Exam 3 - random

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which?

"Moving to a warmer climate should help." Rationale:Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply.

2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Rationale:Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition).

The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply.

2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4.Electrical cardioversion Rationale:The three goals of treatment for atrial fibrillation are ventricular rate control, prevention of embolic stroke, and restoration and maintenance of normal sinus rhythm. Digoxin (Lanoxin) is used for ventricular rate control. Warfarin (Coumadin) is used to decrease the risk of embolic stroke. Electrical cardioversion is used to restore normal sinus rhythm. Amiodarone (Cordarone) is used to treat ventricular tachycardia or ventricular fibrillation. Defibrillation is the treatment of choice for ventricular fibrillation.

The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure.

Atrial fibrillation Rationale:Atrial fibrillation is characterized by no distinct P waves and an irregular ventricular response.

The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which?

Bilberry Rationale:Bilberry is an herbal supplement that has been used to treat varicose veins. This supplement has also been used to treat cataracts, retinopathy, diabetes mellitus, and peripheral vascular disease.

The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?

Hypokalemia Rationale:The nurse assesses the client's serum laboratory results for hypokalemia. The client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect.

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes?

Ingestion of coffee or chocolate Rationale: Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.

The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention?

Limiting movement and abduction of the right arm Rationale:In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk?

Marking the location of the pedal pulses on the right leg Rationale:A problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.

The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem?

Pedal edema that is 3+ Rationale:Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which?

Pulmonary embolism Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted?

Relief of apprehension Rationale:Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. It also promotes peripheral vasodilation and causes blood to pool in the periphery. It decreases pulmonary capillary pressures, which reduces fluid migration into the alveoli. The client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when administered intravenously.

The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health?

The ability to take an accurate pulse in either the wrist or neck Rationale:Clients with permanent pacemakers must be able to accurately take their pulse in the wrist and/or neck. The client needs to identify any variation in the pulse rate or rhythm and immediately report the variation to the health care provider. Clients can safely operate microwave ovens, radios, electric blankets, lawn mowers, leaf blowers, and cars (proper grounding must be ensured if the client is to operate electrical items). Sexual activity is not resumed until 6 weeks after surgery. The arms and shoulders should not be moved vigorously for 6 weeks after insertion. The remaining options do not have the same impact on long-term cardiac health as does the correct option.

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings?

The boot has been applied too tightly. Rationale:An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?

The client complains of leg edema, and skin breakdown has started .Rationale:Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common.

client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?

The ulcer has a brownish or "brawny" appearance. Rationale:Venous leg ulcers, also called stasis ulcers, are typically partial-thick wounds that extend through the epidermis and portions of the dermis. The skin of the lower leg is leathery, with a characteristic brownish or "brawny" appearance from the hemosiderin deposition. The edges of the ulcer are irregular and the tissue is a ruddy color. The client also may exhibit peripheral edema.

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?

status airway Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.