NURS 401 Quiz 3
The nurse instructs a client with Raynaud phenomenon on actions to improve the symptoms. Which client statement indicates the need for additional instruction?
"I will limit the amount of cigarettes I smoke.
The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.)
Activation of the inflammatory response Hypoperfusion of tissues Must produce energy through anaerobic metabolism
The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?
Increase in arterial oxygenation
A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?
Neurogenic
In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart?
Nitroprusside
The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing?
Nonselective debridement
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment?
Numbness, cool skin temperature, and pallor
A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following?
"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct?
"The client is in shock because the blood volume has decreased in the system."
A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?
"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."
The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?
"Walk to the point of pain, rest until the pain subsides, then resume ambulation."
The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply
- weight loss -regular exercise -smoking cessation
Which of the following are indications of a rupturing aortic aneurysm? Select all that apply.
-Constant, intense back pain -Decreasing blood pressure -Decreasing hematocrit
Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value?
1.5 to 2.5
A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first?
100% oxygen via a nonrebreather mask
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers
A continuous infusion of total parenteral nutrition
"What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give?
50
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion
60 mm Hg
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next
Administers oxygen by nasal cannula at 2 liters per minute
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client
Adrenergic drugs
A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits
Adventitious breath sounds
Which colloid is expensive but rapidly expands plasma volume?
Albumin
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the:
Anterior surface of the foot near the ankle joint.
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?
Aortic insufficiency
The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?
Avoid situations that contribute to ischemic episodes
Which of the following assessment results is considered a major risk factor for PAD?
BP of 160/110 mm Hg
Which of the following is a characteristic of an arterial ulcer?
Border regular and well demarcated
Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is:
Cigarette smoking.
Pentoxifylline (Trental) is a medication used for which of the following conditions?
Claudication
The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:
Cold, clammy skin and tachycardia.
A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as
Compensatory
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?
Compensatory stage
The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded?
Compression sleeve
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:
Constrict blood vessels in the cardiorespiratory system
What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client?
Decreased blood pressure.
Which is a characteristic of arterial insufficiency?
Diminished or absent pulses
Which aneurysm results in bleeding into the layers of the arterial wall
Dissection
The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?
Distributive
A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply.
Dopamine Dobutamine Nitroglycerin Vasopressin
A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?
Dorsiflex the foot while the leg is elevated to check for calf pain.
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?
Elevate the legs periodically for at least 15 to 20 minutes.
Which statement is accurate regarding Raynaud disease?
Episodes may be triggered by unusual sensitivity to cold.
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.
Famotidine (Pepcid) Nizatidine Lansoprazole
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?
Head injury
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:
Hemorrhage.
A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?
Hyperbaric oxygen
What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply.
Identify the cause of shock. Administer intravenous fluids. Monitor for changes in vital signs.
The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?
In 3 to 5 days
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?
In the compensation stage, catecholamines are released.
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?
Increased abdominal and back pain
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
A nurse is teaching a client newly diagnosed with arterial insufficiency. Which term should the nurse use to refer to leg pain that occurs when the client is walking?
Intermittent claudication
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?
International normalized ratio (INR) is 2.5.
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?
Intubation and mechanical ventilation
The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?
Lactated Ringer's
The nurse is caring for a client who develops hypotension, declining mental status, and severely decreased urinary output. Which intravenous fluid will the nurse expect to be prescribed for this client?
Lactated Ringer's solution
Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?
Large and superficial
A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the:
Posterior tibial.
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?
Prepare to administer protamine sulfate.
Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg?
Progressive
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Protamine sulfate
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?
Prothrombin time (PT)
Morphine sulfate has which of the following effects on the body?
Reduces preload
A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy?
Scheduled eye surgery in 1 week
The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm?
Severe pain
When a client is in the compensatory stage of shock, which symptom occurs?
Tachycardia
On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?
Taking daily walks
The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?
The patient has developed a stress ulcer that is bleeding.
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue?
Ulcers and infection in the edematous area
What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?
Use strict hand hygiene techniques.
The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.
Vital signs Skin color Urine output Peripheral pulses
What is the major clinical use of dobutamine?
increase cardiac output.
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:
myocardial infarction.
A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing
neurogenic
A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing?
neurogenic
A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next?
ondansetron
A client with a critical illness has a temperature of 38.5°C (101.3°F). Which parameters will the nurse use to determine if the client is developing sepsis? Select all that apply.
urine output, bilirubin level, platelet count, blood pressure, and respiratory rate
A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess
Lung sounds
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
Maintain activity restriction to bedrest.
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?
Stop smoking.
A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit?
compensatory respiratory alkalosis
To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals:
elevational pallor.
A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement?
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
The nurse is educating a client with chronic venous insufficiency about the prevention of complications related to the disorder. What should the nurse include in the information given to the client?
-Avoid constricting garments -Elevate the legs above the heart frequently throughout the day -Sleep with the foot of the bed elevated.
The nurse is caring for an older adult client in cardiac rehabilitation following heart surgery. The client has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day, reporting cramp-like pain in the legs when walking that improves with rest. Which intervention will the nurse suggest to alleviate this discomfort? The client's care plan should address which issue? Select all that apply.
-Pain related to intermittent claudication -Peripheral arterial circulation impairment
A client is diagnosed with a large thoracic aneurysm. Which findings will the nurse expect when assessing this client? Select all that apply
-stridor -hoarse voice -brassy cough
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
A rapid, bounding pulse
The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?
Levophed
The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following?
Low
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:
Lowering the limb so that it is dependent.
A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?
Moderate to severe arterial insufficiency
Which positioning strategy should be used for a client diagnosed with hypovolemic shock?
Modified Trendelenburg
Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?
Obesity
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:
Oxygen at 2 L/min by nasal cannula
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?
Participate in a regular walking program.
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?
Stabilizing heart rate and blood pressure and easing anxiety
Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy?
a client with a chronic, nonhealing skin lesion
The most common site of aneurysm formation is in the:
abdominal aorta, just below the renal arteries.
A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD?
ankle-brachial index
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
forcing blood into the deep venous system.
