Med Surg: Cardiovascular ?s
How do you calculate the ABI (Ankle-brachial index)
Calculated by taking the higher pressure of the 2 arteries at the ankle, divided by the brachial arterial systolic pressure.
The nurse is preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately? "I am allergic to penicillin and midazolam." "I have not been able to eat since yesterday." "I took my metformin this morning." "I am very claustrophobic in small spaces."
Correct response: "I took my metformin this morning." Explanation: The priority would be to notify the health care provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.
A nurse is providing discharge instructions to a client with peripheral vascular disease that include stress-reduction techniques. The client asks the nurse, "Why is reducing stress so important?" What is the nurse's best response? A. "Reducing stress is helpful only because it will assist in smoking cessation." B. "Stress reduction techniques are helpful because stress stimulates the release of vasoconstricting catecholamines." C. "Stress reduction techniques will distract you from focusing on claudication pain." D. "Reducing stress will help decrease the amount of medication you take for peripheral vascular disease."
Correct response: "Stress reduction techniques are helpful because stress stimulates the release of vasoconstricting catecholamines." Explanation: The stress-induced release of vasoactive catecholamines, such as epinephrine, causes vasoconstriction, which directly aggravates peripheral vascular disease by intensifying the ischemic burden of the affected tissues. Vasoconstriction also indirectly aggravates atherogenesis by inducing hypertension. Stress-reduction techniques make it easier for clients to give up bad habits, such as smoking. However, this is not the only reason they are useful. Clients should not ignore claudication, which is a symptom of muscle ischemia. Stress reduction over time may help decrease the amount of medications for anxiety, but not for peripheral vascular disease.
The nurse is caring for a client who has a prescription for antiembolism stockings. The client is confused and begins kicking at the nurse during the measurement of the client's legs. What is the next action by the nurse? A. Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings. B. Administer prescribed lorazepam 1 mg by mouth. C. Contact the health care provider to make aware that the antiembolism stockings cannot be applied. D. Place the antiembolism stockings without measuring the client's legs.
Correct response: A. Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings. Explanation: When a client is confused and is kicking at the nurse, the next action would be to ask a nursing assistant to assist with stabilizing the legs for the application of the stockings. Medicating the client with ordered lorazepam would only be done after attempting the application with additional assistance. Contacting the health care provider would be done after all options for the application of the stockings had been attempted. It is important to have the correct size antiembolism stocking; therefore, the client's legs would need to be measured before applying the stockings.
Which client should the nurse assess first? A. a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain B. a client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker C. a client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache D. a client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria
Correct response: A. a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain Explanation: The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.
A nurse and an unlicensed assistive personnel (UAP) are caring for four clients together on the telemetry unit. Which nursing action can be delegated safely to the UAP? A. applying electrodes in the correct position for ECG monitoring B. teaching a client about an echocardiogram C. assessing peripheral pulses on a client status/post a coronary angiogram D. monitoring blood pressures on a client who is receiving titrated dopamine
Correct response: A. applying electrodes in the correct position for ECG monitoring Explanation: Unlicensed assistive personnel (UAP) can be educated in correct lead placement for ECG monitoring. Assessment of clients and monitoring of unstable clients is not within the scope of practice for a UAP and should be done by the registered nurse. Client teaching must be completed by an RN, not a UAP.
A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mmHg, a heart rate of 110 bpm, and a respiratory rate of 36 breaths/min. Oxygen saturation on room air is 89%. The client reports shortness of breath, and has + 2 pedal edema. The last hemodialysis treatment was yesterday. Which intervention should be done first? Administer oxygen Elevate the foot of the bed Restrict the client's fluids Prepare the client for hemodialysis
Correct response: Administer oxygen Explanation: Airway and oxygenation are always the first priority. Because the client is reporting shortness of breath, and his oxygen saturation is only 89%, the nurse needs to try to increase the partial pressure of arterial oxygen by administering oxygen. The foot of the bed should not be elevated at this time as this may increase venous return to the heart and worsen pulmonary edema. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have fluids restricted.
A client with stage IV heart failure documents in an advance directive that no ventilatory support should be provided. What should the nurse do when the client begins experiencing severe dyspnea? A. Coach the client to take slow deep breaths. B. Administer oxygen, morphine, and a bronchodilator for comfort. C. Ask the client's family to consent to ventilator placement. D. Ask the healthcare provider to prescribe bilevel positive airway pressure (BIPAP).
Correct response: Administer oxygen, morphine, and a bronchodilator for comfort. Explanation: An advance directive identifies a client's wishes in the event that a life-threatening illness or injury occurs. The client's comfort should be paramount and the nurse should respect the client's wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will make breathing easier. The client will need more than coaching to take slow deep breaths. It is a violation of the client's advance directive to ask the family to consent to a ventilator. BIPAP is used to treat sleep apnea and not acute shortness of breath.
A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Immediately following surgery, what should the nurse do as a priority to prevent infection? Assess the temperature in the right arm. Monitor the radial pulse in the right arm. Protect the extremity from cold. Avoid using the arm for a venipuncture.
Correct response: Avoid using the arm for a venipuncture. Explanation: If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.
A client recovering from an abdominal hysterectomy has pain in her right calf. What should the nurse do next? A. Palpate the calf to note pain. B. Measure the circumference of both calves and note the difference. C. Have the client flex and extend her leg and note the presence of pain. D. Raise the right leg and lower it to detect changes in skin color.
Correct response: Measure the circumference of both calves and note the difference. Explanation: After abdominal pelvic surgery, the client is especially prone to thrombophlebitis. Measuring calf circumference can help detect edema in the affected leg. The calf should not be rubbed or palpated because a clot could be loosened and travel to the lungs as a pulmonary embolism. Homan's sign, which is calf pain on dorsiflexion of the foot when the leg is raised, is sometimes associated with thrombophlebitis. Having the client flex and extend the leg does not provide useful assessment data; the leg will not change color when raised and lowered.
The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse? A. Measure the client's legs. B. Ask the client to use the restroom. C. Massage the client's legs. D. Delegate the placement to the unlicensed assistive personnel.
Correct response: Measure the client's legs. Explanation: After receiving orders for graduated compression stockings, the nurse would explain the procedure to the client and then measure the client's legs to determine the appropriate sized stocking. Improperly fitting stockings are uncomfortable and may be harmful to the client. Compression stockings should be placed in the morning, before the client is out of bed for the day to prevent blood vessels from being congested with blood, therefore, the nurse should place the compression stockings prior to having the client use the restroom. The nurse would not want to massage the legs. If a blood clot is present, this may cause the clot to break away from vessel and circulate in the bloodstream. Applying graduated compression stockings may be delegated to unlicensed assistive personnel, but only after the nurse has determined the correct size stocking by measuring the client's legs.
At 0900, the nurse started an infusion of one liter of D5NS infusing at a keep-vein-open rate. At 0945, the client reports a pounding headache, is dyspneic, is experiencing chills, and has a heart rate of 116 bpm. The nurse notes that the IV bag has 400 mL remaining. The nurse should take which action first? Slow the IV infusion. Assess the client's blood pressure. Remove the IV catheter. Call the health care provider (HCP).
Correct response: Slow the IV infusion. Explanation: The nurse notes that 600 mL of D5NS has infused over 45 minutes. The client is showing signs of circulatory overload, and the first action the nurse should take is to slow the IV infusion as the source of the problem. The nurse can then elevate the head of the bed to improve the client's ability to breathe and notify the HCP of the change in condition. The nurse should not remove the IV catheter unless there is infiltration as the open line may be needed for administration of medications.
A 5-year-old child returns to the pediatric unit following a cardiac catheterization using the right femoral vein. The child has a thick elastoplast dressing. Which assessment finding requires immediate intervention? A. One leg is slightly cooler than the other leg. B. The leg used for the catheter insertion is slightly paler than the other leg. C. A small amount of bright red blood is seen on the dressing. D. The pedal pulse of the right leg is not detectable.
Correct response: The pedal pulse of the right leg is not detectable. Explanation: Using the femoral vein during catheterization can cause the affected blood vessels to spasm or cause a blood clot to develop, altering circulation in the leg. The inability to detect the pedal pulse in the affected leg is an ominous sign and requires immediate intervention. Small amounts of coolness or pallor are normal. These findings should improve. Although the nurse should continue to monitor a dressing with a small amount of blood on it, this finding is not the priority in this situation.
The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP: A. ambulates the client. B. massages the client's legs. C. has client wear elasticized stockings. D. assists the client perform range-of-motion exercises in bed.
Correct response: massages the client's legs. Explanation: Massaging the legs postoperatively is contraindicated because it may dislodge small clots of blood, if present, and cause even more serious problems.Ambulation, elasticized stockings, and moving the legs in bed all help reduce the risk of thrombophlebitis.
The nurse is assessing the ankle-brachial index (ABI) for a client with peripheral vascular disease. The highest systolic pressure for each ankle is 80 mm Hg and the highest brachial pressure is 160 mm Hg. What does this client's ABI indicate? no arterial insufficiency mild to moderate insufficiency moderate insufficiency with ischemic rest pain severe ischemia or tissue loss
Correct response: mild to moderate insufficiency Explanation: ABI is calculated by dividing the highest systolic pressure for each ankle by the highest brachial pressure. For this client it would be 80/160 mm Hg = 0.50 ABI. This indicates that the client has mild to moderate insufficiency. Clients with ABI of about 1.0 have no arterial insufficiency; clients with ABI of less than 0.50 have ischemic rest pain; and clients with an ABI of 0.40 or less indicates severe ischemia or tissue loss.
A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used? specialty mattress ring or donut gel flotation pad water bed
Correct response: ring or donut Explanation: The nurse should not use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface.
A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client? stop smoking avoid trauma to extremities begin a walking exercise program report wounds promptly to healthcare provider
Correct response: stop smoking Explanation: Buerger's disease is a nonatherosclerotic, recurrent inflammatory disorder of the small- and medium-sized arteries and veins of the upper and lower extremities. The disease occurs mostly in young men with a long history of tobacco use and chronic periodontal infection, but without other CVD risk factors such as hypertension, hyperlipidemia, and diabetes. Absolute cessation of nicotine is required to reduce the risk for amputation. Conservative management includes avoiding limb exposure to cold temperatures, a supervised walking program, antibiotics to treat any infected ulcers, and analgesics to manage the ischemic pain. Teach clients to avoid trauma to the extremities.
When positioned properly, the tip of a central venous catheter should lie in the superior vena cava. basilic vein. jugular vein. subclavian vein.
Correct response: superior vena cava. Explanation: When positioned correctly, the tip of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters.
Which client has a need for prophylactic antibiotic therapy prior to dental manipulations? -the client who had a TKR (total knee replacement) one year ago -the client who had a left THR (total hip replacement) 3 months ago -the client who had an in ICD (implantable cardiac defibrillator) 2 weeks ago -the client who had an aortic valve replacement 5 years ago
Correct response: the client who had an aortic valve replacement 5 years ago Explanation: A heart valve prosthesis such as an aortic valve replacement is a major risk factor for the development of infective endocarditis. Preventative measures include antibiotic prophylaxis prior to dental work. Other implanted devices (hip, knee, ICD) can increase the risk of infection, but the client with the greatest risk is the one with the valve replacement.
After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first? A. the client with heart failure who is having some difficulty breathing B. the anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today C. the coronary bypass client asking for pain medication for "11 of 10" pain in the donor site D. the client admitted during the previous shift with new-onset controlled atrial fibrillation, who has a call light on
Correct response: the client with heart failure who is having some difficulty breathing Explanation: The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs an analgesic, but that does not take priority over a client with difficulty breathing.