Elevate Module 2

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."

Rationale 1., 3., 4., & 5. Correct: Minimize stationary standing as much as possible. Protect legs from trauma as this can lead to ulcerations. Elastic compression stockings are recommended for clients with chronic venous insufficiency to prevent pooling and promote venous return. Leg elevation decreases edema, promotes venous return, and provides symptomatic relief. Legs should be elevated frequently throughout the day (for at least 15-30 minutes every 2 hours). During the night, the client should sleep with the foot elevated approximately 6 inches (15.24 cm). 2. Incorrect: The client should avoid wearing any constricting clothing, even for short periods of time. This will decrease blood flow. Let's Talk Venous stasis ulcers in the leg are often an indication that venous disease has reached an advanced stage. Because venous disease is progressive, venous reflux can often lead to additional valve failure, and as a result, the pooling of blood can affect a larger area. When blood pools in the lower leg over a long period of time, the condition is referred to as venous stasis. When blood leaks into the tissue of the skin it can cause swelling and damage to the tissue. Tissue damage can result in wounds, or ulcers, that are chronic and do not heal if the condition is left untreated. Ulcers may be painful or itchy and often require constant care and dressing. People most at risk of developing a venous leg ulcer are those who have previously had a leg ulcer. Prevention includes: 1. Weight loss if obese or overweight. Excess weight leads to high pressure in the veins in your legs, which can damage your skin. Venous ulcers are much more common among people who are overweight. 2. Exercise to improve circulation and reduce body fat. 3. Avoid sitting or standing still for long periods. Sitting leads to poor circulation in your legs, which can cause swelling in your ankles, varicose veins, and blood clots known as deep vein thrombosis (DVT). 4. Elevate the legs to prevent swelling in the legs. 5. Decrease sodium intake, which causes fluid retention. 6. Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency. Do you see now that options 1, 3, 4, & 5 are true?

What assessment finding would indicate to the nurse that further treatment is needed for a client hospitalized with systolic heart failure? 1. S3 heart sound 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.91 kg) 4. Hepatomegaly 5. Increasing BNP level 6. Urine output at 50 mL/hr

1, 4, 5 Rationale 1., 4. & 5. Correct: S3 would indicate that the client is not better. S3 is heard when the client is in fluid overload. Hepatomegaly and tenderness in the right upper quadrant of the abdomen result from venous engorgement of the liver. The client is not better. An increase in BNP level would indicate that the heart failure was getting worse, not better. 2. Incorrect: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. 3. Incorrect: Weight loss indicates that fluid is being removed 6. Incorrect: A urine output of 50mL/hour indicates that renal perfusion is adequate. Let's Talk Systolic heart failure is the most common cause of heart failure and occurs when the heart is weak and enlarged. The muscle of the left ventricle loses some of its ability to contract or shorten. In turn, it may not have the muscle power to pump the amount of oxygenated and nutrient-filled blood the body needs. With diastolic heart failure, the muscle becomes stiff and loses some of its ability to relax. As a result, the affected chamber has trouble filling with blood during the rest period that occurs between each heartbeat. Often the walls of the heart thicken, and the size of the left chamber may be normal or reduced. Typical signs of heart failure include: Dyspnea — When the heart begins to fail, blood backs up in the veins attempting to carry oxygenated blood from the lungs to the heart. As fluid pools in the lungs, it interferes with normal breathing. These periods of breathlessness may leave the client feeling exhausted and anxious. Fatigue — As heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the body's needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries. Chronic Cough or Wheezing — The fluid buildup in the lungs may result in a persistent cough or wheezing, that may produce phlegm that may be tinged with blood. Rapid or Irregular Heartbeat — The heart may speed up to compensate for its failing ability to adequately pump blood throughout the body. Lack of Appetite or Nausea — When the liver and digestive system become congested they fail to receive a normal supply of blood. This can make the client feel nauseous or full. Mental Confusion — Abnormal levels of certain substances, such as sodium, in the blood and reduced blood flow to the brain can cause memory loss or disorientation. Fluid Buildup and Swelling — Because blood flow to the kidneys is restricted, the kidneys produce hormones that lead to salt and water retention. This causes edema, that occurs most often in the feet, ankles and legs. Rapid Weight Gain — The fluid build-up throughout the body may cause a rapid weight gain. At the same time, the heart, as well as other parts of the body, attempt to adapt and make up for the deteriorating pumping ability. For example: Heart Grows Larger — The muscle mass of the heart grows in an attempt to increase its pumping power, which works for a while. Heart Pumps Faster — In an attempt to circulate more blood throughout the body, the heart speeds up. Blood Vessels Narrow — As less blood flows through the arteries and veins, blood pressure can drop to dangerously low levels. To compensate, the blood vessels become narrower, which keeps blood pressure higher, even as the heart loses power. Blood Flow Is Diverted — When the blood supply is no longer able to meet all of the body's needs, it is diverted away from less-crucial areas, such as the arms and legs, and given to the organs that are most important for survival, including the heart and brain. In turn, physical activity becomes more difficult as heart failure progresses.

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? 1. Regular rhythm 2. Rate of 101-200 3. Absent P wave 4. P-R interval not measurable 5. QRS complex greater than 0.20 seconds

1, 2 Rationale 1., & 2. Correct: Sinus tachycardia indicates a regular rhythm, although the rate is elevated. The term tachycardia is defined as a heart rate above 100. Sinus rhythms have a normal QRS complex. 3. Incorrect: There is a P-wave with a sinus rhythm and it is normal. 4. Incorrect: P-R interval is not measurable in atrial flutter, atrial fib, PVCs, V tach or V fib. 5. Incorrect: The QRS complex should be no more than 0.12 seconds Let's Talk Normal sinus rhythm, sinus bradycardia, and sinus tachycardia all evolve from the SA node (sinus). Option 1: True. Regular rhythm means the P wave, and QRS complex will be evenly spaced or regular. Option 2: True. Sinus tachycardia means that the HR is greater than 100 beats/minute up to 180-200 beats/min. Option 3: False. There should be a P wave with sinus tachycardia. The P wave would be normal which means that it is upright, and consistent. Option 4: False. The P-R interval will measure between 0.12-0.20 seconds and shortens with increasing heart rate. Option 5: False. The QRS complex is normal when it measures less than 0.12 seconds and is consistent.

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1, 2, 3, 4 Rationale 1., 2., 3., & 4. Correct: These signs and symptoms indicate an emergency with loss of circulation to the extremity. This is an emergency, and the primary healthcare provider is the only one that can save this foot from ischemia. Don't delay. Epigastric pain could indicate the client is having an MI. Always assume the worse! 5. Incorrect: Temperature of 101º F (38.3º C) or more indicates a problem. Let's Talk Look at the clues in this question: "post heart cath", "femoral stick", and "signs and symptoms" of a problem! What are complications the test taker should worry about post heart cath? Hemorrhage, re-occlusion, and decreased circulation to the extremity. Signs and symptoms of hemorrhage include bleeding from the puncture site, decreasing BP, and increasing pulse. Signs of re-occlusion of the artery in the heart include signs of a heart attack such as pressure or tightness in the chest, pain in the chest, back, jaw, and epigastric region, shortness of breath, sweating, nausea, vomiting, anxiety, a cough, dizziness. Signs and symptoms of decreased circulation to the extremities (Remember the 5 Ps) include pain, pulselessness, pallor, paresthesia, and paralysis. Capillary refill should be less than 3 seconds.

The nurse is planning care for a client who has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which intervention would the nurse include in this plan? 1. After voiding, instruct client to void a second time. 2. Encourage the client to void every 4 hours. 3. Teach client to perform the Credé method. 4. Pour warm water over perineum. 5. Insert indwelling urinary catheter if client unable to void.

1, 2, 3, 4 Rationale 1., 2., 3., & 4. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection. Place bedpan, urinal, or bedside commode within reach. Perform Credé method over bladder to increase bladder pressure. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. 5. Incorrect: If these methods are unsuccessful, the client will need education on intermittent catheterization. Let's Talk The stem tells you that the client cannot empty the bladder completely, as evidenced by dribbling, hesitancy, and frequency. Remember that stagnant urine can lead to infection! So what interventions will help the client empty the bladder more completely and decrease the risk of infection? First, the nurse needs to encourage fluids. Unless medically contraindicated, fluid intake should be at least 1500 mL/24 hours. Option 1: True. Double voiding can improve emptying of the bladder. Void, then wait a few minutes and attempt to void again. Option 2: True. Retaining urine in the bladder for an extended period of time can lead to infection. The client should be urged to void every 4 hours. Make it convenient for the client to void by placing the bedpan, urinal, or bedside commode within reach if the client cannot ambulate to the bathroom. And do not forget to provide privacy. Some clients cannot void with someone else nearby. Option 3: True. Perform Credé method over bladder. The Credé method (pressing down over the bladder with the hands) increases bladder pressure, and this in turn may stimulate relaxation of sphincter to allow voiding. Option 4: True. Have the client listen to the sound of running water, place hands in warm water and/or pour warm water over the perineum to stimulate urination. Offer fluids before voiding. Option 5: False. If these other methods do not improve bladder emptying, intermittent catheterization may be needed so that stagnant urine does not cause an infection. Just remember to teach the client about proper catheterization at home.

A manufacturing worker comes into the occupational health nurse's clinic reporting a squeezing pain in the chest. What additional signs and symptoms should the nurse monitor for in the client? 1. Dyspnea 2. Dry, flushed skin 3. Indigestion 4. Restlessness 5. Tachycardia

1, 3, 4, 5 Rationale 1., 3., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI. 2. Incorrect: The skin is not being perfused properly so the skin will be cool and clammy. Let's Talk If you assume the worse when you see the clue "a squeezing pain in the chest", what should you think is happening to the client? The client is having an MI. This question wants to know if the test taker can identify additions signs and symptoms of an MI. Keep in mind that not everyone presents with the classic signs and symptoms. Common heart attack symptoms and warning signs may include: Chest discomfort that feels like pressure, fullness, or a squeezing pain in the center of the chest that lasts for more than a few minutes, or goes away and comes back. Pain and discomfort that extend beyond the chest to other parts of the upper body, such as one or both arms, back, neck, shoulder, stomach, teeth, and jaw. Unexplained shortness of breath, with or without chest discomfort, dyspnea and tachypnea. Other symptoms, such as cold sweats, cool and clammy skin, nausea or vomiting, lightheadedness, anxiety, restlessness, indigestion, unexplained fatigue, irregular pulse.

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective? 1. Variable urine specific gravity 2. Serum K+ 5.5 mEq (5.5 mmol/L) 3. Serum Na+ 140 mEq (140 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours

1, 3, 5 Rationale 1., 3. & 5. Correct: A fixed specific gravity indicates that the kidneys are not working properly. A variable specific gravity changes based on whether the urine is dilute or concentrated. This is a normal sodium level, which indicates that the client is improving. The serum sodium level would be low in the oliguric phase due to increased dilution of the blood. This urine output is adequate to indicate proper kidney perfusion. 2. Incorrect: The serum potassium is high. The serum potassium level is elevated when the client is still in the oliguric phase. 4. Incorrect: The lungs would need to be clear to verify that treatment has been effective. Let's Talk If treatment has been effective, or successful, that means the client must be getting better. Remember, when asked to assess or evaluate, think pertinent signs and symptoms. So the client will have resolved signs and symptoms (absent s/s) of acute kidney injury. Option 1: True. When the kidneys are working properly, they are able to concentrate and dilute urine. Urine specific gravity would go up with concentrated urine and go down with dilute urine. A fixed specific gravity means the kidneys cannot concentrate or dilute urine. Option 2: False. Normal potassium is 3.5-5.0mEq/L (3.5-5.0mmol/l). This value is high. If urine output was low, the potassium level would increase. Remember, the number one way to get rid of potassium is through the kidneys. Option 3: True. Normal sodium is 135-145 mEq/L (135-145 mmol/l). This value is normal. If urine output was still low, then fluid in the vascular space would be dilute, making the serum sodium level drop. Option 4: False. If crackles or "wet" lungs sounds are still being auscultated, the client still has too much fluid in the vascular space, and the left side of the heart is unable to keep blood going in a forward direction. Blood is going backward into the lungs, producing this "wet" lung sound. Option 5: True. This urine output is greater than 50 mL/hour which is adequate to indicate proper kidney perfusion. We worry when urine output drops below 30 mL/hr.

The nurse is planning to teach a client about home peritoneal dialysis. What information should the nurse include? 1. After washing hands with soap and water, put on clean gloves to clean the catheter site. 2. Apply prescription antibiotic cream to the skin around the catheter with fingers. 3. Leave crust formed around the insertion site alone. 4. Gently rub the skin dry around the site after cleaning. 5. Wash the skin around the catheter site with antibacterial soap.

1, 3, 5 Rationale 1., 3., & 5. Correct: Before cleaning the area, wash your hands with soap and water and put on clean gloves. Do not pick at or remove crusts or scabs at the site. The skin around the catheter site should be washed daily or every other day with antibacterial soap or an antiseptic (either povidone iodine or chlorhexidine). The soap should be stored in the original bottle (not poured into another container). 2. Incorrect: Apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab every time the dressing is changed. 4. Incorrect: Pat the skin around the site dry after cleaning. A clean cloth or towel is suggested. Let's Talk Peritoneal dialysis (PD) is a procedure that can be used by people whose kidneys are no longer working effectively. It does not cure or treat the underlying kidney disease. It is intended to replace as many functions of the failing kidneys as possible. The procedure is performed at home and primarily works to remove excess fluid and waste products from the blood. Before peritoneal dialysis can begin, a catheter must be inserted in the abdomen, which allows for transfer of fluid into and out of the abdominal cavity. The catheter has cuffs (which are like Velcro), which are placed under the skin. Skin tissue grows into them to hold the catheter in place. The end of the catheter inside the abdomen has multiple holes to allow fluid to flow in and out. The catheter exit site is typically placed to the left or right of the umbilicus, although, occasionally, the catheter exit site may be placed higher up on the abdominal wall

A nurse is attempting planning care for a client who has self-care difficulty due to left-sided hemiparesis. Which intervention should the nurse include? 1. Offer to take the client to the toilet every two hours. 2. Instruct client to use disposable razors once to prevent infection. 3. Encourage family members to comb hair for client. 4. Provide the client with a button hook for dressing. 5. Teach the client to rely on furniture for support when walking.

1, 4 Rationale 1., & 4. Correct: Offer bedpan or place client on toilet every 1 to 2 hours during the day and three times during the night. The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. 2. Incorrect: The client can be helped by using an electric razor and toothbrush. These will improve client safety during self care. 3. Incorrect: Having client comb own hair helps maintain autonomy. This is a one handed task that will enable the client to maintain autonomy for as long as possible. 5. Incorrect: The client should use prescribed assistive devices for ambulation. Furniture may move or not be in the correct place for support while walking. Let's Talk Hemiparesis is weakness on one side of the body. There is reduced muscular strength on the affected side. You should look for options that promote self-care. Option 1: True. Offer bedpan or place client on toilet every 1 to 2 hours during the day and three times during the night. Option 2: False. Electric razors and toothbrushes will promote self-care and decrease chance of injury. Option 3: False. Having the client comb own hair promotes self-care ability to groom. Option 4: True. Providing the client with a button hook for dressing will promote self-care ability to dress. Option 5: False. Furniture is not stable and should not be relied on for support in walking. It is a safety hazard.

What information should the pre-operative nurse include when educating a client about preventing a deep vein thrombosis (DVT) formation after abdominal surgery? 1. Anticoagulant medication may be prescribed. 2. Caffeinated beverages will be allowed once able to drink in order to promote hydration. 3. Bed rest will be required for at least 5 days. 4. Move feet in a circle 10 times an hour. 5. The sequential compression device (SCD) will be wrapped around the legs.

1, 4, 5 Rationale 1, 4, 5 Correct: 1, 4, 5 Correct: AntiCoagulants can prevent blood clots. Simple exercises while you're resting in a bed or sitting in a chair can help prevent blood clots. Move your feet in the circle or up and down. Do this 10 times an hour to improve circulation. Sequential compression devices (SCDs) or intermittent pneumatic compression (IPC) are wrapped around your legs and can connect to a pump that inflates and deflates the sleeves. This applies gentle pressure to prevent blood flow in the legs and prevent blood clots. 2 incorrect: alcohol and coffee contribute to dehydration which can lead to thickened blood and increased risk for clot formation. 3 incorrect after surgery a nurse should help the client out of bed as soon as possible. Moving around improves circulation and prevents blood clots. Let's Talk Deep Vein Thrombosis forms in one or more of the deep veins in the body, usually in the legs. A DVT can cause leg pain or swelling but may occur without any symptoms. Deep Vein thrombosis can develop with certain medical conditions that affect how the blood clots. It can also happen if the client does not move for a long time such as after a surgery, following an accident, sitting for long periods of time such as driving or flying or when confined to a bed. The vein thrombosis is a serious condition because blood clots can break loose travel through the bloodstream and Lodge in the lungs blocking the flow of blood = pulmonary embolism. To prevent deep vein thrombosis common preventative measures include Anticoagulants: This is a medication that prevent blood clots. Commonly used anticoagulants include Warfarin and heparin. New where anticoagulants may be used including enoxaparin. Compression stockings: these are elastic stockings that fit tightly around the left. They keep blood flowing towards the Heart by the pressure they apply. They prevent blood from pooling and forming clots. Exercise: Simple exercises while resting in bed or sitting in a chair can help prevent blood clots. Move feet in a circle or up and down. Did this 10 times an hour to improve circulation. Ambulation: After surgery a nurse should help the client out of bed as soon as possible. Moving around improve circulation how to prevent blood clots. SCD: sleeves are wrapped around the legs and connect to a pump that inflate and deflate the sleeves. This applies gentle pressure to promote blood flow in the legs and prevent blood clots.

What food should the nurse instruct a client to avoid when prescribed digoxin? 1. Black licorice 2. Coenzyme Q-10 3. Grapefruit 4. Grapes 5. Wheat bran

1, 5 Rationale 1., & 5.Correct: Black licorice contains a natural ingredient called glycyrrhiza, which can deplete the body of potassium while causing an increased retention of sodium. Insoluble fiber such as wheat bran, can slow down the absorption of digoxin and lessen its effectiveness. 2. Incorrect: Taking coenzyme Q-10 can decrease the effectiveness of warfarin. Blood pressure may be affected if the client is also taking a calcium channel blocker, such as diltiazem. 3. Incorrect: Grapefruit interacts with statin drugs 4. Incorrect: Grapes do not interact with digoxin Let's Talk Digoxin is derived from the leaves of a digitalis plant. It helps make the heart beat stronger and with a more regular rhythm. Digoxin is used to treat heart failure and atrial fibrillation. Foods and other drugs may interact with digoxin, including prescription and over-the-counter medicines, vitamins, and herbal products. Insoluble fiber such as wheat bran, can slow down the absorption of digoxin and lessen its effectiveness. To prevent this, clients should take digoxin at least one hour before or two hours after eating a meal. Herb use can also affect digoxin. Black licorice contains a natural ingredient called glycyrrhiza, which can deplete the body of potassium while causing an increased retention of sodium. When the body is depleted of potassium, the action of digoxin can be greatly enhanced, resulting in digoxin toxicity.

An elderly client with a history of coronary artery disease (CAD) has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? Exhibit= bradycardia with PVCs 1. Request order for a foley catheter. 2. Assist client with the use of a bedpan. 3. Provide a bedside commode chair. 4. Perform in and out straight catherization.

2 Rationale 2. CORRECT. The exhibit shows bradycardia with premature ventricular contractions (PVCs), and more specifically, bigeminy. The safest approach for a syncopal client with this rhythm is the use of a bedpan for bathroom needs. Even with assistance, this client would be at risk for falls when ambulating. 1. INCORRECT. Because the client has experienced syncope and is bradycardic, keeping the client in bed is safer than ambulating to the bathroom. However, a foley catheter is an invasive procedure that could place the client at risk of infection. There is a better option. 3. INCORRECT. The client has experienced syncope and is bradycardic. Keep the client in bed. This is a safety issue. 4. INCORRECT. This client is newly admitted with a diagnosis of syncope. The exhibit shows the heart rate is bradycardic with PVCs, which are non-perfusing beats. In and out straight catheterization is an invasive procedure that could place the client at risk for infection. There is a better option. Let's Talk What facts do you know at this time? An elderly client has been admitted for a syncopal episode. The exhibit shows a monitor strip indicating bradycardia with premature ventricular contractions. You are aware that PVCs are non-perfusing beats, and although the monitor shows 8 beats, only 4 of them are functional for cardiac output. Therefore, this client's functional heart rate is just 40! The first thing that should pop into your mind is that the client is at high risk for a fall! This client certainly does not need a broken hip or head injury on top of cardiovascular issues! So, what is the safest method to assist the client with elimination? Let's look at the options. Option 1: Sounds simple - for the nurse, not the client! First of all, a foley is an invasive procedure, and would place the client at risk for infection. On the NCLEX, you always select the "least invasive" action first. Besides, the client is capable of voiding. Catheters are reserved for those who are unable to void normally. Option 2: Excellent choice! The use of a bedpan will allow the client to void without inserting a catheter and is a safer choice since the client does not need to ambulate to a bathroom. Once the client's cardiovascular status is more stable, ambulating to the bathroom may be considered. Option 3: No! Keep the client in bed. This is the safest action at this time. Option 4: Not quite. This is an invasive procedure and places the client at risk for infection. Select the least invasive action first when possible.

A client has sublingual (SL) nitroglycerin prn added to the medication regimen. Which statement made by the client indicates to the nurse that teaching has been effective? 1. "If the medication burns in my mouth, it is old and should be discarded." 2. "I must keep this medication in its original dark, glass bottle." 3. "I can take one tablet every five minutes up to 3 doses for chest pain." 4. "I know that I must put this tablet under my tongue for it to work." 5. "My medication should be renewed yearly."

2, 3, 4 Rationale 2., 3., & 4. Correct: These are true statements and would indicate that teaching has been effective. 1. Incorrect: Nitroglycerin may or may not burn or fizz in the client's mouth. It is normal. 5. Incorrect: Nitroglycerin should be renewed on average every three to five months. Two years for the spray. Let's Talk This question is asking you to identify correct statements made by the client about sublingual nitroglycerin. Sublingual nitroglycerin can be given either as a tablet or spray. Nitroglycerin causes venous vasodilation which results in venous pooling which decreases venous return... preload. Nitroglycerin causes arterial vasodilation which decreases resistance in the arteries so it decreases afterload. Now, this is a good thing because this result will cause decreased preload and afterload, which will also decrease the workload and oxygen demands on the heart. Nitro also causes dilation of what arteries? Coronary arteries, which will increase blood flow to the actual heart muscle, the myocardium. Because if I can increase blood flow to the actual heart muscle then, blood is going to carry more, what? Oxygen. A client can take one every five minutes up to 3 doses. "Clients should be instructed to contact the Energency management system (EMS) if pain is unrelieved or increases after 1 tablet of sublingual or spray." Is it okay to swallow your nitro? No. Now, nitro should be kept in a dark, glass bottle. Do not mix medications in the bottle with nitroglycerin and do not open the bottle frequently. Keep it dry. Keep it cool. It may or may not burn or fizz in the client's mouth. And the client will get a what? Headache. Now, how often should nitroglycerin be renewed? An average of every three to five months. Two years for the spray. And after nitroglycerin, what do you expect the blood pressure to do? Drop.

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? 1. Develop a response plan for each potential disaster. 2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

2, 3, 4, 5 Rationale 2., 3., 4., & 5. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. Consideration must be given to the proximity of chemical plants, nuclear facilities, schools, and areas where large groups gather. 1. Incorrect: One good response plan should be developed rather than multiple plans. Let's Talk The basic principle of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. So, one good response plan should be developed rather than multiple plans. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. Does every hospital in an area need to prepare for a chemical disaster if there is no chemical plant near? No. Remember education, practice, and evaluation are key to a good response plan.

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

2, 3, 4, 5 Rationale 2., 3., 4., & 5. Correct: Caffeine, stress, and nicotine cause vasoconstriction and vasospasm, which impedes peripheral circulation. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling. Vasodilation will be increased by providing warmth in the environment. Cold causes vasoconstriction. Isometric exercise and walking promote the development of collateral circulation. 1. Incorrect: Lower the extremities below the level of the heart for arterial problems. Dependent extremities enhance arterial blood supply. Let's Talk Look at the clues in the stem: arterial disease, and lower extremities. With arterial disorders, oxygenated blood cannot get to the tissues, so there is ischemia. In this case the lack of oxygen is in the lower extremities causing intermittent claudication (pain) in the calf, thigh, or buttocks. As the disease gets worse, the client may have foot or toe pain at rest. Blisters and ulcers that do not heal can develop on the skin which can progress to gangrene and tissue death. Other signs/symptoms include weak or absent pulse, bruits, muscle atrophy, cooler skin temperature, pale skin, slowly growing nails, and hair loss below the area of blockage. Factors that increase a person's risk for lower extremity disease include smoking, advanced age, male gender, diabetes mellitus, high cholesterol, and high blood pressure. Based on this knowledge, what should the nurse teach the client? Option 1: False. If the nurse elevates the legs, then it just became harder for oxygenated blood to get to the tissue. Option 2: True. Caffeine, stress, and nicotine cause vasoconstriction. Option 3: True. The goal is to enhance circulation. Cold causes vasoconstriction which will decrease circulation. Option 4: True. Warmth causes vasodilation and increases the diameter of the blood vessels with better blood flow occurring. Option 5: True. Isometric exercise and walking encourage the development of collateral circulation. Walk or exercise until point of pain, rest until the pain subsides, and then resume so that endurance can be increased as collateral circulation develops.

he nurse is planning to educate a client who has a diagnosis of right sided heart failure? What information should the nurse include? 1. Blood backs up in the left upper chamber of the heart. 2. Your feet, legs, and ankles will likely swell because blood is backing up in your veins. 3. Activity will increase your heart rate. 4. You might find that you go to the bathroom more often at night. 5. Weigh yourself daily to monitor for rapid weight gain.

2, 3, 4, 5 Rationale 2., 3., 4., & 5. Correct: Vascular congestion is evident by swelling of the lower extremities. Ascites may increase pressure on the stomach and intestines causing GI upset with nausea and anorexia. The heart rate increases in an attempt to increase cardiac output. Bedrest induces diuresis. The fluid leaves the extremities and goes back into the vascular space where the kidneys get rid of the excess fluid. Daily weights are important to monitor fluid retention. A rapid weight gain is fluid not fat. 1. Incorrect: The blood backs up into the right atrium and venous circulation. Let's Talk The right side of the heart wants blood to go forward to the lungs for oxygenation. If the right side of the heart is weakened, blood cannot go forward to the lung, it will start going backward to the venous system. There is a decrease in cardiac output and decreased oxygenation of tissues. This causes edema in the extremities, distended neck veins, enlarged organs such as the liver. Lack of oxygen can lead to fatigue, and depression. Edema of the organs can cause GI upset such as nausea, and anorexia. Fluid in the peripheral tissue is being mobilized and excreted at rest so increased urination occurs at night. The client awakens during the night to urinate.The heart rate will increase in an effort to keep blood moving in a forward direction.​ Do you remember what causes pure right sided heart failure or "cor pulmonale"? It started out as a lung problem like COPD, or pulmonary embolus.

A client has a coronary artery bypass surgery (CABG) x3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade? 1. Bradycardia with wet lungs 2. Increased central venous pressure 3. Distended bilateral neck veins 4. A widening pulse pressure 5. Decreasing blood pressure

2, 3, 5 Rationale 2, 3, and 5. CORRECT: Cardiac tamponade occurs when blood or fluid enters the pericardial sac, causing compression of the heart chambers. Such pressure prevents blood from either entering or leaving the heart, thus decreasing cardiac output. Central venous pressure (CVP) increases because of the compression of the right atria, but because no fluid is exiting the heart, blood pressure drops. Since the returning blood cannot enter the heart, neck veins become distended, though lungs remain clear. 1. INCORRECT: Because little blood is moving within the heart chambers, no fluid would back up into the lungs. The client's lungs remain clear, even though the cardiac output decreases and neck veins are distended. 4. INCORRECT: Widening pulse pressure is noted with increased intracranial pressure, not cardiac tamponade. Pulse pressure in tamponade would narrow since the heart is being compressed. Let's Talk First, let's establish the definition of cardiac tamponade and how it differs from other cardiac problems. Many heart problems have similar symptoms because of the nature of the cardiovascular system! The word "tamponade" means to block, or close off. In cardiac tamponade, the flow of blood is 'blocked' from re-entering the heart as well as 'closed off' from exiting the heart. As you recall, a small opening has occurred between the heart and the pericardial sac that surrounds the heart. As blood (or exudate) fills this sac, the pressure prevents the heart from beating properly. In fact, just 50 milliliters can completely stop a heart from beating! As the fluid builds up, pressure in all four heart chambers becomes equal, which is not compatible with life. Cardiac output decreases, heart sounds are muffled, and the client goes into cardiogenic shock. The classic signs start with an increased CVP (because of the right atria being squeezed) a decrease in blood pressure (because the heart has no output). In just moments, neck veins will distend even though the lungs are clear - remember that no fluid is moving in or out of the vascular spaces! Since the heart is literally being "crushed", pulse pressure will decrease. If not immediately treated, the client will die. Option 1: No way. First, you are already aware that since blood is not moving well inside the heart, fluid would not enter the lungs, so the lungs would remain clear. Secondly, as a client ascends into shock, the initial response is for the pulse to increase to maintain cardiac output. Bradycardia is not an indication of cardiac tamponade. Option 2: Awesome! You remembered that blood building up inside the pericardial sac is actually crushing the right atria, causing an increase in the CVP. Even though nothing is entering or leaving the heart chambers, the pressures inside the heart are changing rapidly. Option 3: Great choice. Venous blood cannot enter the right atria because the pericardial sac is literally crushing the heart chambers. Remember what you learned about overload in the vascular spaces: the veins enlarge (distend) because they cannot drain back into the heart! But the lungs will remain clear! Option 4: Definitely not! Nothing gets wider in cardiac tamponade! The heart chambers are being squeezed tightly and blood pressure drops because no fluid can leave the heart. The result would be a narrowing pulse pressure. A widening pulse pressure occurs with increased intracranial pressure. Option 5: Amazing. You have realized that because no blood flow can exit from the heart, cardiac output decreases along with the blood pressure. One of the classic signs of cardiac tamponade is decreased blood pressure while CVP increases. Good job!

The nurse is assessing a male client suspected of having a myocardial infarction (MI). What signs/symptoms would the nurse expect the client to exhibit? 1. Bradycardia 2. Chest pressure 3. Cough 4. Flu like symptoms 5. Vomiting

2, 3, 5 Rationale 2., 3., & 5. Correct: These are symptoms commonly seen in a male client having an MI 1. Incorrect: Tachycardia rather than bradycardia will be noted with an MI 4. Incorrect: A woman, rather than a male, having an MI my exhibit flu like symptoms. Let's Talk While the classic symptoms of a myocardial infarction are chest pain and shortness of breath, the symptoms can be quite varied. The most common symptoms include pressure or tightness in the chest, pain in the chest, back, jaw, and other areas of the upper body that lasts more than a few minutes or that goes away and comes back, shortness of breath, sweating, nausea, vomiting, anxiety, a cough, dizziness, tachycardia. It's important to note that not all people experience the same symptoms or the same severity of symptoms. Chest pain is the most commonly reported symptom among both women and men. However, women are more likely than men to have shortness of breath, jaw pain, upper back pain, lightheadedness, nausea, vomiting. In fact, some women report that their symptoms felt like the symptoms of the flu.

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client? 1. Chronic urinary retention 2. Fecal impaction 3. Menopause 4. Restricted mobility 5. Stroke

2, 4 Rationale 2., & 4. Correct: Transient incontinence: a temporary type of urinary incontinence caused by an illness or a specific medical condition that is short-lived and is, therefore, quickly remedied by appropriate treatment of the condition and a disappearance of symptoms. The potential causes of transient incontinence may be easily remembered by the mnemonic 'delirium, infection, atrophy, pharmaceuticals, excess urine output, restricted mobility, stool impaction' (DIAPERS). Fecal impaction can compress the urethra resulting in urinary incontinence. Use of diuretics can make it difficult to get to the toilet in time to void, thus causing urinary incontinence. Diabetics have polyuria, which can contribute to urinary incontinence. Vaginitis, a condition caused by an infection or inflammation of the vagina, can contribute to urinary incontinence. 1. Incorrect: Urinary incontinence that is associated with chronic retention occurs when the bladder does not empty properly, resulting in frequent leakage of small amounts of urine. This is a chronic, rather than a transient condition. 3. Incorrect: After menopause women produce less estrogen, a hormone that helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence. This leads to persistent rather than transient incontinence. 5. Incorrect: Multiple sclerosis, Parkinson's disease, a stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing persistent urinary incontinence. Let's Talk Look at the clues in this question: "contributing factors", "transient", and "elderly". So, what can cause transient or temporary urinary incontinence in an elderly client? Transient urinary incontinence usually arrives suddenly, lasts six months or less, and has reversible causes. Use the "TOILETED" mnemonic to identify possible contributing factors. 1. Thin and dry vaginal and urethral epithelium. (The "T" in the mnemonic is specific only to female clients, who should be assessed for vaginitis and urethritis.) While performing hygiene care the nurse asks about vaginal pruritus and assesses the external genitalia for evidence of vaginal atrophy, such as thin and dry mucous membranes or tenderness and inflammation. The reduced estrogen level common in older women can have a negative effect on their lower urinary tract, causing periurethral tissue to become atrophied, dry, and less elastic. 2. Obstruction. The nurse should ask the client about normal bowel patterns and the time of the last bowel movement and perform an abdominal assessment. A bowel full of stool may be palpable and dull to percussion over the left side of the abdomen. Hyperactive bowel sounds may indicate increased peristaltic activity (above the point of or proximal to the impaction), as the body attempts to move fecal matter. A fecal impaction can compress the urethra, which can result in a distended bladder and small amounts of urine leakage. If the nurse suspects that the bladder is distended, a post void residual (PVR) urine volume test may be conducted. The PVR volume should be measured a few minutes after the client has voided, either by bladder ultrasonography or catheter insertion. A PVR volume of more than 100 mL suggests incomplete bladder emptying. A digital rectal examination is part of the evaluation for fecal impaction and can reveal hardened stool or an absence of fecal matter. Even if no stool is present in the rectum, there may still be an impaction higher in the colon. An abdominal flat plate radiograph may be needed to determine the degree of impaction. 3. Infection. Older adults don't always display the typical signs and symptoms of infection. When transient urinary incontinence occurs, a urinary tract infection (UTI), which can cause increased urinary urgency and frequency, should be suspected. The nurse may need to obtain a urine specimen to test for the presence of nitrites and leukocyte esterase, signs of bacteriuria. 4. Limited mobility. The nurse should assess for restricted mobility and identify any environmental barriers to toileting, such as the distance of the bed from the toilet, the use of physical restraints, bed rest orders, and the presence of bed rails. 5. Emotional or psychological factors. Research on the relationship between transient urinary incontinence and psychological factors is scant, but depression is strongly associated with chronic urinary incontinence. Depression in older adults can be determined by using a valid and reliable screening tool. 6. Therapeutic medications may contribute to urinary incontinence in some clients. These include hypnotics, narcotics, tranquilizers, antidepressants, laxatives, diuretics, and antibiotics. Diuretics, for example, are associated with urinary urgency and frequency. It's important to ask the client about new medications, both prescribed and over the counter. 7. Endocrine disorders. Assess for diabetes, which can result in polyuria. Diabetic clients with poor glucose control often produce more urine as the kidneys work to rid the body of the excess glucose in the blood. And glucose in the urine is a good medium for the growth of bacteria, which increases the risk of UTI. 8. Delirium, common in hospitalized older adults, increases the likelihood that a client will experience episodes of urinary incontinence.

Community has experienced a Mudslide that hit a restaurant causing Mass casualties. What should the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to the victim's injuries as they are encountered. 3. Activate the community Emergency Response Team. 4. Triage and tag victims according to injury.

3 Rationale 3 Correct: Mass casualties Community response teams are needed. 1 incorrect: This would be the second step so that further injuries are not encountered. 2 incorrect: Triage must occur before treatment of anyone so that an accurate assessment of the level of injuries can be made. With mass casualties a color tag system is usually implemented. 4 incorrect: This would be the third step. Let's Talk By using the word first in this question you must put a rank order on the options and choose the most important option. Look at the clue "Mass casualties". In order to handle an event that can exceed the demand of the community's resources more help will need to be available. So get them coming ASAP by activating the community Emergency Response Team. Then you can proceed to perform option one then option four. Option 2 is incorrect. If you attend to the injuries as they are encountered you might be tending to a minor injury when someone else is dying.

A client has been admitted with Advanced cirrhosis. The nurse's assessment verifies an increased weight of 6 lb (2.71 kg) since yesterday's weight and abdominal girth increase of 5 in (12.7 cm). What is the priority assessment? 1. Urinary output 2. daily weight 3. blood pressure 4. LOC

3 Rationale 3 Correct: blood pressure. We said that all of this ascites is coming from the vascular space and it's getting worse... so what will happen to my blood pressure? It will drop! 1, 2, 4 Incorrect: Yes, you are going to watch that urinary output and daily wait. LOC is very important as well and one of the first assessments we will make. But if I can only do one of these assessments I better take the blood pressure because this is the one that says SHOCK. Let's Talk Look at the clues in the question: "Advanced cirrhosis", "abdominal girth increase of 5 in" and "increased weight of 6 lb". This is too much fluid gain. That is 2.72 L of water! We said that all of the ascites is coming from the vascular space. It's getting worse so our blood pressure will drop. Because less volume = less pressure. Then I am not going to perfuse adequately and I could kill my brain, kidneys and all of my vital organs. Remember 30 / 15. 30 off the systolic baseline and/or 15 off the diastolic baseline and I'm scared. So the priority assessment here is always blood pressure.

A home heath nurse is educating a client about home care considerations for clean intermittent catheterization. Which statement made by the client would indicate to the nurse that further teaching is needed? 1. "I will wash the re-usable catheter thoroughly with soap and water after use." 2. "When urine stops flowing, I will press over the bladder area with my free hand." 3. "It is important that maintain sterile technique when catheterizing myself." 4. "Catheterization should be done when I feel the need to void."

3 Rationale 3. Correct: This is an incorrect statement by the client so further teaching is needed. Catheterization is done using a clean technique rather than sterile technique when the client is in their own home. 1. Incorrect: This is a correct statement by the client. The catheter is reusable and should be cleaned with soap and water between uses. 2. Incorrect: This is a correct statement by the client. When urine stops flowing, press over the bladder area with your free hand. Pushing on the bladder may be necessary to help it empty completely. When the urine stops flowing, slowly and gently withdraw the catheter. 4. Incorrect: Catheterization is done when the client feels the need to void, but cannot void. Some clients, such as paralegics, may need to self catheterize every 2-4 hours initially. So this is a correct statement by the client. Let's Talk Look at the clues in this question: "intermittent cath", and "understands". In the home setting, clean technique is recommended because individuals are exposed to bacterial organisms that do not routinely cause them to have infections. Also, it is considered to be less expensive and more practical for individuals because the original sterile technique is believed to be more time-consuming and costly.

When An explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention? 1. An elderly adult with a traumatic left eye enucleation. 2. A child with an open compound fracture of the femur. 3. An adult with a head laceration bleeding profusely. 4. An Adolescent with a rigid board-like lower abdomen.

4 Rationale 4 correct: this client's symptoms indicate a presence of internal bleeding. Without emergency surgery this client will quickly develop hypovolemic shock and may not survive. 1 incorrect: this parent client has lost the left eye due to trauma. Despite the fact that this client is elderly and may have other Comorbidities the eye injury is not considered life-threatening. 2 incorrect: a fractured femur can lead to other issues such as blood loss or fat emboli however an open compound fracture is not considered the most life-threatening injury here. 3 incorrect: lacerations to the face, head or hands generally do bleed profusely because the vessels are near the surface of the skin. However this represents capillary blood is and is not critical. Let's Talk It is especially important in a chaotic situation to focus on your nursing knowledge and to assist the most in need. When considering each option think about the ABC's and Maslows. Is there anyone who could die without an immediate intervention? Do not allow the fact that this is a public setting with no medical equipment to affect your choice. Focus only on the injuries. Option 1: it sounds like a serious problem particularly considering that the client is elderly. However this is not the most critical injury. While it is true that the loss or dislodgement of an eye will seriously impact the client's Vision, this is not considered life-threatening. In an emergency situation an inverted paper cup is placed over the eye and taped in position to prevent further damage until the client reaches Medical Care. Option two is serious but not life-threatening. We tend to want to help children first but even an open compound fracture of the femur is not as serious as the other injuries listed. You must remember that bone is living tissue so moist (hopefully sterile) covering should be placed over the exposed bone until the client is transported to the hospital. However there are still more critical clients. Option three: Were you tempted by the phrase bleeding profusely? Don't be fooled: the head, face and hands always bleed profusely because the skin has been and vessels are near the surface. But this is only capillary blood and it's always looking worse than it is. Having the client hold pressure dressing and place generally will stop the bleeding quickly. Option four is the most critical. Remember that rigid, board-like abdomen indicates the presence of internal bleeding which can quickly result in hypovolemic shock or death if the client does not reach medical help in time. The only treatment here is emergency surgery.

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.

4 Rationale 4. Correct: This answer provides visible proof that the renal calculi has been broken up by the shock waves. 1. Incorrect: Pain can occur because of spasm of smooth muscle when the stone is moving. 2. Incorrect: There will be blood in the urine for several days after treatment. 3. Incorrect: Blocked urine flow from stone fragments may cause decreased urine output. Let's Talk This question is asking for the "best" indicator that treatment has been effective. So what is extracorporeal lithotripsy? Extracorporeal lithotripsy uses shock waves to break a kidney stone into small pieces (sand-like sediment) that can move more easily through the urinary tract and pass from the body. Knowing this, what would you expect to note in the client? Sediment in the urinary catheter bag, right? Right. This will best indicate effective treatment. Pain level is not the best indicator of effective treatment. Renal colic (pain) occurs because of spasm of smooth muscle! The urine may have blood in it for several days and is not the best indicator of effective treatment. Increased urinary output does not indicate that the stone has been crushed. Decreased urine output may occur from blockage with stone fragments.

The nurse is teaching a male client how to perform intermittent self-catheterization. In which order should this procedure be taught? 1 Clean the meatus. 2. Lubricate several inches of the catheter tip. 3. Hold your penis on both sides just behind the head. 4. Insert the catheter 6 in (15.24 cm) into the urethra. 5. Gently but firmly push past the sphincter muscle 2 to 3 in (5 to 7.6 cm) 6. Allow the urine to drink completely.

This is the correct order. Rationale Fifth step: Use Gentle but firm pressure on the catheter until the muscle relaxants and the catheter becomes easier to advance. It will be necessary to pass the catheter another two or three in before it enters the bladder. Let's Talk To understand the fundamentals of intermittent self catheterization. The procedure is slightly different for male versus female so the sex of the client is important here. Other than this there is really no just taking strategy.