Nursing Concepts - Cardiovascular
Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all the apply. One, some, or all responses may be correct. Crackles Coughing Orthopnea Yellow sputum Anxiety Dependent edema Restlessness Lethargy
Crackles Coughing Orthopnea Anxiety Restlessness Lethargy Rationale: In pulmonary edema, fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. The client with pulmonary edema may present as anxious, restless, or with generalized lethargy. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood tinged. Pulmonary interstitial edema, not dependent edema, occurs.
What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)? Deflate the balloon as soon as the PCWP is measured. Have the client bear down when measuring the PCWP. Place the client in a supine position before measuring the PCWP. Flush the catheter with a heparin solution after the PCWP is determined.
Deflate the balloon as soon as the PCWP is measured. Rationale: Although the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lungs. Bearing down will increase intrathoracic pressure and alter the reading. Although a supine position is preferred, it is not essential. Agency protocols relative to flushing of unused ports must be followed.
A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? "Do you have chest pain?" "Are you feeling anxious?" "Do you have any palpitations?" "Are you feeling short of breath?"
Do you have chest pain Rationale: Females may present with atypical symptoms of myocardial infarction, such as absence of chest pain, overwhelming fatigue, and indigestion. Anxiety, palpitations, and shortness of breath are common clinical manifestations in both males and females who are experiencing a myocardial infarctions.
A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? Feeling of heaviness in both legs Intermittent claudication of the legs Calf pain on dorsiflexion of the foot Hematomas of the lower extremities
Feeling of heaviness in both legs Rationale: Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom of hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.
When assessing a client with varicose veins, which clinical manifestation would the nurse expect to find? Select all that apply. One, some, or all responses may be correct. Presence of ankle edema Increased leg fatigue Diminished peripheral pulses Report of leg fullness and pruritus Leg pain with activity that resolves with rest No hair on lower extremities Thickened toenails Pallor to bilateral lower extremities
Presence of ankle edema Increased leg fatigue Report of leg fullness and pruritus Rationale: Presence of ankle edema, increase leg fatigue, and a report of leg fullness and pruritus are signs of varicose veins, due to poor venous return and increase venous pressure. Diminished peripheral pulses occur with decreased arterial blood blow. Intermittent claudication (as evidence by leg pain with activity that resolves with rest) occurs with decreased arterial, not venous, perfusion. Additional signs of peripheral artery disease (PAD) include hair loss on lower calf, ankle, and foot areas along with thickened toenails. the nurse would expect to see brown pigmentation or skin staining, not pallor, associated with extravasated red blood cells in lower extremities.
A nurse is assigned 4 clients with various diagnoses and is reviewing their orders. The nurse would expect to put the client with which of the following diagnosis on continuous cardiac monitoring telemetry? Pancreatitis Syncope DKA COPD
Syncope Rationale: The client with syncope should be placed on a continuous heart monitor telemetry to ensure that the rate and rhythm are within normal limits.
a client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? Arteriolar constriction occurs The cardiac workload decreases Contractility of the heart decreases. The parasympathetic nervous system is triggered.
The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not the parasympathetic, nervous system is triggered to produce vasoconstriction.
The nurse administers a calcium channel blocker to a client. Which of the following is an expected outcome? The heart will contract with more force. The heart will contract with less force The heart will beat faster The heart will need more oxygen
The heart will beat with less force. Rationale: Calcium increases the strength of contraction. When a calcium channel blocker is given, less calcium enter the cell to help with depolarization, which causes a weaker contraction. This decreases the workload of the heart, which is an expected outcome of a calcium channel blocker. This helps relieve angina and decrease arrhythmias. Calcium channel blockers also dilate arteries, which further decreases the workload of the heart.
When a client heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factor that may have contributed to the ankle swelling? Select all the apply. One, some, or all responses may be correct. Intake of salty foods Increase fluid consumption Dietary fat intake Medication compliance Family stresses Recent travel Alcohol intake Increased physical activity
Intake of salty foods Increase fluid intake Medication compliance Recent travel Alcohol intake Rationale: Fluid retention in heart failure may be caused by increased salt intake, with associated water retention. This may be caused by increased dietary fluids. Poor adherence to medication used to treat heart failure, such as angiotensin-converting-enzyme and diuretics, may also cause fluid retention. Recent travel may cause fluid retention because of changes in environmental temperature, effects of airplane travel on fluid retention, or changes in dietary sodium intake. Increased alcohol intake can worsen the effects of heart failure, including edema. Increased or decreased fat intake will not cause fluid retention. Stress is not a contributor to fluid retention. The client with heart failure is encouraged to stay as active as possible, with overdoing it. A sedentary, not active, lifestyle would contribute to fluid accumulation.
When a client develops internal bleeding after abdominal surgery, which clinical manifestation would the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct. Pallor Polyuria Decreased mean arterial pressure (MAP) Bradypnea Tachycardia Hypertension Increased pulse pressure Warm skin temperature
Pallor Decreased mean arterial pressure (MAP) Tachycardia Rationale: Pallor occurs as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. During the initial stages, MAP will decrease 5 - 10 mmHg due to the blood pressure dropping. Heart rate accelerates (tachycardia) in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases (the opposite of polyuria) with hemorrhage because of lowered glomerular filtration rate secondary to hypovolemia. Respirations increase (the opposite of bradypnea) and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension, not hypertension, occurs in response to hemorrhage as the person experiences hypovolemia. With loss of blood the pulse pressure will decrease and skin will become cold, not warm to touch and moist due to reduced blood flow.
Which finding would the nurse expect when assessing a client with peripheral arterial disease (PAD)? Select all that apply. One, some, or all responses may be correct. Pallor of feet Warm extremities Ulcers on the toes Delayed capillary refill Thick, hardened skin Hair loss to lower extremities Muscle atrophy Intermittent claudication
Pallor of feet Ulcers on the toes Delayed capillary refill Hair loss to lower extremities Muscle atrophy Intermittent claudication Rationale: PAD affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit pallor, ulcers on the feet and toes, cool skin, and capillary refill longer than 3 seconds. Hair loss to the lower calf, ankle and foot are noted with PAD. Chronic PAD can result in muscle atrophy. Intermittent claudication is the most common presenting symptom of this disease. Warm extremities occur with venous disease. Venous disease leads to thick, hardened skin on the legs.
A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to reeducate the client? Whole milk with oatmeal Garden salad with olive oil Tuna fish with a small apple Soluble fiber cereal with yogurt
Whole milk with oatmeal Rationale: An overall heart healthy diet includes a variety of fruits and vegetables, whole grains, low-fat diary products, skinless poultry and fish, nuts, legumes and non-tropical vegetables oils. Whole milk is high in saturated fat and should be avoided.
