Passpoint Questions Perfusion & Clotting
What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine? "Morphine decreases the heart's need for oxygen and also makes your heart not work as hard." "Morphine decreases blood pressure and increases your heart's ability to stretch." "Morphine is a medication that is commonly administered for pain control." "Morphine increases your heart's ability to stretch and squeeze and decreases pain."
"Morphine decreases the heart's need for oxygen and also makes your heart not work as hard."
A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take? Notify the health care provider (HCP). Tell the woman to massage the area. Apply warm compresses to the area. Instruct the woman on how to do ankle pumps.
Notify the health care provider (HCP).
The nurse is administering adenosine to a client with supraventricular tachycardia. What is the expected therapeutic response? a short period of asystole an increase in blood pressure a brief episode of ventricular tachycardia A brief feeling of numbness and tingling of extremities
a short period of asystole
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which factor? -effects of analgesics used during labor -hemorrhage during the birth process -effects of the anesthetic during labor -decreased blood volume in the vascular system
decreased blood volume in the vascular system
While caring for a 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 health care provider (HCP) immediately if the client exhibits which symptom?
dyspnea
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? platelet count, prothrombin time, and partial thromboplastin time thrombin time, fibrinogen, and hemoglobin level D-dimer, red blood cell count, and partial thromboplastin time platelet count, red blood cell count, and hemoglobin
platelet count, prothrombin time, and partial thromboplastin time
A woman is taking oral contraceptives. The nurse teaches the client to report which complication? weight gain of 3 lb (1.4 kg) breakthrough bleeding mild headache severe calf pain
severe calf pain
A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client? begin a walking exercise program avoid trauma to extremities stop smoking report wounds promptly to healthcare provider
stop smoking
An older adult had a myocardial infarction (MI) 4 days ago. At 0930, the client's blood pressure is 102/64 mm Hg. After reviewing the client's progress notes (see chart), what should the nurse do first?
Notify the health care provider (HCP).
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. What should the nurse do first? Administer morphine sulfate 2 mg IV. Call the health care provider (HCP). Assess the oxygen saturation. Perform range of motion exercises in the involved leg.
Assess the oxygen saturation.
A client in the emergency department has symptoms of anxiety, a "racing heart," and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse? Obtain a stat 12-lead electrocardiogram (EKG) and troponin level. Assess the client's vital signs and oxygen saturation. Administer a beta blocker to slow the heart rate. Administer diazepam 2.5 mg I.V. push for anxiety.
Assess the client's vital signs and oxygen saturation.
A client fell and broke an arm and had a cast applied. Which of these statements by the client indicates an immediate risk for compartment syndrome?
"I can't wiggle my fingers."
A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. What activity should the nurse immediately perform? -Begin continuous fetal heart rate monitoring. -Change the client to the left lateral position. -Administer oxygen via nasal cannula at 4 L/min. -Inform the physician that birth is imminent.
Begin continuous fetal heart rate monitoring.
A client with a cerebral embolus is receiving IV recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy? -Dissolved emboli -Improved cerebral vascularization -Prevention of cerebral hemorrhage -Decreased vascular permeability
Dissolved emboli
The nurse is caring for a client during a prolonged hospital stay for congestive heart failure. The client has a prescription for thigh high antiembolism stockings. In regard to the antiembolism stockings, what is the priority action by the nurse?
Remeasure the client's legs routinely.
The laboratory notifies the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 95 seconds. After verifying the values, the nurse calls the health care provider (HCP). What prescription for the client should the nurse recommend the HCP consider? -vitamin K -protamine sulfate -packed red blood cells -warfarin
protamine sulfate explaination: The aPTT is at a critical value, and the client should receive protamine sulfate as the antidote for heparin. Vitamin K is the antidote for warfarin. Packed red blood cells are administered to increase the hematocrit.
Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy? prothrombin time (PT) partial thromboplastin time (PTT) serum potassium arterial blood gas (ABG) values
prothrombin time (PT)
A 20-year-old client visiting the clinic requests the use of oral contraceptives. When reviewing the client's history, which finding would alert the nurse to a possible contraindication to using these agents? thrombophlebitis ulcerative colitis menorrhagia urinary tract infections
thrombophlebitis
A client diagnosed concurrently with myocardial infarction and atrial fibrillation is prescribed rivaroxaban and asks the nurse the purpose of this medication. How should the nurse respond? "This medication is a blood thinner, which will make it easier to move blood through your arteries." "This medication prevents clots, which reduces your risk of another heart attack." "Rivaroxaban is an oral anticoagulant medication used to prevent your blood from clotting." "Rivaroxaban can reduce your risk for stroke related to having atrial fibrillation."
"Rivaroxaban can reduce your risk for stroke related to having atrial fibrillation."
The unlicensed assistive personnel (UAP) obtained vital signs on a 7-month-old infant and recorded the peripheral pulse as 85 beats/minute. The RN immediately reassesses the child's pulse and discovers the pulse is 115 beats/minute. What should the nurse teach the UAP about obtaining an accurate heart rate in an infant? -"To assess a pulse under age 1, you should check the brachial artery." -"Here is a copy of normal heart rates in children so you can report abnormal findings." -"Always assess the pulse rate after you take the blood pressure." -"To assess a pulse in children, always assess the apical pulse."
"To assess a pulse in children, always assess the apical pulse."
A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). To determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? "What time did your chest pain start?" "Do you have any allergies?" "Is this the first time you experienced this type of pain?" "Did you take any nitroglycerine before coming to the emergency department?"
"What time did your chest pain start?"
The nurse is observing the electrocardiogram (EKG) rhythm of a client with a permanent pacemaker and determines there is not a QRS complex that follows the pacemaker spike. Which follow-up action is most appropriate? Ask the client to take deep breaths and cough. Check the client's electrolyte results from the daily laboratory work for any changes. Place the client on the right side and elevate the head of the bed 30 degrees. Report to the health care provider that the pacemaker is failing to capture.
Report to the health care provider that the pacemaker is failing to capture.
A client is prescribed adenosine for treatment of supraventricular tachycardia (SVT). When should the nurse assess the client for a response to the dose of adenosine? after 15 to 20 minutes after 5 to 10 minutes after 1 to 2 minutes after 30 minutes
after 1 to 2 minutes
A nurse is monitoring a client following the administration of sotalol. Which finding would be of greatest concern to the nurse? heart rate of 58 bpm bilateral inspiratory wheezing upon auscultation 2 lb (.91 kg) weight gain in 2 days blood pressure of 102/50
bilateral inspiratory wheezing upon auscultation Nonselective beta-blocking drugs may cause bradycardia, hypotension, heart block, heart failure, bronchoconstriction, and/or increased airway resistance.
A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? temperature blood pressure respirations pulse
blood pressure
The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the health care provider (HCP)? slightly decreased levels of calcium elevated PT/INR decreased ammonia normal serum albumin
elevated PT/INR
A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. Administer warfarin. Start a dopamine drip for a systolic BP less than 100 mm Hg. Check the postoperative CBC, INR, PTT, and platelet levels. Monitor the mediastinal chest tube drainage. Confirm availability of blood products.
Check the postoperative CBC, INR, PTT, and platelet levels. Monitor the mediastinal chest tube drainage. Confirm availability of blood products.
What dietary recommendations should the nurse provide for a client with intermittent claudication to assist in the prevention of disease? Select all that apply. -refrain from eating processed foods -substitute saturated fats for unsaturated fats -limit calorie intake to 1500 calories per day -decrease cholesterol reduce fat
reduce fat decrease cholesterol
A client at 11 weeks gestation calls the antepartum clinic nurse. She has soaked a perineal pad with fresh blood in less than 30 minutes. The uterine cramping has also become worse. What is the most appropriate response from the nurse? -"You need to seek immediate attention from your physician." -"I am sorry. There is nothing to do because you are likely miscarrying." -"This is nothing to worry about. Many women have bleeding during their pregnancy." -"Lie down and call your physician tomorrow if your symptoms are continuing."
"You need to seek immediate attention from your physician."
A nurse in a prenatal clinic is assessing a client who is 28 weeks' pregnant. Which findings lead the nurse to suspect that the client has mild preeclampsia? glycosuria and blood pressure of 150/92 mmHg 1+ protein, blood pressure 142/92 mmHg blood pressure 138/78 mmHg, 1+ edema in feet reduced urine output, 1+ edema
1+ protein, blood pressure 142/92 mmHg
The nurse is evaluating arterial wave formation from an arterial line and notes a slow upstroke. What is the best action by the nurse? Auscultate lung sounds. Assess capillary refill time. Auscultate heart sounds. Assess wrist for hyperextension.
Auscultate heart sounds.
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. Keep the legs in a dependent position. Use a heating pad to promote vasodilation. Avoid prolonged standing and sitting. Keep extremities elevated on pillows. Limit walking so as not to activate the "muscle pump."
Avoid prolonged standing and sitting. Keep extremities elevated on pillows.
Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg? Appropriate dose of aspirin and rest Pressure on the site and administration of the required clotting factor Immobilization of the leg and a dose of ibuprofen Heating pad and administration of factor VIII concentrate
Pressure on the site and administration of the required clotting factor
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? Decrease the likelihood of pressure ulcer formation. Promote urinary and intestinal elimination. Prepare the client for ambulation. Prevent thrombophlebitis and blood clot formation.
Prevent thrombophlebitis and blood clot formation.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor? -request local anesthesia for vaginal birth. - Breathe slowly after each contraction -Remain in a side-lying position with the head elevated. -Avoid the use of analgesics for the labor pain.
Remain in a side-lying position with the head elevated
A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? The client is experiencing an exacerbation of the heart failure. The dobutamine needs to be increased. The dobutamine may need to be decreased. The client is experiencing an allergic reaction to the dobutamine.
The dobutamine may need to be decreased.
The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? a urinary output of 50 mL in the past 3 hours vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60 a Sa02 reading of 92% a white blood cell count of 19,000/mm3
a urinary output of 50 mL in the past 3 hours
A nurse is caring for a client with deep vein thrombosis. Which change in assessment findings would the nurse be alert for related to the condition? chest pain and dyspnea hypertension and fever calf pain and redness bradypnea and bradycardia
chest pain and dyspnea
The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort? -dark, protruding veins of both legs that are uncomfortable when standing -red, warm, palpable linear cord along the vein that is painful on palpation -absence of pain or swelling when the client dorsiflexes the left foot -brown discoloration of the skin with edema in the lower left leg
red, warm, palpable linear cord along the vein that is painful on palpation
A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first? the client with unilateral leg swelling who reports anxiety and shortness of breath the client with crackles and fever who reports pleuritic pain the client with anorexia, weight loss, and night sweats the client who had difficulty sleeping, daytime fatigue, and morning headache
the client with unilateral leg swelling who reports anxiety and shortness of breath
A client is scheduled for a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory value to the health care provider (HCP) prior to the stress test? cholesterol level prothrombin time troponin level erythrocyte sedimentation rate
troponin level
The client returns to the hospital 3 days after diagnosis of deep vein thrombosis, with reports of cough, hemoptysis, shortness of breath, and sharp pain under the right scapula. The client is subsequently is diagnosed with a pulmonary embolus (PE). The client asks the nurse, "How did I even get a pulmonary embolus?" What is the best response by the nurse? Select all that apply. -increased blood coagulability -having any condition that produces venous stasis -taking medications such as warfarin sodium -frequent falls -venous endothelial changes
venous endothelial changes having any condition that produces venous stasis increased blood coagulability
A client has extreme fatigue and is malnourished, and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food low in which nutrients? vitamins A, E, and C vitamins A and B vitamins B6 and B12, folate, iron, and copper thiamine, riboflavin, and niacin
vitamins B6 and B12, folate, iron, and copper
A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend? birth control patch etonogestrel/ethinyl estradiol vaginal ring combined hormonal oral contraceptive depot medroxyprogesterone acetate injection
depot medroxyprogesterone acetate injection
A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern?
"The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs."
