoconstrictor and should be avoided in clients with arterial problems." 4 "The healthcare provider may allow you to begin smoking again after you are feeling better."
3 The response "Nicotine is a vasoconstrictor and should be avoided in clients with arterial problems" is a truthful answer that explains how nicotine is detrimental to physical status. Nicotine also can increase blood viscosity. Although the hospital is a smoke-free environment, it is not an appropriate explanation of why the client should not smoke. The healthcare provider probably will advise against smoking because resuming smoking will continue to decrease oxygen flow to the lower extremities.
The nurse is caring for a postpartum client with a history of rheumatic heart disease. The nurse plans care for this client with what knowledge regarding this client? 1 She should increase her oral fluid intake. 2 She should maintain bed rest for a minimum of 4 days. 3 She is out of immediate danger, because the stress associated with pregnancy is over. 4 She requires monitoring during the first 48 hours because of the stress on the cardiopulmonary system.
4 The blood volume was increased during pregnancy. The rapid fluid shift after the placenta is expelled causes hypervolemia, which increases the workload of the heart, making the first 48 postpartum hours crucial. Increasing the client's oral fluid intake is not recommended, because it will further increase the circulating blood volume and necessitate an increased cardiac output. Progressive ambulation as tolerated is recommended. It takes 48 hours after the birth for the stress of childbearing to be minimized.