CV questions
A nurse is planning to teach a client with PAD about measures to limit disease progression. Which of the following items would the nurse include on a list of suggestions for the client? *Select all that apply* 1. cut down on amt of fats consumed in diet 2. use heating pad on legs to aid vasodilation 3. walk each day to increase circulation to the legs 4. be careful not to injure the legs or feet 5. soak feet in hot water daily
1, 3, 4 Longterm management of PAD consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of heating pad on extremity is contraindicated. The affect extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen an nutritional requirements of the tissue even further
A nurse is planning care for client with DVT of right leg. Which interventions would be apropriate to include in the plan of care? *Select all that apply.* 1. elevation of right leg 2. ambulation in the hall twice per shift 3. application of moist heat to the right leg 4. administration of tylenol 5. monitor for sign of pulmonary embolism
1, 3, 4, 5 *medsurg text says patient may ambulate as needed and strict bedrest is not needed*
A client is admitted to hospital w/ dx of mitral stenosis. The nurse plans care for the client knowing the narrowing of this valve impedes circulation of blood from: 1. left atrium to left ventricle 2. left ventricle to aorta 3. right atrium to right ventricle 4. right ventricle to pulmonary artery
1.
9. The client admitted with peripheral vascu- lar disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: ■ 1. Decreased blood flow. ■ 2. Increased blood flow. ■ 3. Slow blood flow. ■ 4. Thrombus formation.
1. Decreased blood flow is a common charac- teristic of all PVD. When the demand for oxygen to the working muscles becomes greater than the sup- ply, pain is the outcome. Slow blood flow through- out the circulatory system may suggest pump failure. Thrombus formation can result from stasis or damage to the intima of the vessels.
100. The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has: 1. Mild peripheral artery disease. 2. Moderate peripheral artery disease. 3. No apparent occlusion in the left lower extremity. 4. Severe peripheral artery disease.
1. The ABI test is a noninvasive test that compares the systolic blood pressure in the arm with that of the ankle. It may be done before or after exercise. The client's highest brachial systolic pressure is divided by the left ankle systolic blood pressure to get 0.81. This score is between 0.71 and 0.90, which suggests mild peripheral artery disease. Moderate peripheral artery disease would yield a score of 0.41 to 0.70. Severe peripheral artery dis- ease would result in a score of 0.00 to 0.40.
99. A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first? ■ 1.Prepare for transcutaneous pacing. ■ 2.Prepare to defibrillate the client at 200 joules. ■ 3.Administer an I.V. lidocaine infusion. ■ 4.Schedule the operating room for insertion of a permanent pacemaker.
1. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third- degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pace- maker can be inserted.
65. A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first? 1. Elevate the legs. 2. Elevate the legs by using a pillow under the knees. 3. Encourage adequate fluid intake. 4. Massage the lower legs.
1. Venous stasis can increase pain. Therefore, proper positioning in bed or when sitting up in a chair can help promote venous drainage, reduce swelling, and reduce the amount of pain the client might experience. Placing a pillow under the knees causes flexion of the joint, resulting in a dependent position of the lower leg and causing a decrease in blood flow. Fluids are encouraged to maintain normal fluid and electrolyte balance but do little to relieve pain. Therapeutic massage to the legs is dis- couraged because of the danger of breaking up the clot.
81. A client weighs 300 lb (136 kg) and has a his- tory of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse knows that the client has understood the nurse's instructions when he states he will: 1. Avoid exercise. 2. Lose weight. 3. Perform leg lifts every 4 hours. 4. Wear support hose, using rubber bands to hold the stockings up.
2
67. A client is discharged after being hospital- ized for thrombophlebitis. She will be driving home with her daughter, who lives 2 hours away. During the 2-hour ride, the nurse should advise the client to: 1. Perform arm circles while riding in the car. 2. Perform ankle pumps and foot range-of- motion exercises. 3. Elevate her legs while riding in the car. 4. Take an ambulance home.
2.
A home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home-care management and self-care management. Which statement, if made by client, indicates a need for further instruction? 1. "I need to be sure not to go barefoot around the house." 2. "I need to be sure that I elevate my leg above my heart level for at least an hour every day." 3. If I cut my toenails, I need to be sure that I cut them straight across." 4. "It is all right to apply lanolin to my feet, but I shouldn't place it b/w my toes."
2. The client with arterial disease should avoid raising leg above level of the heart
72. A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having: ■ 1. Palpitations. ■ 2. Tinnitus. ■ 3. Urinary frequency. ■ 4. Lethargy.
2. Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremi- ties, excessive perspiration, hypotension, seizures, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.
6. A common abnormal laboratory result associ- ated with the development of peripheral vascular disease (PVD) is: ■ 1. High serum calcium level. ■ 2. High serum lipid levels. ■ 3. Low serum potassium level. ■ 4. Low serum lipid levels.
2. High serum lipid levels are associated with an increased incidence of PVD. High serum calcium level, low serum potassium level, and low serum lipid levels have no relation to PVD.
100. A 74-year-old female is admitted to the telemetry unit for placement of a permanent pace- maker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to: ■ 1. Maintain skin integrity. ■ 2. Maintain cardiac conduction stability. ■ 3. Decrease cardiac output. ■ 4. Increase activity level.
2. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitor- ing until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours.
2. A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first? ■ 1. IV fluid solution. ■ 2. Pedal pulses. ■ 3. Nasal cannula flow rate. ■ 4. Capillary refill.
2. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfu- sion to the lower extremity with the drop in blood pressure. I.V. fluids, nasal cannula setting, and capil- lary refill are important to assess, however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.
66. A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingooophorectomy 2 days ago. The client's abdominal dressing is dry and intact. In addition, the client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair after her bath, the client complains of severe pain and numbness in her left leg. The nurse should respond immediately by: 1. Administering pain medication. 2. Assessing for edema in the left leg. 3. Assessing color and temperature of the left leg. 4. Encouraging the client to change her position.
3. The client is likely suffering from an embolus as a result of abdominal surgery. The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Admin- istering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation. Encouraging the client to change her position does not adequately address the need for gathering more data.
72. A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first: ■ 1. Administer acetaminophen (Tylenol). ■ 2. Change the D5W to normal saline. ■ 3. Discontinue the I.V. ■ 4. Place a warm compress on the area.
3. The first action should be to discontinue the I.V. The nurse should restart the I.V. elsewhere and then apply a warm compress to the affected area. The nurse should administer acetaminophen or an anti-inflammatory agent only if ordered by the physician. The type of infusion cannot be changed without a physician's order, and such a change would not help in this case.
29. A client who has been diagnosed with peripheral vascular disease (PVD) is being dis- charged. The client needs further instruction if she says she will: ■ 1. Avoid heating pads. ■ 2. Not cross her legs. ■ 3. Wear leather shoes. ■ 4. Use iodine on an injured site.
4.
4. Peripheral blood flow is dependent on which of the following variables? 1. Blood viscosity and diameter of vessels. 2. Diameter and resistance of vessels. 3. Force of contraction of the heart and resis- tance of vessels. 4. Pressure differences in the arterial and venous systems and resistance.
4.
98. The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drain- age coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. To maintain tissue integrity, the primary nursing goal should focus on: 1. Administering prescribed analgesics. 2. Applying lanolin lotions to the left ankle stasis ulcer. 3. Encouraging the client to sit up in a chair four times per day. 4. Providing an over-the-bed cradle to protect the left ankle from the pressure of bed linens.
4. Providing an over-the-bed cradle will decrease the amount of pressure that the linens exert upon the lower extremity and prevent further tissue breakdown. Administering prescribed analge- sics would be an intervention for reducing the pain. Applying lanolin lotions to the left ankle ulcer will not promote healing. Encouraging the client to sit up in a chair four times per day is an intervention to promote activity. The nurse would elevate the involved extremity while the client is sitting up to reduce venous stasis and capillary pressure.
A nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. A priority intervention in the plan of care is to: 1. keep legs aligned with the heart 2. position client onto the side every shift 3. clean the skin with alcohol every hour 4. elevate the legs higher than the heart
4. the legs are elevated above the level of the heart to assist with the return of venous blood to the heart
The cardiac cycle consists of contractions and relaxation of the heart muscle. The heart normally sends out about __ L of blood every minute to the body
5 L/minute
ECG strip reads: P wave and QRS complexes are regular; PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall HR is 64 bpm. What is correct interpretation of this rhythm?
Normal sinus rhythm PR (0.12 to 0.20 sec) QRS (0.04 to 0.10 sec)
96. A well-nourished client is admitted with a stasis ulcer. The nurse assesses the ulcer and finds excavation of the skin surface as a result of slough- ing of inflammatory necrotic tissue. The physician has ordered the ulcer to be flushed with a fibrin- olytic agent. Which of the following goals are appro- priate for this client? Select all that apply. ■ 1. Increase oxygen to the tissues. ■ 2. Prevent direct trauma to the ulcer. ■ 3. Improve nutrition. ■ 4. Prevent infection. ■ 5. Reduce pain.
1, 2, 4, 5. The underlying pathophysiology in stasis ulcers of the skin surface is a result of inad- equate oxygen and other nutrients to the tissues because of edema and decreased circulation. The nurse should first initiate care that will increase oxygen and improve tissue integrity. It is also impor- tant to prevent trauma to the tissues and prevent infections, which result from decreased microcircu- lation that limits the body's response to infection. Stasis ulcers are painful. The nurse can administer prescribed analgesics 30 minutes before changing the dressing. There is no indication that the client's overall nutrition needs to be improved.
104. The nurse is preparing the client for cardioversion. The nurse should do which of the following? Select all that apply. 1. Use a conducting agent between the skin and the paddles. 2. Place the paddles over the client's clothing. 3. Call "clear" before discharging the electrical current. 4. Record the delivered energy and the resulting rhythm. 5. Exert 5 to 10 lb of pressure on each paddle to ensure good skin contact.
1, 3, 4. A conducting agent is placed between the skin and the paddles to conduct the electrical current when discharged. The nurse must make sure to call "clear" before discharging the electrical cur- rent to prevent injury to others who may be helping with the client. Each paddle is placed directly on the conductive pads that are on the client's skin. Applying approximately 20 to 25 lb of pressure on each paddle is recommended to ensure good skin contact. The nurse must record the amount of elec- trical current delivered and the resulting rhythm.
A client with first-degree heart block has an ECG taken during an episode of chest [ain. The nurse knows that which ECG finding indicates first-degree heart block? 1. prolonged PR interval 2. widened QRS complex 3. tall, peaked T waves 4. Presence of Q waves
1.
A nurse is reviewing the ECG strip obtained on a client with a dx of MI. The nurse notes that the PR inerval is 0.20 second. The nurse determines that this is: 1. normal 2. indicative of atrial flutter 3. indicative of impending reinfarction 4. indicative of atrial fibrillation
1. rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range is 0.12 to 0.20 second
A client has frequent bursts of ventricular tachycardia on cardiac monitor. What should nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to NSR 3. It is uncomfortable for client, giving sense of impending doom 4. It produces a high CO that quickly leads to cerebral and myocardial ischemia
1. rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results in an irritable ectopic focus that takes over as the pacemaker for the heart. The low CO that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated w/ antidysrhythmic meds, cardioversion (client awake), or defibrillation (loss of consciousness).
7. The nurse is planning care for a client with a history of peripheral vascular disease who has symptoms of claudication. Nursing care should be directed to avoiding which of the following situations? 1. Oxygen demand by the muscle exceeds the supply. 2. Oxygen demand and supply of the working muscle are in balance. 3. Oxygen supply exceeds the demand of the working muscle. 4. Oxygen is absent.
1. Claudication is the term used to describe the discomfort a person experiences when oxygen demand in the leg muscles is greater than the sup- ply. The pain is a result of tissue hypoxia in the working muscle. Symptoms include aching, cramp- ing, and weakness.
80. Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: ■ 1. A manual toothbrush. ■ 2. An electric toothbrush. ■ 3. An irrigation device. ■ 4. Dental floss.
1. Daily dental care and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the blood- stream, increasing the risk of endocarditis.
8. Which of the following explains the influence of aging on the development of peripheral vascular disease? ■ 1. Decreased resistance. ■ 2. Increased resistance. ■ 3. Decreased viscosity.
2. As people age, the accumulation of col- lagen in the intima of the blood vessels results in the vessels' becoming stiff and less flexible. Conse- quently, there is an increased resistance within the aging adult's circulatory system.
105. A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condi- tion. The most effective way to determine the effec- tiveness of CPR is noting whether the: ■ 1. Pulse rate is normal. ■ 2. Pupils are reacting to light. ■ 3. Mucous membranes are pink. ■ 4. Systolic blood pressure is at least 80 mm Hg.
2. Pupillary reaction is the best indication of whether oxygenated blood has been reaching the client's brain. Pupils that remain widely dilated and do not react to light probably indicate that serious brain damage has occurred. The pulse rate may be normal, mucous membranes may still be pink, and systolic blood pressure may be 80 mm Hg or higher, and serious brain damage may still have occurred.
14. The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). Dur- ing the assessment, the nurse should expect to find which of the following clinical manifestations of PVD? ■ 1. Hairy legs. ■ 2. Mottled skin. ■ 3. Pink, cool skin. ■ 4. Warm, moist skin.
2. Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As a result, the skin may appear mottled. Loss of hair and cool, dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities.
114. The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action? 1. Activate the rapid response team. 2. Assess the client's orientation and vital signs. 3. Call the physician. 4. Administer a bolus of lidocaine.
2. The priority action is to assess the client and determine whether the rhythm is life-threaten- ing. More information, including vital signs, should be obtained and the physician should be quickly notified. A bolus of lidocaine may be ordered to treat this arrhythmia. This is not a code-type situation unless the client has been determined to be in a life-threatening situation.
115. The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should: ■ 1. Begin chest compressions. ■ 2. Call the rapid response team. ■ 3. Remove the family from the room. ■ 4. Ventilate the client with an ambu bag.
2. The rapid response team should be called immediately to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. If the family is not interfer- ing in client care, it can be reassuring to the family to see that all possible care is being provided.
80. Which of the following clients is at risk for varicose veins? ■ 1. A client who has had a cerebrovascular accident. ■ 2. A client who has had anemia. ■ 3. A client who has had thrombophlebitis. ■ 4. A client who has had transient ischemic attacks.
3
91. Which of the following increases the risk of having a large abdominal aortic aneurysm rupture? ■ 1. Anemia. ■ 2. Dehydration. ■ 3. High blood pressure. ■ 4. Hyperglycemia.
3
28. A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilater- ally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interven- tions will help achieve this outcome? ■ 1. Administering pain medication. ■ 2. Encouraging fluids. ■ 3. Turning the client every 1 to 2 hours. ■ 4. Maintaining hygiene.
3.
68. A client is admitted from a nursing home with an acute onset of shortness of breath. A dx of pulmonary embolism is made. One common cause of pulmonary embolism is: ■ 1. Arteriosclerosis. ■ 2. Aneurysm formation. ■ 3. Deep vein thrombosis (DVT). ■ 4. Varicose veins.
3.
69. A client receives a thrombolytic agent. The expected outcome of this drug therapy includes: ■ 1. Improved cerebral perfusion. ■ 2. Decreased vascular permeability. ■ 3. Dissolved emboli.
3.
A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1. vascular ulcer 2. venous stasis ulcer 3. arterial ulcer 4. stage 1 ulcer
3.
A nurse notes that a client's rhythm shows absent P waves and no PR interval. The nurse interprets the rhythm as: 1. NSR 2. bradycardia 3. atrial fibrillation 4. tachycardia
3.
A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse next assess the client for: 1. coolness and pallor of affected limb 2. diminished distal peripheral pulses 3. increased calf circumference 4. bilateral edema
3. client w/ DVT would exhibit redness or warmth of affected leg, tenderness, possibly dilated veins, low-grade fever, edema distal to obstruction, and increased calf circumference in affected extremity
A hospitalized client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned and takes action, knowing that this level could ultimately lead to: 1. high BP 2. stroke 3. Cardiac arrest 4. Urinary Stone formation
3. normal Ca+ is 8.6 to 10. low Ca+ could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Ca is needed by heart for contraction. Ca ions move across cell membranes into cardiac cells during depolarization and move back during repolarization. Depolarization is responsible for cardiac contraction. Elevated Ca levels can lead to urinary stone formation
106. A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect? 1. The ventricular rate is increasing. 2. The absent pulse is now palpable. 3. The number of premature ventricular contractions is decreasing. 4. The fine ventricular fibrillation changes to coarse ventricular fibrillation.
3. Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.
5. Blood pressure in the systemic circulation is highest in the: ■ 1. Arterioles. ■ 2. Capillaries. ■ 3. Aorta. ■ 4. Venules.
3. Blood pressure is the highest in the aorta as the blood is being ejected out of the left ventricle into the aorta. The pressure declines as the blood flows through the arteries, capillaries, arterioles, veins, capillaries, and venules. The force of the con- traction of the heart and resistance of vessels influ- ence flow; however, it is the pressure differences that control blood flow.
15. The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages? ■ 1. 20%. ■ 2. 40%. ■ 3. 50%. ■ 4. 100%.
3. Generally, a 50% to 75% occlusion in the arterial lumen causes symptoms associated with intermittent claudication. When the demand for oxy- gen becomes greater than the supply in the working muscle, the client experience pain (aching, cramping). When the individual sits down and rests, the demand and supply of oxygen become balanced and the dis- comfort dissipates. Occlusion of 100% would result in ischemia and necrosis of tissue distal to the artery and would require immediate surgical intervention
71. A 70-year-old female is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furo- semide. During the initial interview with the client, the nurse would most likely learn that the client's childhood health history included: ■ 1. Chickenpox. ■ 2. Poliomyelitis. ■ 3. Rheumatic fever. ■ 4. Meningitis.
3. Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. Chickenpox, poliomyelitis, and meningitis are not associated with mitral stenosis.
103. Ventricular tachycardia is displayed on the cardiac monitor of a client admitted to the telemetry unit. Which should the nurse do first? ■ 1. Prepare for immediate cardioversion. ■ 2. Begin cardiopulmonary resuscitation (CPR). ■ 3. Check for a pulse. ■ 4. Prepare for immediate defibrillation.
3. The presence of a pulse determines the treatment for ventricular tachycardia. It is also important to assess the client's heart rate and level of consciousness. Cardioversion may be used to treat hemodynamically unstable tachycardias. Assess- ment of instability is required before cardioversion. It is not appropriate to begin CPR unless the pulse is absent. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia.
88. A client is admitted to the emergency depart- ment complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneu- rysm. The primary goal at this time is to: ■ 1. Maintain circulation. ■ 2. Manage pain. ■ 3. Prepare the client for emergency surgery. ■ 4. Teach postoperative breathing exercises.
3. The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circu- lation is maintained, unless the aneurysm ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about post- operative breathing exercises, and administer pain medication if ordered.
102. Upon assessment of third degree heart block on the monitor, the nurse should first: ■ 1.Call a code. ■ 2.Begin cardiopulmonary resuscitation. ■ 3.Have transcutaneous pacing ready at the bed- side ■ 4.Prepare for defibrillation.
3. Transcutaneous pads should be placed on the client with third degree heart block. For a client who is symptomatic, transcutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is performed for ven- tricular fibrillation or ventricular tachycardia with no pulse.
16. The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? ■ 1. Auscultate the pulses with a stethoscope. ■ 2. Call the physician. ■ 3. Use a Doppler ultrasound device. ■ 4. Inspect the lower left extremity.
3. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in the client's condition.
71. A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications? ■ 1. Air embolus. ■ 2. Fat embolus. ■ 3. Stress fractures. ■ 4. Thrombophlebitis.
4.
73. The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following: 1. Turning every 2 hours. 2. Passive and active range-of-motion exercises. 3. Use of thromboembolic disease support (TED) hose. 4. Maintaining the client in the supine position.
4.
76. A client who has undergone abdominal or pelvic surgery. In order to prevent deep vein throm- bosis (DVT), the nurse should: ■ 1. Restrict fluids. ■ 2. Encourage deep breathing. ■ 3. Assist the client to remain sedentary. ■ 4. Use pneumatic compression stockings.
4.
79. The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should: 1. Apply a half-leg pneumatic compression device. 2. Suggest the client contact her physcian. 3. Assess the client for foot ulcers. 4. Encourage the client to avoid standing in one position for long periods of time.
4.
A client is being d/c from hospital after being treated for infective endocarditis IE. The nurse provides the client with which d/c instructions? 1. take tylenol if chest pain worsens 2. use firm-bristle toothbrush and floss vigorously to prevent cavities 3. take ABX until chest pain fully resolved 4. notify all HCP of hx of IE before invasive procedures
4.
A nurse is caring for a client with cardiac disease who has been placed on cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 bpm. The nurse should next assess the client for which of the following? 1. flat neck veins 2. complaints of nausea 3. complaints of HA 4. hypotension
4. The client with uncontrolled atrial fibrillation with a ventricular rate > 100 bpm is at risk for low CO d/t loss of atrial kick. The nurse assesses client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, SOB, and distended neck veins
A client is having frequent PVCs. A nurse would place priority on assessment of which of the following? 1. sensation of palpitatiosn 2. causative factors, such as caffeine 3. precipitating factors, such as infection 4. BP and O2 Sat
4. rationale: PVCs can cause hemodynamic compromise. The shortened ventricular filling time w/ the ectopic beat leads to decreased stroke volume and, if frequent enough, to decrease CO. The client may be asymptomatic or may feel palpitations. PVCs can be caused by cardiac disorders, states of hypoxia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol
1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that dis- appears at rest. Which of the following findings requires further evaluation? ■ 1. Heart rate 57 bpm. ■ 2. SpO2 of 94% on room air. ■ 3. Blood pressure 134/82. ■ 4. Ankle brachial index of 0.65.
4. An Ankle Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history.
19. When assessing an individual with periph- eral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? ■ 1. Aching pain in the left calf. ■ 2. Burning pain in the left calf. ■ 3. Numbness and tingling in the left leg. ■ 4. Coldness of the left foot and ankle.
4. Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numb- ness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated within incomplete obstruction.
11. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to: ■ 1. Competent venous valves. ■ 2. Decreased blood volume. ■ 3. Increase in muscular activity. ■ 4. Increased venous pressure.
4. In PVD, decreased blood flow can result in increased venous pressure. The increase in venous pressure results in an increase in capillary hydro- static pressure, which causes a net filtration of fluid out of the capillaries into the interstitial space, result- ing in edema. Valves often become incompetent with PVD. Blood volume is not decreased in this condi- tion. Decreased muscular action would contribute to the formation of edema in the lower extremities.
