cardio eaq
A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period?
Dysrhythmias, especially atrial fibrillation why - Dysrhythmias such as atrial fibrillation, bradydysrhythmias, or heart block must be closely monitored for in the client immediately after surgery.
How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction?
Replace the top linen and only the necessary bottom linen. why- Until a client's condition has reached some degree of stability after a myocardial infarction, routine activities such as changing sheets are avoided so that the client's movements will be minimized and the cardiac workload reduced. Lifting the client from side to side while changing the bed linen is contraindicated because it increases oxygen consumption and cardiac workload; also, it may strain the health team members who are lifting the client. Changing all the linen causes unnecessary movement, which increases oxygen demand and makes the heart work harder. Any activity is counterproductive to rest; rest must take precedence so that the cardiac workload is reduced.
low potassium pt's EKG will show
Elevated U and flattened T waves why -Elevated U and flattened T waves reflect low serum potassium levels. U waves are not expected; they signify repolarization of the terminal Purkinje fibers and are seen with hypokalemia. T waves represent ventricular repolarization; T waves flatten with hypokalemia and peak with hyperkalemia. Changes in P waves reflect atrial depolarization and contraction activity; P waves flatten with hyperkalemia, not hypokalemia. Increased P-R intervals are related to a delay in conduction from the sinoatrial (SA) node to the ventricles and are not altered with hypokalemia. Trigeminy and bigeminy reflect ventricular irritability, not the serum potassium level.
A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. What would be the best explanation by the nurse regarding the cause of this discoloration?
Leakage of red blood cells through the vascular wall why -Increased venous pressure alters the permeability of the veins, allowing extravasation of red blood cells (RBCs); hemolysis of RBCs releases a pigment called hemosiderin, which causes a characteristic brownish discoloration (brawny appearance).
A nurse is determining whether or not a client's atrial rhythm is regular when reviewing the ECG rhythm strip. Which consistency of spacing will the nurse use to determine regularity?
P waves why - The P wave represents atrial contraction. Regularity is assessed by using electronic or physical calipers, or a piece of paper and pencil. To determine atrial regularity, identify the P wave and place one caliper point on the peak of the P wave. Locate the next P wave and place the second caliper point on its peak. The second point is left stationary, and the calipers are flipped over. If the first caliper point lands exactly on the next P wave, the atrial rhythm is perfectly regular. If the point lands one small box or less away from the next P wave, the rhythm is essentially regular. If the point lands more than one small box away, the rhythm is considered irregular. The same process can be performed with a simple piece of paper. Place the paper parallel and below the rhythm line, make a hatch mark below the first and second P waves, and then move the paper over to determine if the distance between the second and third P waves is equal to the first and second. When an atrial rhythm is perfectly regular, each P wave is an equal distance from the next P wave. This process is also used to assess ventricular regularity, except that the caliper points are placed on the peak of two consecutive R waves. QRS intervals can lengthen in response to new bundle branch blocks or with ventricular dysrhythmias.
When assessing for hemorrhage on a client who has a total hip replacement, what is the most important nursing action to implement?
examine the bedding under the pt why- Because of the recumbent position, drainage may flow by gravity under the client and not be noticed unless the bedding is examined. Measuring the girth of the thigh is inaccurate when there is a dressing in place. In the immediate postoperative period, vital signs should be taken more frequently than every 4 hours; in addition, observation of the site is a more reliable indicator of hemorrhage. Dressings impede an accurate assessment of the site for ecchymosis.
After receiving 75 mL of packed red blood cells, the client complains of chills and low back pain. The nurse suspects a hemolytic transfusion reaction and stops the infusion. The blood bag and a urine specimen are sent to the laboratory. What will the urine specimen be tested for?
free hemoglobin why - Blood incompatibility causes lysis of red blood cells with the result that hemoglobin is freed into the circulation; if a sufficient (100 mL or more) amount of incompatible blood is transfused, permanent renal damage can occur. Chills and low back pain indicate kidney involvement. Specific gravity need not be determined. Carboxyhemoglobin need not be determined. DIC is an intravascular clotting disorder that does not occur with a transfusion reaction.
A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? Select all that apply.
malaise, swollen lymph glands why - Development of HIV-specific antibodies (seroconversion) is accompanied by a flulike syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs 1 to 3 weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flulike syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or opportunistic infection that affects the neurologic system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection.
The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?
oliguria
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.
rapid pulse, decreased urinary output why - The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.
A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client?
reduced peripheral pulses why- Hypovolemia results in decreased cardiac output and decreased arterial pressure, which are reflected by a weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. The pulse pressure narrows with decreased cardiac output associated with hypovolemic shock. Lethargy with confusion is a late sign of shock.
