module 7 & 8 prepu

The nurse is administering medications to a client with pericarditis. What medications will be commonly prescribed to treat pericarditis? Select all that apply. - Colchicine - Indomethacin - Ibuprofen - Prednisone

- Colchicine - Ibuprofen - Prednisone

Before discharge, which instruction should a nurse give to a client receiving digoxin?

"Call the physician if your heart rate is above 90 beats/minute."

A patient has received a heterograft for a tricuspid valve replacement. What statement made by the patient demonstrates understanding of the valve replacement?

"I will not take long-term anticoagulation because I want to get pregnant."

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) - A heart rate >100 bpm - Crackles - Lethargy and mental confusion - Respiration <15 breaths/min - Compensatory respiratory acidosis

- A heart rate >100 bpm - Crackles - Lethargy and mental confusion

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.) - Increased intravascular volume - Activation of the inflammatory response - Hypoperfusion of tissues - Must produce energy through anaerobic metabolism - increase in cellular activity

- Activation of the inflammatory response - Hypoperfusion of tissues - Must produce energy through anaerobic metabolism

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what actions should the nurse perform? Select all that apply. - Administer oxygen - Place the client in an upright position - Have the client take deep breaths - Perform chest physiotherapy - Instruct the client to cough

- Administer oxygen - Place the client in an upright position

A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication should the nurse monitor for? Select all that apply. - Nausea and vomiting - Pulmonary embolism - Cardiac arrythmias - Respiratory arrest - Cardiac arrest

- Cardiac arrythmias - Respiratory arrest - Cardiac arrest

A 46-year-old man has been diagnosed with pericarditis and has begun treatment. When assessing this patient, the nurse should prioritize assessments relevant to what complications of pericarditis? Select all that apply. - Cardiac tamponade - Pericardial effusion - ST elevation myocardial infarction (STEMI) - Cardiac arrest - Transient ischemic attacks (TIAs)

- Cardiac tamponade - Pericardial effusion

The nurse working in the medical intensive care unit is caring for a client admitted with mitral stenosis. What will the nurse assess is related to the pathophysiology of mitral stenosis? Select all that apply. - High-pitched murmur - Fatigue - Low-pitched murmur - Shortness of breath with activity - History of endocarditis

- Fatigue - Low-pitched murmur - Shortness of breath with activity - History of endocarditis

A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply. - Norepinephrine - Milrinone - Epinephrine - Vasopressin - Phenylephrine

- Norepinephrine - Epinephrine - Vasopressin - Phenylephrine

What are the first symptoms of cardiac tamponade? Select all that apply. - SOB - Chest tightness - Dizziness - Tachycardia - Neck vein distention

- SOB - Chest tightness - Dizziness

What disease process(es) contributes to chronic heart failure? Select all that apply. - Tachyarrythmias - Valvular disease - Pancreatic disease - Renal failure - Pulmonary insufficiency

- Tachyarrythmias - Valvular disease - Renal failure

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. - The client wo is in the first 15 minutes of receiving 1 unit of PRBCs - The 55 year old client with spina bifida - The client who is scheduled for a repeat CT scan of the abdomen - The client with an infection who is prescribed intravenous vancomycin - The client who reports an allergy to peanuts that causes throat swelling

- The client wo is in the first 15 minutes of receiving 1 unit of PRBCs - The 55 year old client with spina bifida - The client who reports an allergy to peanuts that causes throat swelling

A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply. - Administer through an intact peripheral line - Assess vital signs every hour - Use an intravenous controller or pump - Verify dosage and pump settings with another RN - Measure urine output every hour

- Use an intravenous controller or pump - Verify dosage and pump settings with another RN - Measure urine output every hour

A client was admitted to the hospital with a diagnosis of aortic regurgitation. On assessment, what positive indicators for the disease process will the nurse note? Select all that apply. - Visible neck vein pulsations - Shortened pulse pressure - The pulse has a rapid upstroke, then collapses - Systolic pressure in the lower extremities is lower than the upper extremities - The presence of a diastolic murmur

- Visible neck vein pulsations - The pulse has a rapid upstroke, then collapses - The presence of a diastolic murmur

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. - Vomiting - Burns - Diarrhea - Dehydration - Trauma

- burns - dehydration

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply. - obtain a urine specimen for culture - maintain the IV site inserted on admission - institute vital signs every 4 hours - administer pantoprazole IV daily - monitor urine output every hour

- obtain a urine specimen for culture - administer pantoprazole IV daily - monitor urine output every hour

A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order. - Collect a stool specimen for culture. - Initiate an intravenous (IV) site and prescribed IV fluids. - Assess the capillary blood glucose level. - Place the client in the modified Trendelenburg position.

1. Place the client in the modified Trendelenburg position. 2. Initiate an intravenous (IV) site and prescribed IV fluids. 3. Assess the capillary blood glucose level. 4. Collect a stool specimen for culture.

The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate?

3:1

The nurse is caring for a client at risk for impending shock. The nurse is assessing the vital signs frequently. What systolic blood pressure (BP) value would indicate impending shock?

91 mm Hg

The nurse observes that a patient has 2+ pitting edema in the lower extremities. What does the nurse know that the presence of pitting edema indicates regarding fluid retention?

A weight gain of 10 lbs

The nurse is assigned to care for a patient with heart failure. What classification of medication does the nurse anticipate administering that will improve symptoms as well as increase survival?

ACE inhibitor

The nurse is assessing a client with left-sided heart failure. What assessment finding is expected?

Air hunger

A client with restrictive cardiomyopathy (RCM) is taking digoxin. Because of the risk of increased sensitivity, the nurse should carefully assess the client for which manifestations?

Anorexia and confusion

The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause increased preload. Which response by the student indicates understanding?

Application of antiembolic stockings

Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of which complication?

Cardiac tamponade

The ICU nurse is required to closely monitor four clients diagnosed with shock. During the shift assessment, the nurse documents the following values for the clients. Which client is most stable?

Client C: Heart rate 115 beats per minute, systolic BP 129 mm Hg, urine output 60 mL/hour

A community health nurse is participating in a healthy-living workshop that has been sponsored by a local seniors' center. The discussion has turned to the problem of heart failure, and the nurse is emphasizing preventative measures. When teaching older adults to decrease their future risks of developing heart failure, the nurse should emphasize what action?

Close blood pressure monitoring and vigilant adherence to hypertension therapy

A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client?

Control the shivering

Which type of cardiomyopathy is associated with syncope?

Hypertrophic

A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?

Intubation and mechanical ventilation

A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure?

Low urine output

The nurse is caring for a client with heart failure who has been prescribed digoxin. What laboratory value for the client can precipitate digoxin toxicity?

Potassium 3.0 milliequivalents per liter

A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?

Mask

A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus?

Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally.

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?

Myocardial depression

The nurse is caring for a client with aortic regurgitation. What medication will the nurse administer to reduce afterload?

Nitroprusside

The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?

Production of antidiuretic hormone and corticosteroid hormones

The nurse assessing a patient with pericardial effusion at 0800 notes the apical pulse is 74 and the BP is 140/92. At 1000, the patient has neck vein distention, the apical pulse is 72, and the BP is 108/92. Which action would the nurse implement first?

Stay with the patient, use a calm voice, and ask for assistance via call light.

A client with severe mitral valve insufficiency has been admitted to your unit. The client is in heart failure and has developed pulmonary edema. What would be the best course of treatment for this client?

Surgery

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock?

The client with testicular cancer who is receiving intravenous chemotherapy

A client with sepsis is experiencing disseminated intravascular coagulation (DIC). The client is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of Risk for deficient fluid volume related to bleeding. The most appropriate and measurable outcome for this client is that the client exhibits

Urine output greater than or equal to 30 mL/hour

A client taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the client no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the health care provider ordering?

Valsartan

The nurse caring for a client with cardiomyopathy plans to have an education session with the client and the client's spouse about ways to improve cardiac output and reduce the workload of the heart. Which of the following instructions would help reduce preload?

When resting, sit up with the legs down to pool blood in the legs.

The client asked the nurse to describe Stage C heart failure. What is the best explanation by the nurse?

a client who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity

The nurse is obtaining a history from a client diagnosed with hypertrophic cardiomyopathy. What information obtained from the client is indicative of hypertrophic cardiomyopathy?

a parent has the same disorder

A client with infective endocarditis is admitted to the hospital. While obtaining a history, what should the nurse ask the client about? Select all that apply. - Renal dialysis - Intravenous drug use - Nasal piercing - Prosthetic cardiac valves - Recent urinary tract infection

all of the above!

A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has a new onset of hypertrophic cardiomyopathy (HCM). What will be included on the plan of care?

an insertion of an implantable cardiac defibrillator

A client with a history of cardiomyopathy experiences dyspnea on exertion, fatigue, leg swelling, and chest pain. This client has which type of cardiomyopathy?

dilated cardiomyopathy

The nurse is admitting a client immigrating from a developed country with mitral valve regurgitation. What is the most common cause of mitral valve regurgitation in developed countries?

ischemia of the left ventricle