Adult Health II: Test 3

The nurse identifies which of the following risk factors as contributing to the development of peripheral artery disease? Select all that apply. 1. Cigarette smoking 2.Diabetes mellitus 3.Hyperlipidemia 4.Oral contraceptive use 5.Prolonged standing

1. Cigarette smoking 2.Diabetes mellitus 3.Hyperlipidemia In peripheral artery disease (PAD), the arteries of the extremities become atherosclerotic (progressive thickening and hardening due to chronic vascular damage). PAD reduces tissue perfusion and can cause ischemic pain of the lower extremities with movement or exercise (intermittent claudication). Pain with PAD can also occur at rest and manifests in the lower extremities as burning, aching, or numbness. Factors that cause chronic vascular changes and increase risk for PAD include: Smoking: Chronic vasoconstriction from nicotine inhalation (Option 1) Hypertension: Vessel damage from chronically elevated vascular resistance Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option 2) Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option 3)

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. 1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg 4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value

1.Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2.Client on newly prescribed lisinopril and is at 8 weeks gestation 3.Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. 1. "I will need to take my blood thinner for about 3-6 months." 2. "I will place small rugs on my wood floors to cushion a fall." 3."I will take a baby aspirin if I have mild chest pain." 4."I will use a soft-bristled toothbrush to clean my teeth." 5."I will wear a blood thinner MedicAlert tag."

2. "I will place small rugs on my wood floors to cushion a fall." 3."I will take a baby aspirin if I have mild chest pain."

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply. 1. Crackles in lung bases 2. Increased abdominal girth 3. Jugular venous distension 4. Lower extremity edema 5. Orthopnea

2. Increased abdominal girth 3. Jugular venous distension 4. Lower extremity edema Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation. Clinical manifestations of right-sided heart failure include: Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option 4). Jugular venous distension (Option 3). Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option 2). Hepatomegaly due to hepatic venous congestion.

An IV infusion of norepinephrine at 8 mcg/min is prescribed for a client in shock. The concentration of norepinephrine is 4 mg in 250 mL of D5W. For how many milliliters per hour (mL/hr) should the nurse program the IV pump?

30ml

The health care provider prescribes a continuous heparin infusion at 18 units/kg/hr for a client who has a pulmonary embolus and weighs 198 lb. The infusion bag contains 25,000 units of heparin in 500 mL of D5W. At what rate in milliliters per hour (mL/hr) does the nurse set the IV infusion pump?

32 ml/hr

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning? 1. Client rates leg pain as "7" 2.Negative Homan sign 3.Prominent varicose veins bilaterally 4.Right calf is 4 cm larger than left calf

4cm

What is heart failure? a condition that the patient experiences chest pain A condition in which the heart cannot pump enough blood to meet the body's needs A condition in which the heart stops beating A myocardial infarction

A condition in which the heart cannot pump enough blood to meet the body's needs

How does the body attempt to compensate in response to low cardiac output during heart failure? Increased sympathetic tone; RAAS activation; increased body fluid volume Decrease sympathetic tone; RAAS inactivation; decreased body fluid volume Increased sympathetic tone; RAAS inactivation; decreased body fluid volume Decreased sympathetic tone; RAAS activation; increased body fluid volume

Increased sympathetic tone; RAAS activation; increased body fluid volume

CVP is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid volume problems. The normal CVP is 2-8 mm Hg. An elevated CVP can indicate right ventricular failure or fluid volume overload. Clinical signs of fluid volume overload include the following:

Peripheral edema Increased urine output that is dilute Acute, rapid weight gain Jugular venous distension S3 heart sound in adults Tachypnea, dyspnea, crackles in lungs Bounding peripheral pulses

The charge nurse is evaluating the skills of graduate nurses (GNs) who are caring for clients with shock. Which action taken by a GN indicates a need for further education? 1. Administers furosemide to a client with elevated pulmonary artery wedge pressure and cardiogenic shock 2. Applies an SpO2 sensor to the forehead of a client with septic shock rather than using a finger 3. Raises the head of the bed to high Fowler position for a client with hypovolemic shock 4. Titrates norepinephrine infusion to maintain mean arterial pressure ≥65 mm Hg in a client with anaphylactic shock

Raises the head of the bed to high Fowler position for a client with hypovolemic shock

compensatory mechanisms of heart failure result in (select all that apply): Ventricular hypertropy vasodilation bradycardia with decreased contractility vasoconstriction tachycardia with increased contractility

Ventricular hypertropy vasoconstriction tachycardia with increased contractility

Neurogenic shock can occur after a high thoracic spinal cord injury because there is

a sudden loss of sympathetic stimulation to the blood vessels

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? 1. Administer IV normal saline 2.Determine if urinary occult blood is present 3.Perform a neurological assessment 4.Verify that there is no stool impaction

administer normal saline

A nurse would assign which nursing diagnosis to any patient diagnosed with shock?

altered tissue perfusion

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a motorcycle collision. Which assessment finding leads the nurse to suspect neurogenic shock? 1. Apical heart rate 48/min 2.Blood pressure 186/92 mm Hg 3.Cool, clammy skin 4.Temperature 100 F (37.8 C)

apical Neurogenic shock belongs to the group of distributive (vasodilatory) shock. Parasympathetic nervous system (PNS) activity, which is directed from the brain through the vagus nerve (cranial nerve X), includes relaxing smooth muscle tone (eg, blood vessels) and decreasing heart rate and contractility. Sympathetic nervous system (SNS) activity, which normally balances the PNS, is communicated from the spinal cord. In neurogenic shock, a cervical or thoracic injury (or spinal anesthesia) disrupts the SNS, leading to bradycardia (eg, apical heart rate 48/min), massive vasodilation, and pooling of blood in the venous circulation

arterial vs venous insufficiency

arterial: -gangrene -decreased peripheral pulses at posterior tibial artery and dorsalis pedis artery -thick, brittle nails -atherosclerotic plaque -decreased blood flow -intermittent claudication (ischemic calf pain) -cool dry skin -hair loss above ankles -small, circular, deep ulcers venous insufficiency -varicose vein -incompetent valve -retrograde flow -warm thick indurated skin -edema -bronze-brown pigmentation -large, irregular, superficial ulcer with drainage

A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first? 1. Auscultate breath sounds 2.Check for peripheral edema 3.Measure the client's vital signs 4.Review the client's weight log over the past several days

auscultate

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? Select all that apply. 1. Blood pressure 2.Blood urea nitrogen 3.Liver enzymes 4.Potassium 5.White blood cell count

bp bun potassium

Which client is at greatest risk for pulmonary embolism? 1. A client 6 hours postoperative cesarean section 2. A client in atrial fibrillation 3. A client with a subdural hematoma 4. A client with pneumonia

c section

What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg? Select all that apply. 1. Crackles in lungs 2.Dry mucous membranes 3.Hypotension 4.Jugular venous distension 5.Pedal edema

crackles jvd pedal edema

A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? Select all that apply. 1. Crackles on auscultation 2.Dry mucous membranes 3.Increased jugular venous distention 4.Rhonchi on auscultation 5.Skin "tenting" 6.3+ pitting edema of the lower extremities

crackles on auscultation increased jugular venous distention 3+ pitting edema of the lower extemities

A patient is being treated for shock secondary to multiple rib fractures and a lacerated liver. Two units of packed red blood cells have been administered. Which of these measurements is an indication the patient has received adequate volume replacement?

decreased serum lactate

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?

head of bed elevated 30-45 degrees

After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? Left-sided heart failure Pulmonic valve malfunction Right-sided heart failure Tricuspid valve malfunction

left sided

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: Stroke volume Left ventricular functioning Cardiac output Venous pressure

left ventricular fxning

Which are indications that a client with a history of left-sided heart failure is developing pulmonary edema (select all that apply)? dependent edema distended jugular veins tachycardia coarse crackles anorexia

tachycardia coarse crackles

When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? urine output 15ml for 2 hrs arterial oxygen saturation 93% apical pulse 110 beats/min BP 88/56 mmHg

urine output 15ml for 2 hrs

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. 1. "I don't plan on eating any more frozen meals." 2."I plan to take my diuretic pill in the morning." 3."I will weigh myself at least every other day." 4."I'm going to look into joining a cardiac rehabilitation program." 5."Ibuprofen works best for me when I have pain."

weigh myself & ibuprofen

The nurse is teaching a client to self-administer enoxaparin subcutaneously for the outpatient treatment of deep-vein thrombosis (DVT). The client points to the site of planned injection. Which site indicates that the client understands the instructions?

right or left side of the abdomen, at least 2 in from the umbilicus.

In which of the following disorders would the nurse expect to assess sacral edema in bedridden client? Right-sided heart failure Coronary artery disease Left-sided heart failure Right-sided heart failure

right sided

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client? 1. Diet recall for this current week 2. Fluid intake for the past 2 days 3. Medications and dosages taken over the past 2 days 4. Presence of shortness of breath, coughing, or edema

sob, coughing, edema

the nurse suspects their patient has septic hock. which of the following assessments indicates the patient is compensating by increasing cardiac output? weak peripheral pulses warm, flushed skin tachycardia tachypnea

tachycardia

Which client is in need of follow-up education by the nurse? 1. Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping 2.Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out 3.Client with venous leg ulcer who refuses to wear elastic compression stockings during the day 4.Postsurgical client who points and flexes feet when lying in bed

Client with venous leg ulcer who refuses to wear elastic compression stockings during the day

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply. 1. "Antibiotics can affect my INR value." 2."I am going to eat more leafy greens." 3."I will shoot for my INR value to be between 4 and 5." 4."I will take warfarin at the same time daily." 5."If I miss a dose, I can double it on the following day."

"Antibiotics can affect my INR value." 4."I will take warfarin at the same time daily." A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 (Option 3). Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding (Option 1). Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically

A hospitalized client has been treated for the past 48 hours with a continuous heparin infusion for a deep vein thrombosis (DVT). When the nurse prepares to administer the evening dose of warfarin, the client's spouse says "Wait! My spouse can't have that! My spouse is already getting heparin for DVT." How should the nurse respond? 1. "Both medications will be given for several days until the warfarin has time to take effect." 2."I will be discontinuing the heparin infusion as soon as I give this dose of warfarin." 3."The two medications work synergistically to help break down the clot in your spouse's leg." 4."We will hold the medication until I can call the health care provider (HCP) for clarification."

"Both medications will be given for several days until the warfarin has time to take effect." Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse.

A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond? 1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." 2."Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." 3."Heparin will keep the current clot from getting bigger and help prevent new clots from forming." 4."I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving."

"Heparin will keep the current clot from getting bigger and help prevent new clots from forming.

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing." 2."I know you are frustrated with losing control of your life." 3."It sounds like you are angry. Tell me what's bothering you." 4."Okay. I'll just check your blood pressure and then go."

"It sounds like you are angry. Tell me what's bothering you."

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? Select all that apply. 1. Blue, cyanotic toes 2.Calf pain 3.Dry, shiny, hairless skin 4.Lower leg warmth and redness 5.Unilateral leg edema

2.Calf pain 4.Lower leg warmth and redness 5.Unilateral leg edema also low grade fever

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. 1. "I will apply moisturizing lotion on my legs every day." 2."I will elevate my legs at night when I am sleeping." 3."I will keep my legs below heart level when sitting." 4."I will start walking outside with my neighbor." 5."I will use a heating pad to promote circulation."

1. "I will apply moisturizing lotion on my legs every day." 3."I will keep my legs below heart level when sitting." 4."I will start walking outside with my neighbor." Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene). Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development

The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. 1. Conduct teaching sessions while a family member is present 2.Discourage the client from using the internet to look up health information 3.Have client watch a DVD about heart failure management 4.Print out pictures of a food label and review where to look for sodium content 5.Speak slowly and loudly so the client can understand you

1. Conduct teaching sessions while a family member is present 3.Have client watch a DVD about heart failure management 4.Print out pictures of a food label and review where to look for sodium content

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply. 1. "Do not take car rides longer than 4 hours for at least 3-4 weeks." 2."Drink plenty of fluids every day and limit caffeine and alcohol intake." 3."Elevate legs on a footstool when sitting and dorsiflex the feet often." 4."Resume your walking program as soon as possible after getting home." 5."Sit in a cross-legged position for 5-10 minutes to improve circulation."

2."Drink plenty of fluids every day and limit caffeine and alcohol intake." 3."Elevate legs on a footstool when sitting and dorsiflex the feet often." 4."Resume your walking program as soon as possible after getting home." A deep venous thrombosis (DVT) is a blood clot (ie, thrombus) formed in large veins, generally of the lower extremities. Risk factors for DVT include venous stasis, blood hypercoagulability, and endothelial damage. Therefore, discharge teaching for a client with resolved DVT emphasizes interventions to promote blood flow and venous return (eg, exercise, smoking cessation) to prevent reoccurrence. Interventions to prevent DVT reoccurrence include: Obtain adequate fluid intake and limit caffeine and alcohol intake to avoid dehydration because dehydration increases the risk for blood hypercoagulability (Option 2). Elevate the legs when sitting and dorsiflex the feet often to reduce edema and promote venous return (Option 3). Resume an exercise program (eg, walking, swimming) and change positions frequently to promote venous return (Option 4). Stop smoking to prevent endothelial damage and vasoconstriction. Avoid restrictive clothing (eg, tight jeans), which interferes with circulation and promotes clotting. Consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels.

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? 2.2 1.6 1.2 1.0

2.2

The nurse is caring for a client who has deep venous thrombosis and is prescribed a continuous IV infusion of heparin 25,000 units in 500 mL of D5W at 1300 units/hr. After 6 hours of the heparin infusion, the client's PTT is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol (shown in the exhibit). According to the protocol, at what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump? chart said to increase by 100units per hour

28 mL/hr

The patient at highest risk for venous thromboembolism (VTE) is an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia. 62-year-old man with spider veins who is having arthroscopic knee surgery. a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor.

32 yo

The nurse is providing community health screening. Which of the following clients should be referred to a health care provider for further evaluation? 1. 30-year-old athlete with a heart rate of 50/min 2. 45-year-old client with a body mass index of 35 kg/m2 and fingerstick glucose of 150 mg/dL (8.3 mmol/L) 3. 55-year-old client missing all the hair on the lower legs and failing the pinprick test 4. 80-year-old client with a blood pressure of 150/90 mm Hg

55 yo

The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? 1. A 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives 2. A 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% 3. A 72-year-old client with a fever who is 2 days post coronary stent placement 4. An 80-year-old client who is 4 days postoperative from repair of a fractured hip

80 yo Venous thromboembolism includes both DVT and pulmonary embolism (PE). DVT is the most common form and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: Trauma (endothelial injury and venous stasis from immobility) Major surgery (endothelial injury and venous stasis from immobility) Prolonged immobilization (eg, stroke, long travel) causing venous stasis Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) Oral contraceptives (estrogen is thrombotic) Underlying malignancy (cancer cells release procoagulants) Smoking (produces endothelial damage by inflammation) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase blood viscosity) The 80-year-old 4-day postoperative client has the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age, and is at greatest risk for developing a DVT.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3.Cardiac enzymes (CK-MB) 4.Chest x-ray

B-type natriuretic peptide (BNP) B-type natriuretic peptide (BNP) is a peptide that causes natriuresis. BNPs are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL (>28.9 pmol/L) helps to distinguish cardiac from respiratory causes of dyspnea

A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply. 1. Bathroom scale for daily weights 2.Blood pressure cuff 3.Central line dressing change kits 4.Infusion pump 5.Intermittent urinary catheterization kits

Bathroom scale for daily weights Blood pressure cuff Central line dressing change kits Infusion pump Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line. The home health nurse should perform the following: Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting (Option 4). Evaluate medication effectiveness and possible side effects. Monitor the central line insertion site for infection. Change the central line dressing as prescribed (Option 3). Monitor daily weight (Option 1). Monitor blood pressure for possible hypotension (Option 2). Implement safety precautions as hypotension increases the client's risk of falling.

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? 1.Bumetanide 2.Candesartan 3.Carvedilol 4.Isosorbide

Bumetanide Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide).

The clinic nurse is reviewing telephone messages from four clients. Which client's call should the nurse return first? 1. Client who has just taken albuterol and reports a heart rate of 108/min and a coarse tremor in both arms 2.Client who is prescribed azithromycin and reports frequent, foul-smelling, liquid stools and abdominal cramping 3.Client who is prescribed metformin and reports a blood glucose of 284 mg/dL (15.76 mmol/L) and frequent urination 4.Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house

Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias that cannot be controlled with other medications. Amiodarone therapy is used only if other treatments have failed, as it has many toxic, adverse effects that may be severe. Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible lung damage

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up? 1. Client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg (6.9 kPa) 2. Client with heart failure who has a brain natriuretic peptide level of 800 pg/mL (800 ng/L) 3. Client with infected pressure ulcer who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) 4. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds

Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds Clients with pulmonary embolism or deep venous thrombosis are treated with anticoagulation. Unfractionated heparin is one such agent, and its efficacy is measured through partial thromboplastin time (PTT) levels. The goal during anticoagulation therapy is a PTT 1.5-2 times the normal reference range of 25-35 seconds. A PTT of 127 seconds is much too prolonged, and spontaneous bleeding could occur.

A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching? 1. "I always take my simvastatin in the evening." 2."I prop my legs up in the recliner and use a heating pad when my feet are cold." 3."I've been walking on my treadmill at home for 15 minutes each day." 4."I've noticed that I don't have much hair on my lower legs anymore."

I prop my legs up in the recliner and use a heating pad when my feet are cold." Clients with peripheral arterial disease (PAD) have decreased sensations from nerve ischemia or coexisting diabetes mellitus. They should never apply direct heat to the extremity due to the risk for a burn wound. Wound healing is impaired in these clients. Swelling in the extremities (edema) could result from venous stasis (venous valve incompetence or varicose veins); these clients are asked to elevate their extremities during rest. However, clients with PAD usually do not have swelling, but rather have decreased blood supply. The extremities should not be elevated above the level of the heart because extreme elevation further impedes arterial blood flow to the feet. Additional teaching for the client with PAD includes the following: Smoking cessation Regular exercise Achieving or maintaining ideal body weight Low-sodium diet Tight glucose control in diabetics Tight blood pressure control Use of lipid management medications Use of antiplatelet medications Proper limb and foot care

The nurse is teaching a client who is scheduled to have an inferior vena cava filter inserted via the right femoral vein. Which statement by the client requires further teaching? 1. "I need to make all health care providers aware of my filter before I have body scans." 2."I need to stay active and avoid crossing my legs for extended periods when I get home." 3."I should call the health care provider if I develop numbness, tingling, and swelling in my right leg." 4."It is normal to have some chest or back discomfort for a few days after filter placement."

It is normal to have some chest or back discomfort for a few days after filter placement." An inferior vena cava filter is a device that is inserted percutaneously, usually via the femoral vein. The filter traps blood clots from lower extremity vessels (eg, embolus from deep venous thrombosis) and prevents them from migrating to the lungs and causing a pulmonary embolism (PE). It is prescribed when clients have recurrent emboli or anticoagulation is contraindicated. Clients should be questioned about and report any metallic implants (eg, vascular filters/coils) to the health care team prior to radiologic imaging, specifically MRI (Option 1). Physical activity should be promoted, and clients should avoid crossing their legs to promote venous return from the legs (Option 2). Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be reported immediately

A patient has received intravenous heparin therapy for six days for treatment of deep vein thrombophlebitis. The healthcare provider now orders warfarin without discontinuing the heparin. The patient questions the nurse about the use of both drugs. The nurse's best response is:

It takes several days for the warfarin to have an effect, so we need to keep you on the heparin for a few more days.

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy? 1. Assess how far the client can walk 2.Check sensation in fingers and toes 3.Inspect extremities for diabetic ulcers 4.Take the blood pressure sitting and standing

take bp sitting and standing Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension and put the client at risk for falls.

The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse? 1. Ambulates through the hallway several times per day 2.Applies a warm compress to the site of inflammation 3 .Elevates the limb above the level of the heart while in bed 4.Massages the affected leg to reduce pain and swelling

Massages the affected leg to reduce pain and swelling Venous thromboembolism (VTE) (eg, deep venous thrombosis [DVT]) occurs when a clot becomes lodged in a vein, most often in the deep veins of the lower extremities due to venous stasis, endothelial damage, and hypercoagulability of blood (ie, Virchow triad). Treatment of a VTE includes anticoagulants (eg, enoxaparin, rivaroxaban, heparin, warfarin) to prevent further clotting as the body's fibrinolytic system naturally dissolves the clot by breaking down fibrin deposits. Clients with DVT are at risk for developing a life-threatening pulmonary embolism (PE). The clot may become dislodged by massage or use of sequential compression devices on the affected extremity. The nurse would intervene immediately if a client was observed massaging the site because this may trigger an embolism

To prevent the development of heart failure in a patient with hypertension, the nurse stresses the importance of compliance with antihypertensive therapy based on the knowledge that: Systolic failure and low forward blood flow is caused by impaired contractile force of the heart Diastolic failure and venous congestion may be caused by decreased preload Systolic failure and low forward blood flow can result from increased afterload Mixed systolic and diastolic failure may result from dilated cardiomyopathy precipitated by hypertension

Systolic failure and low forward blood flow can result from increased afterload

A client recently diagnosed with heart failure is being discharged with a prescription for lisinopril. Which client teaching related to this new medication is important to review at discharge? 1. Instruct client to report for monthly blood work to monitor drug levels 2.Review foods high in potassium that client should include in diet 3.Teach client to count own pulse for 1 minute; hold medication if pulse <60/min 4.Teach client to rise slowly and sit on side of bed for several minutes before rising

Teach client to rise slowly and sit on side of bed for several minutes before rising Angiotensin converting enzyme (ACE) inhibitors (eg, captopril, enalapril, lisinopril, ramipril) prevent the pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation. Interrupting this step of the renin-angiotensin-aldosterone system has following effects: A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury). The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation of bradykinin.

The nurse has identified the collaborative problem of potential complication: pulmonary embolism for a patient with deep vein thrombophlebitis. Which intervention does the nurse plan to prevent embolization of a thrombus? Monitor vital signs and pulmonary status every four hours. Apply compression gradient stockings while the patient is on bed rest. Perform passive range of motion of the affected extremity to increase venous return. Teach the patient to avoid the Valsalva maneuver when turning and moving in bed.

Teach the patient to avoid the Valsalva maneuver when turning and moving in bed.

A critically ill client receiving vasopressor therapy for hypotension requires continuous blood pressure monitoring via an arterial catheter. The nurse sets up the pressure monitoring system and correctly places the transducer at the phlebostatic axis. Where on the chest does the nurse mark this reference point?

The phlebostatic axis is an external anatomical point on the chest at the level of the atria of the heart (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest). It is used as a reference point for correct placement of the zeroing point of the transducer when measuring continual arterial blood pressure (BP), central venous pressure (CVP) using a central line, and/or cardiopulmonary pressures via a pulmonary artery (Swan-Ganz) catheter. The nurse places the transducer and marks the chest at the phlebostatic axis, which helps to assure accuracy of measurement. After it is placed, the zero reference stopcock of the transducer is "leveled," or aligned with the level of the atrium, using a ruler or carpenter's level. If the zeroing stopcock is placed below this level, falsely high readings occur; if it is too high, falsely low readings are obtained.

A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? 1. Jugular venous distension 2.Mean arterial blood pressure 65 mm Hg 3.Urine output <0.5 mL/kg/hr 4.Warm, flushed skin

Urine output <0.5 mL/kg/hr Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, hemorrhage, surgery, gastrointestinal bleeding, vomiting, diarrhea) or a relative (eg, pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: --Change in mental status --Tachycardia with thready pulse --Cool, clammy skin --Oliguria --Tachypnea Decreased urine output (<0.5 mL/kg/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform? 1. Assess for dry, scaly skin on the lower legs (4%) 2.Assess for presence or absence of hair growth on lower extremities (26%) 3.Check for presence and quality of posterior tibial and dorsalis pedis pulses (67%) 4.Obtain a dietary history

tibial and dorsalis

The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? 1. "At the end of the day, my shoes and socks are tight." 2."I have a slow-healing sore right above my ankle." 3."My legs ache when I stand for extended periods." 4."When I sit down to rest and elevate my legs, the pain increases."

When I sit down to rest and elevate my legs, the pain increases." Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation.

A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml and a urinary output of 120 ml in the first hour. The vital signs are blood pressure 72/52; heart rate 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the

a progressive stage of hypovolemic shock

A 32-yo physical therapist is admitted to the hospital with possible deep vein thrombophlebitis. Her left calf is swollen and tender to touch. Which of the following admission orders should the nurse question? Elevate the foot of the bed above the level of her heart. No IM injections. Duplex scan of bilateral lower extremities. Apply SCDs and assess every 8 hours.

apply scds

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action? 1. Auscultate the client's breath sounds 2.Encourage the client to increase fluid intake 3.Report the findings to the health care provider (HCP) 4.Start an intravenous line for diuretic administration

auscultate

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation? 1. B-type natriuretic peptide (BNP) 1382 pg/mL [399 pmol/L] 2.Flat jugular veins when seated at a 45-degree angle 3.Sodium 150 mEq/L [150 mmol/L] 4.Urine output greater than 100 mL/hr

b type Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of left ventricular filling pressure elevation and mortality. A normal BNP level is <100 pg/mL [<28.9 pmol/L]. The nurse would expect a high BNP in a client exhibiting symptoms of acute decompensated heart failure

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action? 1. Auscultate the client's lungs 2.Check the client's capillary refill 3.Measure the client's blood pressure 4.Review the client's electrocardiogram (ECG)

bp Sodium nitroprusside is a highly potent vasodilator (both venous and arteriolar). Venous dilation reduces preload (volume of blood in ventricles at the end of diastole), and arterial dilation reduces afterload (resistance ventricle must overcome to eject blood during systole). Sodium nitroprusside is commonly used in hypertensive emergencies and for conditions in which blood pressure control is of utmost importance (eg, aortic dissection, acute hypertensive heart failure). Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely due to hypotension. Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally develop fatal cyanide toxicity.

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency? 1. Brownish, hardened skin on lower extremities 2.Diminished peripheral pulses 3.Nonhealing ulcer on lateral surface of great toe 4.Shiny, hairless lower extremities

brownish

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. 1. Capillary refill is less than 3 seconds2.Pulse pressure is narrowed3.Systolic blood pressure drops only when standing4.Urine output is 360 mL in 4 hours5.Urine specific gravity is 1.020

cap refil, urine specific, urine output

A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply. 1. Apical pulse 2.Capillary refill 3.Lung sounds 4.Pupillary response 5.Skin color and temperature

cap refill skin color and temp Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity temperature, and peripheral pulses. Capillary refill indicates adequacy of blood flow to the peripheral tissues. It is measured by the time taken for color (pink) to return to an external capillary bed (nail bed) after pressure is applied to cause blanching. In an adult, color should return in less than 3 seconds. Normal skin color and temperature are indicators of the adequacy of peripheral blood flow; these are usually within normal limits during the initial and compensatory stages of shock.

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? cerebral or pulmonary emboli decreased cardiac output excessive bleeding increased blood pressure

cerebral or pulmonary emboli

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? 1. Apical heart rate is 62/min 2.Blood sugar level is 240 mg/dL (13.3 mmol/L) 3. Client is taking 20 mg fluoxetine daily 4. Serum creatinine is 2.3 mg/dL (203 µmol/L)

creatinine

The nurse is preparing to discharge a client who developed heart failure after a myocardial infarction. Based on the discharge data, the nurse plans to include which topics during teaching? Select all that apply. Click on the exhibit button for additional information. 1. Daily weighing2.How to take own pulse3.Need for monthly International Normalized Ratio (INR)4.Need to increase foods high in potassium5.Reduction of sodium in diet6.Use of home oxygen

daily weigh take own pulse reductioon of sodium

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30) 2.Partial thromboplastin time of 110 seconds 3.Platelet count of 80,000/mm3 (80 x 109/L) 4.Prothrombin time of 11 seconds

ptt 110 sec Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds.

The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client's aPTT is 5 times the control value and the PT/INR is 2 times the control value. What action does the nurse anticipate? 1. Clarify vegetable consumption with client 2.Decrease the heparin rate 3.Decrease the warfarin dose 4.Obtain an order for vitamin K injection

decrease heparin rate The anticoagulant heparin has to be administered intravenously or subcutaneously. The duration is 2-6 hours intravenously and 8-12 hours subcutaneously. It is measured by the aPTT (activated partial thromboplastin time) laboratory value. Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days. It is measured by prothrombin time (PT) or International Normalized Ratio (INR). The therapeutic range for aPTT or PT/INR is generally 1.5-2.0 times the control value (up to 3 times the control value at times). An aPTT value above the therapeutic range places the client at risk for excess bleeding. The heparin administration would need to be stopped or decreased.

A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, blood pressure 100/60, and respirations of 42. The patient is coughing bloody sputum. Which action by the nurse is most appropriate initially? Calm the patient with emotional support and reassurance. Administer pain medication. Draw arterial blood gas sample. Elevate the head of the bed and call the healthcare provider.

elevate hob

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. 1. Epoetin alfa 2.Fresh frozen plasma 3.Homologous packed red blood cells 4.Normal saline 5.Platelet transfusion

epoetin alfa and normal saline

A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority? 1. Administer digoxin 0.25 mg 2.Administer furosemide 40 mg IV push 3.Initiate dopamine infusion at 5 mcg/kg/min 4.Obtain blood sample for arterial blood gases

furosemide

A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? 1. 0.45% sodium chloride IV 2.Calcium gluconate 3.Furosemide 4.Sodium polystyrene sulfonate

furosemide

Based on the progress note documentation, which priority intervention does the nurse anticipate? Click on the exhibit button for additional information. 1. 0.9% sodium chloride, 500 mL intravenous bolus 2.Furosemide, 40 mg intravenous push 3.Metoprolol, 5 mg intravenous push 4.Vancomycin, 1 g intravenously every 12 hours Client admitted to CCU #4, reporting vise-like chest pain and shortness of breath. Pulmonary artery (PA) catheter inserted by the health care provider via right internal jugular vein without difficulty. Central venous pressure (CVP) 18 mm Hg, pulmonary artery wedge pressure (PAWP) 25 mm Hg and coarse crackles auscultated bilaterally.

furosemide

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? furosemide potassium levofloxacin glipizide

furosemide

The nurse closely monitors the fluid balance of a patient in congestive heart failure with the knowledge that additional sodium and water retention occurs in an already congested vascular system as a result of: Venous congestion in the liver Decreased glomerular blood flow in the kidney Excessive release of ADH from stress response Increased pressure in lung arterioles

glomerular flow

A nurse in the intensive care unit is caring for a postoperative cardiac transplant client. What intervention is most important to include in the plan of care? 1. Apply sequential compression devices to prevent deep venous thrombosis 2.Assist client to change positions slowly to prevent hypotension 3.Encourage coughing and deep breathing to prevent pneumonia 4.Use careful hand washing and aseptic technique to prevent infection

hand hygeine baby

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? 1. Central venous pressure is 6 mm Hg 2. Heart rate is 120/min 3. Mean arterial pressure is 78 mm Hg 4. Systemic vascular resistance is 900 dynes/sec/cm-5

hr 120

A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98.0 F (36.3 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock?

hypovolemic

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective?

i should avoid taking aspirin while receiving the medication

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time? 1. Immunosuppressive therapy as a lifelong commitment 2.Importance of accurate daily weight monitoring 3.Importance of periodic endomyocardial biopsies 4.Maintenance of meticulous surgical incision care

immunosuppressive

During a visit to an elderly patient with chronic congestive heart failure, the nurse finds that the patient has severe dependent edema and that her legs appear to be weeping serous fluid. Which of the following is the best nursing diagnosis for the patient condition: Risk for impaired tissue perfusion related to decreased circulation Fluid volume excess related to congestive heart failure Activity intolerance related to edema Impaired skin integrity related to edema

impaired skin

A client taking a diuretic for chronic heart failure experiences constipation. What is the nurse's best recommendation? 1.Drink 2 extra glasses of water with each meal 2.Exercise for longer periods 3.Include more fiber in the diet 4.Take warm baths to relax the abdomen

include more fiber in diet

A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse? 1. Client eats a vegetarian diet 2.Client has chronic atrial fibrillation 3.Client takes indomethacin for osteoarthritis 4.Client's platelet count is 176 x103/mm3 (176 x109/L)

indomethacin A pulmonary embolism (PE) occurs when the pulmonary arteries are blocked by a thrombus. Initial management of PE includes low-molecular-weight heparin (eg, enoxaparin, dalteparin) or unfractionated IV heparin. Once the PE is resolved, maintenance drug therapy often includes oral anticoagulants such as factor Xa inhibitors (eg, apixaban, rivaroxaban, dabigatran). Anticoagulants place the client at increased risk of bleeding, and the nurse should provide education regarding signs and symptoms of bleeding (eg, bruising; blood in the urine; black, tarry stools) and bleeding precautions (eg, use of an electric razor and soft-bristled toothbrush). Concurrent NSAID use (eg, indomethacin, ibuprofen, meloxicam) significantly increases the risk of bleeding. The nurse should discuss this risk with the health care provider prior to initiation of apixaban therapy

The pathogenesis of deep venous thrombosis (DVT) involves 3 factors, known as Virchow's triad. All of the following are part of the triad EXCEPT Endothelial damage venous stasis hypercoagulability infection

infection

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? antibiotics to treat the underlying infection iv fluids to increase intravascular volume corticosteroids to reduce inflammation vasopressors in increase blood pressure

iv fluids to increase intravascular volume

The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription? 1. Furosemide 20 mg IV push twice daily 2.Maintenance IV line of 0.9% normal saline at 85 mL/h 3.Potassium chloride 20 mEq orally twice daily 4.Sodium-restricted diet

maintenance iv

A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication?

metoprolol Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility. In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this client has stabilized and exacerbation of ADHF has resolved with diuresis.

A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority? 1. Ask the client how long the leg has been tender and warm 2.Assess the electrocardiogram (ECG) for any ectopic beats 3.Check vital signs including pulse oximetry 4.Complete neurovascular assessment on lower extremities

neurovascular assessment on lower extremities This client with a tender calf that feels warm to the touch is exhibiting signs and symptoms of a possible deep vein thrombosis (DVT). Additionally, the client has several risk factors for DVT (age >60, being hospitalized and in bed for 3 days). The nurse will need to notify the health care provider (HCP) immediately. However, prior to this, the nurse must perform a thorough assessment of the client to report to the HCP. The priority action by the nurse should include a thorough neurovascular assessment of the extremities, including presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison.

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday 2.The client has a painful red area on the buttocks 3.The client has new dependent edema of the feet 4.The client has strong, foul smelling urine

new dependent edema of feet New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment.

Duplex ultrasound scanning confirms the presence of a deep vein thrombosis, and the physician orders continuous IV heparin infusion. Which intervention does the nurse plan while the patient is receiving the heparin infusion? Maintain strict bed rest to prevent accidental trauma. Teach the patient to given herself subcutaneous heparin injections for long-term home therapy. Have vitamin K available in case the patient bleeds from the action of heparin. Notify the physician if the PTT value is greater than 180 seconds.

notify physician

The nurse performing an assessment with a patient who has chronic arterial insufficiency would expect which finding? Scaling eczema of the lower legs with stasis dermatitis. Pallor on elevation of limbs, rubor when limbs are dependent. Ulceration around the medial malleoli. Edema around the ankles and feet.

pallor

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required? 1. "I should supplement my potassium intake." 2."I should weigh myself daily." 3."Moderate exercise may be helpful in my condition." 4."Potato chips are an acceptable snack in moderation."

potato chips bc of salt overload

The laboratory results of a patient with disseminated intravascular coagulation are likely to include: decreased d-dimer increased platelet count increased fibrinogen prolonged prothrombin and partial thromboplastin times

prolonged prothrombin and partial thromboplastin times

A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is

release of aldosterone and antidiuretic hormone, which cause sodium and water retention

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? 1. Alprazolam 2.Dextromethorphan 3.Lisinopril 4.Valsartan

valsartan Major side effects of angiotensin-converting enzyme (ACE) inhibitors include: Symptomatic hypotension Intractable cough Hyperkalemia Angioedema (allergic reaction involving edema of the face and airways) Temporary increase in serum creatinine For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites.