CARDIAC PT 5
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. Elevate the head of the bed 30 to 45 degrees. 2. Encourage the client to cough and deep breathe. 3. Auscultate the lungs to detect abnormal breath sounds. 4. Contact the healthcare provider (HCP).
1. Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep - breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The HCP must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.
ANS : 3 Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors.
A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first: 1. assess the oxygen saturation. 2. call the healthcare provider (HCP). 3. administer morphine sulfate, 2 mg IV. 4. perform range-of-motion exercises in the involved leg.
1. A client with deep vein thrombosis (DVT) is at high risk for a pulmonary embolism from an embolus traveling to the lung. Sudden onset of symptoms and worsening of chest pain with a deep breath suggest a pulmonary embolism. The nurse assesses the client and obtains oxygen saturation levels prior to calling the HCP and administering morphine. Range of motion is a preventive measure for DVT and is not appropriate that this time.
The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for: 1. decreased urinary output. 2. electrolyte imbalance. 3. anxiety. 4. wound infection
1. Following surgical repair of an aortic aneurysm, there is a potential for an alteration in renal perfusion, manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during surgery. Electrolyte imbalance and anxiety do not present imminent risk for this client; signs of wound infection are generally not evident immediately following surgery, but the nurse should monitor the incision on an ongoing basis.
A client has undergone an amputation of three toes and a femoral popliteal bypass. The nurse should teach the client that after surgery, which leg position is contraindicated while sitting in a chair? 1. crossing the legs 2. elevating the legs 3. flexing the ankles 4. extending the knees
1. Leg crossing is contraindicated because it causes adduction of the hips and decreases the flow of blood into the lower extremities. This may result in increased pressure in the graft in the affected leg. Elevating the legs, flexing the ankles, and extending the knees are not necessarily contraindicated.
A client with peripheral artery disease has femoral-popliteal bypass surgery. The primary goal of the plan of care after surgery is to: 1. maintain circulation. 2. prevent infection. 3. relieve pain. 4. provide education.
1. Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent. Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.
While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. The nurse should: 1. stop and assess the client further. 2. obtain the client's blood pressure and heart rate. 3. call for help and place the client in a wheelchair. 4. administer nitroglycerin
1. The nurse should stop and assess the client further. A chair should be available for the client to sit down. Obtaining the client's blood pressure and heart rate are important when exercising. These values can be used to predict when the oxygen demand becomes greater than the oxygen supply. Calling for help is not necessary for the midsternal burning. If the healthcare provider (HCP) has prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen balance.
A client has returned to the surgical care unit after having femoral popliteal bypass grafting. Indicate in which order from first to last the nurse should conduct assessment of this client. All options must be used. 1. postoperative pain 2. peripheral pulses 3. urine output 4. incision site
2,4,3,1. Because assessment of the presence and quality of the pedal pulses in the affected extremity is essential after surgery to make sure that the bypass graft is functioning, this step should be done first. The nurse should next ensure that the dressing is intact and then that the client has adequate urine output. Lastly, the nurse should determine the client's level of pain.
A client with an enlarged abdominal aorta admitted to the emergency department has severe back pain, nausea, blood pressure of 90/40 mm Hg, heart rate 128 bpm, and respirations 28/minute. In which order from first to last should the nurse implement these prescriptions? All options must be used. 1. Monitor intake and output. 2. Establish an intravenous infusion. 3. Administer pain medication. 4. Insert a nasogastric tube.
2,4,3,1. The data suggest an abdominal aortic aneurysm that is leaking or rupturing. When implementing the prescriptions, the nurse should first establish an intravenous infusion with a large-bore needle for immediate volume replacement. Next, the nurse should insert the nasogastric tube to relieve the nausea and vomiting and decompress the stomach. The nurse next should administer pain medication. Last, the nurse should monitor intake and output; with hypovolemia, the urine output will be diminished
Which is a priority for exercising for a client who has just had a myocardial infarction? 1. low-back training program 2. risk modification education 3. strength training program 4. jogging exercise program
2. Cardiac rehabilitation includes client and family education and individualized activity counseling. Generally, the educational programs focus on presenting all of the risk factors associated with coronary artery disease. Low-back training is associated with a back injury recovery program. A strength training or jogging exercise program is not appropriate immediately after a cardiac event.
A client has peripheral artery disease of both lower extremities. The client tells the nurse, "I have really tried to manage my condition well." Which example indicates the client is using appropriate care management strategies? 1. The client rests with the legs elevated above the level of the heart. 2. The client walks slowly but steadily for 30 minutes twice a day. 3. The client limits activity to walking around the house. 4. The client wears antiembolism stockings at all times when out of bed
2. Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it stimulates the development of collateral circulation. The client with PVD should not remain inactive. Elevating the legs above the heart or wearing antiembolism stockings is a strategy for alleviating venous congestion and may worsen peripheral artery disease.
The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of: 1. aortic aneurysm. 2. deep vein thrombosis (DVT) in the left leg. 3. IV drug abuse. 4. intermittent claudication.
2. The client demonstrates classic symptoms of DVT, and the nurse should continue to assess the client. Signs and symptoms of an aortic aneurysm include abdominal pain and a pulsating abdominal mass. Clients with drug abuse demonstrate confusion and decreased levels of consciousness. Claudication is an intermittent pain in the leg.
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. What should the nurse do immediately? 1. Apply a tourniquet. 2. Assess vital signs. 3. Call the healthcare provider (HCP). 4. Elevate the involved extremity with a large pillow.
2. The client should be evaluated for hemodynamic stability and extent of bleeding prior to calling the HCP. Direct pressure can be used prior to applying a tourniquet if there is significant bleeding. To avoid flexion contractures, which can delay rehabilitation, elevation of the surgical limb is contraindicated
A client with peripheral artery disease has undergone a right femoralpopliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? 1. IV fluid infusion rate 2. pedal pulses 3. nasal cannula flow rate 4. capillary refill
2. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.
The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hours ago. Which finding warrants further evaluation? 1. absent bowel sounds and mild abdominal distension 2. a BUN of 26 mg/dL(26 mmol/L) and creatinine of 1.2 mg/dL(1.2 μmol/L) 3. an arterial blood pressure of 80/50 mm Hg 4. +1 pedal pulses in bilateral lower extremities
3. A blood pressure of 80/50 mm Hg in a client who has just had surgical repair of an abdominal aortic aneurysm warrants further evaluation as this indicates decreased perfusion to the brain, heart, and kidneys. A BUN of 26 and a creatinine of 1.2 are normal findings. While +1 pedal pulses may be an abnormal finding, it is not uncommon, and it is important to compare this finding to previous assessments and note if this is a change of the strength of the pedal pulses. Absent bowel sound and mild abdominal distension are expected for a client immediately following surgery. However, this finding should be monitored as it could indicate a paralytic ileus
A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair in no evident distress with the legs in a dependent position. The nurse should first: 1. assist the client to the bed. 2. request a prescription for support stockings. 3. elevate the client's legs on a foot stool. 4. take the client's blood pressure
3. Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client's legs. It is not necessary for the client to return to bed. Support stockings are not indicated at this time. The client is not having difficulty breathing or other signs of distress; it is not necessary to take the vital signs
A client is admitted for a revascularization procedure for arteriosclerosis in the left iliac artery. To promote circulation in the extremities, the nurse should: 1. position the client on a firm mattress. 2. keep the involved extremity warm with blankets. 3. position the left leg at or below the body's horizontal plane. 4. encourage the client to raise and lower the leg four times every hour
3. Keeping the involved extremity at or below the body's horizontal plane will facilitate tissue perfusion and prevent tissue damage. The nurse should avoid placing the affected extremity on a hard surface, such as a firm mattress, to avoid pressure ulcers. In addition, the involved extremity should be free from heavy overlying bed linens. The nurse should handle the involved extremity in a gentle fashion to prevent friction or pressure. Raising the leg would cause occlusion to the iliac artery, which is contrary to the goal to promote arterial circulation.
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: 1. avoid eating low-fat foods. 2. elevate the legs above the heart. 3. stop smoking. 4. begin a jogging program
3. Nicotine causes vasospasm and impedes blood flow. Stopping smoking is the most significant lifestyle change the client can make. The client should eat low-fat foods as part of a balanced diet. The legs should not be elevated above the heart because this will impede arterial flow. The legs should be in a slightly dependent position. Jogging is not necessary and probably is not possible for many clients with arterial occlusive disease. A rehabilitation program that includes daily walking is suggested.
A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema; the client is on complete bed rest. To maintain skin integrity, what should the nurse do? 1. Administer pain medication. 2. Ensure fluid intake of 3,000 mLper 24 hours. 3. Turn the client every 1 to 2 hours. 4. Maintain hygiene
3. The client is at greater risk for skin breakdown in the lower extremities related to the edema and to remaining in one position, which increases capillary pressure. Turning the client every 1 to 2 hours promotes vasodilation and prevents vascular compression. Administering pain medication will not have an effect on skin integrity. Encouraging fluids is not a direct intervention for maintaining skin integrity, although being well hydrated is a goal for most clients. Maintaining hygiene does influence skin integrity but is secondary in this situation.
A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline, metoprolol, and furosemide. On postoperative day 1, the 1200 vital signs are as follows: temperature 98.9°F (37.2°C), heart rate 132 bpm, respiratory rate 20 breaths/min, and blood pressure 126/78 mm Hg. Urine output is 50 to 70 mL/h. The hemoglobin and the hematocrit are stable. The medications have not been prescribed for administration after surgery. Using the SBAR (Situation-BackgroundAssessment-Recommendation) technique for communication, the nurse contacts the healthcare provider (HCP) and recommends to: 1. continue the pentoxifylline. 2. increase the IV fluids. 3. restart the metoprolol. 4. resume the furosemide.
3. The client is experiencing a rebound tachycardia from abrupt withdrawal of the beta-blocker. The beta-blocker should be restarted due to the tachycardia, history of hypertension, and the desire to reduce the risk of postoperative myocardial morbidity. The bypass surgery should correct the claudication and need for pentoxifylline. The furosemide and increase in fluids are not indicated since the client's urine output and blood pressure are satisfactory and there is no indication of bleeding. The nurse should also determine the potassium level before starting the furosemide
A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to: 1. maintain circulation. 2. manage pain. 3. prepare the client for emergency surgery. 4. teach postoperative breathing exercises.
3. The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circulation is maintained, unless the aneurysm ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about postoperative breathing exercises, and administer pain medication if prescribed.
When assessing an individual with peripheral artery disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? 1. aching pain in the left calf 2. burning pain in the left calf 3. numbness and tingling in the left leg 4. coldness of the left foot and ankle
4. Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction
The client with peripheral artery disease has been prescribed diltiazem. The nurse should determine the effectiveness of this medication by assessing the client for: 1. relief of anxiety. 2. sedation. 3. vasoconstriction. 4. vasodilation.
4. Diltiazem is a calcium channel blocker that blocks the influx of calcium into the cell. In this situation, the primary use of diltiazem is to promote vasodilation and prevent spasms of the arteries. As a result of the vasodilation, blood, oxygen, and nutrients can reach the muscle and tissues
A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve: 1. administering aspirin as prescribed. 2. encouraging green leafy vegetables in the diet. 3. monitoring the client's prothrombin time (PT). 4. monitoring the client's activated partial thromboplastin time (aPTT) and international normalized ratio (INR).
4. Heparin dosage is usually determined by the healthcare provider 861 (HCP) based on the client's aPTT and INR laboratory values. Therefore, the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client's PT is done when the client is receiving warfarin sodium
A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which findings should the nurse consider unexpected and report to the healthcare provider (HCP) immediately? 1. abdominal pain at 5 on a scale of 0 to 10 for the last 2 days 2. heart rate of 100 bpm after ambulating 200 feet (0.06 km) 3. urine output of 2,000 mLin 24 hours 4. weakness and numbness in the lower extremities
4. One of the complications of a thoracoabdominal aneurysm repair is spinal cord injury. Therefore, it is important for the nurse to assess for signs and symptoms of neurologic changes at and below the site where the aneurysm was repaired. The client is expected to have moderate pain following surgery. An elevated heart rate is expected after physical exertion. It is important to monitor urine output following aneurysm surgery, but a urine output of 2,000 mLin 24 hours is adequate following surgery.
A client who has been diagnosed with peripheral artery disease is being discharged. The client needs further instruction if the client states he or she will: 1. avoid heating pads. 2. not cross the legs. 3. wear leather shoes. 4. use iodine on an injured site
4. The client should avoid using iodine or over-the-counter medications. Iodine is a highly toxic solution. An individual who has known PVD should be seen by a healthcare provider (HCP) for treatment to avoid infection. The client with PVD should avoid heating pads and crossing the legs, and should wear leather shoes. A heating pad can cause injury, which, because of the decreased blood supply, can be difficult to heal. Crossing the legs can further impede blood flow. Leather shoes provide better protection.
In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should: 1. limit fluids to 1,000 mLin 24 hours. 2. encourage deep breathing. 3. assist the client to remain sedentary. 4. use pneumatic compression stockings.
4. The use of pneumatic compression stockings is an intervention used to prevent DVT. Other strategies include early ambulation, leg exercises if the client is confined to bed, adequate fluid intake, and administering anticoagulant medication as prescribed. Deep breathing would be encouraged postoperatively, but it does not prevent DVT
The nurse is caring for a client with peripheral artery disease who has recently been prescribed clopidogrel. The nurse understands that more teaching is necessary when the client states: 1. "I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth." 2. "It does not really matter if I take this medicine with or without food, whatever works best for my stomach." 3. "I should stop taking my medicine if it makes me feel weak and dizzy." 4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming."
Weakness, dizziness, and headache are common adverse effects of clopidogrel, and the client should report these to the healthcare provider (HCP) if they are problematic; in order to decrease risk of clot formation, the drug must be taken regularly and should not be stopped or taken intermittently. The main adverse effect of clopidogrel is bleeding, which often occurs as increased bruising or bleeding when brushing teeth.
The nurse is providing discharge instructions to the client with peripheral vascular disease. The nurse should include which information in the discussion with this client? Select all that apply. 1. Avoid prolonged standing and sitting. 2. Limit walking so as not to activate the "muscle pump." 3. Keep extremities elevated on pillows. 4. Keep the legs in a dependent position. 5. Use a heating pad to promote vasodilation.
1, 3. Elevating the extremities counteracts the forces of gravity and promotes venous return and reduces venous stasis. Walking is encouraged to activate the muscle pump and promote collateral circulation. Prolonged sitting and standing lead to venous stasis and should be avoided. Although heat promotes vasodilation, use of a heating pad is to be avoided to reduce the risk of thermal injury secondary to diminished sensation.
The nurse instructs a patient about modifiable risk factors for coronary artery disease. Which statements indicate that teaching has been effective? (Select all that apply) 1. I should stop smoking to reduce my risk of heart disease 2. Restricting my activity reduces the onset of heart disease 3. I should drink alcohol because this prevents hearts disease 4. There is not much that can be done to prevent heart disease 5. Obesity is a risk actor that I can change to reduce the onset of heart disease
1, 5 Modifiable risk factors for the development of coronary artery disease include obesity, smoking, and physical inactivity
An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet. 3. Inspect the involved areas daily for new ulcerations. 4. Limit activities of daily living (ADLs). 5. Use an electric razor to shave.
1,2,3,5. Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving warfarin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply. 1. Check urine for bright blood and a dark smoky color. 2. Walk daily as a good exercise. 3. Use garlic and ginger, which may decrease bleeding time. 4. Perform foot/leg exercises and walking around the airplane cabin when on long flights. 5. Prevent DVT because of risk of pulmonary emboli. 6. Avoid surface bumps because the skin is prone to injury.
1,2,4,5,6. Clients with resolving DVT being sent home on anticoagulant therapy need instructions about assessing and preventing bleeding episodes and preventing a recurrence of DVT. Blood in the urine (hematuria) is often one of the first symptoms of anticoagulant overdose. Fresh blood in the urine is red; however, blood in the urine may also be a dark smoky color. Daily ambulation is an excellent activity to keep the venous blood circulating and thus to prevent blood clots from forming in the lower extremities. Garlic and ginger increase the bleeding time and should not be used when a client is on anticoagulant therapy
What instructions should the nurse give a client experiencing signs and symptoms related to decreased arterial insufficiency? Select all that apply. 1. Avoid smoking and exposure to the cold. 2. Take acetaminophen if experiencing pain at night. 3. Take aspirin or clopidogrel as prescribed. 4. Use additional bed clothes at night. 5. Wear tight socks to keep feet warm
1,3,4. Smoking and exposure to the cold cause vasoconstriction and should be avoided. Aspirin and clopidogrel should be taken as prescribed for the antiplatelet properties. Using extra bed clothes at night provides warmth, which increases vasodilation. The presence of pain should be investigated as it could indicate increasing arterial insufficiency. Tight socks should be avoided as they could impair circulation.
A sedentary, obese, middle-aged client is recovering from surgery to remove an embolus in the right iliac artery. The nurse should develop a discharge plan with the client that will focus on participating in which activities? Select all that apply. 1. aerobic activity 2. strength training 3. weight control 4. stress management 5. wearing supportive athletic shoes
1,3. Discharge teaching begins when the client enters the hospital. One of the risk factors for clot formation is a sedentary lifestyle, and the client should engage in daily aerobic activity, such as biking or swimming (non- weight bearing). The client is also overweight and should plan to control the weight through dietary counseling or attending weight management programs in the community. Strength training is beneficial by increasing strength and lean body mass, but not helpful in preventing vascular disease. Stress management is not a focus based on the client's needs at this time. It is not necessary to wear special supportive shoes; comfortable shoes for walking are adequate.
The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stockings (support hose). What instructions should the teaching plan include? Select all that apply. 1. Apply the elastic stockings before getting out of bed. 2. Remove the stockings if swelling occurs. 3. Remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes. 4. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff. 5. Keep the stockings in place for 48 hours, and reapply using a clean pair of stockings.
1,3. Elastic stockings (support hose) are used to promote circulation by preventing pooling of blood in the feet and legs. The stockings should be applied in the morning before the client gets out of bed. The stockings should be applied smoothly to avoid wrinkles, but the top should not be rolled down to avoid constriction of circulation. The stockings should be removed every 8 hours, and the client should elevate the legs for 15 minutes and reapply the stockings. Clean stockings should be applied daily or as needed.
The nurse is caring for a client with peripheral artery disease who has just returned from having a percutaneous transluminal balloon angioplasty. Which of these findings require immediate attention from the nurse? 1. a change in the intensity of the pulse from the baseline 2. pain "2 out of 10" at the catheterization site 3. shiny skin and a hairless appearance on the affected leg 4. the presence of an ulcer on the limb of the catheterization site
1. A change in the intensity of a pulse may be indicative of arterial closure and warrants immediate attention; the nurse should notify the healthcare provider (HCP) immediately. A pain level of 2 out of 10 is not uncommon from the catheter insertion site especially after the placement of a stent. Shiny and hairless skin is expected in clients with PAD. A client undergoing a catheterization may experience pain at the catheterization site as large-bore sheaths are placed in the femoral artery. Because people with PAD have poor circulation in their lower extremities, it is possible for them to develop leg ulcers.
The nurse is teaching a client who has deep vein thrombosis caused by a pulmonary embolus, which has now resolved. What should the nurse tell the client? 1. "Report such signs as leg swelling, discomfort, redness, or warmth." 2. "Sit with your legs lower than the rest of your body." 3. "Walk at least every other day." 4. "Limit your fluids to 1 Leach day."
1. Prevention of another pulmonary embolus is important; the nurse should teach the client to observe for signs of clot formation to prevent a potentially fatal episode and maintain cardiopulmonary integrity and adequate ventilation and perfusion. Elevation of the lower extremities, not lowering them, promotes venous return to the heart. Ambulation must be done several times each day. Limiting fluid intake increases blood viscosity, promoting clot formation.
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? 1. Notify the healthcare provider (HCP). 2. Administer a sedative. 3. Try to elicit a positive Homans'sign. 4. Increase the flow rate of intravenous fluids.
1. Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client's change in mental status, tachypnea, and tachycardia indicate a possible pulmonary embolism. The nurse should promptly notify the HCP of the client's condition. Administering a sedative without further evaluation of the client's condition is not appropriate. There is no need to elicit a positive Homans'sign; the client is already diagnosed with deep vein thrombosis. Increasing the IV flow rate may be an appropriate action but not without first notifying the HCP. C
An obese diabetic client who has bilateral leg aching is to start a cardiac rehabilitation with an exercise program. Using which exercise equipment will be most helpful to the client? 1. stationary bicycle 2. treadmill 3. elliptical trainer 4. stair climber
1. The stationary bicycle is the most appropriate training modality because it is a non-weight-bearing exercise. The time that the individual exercises on the stationary bicycle is increased with improved functional capacity. The other exercise equipment requires exercising while standing
While caring for a the postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's healthcare provider (HCP) immediately if the client exhibited which symptom? 1. pain in her calf 2. dyspnea 3. hypertension 4. bradycardia
2. A major complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immediate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis.
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client states a willingness to: 1. limit exercise that involves walking. 2. lose weight by following a reduced-calorie, balanced diet. 3. perform leg lifts every 4 hours to strengthen hamstring muscles. 4. wear knee-high stockings, rolled at the top to hold the stockings up.
2. The client is at risk for development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should consume a balanced diet and participate in a regular exercise program. Performing leg lifts improves muscle strength, but it is more important for the client to increase exercise by walking. Wearing support stockings is helpful to promote circulation, but the client should not roll the stockings at the top to hold the stockings up as this will decrease circulation at the knees.
The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do? 1. Avoid walking when the pain occurs. 2. Rest frequently with the legs elevated. 3. Wear support stockings. 4. Enroll in a supervised exercise training program.
4. Decreased blood flow is a common characteristic of all peripheral artery disease. When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. The nurse should suggest that the client enroll in a supervised exercise training program that will assist the client to gradually increase walking distances without pain. Not walking and resting will not increase blood flow to the legs. Support stockings may be prescribed, but the client should improve the capacity to walk and obtain exercise.
The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker? 1. Auscultate the client's apical pulse rate 2. Measure the client's blood pressure 3. Obtain a 12-lead ECG 4. Palpate the client's radial pulse rate
ANS : 1 Clients with an implanted permanent pacemaker should be assessed for both electrical capture of heart rhythm and mechanical capture of heart rate. The best method for checking for a pulsatile rhythm is to assess a central pulse (eg, auscultation of apical, palpation of femoral) (Option 1). This rate should be compared to the electrical rate displayed on the cardiac monitor to assess for pulse deficit.
A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? 1. Decrease mean arterial pressure (MAP) by no more than 25% 2. Keep blood pressure at or below 120/80 mm Hg 3. Maintain heart rate (HR) of 60-100/min 4. Maintain urine output of at least 30 mL/hr
ANS : 1 The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. (Option 2) A blood pressure of 120/80 mm Hg (MAP 93 mm Hg) is too low for an initial goal. This rapid drop from the client's initial pressure of 250/145 mm Hg (MAP 180 mm Hg) is a decrease of greater than 25% and could cause organ damage. However, it may be necessary to lower the SBP below 120 mm Hg if the client is experiencing an aortic dissection, as a higher BP can cause rupture. (Option 3) The nurse should monitor HR and rhythm for signs of MI or heart failure. However, the priority goal for this client is to achieve a therapeutic blood pressure, not HR. (Option 4) The nurse should carefully monitor urine output as an indicator of renal function. Output should be greater than 30 mL/hr, but this is not the priority goal in management of hypertensive crisis.
The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. 1. Ecchymosis of the scrotum 2. Increased abdominal girth 3. Increased urinary output 4. Report of groin pain 5. Report of increased thirst and appetite loss
ANS : 1,2,4 Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output (Options 1, 2, and 4). (Option 3) Urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension. (Option 5) Increased thirst and appetite loss are not signs of graft leakage.
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."
ANS : 1,3,4 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 (Option 2) Elevating the legs promotes venous return, but does not promote arterial circulation. (Option 5) Heating pads should not be used in clients with altered perfusion or sensation due to the increased risk for burns.
The nurse is performing an initial assessment on a client in hypertensive crisis. What is the nurse's priority assessment? Click on the exhibit button for additional information. 1. Heart sounds 2. Level of consciousness 3. Lung sounds 4. Visual fields and acuity
ANS : 2 The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention (Option 2). Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting. (Options 1 and 3) Assessing heart and lung sounds allows the nurse to identify and monitor for other complications of hypertensive crisis (eg, heart failure, pulmonary edema). However, this client's vital signs do not indicate respiratory distress (ie, normal oxygen saturations and respiratory rate); therefore, neurological assessment is the priority because a change in LOC may indicate a life-threatening hemorrhagic stroke. (Option 4) The nurse should assess for vision changes (eg, blurred vision, blind spot) or papilledema, as these are signs of progressing hypertensive crisis; however, assessment of LOC is the priority.
Which interventions should the nurse discuss with the client diagnosed with coronary artery disease? Select all that apply. 1. Instruct the client to stop smoking. 2. Encourage the client to exercise three (3) days a week. 3. Teach about coronary vasodilators. 4. Prepare the client for a carotid endarterectomy. 5. Eat foods high in monosaturated fats.
ANS : 2,3 1. Smoking is the one risk factor that must be stopped totally; there is no compromise. 2. Exercising helps develop collateral circulation and decrease anxiety; it also helps clients to lose weight. 3. Clients with coronary artery disease are usually prescribed nitroglycerin, which is the treatment of choice for angina. 4. Carotid endarterectomy is a procedure to remove atherosclerotic plaque from the carotid arteries, not the coronary arteries. 5. The client should eat polyunsaturated fats, not monosaturated fats, to help decrease atherosclerosis.The nurse instructs a patient about modifiable risk factors for coronary artery disease.
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."
ANS : 2,3,4 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. (Option 1) Clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour). (Option 5) Clients should avoid crossing the legs at the knees or ankles because this compresses the veins and limits venous return.
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 2. Assess for presence or absence of hair growth on lower extremities 3. Check for presence and quality of posterior tibial and dorsalis pedis pulses 4. Obtain a dietary history
ANS : 3 This client is exhibiting symptoms of intermittent claudication or ischemic muscle pain that can be due to peripheral artery disease (PAD). PAD impairs circulation to the client's extremities. The nurse should first check for the adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? a) Take the client's blood pressure. b) Ask the client if he has a headache. c) Ask the client if he has trouble breathing. d) Place antiembolism stockings on the client.
ANS : C The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 200 mL less than the fluid intake. b. The patient is unable to move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a severe headache with pain at level 8/10 (0 to 10 scale).
ANS: B The patient's inability to move the left arm and leg indicates that a hemorrhagic stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations also likely are caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.
Which action will be included in the plan of care when the nurse is caring for a patient who is receiving sodium nitroprusside (Nipride) to treat a hypertensive emergency? a. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. b. Assist the patient up in the chair for meals to avoid complications associated with immobility. c. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements. d. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.
ANS: C Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and has a BP of 240/118 mm Hg. Which question should the nurse ask first? a. Did you take any acetaminophen (Tylenol) today? b. Do you have any recent stressful events in your life? c. Have you been consistently taking your medications? d. Have you recently taken any antihistamine medications?
ANS: C Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.
During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's most recent BP reading is 156/94 mm Hg. b. The patient's pulse has dropped from 64 to 58 beats/minute. c. The patient has developed wheezes throughout the lung fields. d. The patient complains that the fingers and toes feel quite cold.
ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with β-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated; however, this is not as urgently needed as addressing the bronchospasm.
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply. 1. Assess peripheral circulation. 2. Monitor for abdominal distention. 3. Educate the client that abdominal pain is to be expected. 4. Assess the client for observable ecchymoses on the lower back. 5. Perform deep palpation of the abdomen to assess the size of the aneurysm
Answer: 1, 2, 4 Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected. Doing so could place the client at risk for rupture.
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare? 1. Vitamin K 2. Phentolamine 3. Protamine sulfate 4. Calcium gluconate
Answer: 2 Rationale: The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin. Calcium gluconate is used for magnesium overdose. Phytonadione is the antidote for warfarin overdose
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern? a) Blood pressure (BP): 128/86 mm Hg b) Neck pain: 3/10 (0 to 10 pain scale) c) Mild neck edema d) Difficulty swallowing
D. Difficulty swallowing The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but would not cause the nurse the most concern.