420 Perfusion PrepU

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Place the client in a modified Trendelenburg position. Facilitates blood flow to the brain.

The client's ultrasound shows a thrombus in the venous sinus in the soleus muscle. The nurse explains that early treatment is important to prevent:

Pulmonary embolism

A mother asks why her infant with a cyanotic heart defect turns blue. What is the nurse's best explanation?

This is due to a decreased amount of oxygen to the peripheral tissue.

Parents are told that their infant has a heart defect with a left-to-right shunt. What is the best way for the nurse to explain this type of shunting to the parents?

This type of shunting causes an increase of blood to the lungs.

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first?

Increase the oxygen flow rate from 2 to 4 L/min.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased.

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?

Aspirin 81 mg PO o.d.

While caring for a client with a deep vein thrombosis of the leg, the nurse monitors for collaborative problems. Which action will the nurse implement while treating collaborative problems for this client?

Assess the respiratory status every 4 hours. ABCs. monitoring for the Complication of a pulmonary embolism.

A child has been admitted to the inpatient unit to rule out acute Kawasaki(inflammation of arteries) disease. A series of laboratory tests have been ordered. Which findings are consistent with this disease? Select all that apply.

reduced hemoglobin levels, elevated erythrocyte sedimentation rate (ESR).

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?

severe exploding headache

A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?

"We can stop the penicillin when her symptoms disappear."

A 55-year-old client has been diagnosed with coronary artery disease and begun antiplatelet therapy. The client has asked the nurse why a "blood thinner like warfarin" hasn't been prescribed. What is the most likely rationale for the clinician's use of an antiplatelet agent rather than an anticoagulant?

Antiplatelet agents are more effective against arterial thrombosis; anticoagulants are more effective against venous thrombosis.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?

Call the rapid response team. PE.

A client in the intensive care unit is diagnosed with hypovolemic shock based on a blood pressure of 88/53 mm Hg, heart rate of 122 beats/min, respiratory rate of 26 breaths/min. Given these vital signs, what urine output should the nurse expect?

Decreased below 30 mL/hr with decrease glomerular filtration rate (GFR).

A 50-year-old client has undergone a bunionectomy and has been admitted to the postsurgical unit. What aspect of the client's medical history would contraindicate the use of heparin for deep vein thrombosis (DVT) prophylaxis?

Diagnosis of ulcerative colitis

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke

The nurse is collecting data on a 5-year-old child admitted with the diagnosis of congestive heart failure. Which clinical manifestation observed during the physical assessment would be consistent with this diagnosis?

Failure to gain weight.

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?

Fat embolism syndrome. Fat embolism syndrome occurs most frequently in young adults and elderly clients who experience fractures of the proximal femur

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances?

Fluid volume circulating in the blood vessels decreases.

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?

Frequent neurologic checks, to detect paralysis, confusion, facial asymmetry, or aphasia.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication?

Hypovolemic shock. Indicators of hypovolemic shock include a heart rate greater than 100 beats per minute, a blood pressure less than 90/60 mm Hg, and urine output less than 30 ml per hour.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?

IV administration of lactated Ringer's. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage.

The nurse is caring for a client who develops sudden onset dyspnea. Which assessment should the nurse prioritize to best identify if the cause may be a pulmonary embolism?

Lower limb appearance. Because most pulmonary emboli are the result of a deep vein thrombosis (DVT), the nurse can best support this as the cause of dyspnea by examining the lower legs for evidence of DVT.

The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?

Maternal tachycardia and falling blood pressure

The parents of a 13-year-old boy with a sore throat for a week, vomiting for two days, swollen lymph glands, and stiff achy joints is now seeking antibiotic treatment after herbal remedies were unsuccessful. Throat cultures reveal infection with group A streptococci. This child is at high risk for development of which cardiac complication?

Mitral valve stenosis. Group A streptococcal infection can be adequately treated with antibiotics, but this infection may have been present long enough to trigger an immune response-rheumatic fever that will damage his heart valves, ultimately causing mitral valve stenosis

A client has a transverse fracture of the left humerus. Which assessment indicates a developing complication?

New onset of shortness of breath

A client arrives via ambulance with a suspected pelvic fracture from a motor vehicle collision. The client's vital signs are: blood pressure 85/50 mm Hg, heart rate 120 beats/min, respiratory rate 22 breaths/min, and an oxygen saturation of 98% on room air. The client is afebrile. The health care provider has written several prescriptions. What is the nurse's priority action?

Obtain STAT hemoglobin and group and match. The client is hypotensive, tachycardic, and tachypenic. These signs in a client with pelvic fracture could indicate internal blood loss and impending hypovolemic shock.

A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?

This is caused by an opening that usually closes by 1 week of age.

The nurse in a rural nursing outpost will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. What principle should guide the nurse's administration of intravenous fluid?

Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency.

A client has been prescribed intravenous heparin. What laboratory value will the nurse prioritize when providing care for this client?

aPTT

A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply

activity intolerance related to inadequate oxygenation, anxiety related to breathlessness, ineffective breathing pattern related to hypoxia, risk for decreased cardiac output related to failure of the left ventricle.

A 10-year-old child is admitted to the hospital with a temperature of 104°F (40°C) and is difficult to arouse. The child has history of Varicella two weeks ago. Reye's syndrome is suspected. Which objective data is supportive of the diagnosis? Select all that apply.

an abnormal liver biopsy, vomiting, coma, disorientation.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus.

Which assessment finding would be suggestive of adequate tissue perfusion in a client who has experienced a postpartum hemorrhage?

urinary output of 60 cc's over the last hour

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony. Loss of uterine tone places a client at higher risk for hemorrhage.

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?

Provide close supervision because of the client's impulsiveness and poor judgment.

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?

Pulmonary embolism.

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?

Rheumatic fever. Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal.

A 74-year-old woman states that many of her peers underwent hormone replacement therapy (HRT) in years past. The woman asks the nurse why her primary care provider has not yet proposed this treatment for her. What fact should underlie the nurse's response to the woman?

The risks of stroke and breast cancer are unacceptably high in women taking HRT.

A 40-year-old male presents to the emergency department reporting chest pain and shortness of breath. The health care provider suspects a pulmonary embolism and orders several diagnostic tests. Select the test that would require further follow-up.

Positive D-dimer. A positive result indicates a need to be further investigated for possible pulmonary embolism given the client's symptoms.

A nurse is caring for a client with a new diagnosis of rheumatic fever. What is the highest priority goal of treatment during the acute phase?

Prevent cardiac complications

The nurse is caring for a client who is going home on warfarin. What lab test(s) will the client require to evaluate therapeutic effects of the drug?

Prothrombin time (PT) and international normalized ratio (INR)

Which client statement demonstrates an accurate understanding of the action of a prescribed anticoagulant?

"This medication will keep unnecessary clots from forming in my blood."

Which client would be the best candidate to receive alteplase recombinant therapy?

A 68-year-old male who has had an ischemic stroke that resulted in neurological deficits

A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?

An obese woman with a history of atrial fibrillation and type 2 diabetes

A teenager is seen in the emergency room with reports of a sore throat, headache, fever, abdominal pain, and swollen glands. His mother tells the nurse that he was seen 3 weeks before in the clinic and treated with antibiotics for strep throat. He was better for a few days but now he seems to have gotten worse in the last 2 days. What should the nurse suspect is wrong with this client?

Rheumatic fever. Rheumatic fever is an immune-mediated inflammatory disease that occurs a few weeks after a group A strep (sore throat)

A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor?

Serum potassium level