PCC 2 Exam 1 Study Guide

What is high-output failure?

-Cardiac output remains normal/above normal -It

Right-sided heart failure (cor pulmonate) is usually related to what condition?

COPD or pulmonary hypertension

Signs and symptoms: Potassium level of 5.5 and flaccid paralysis

Correct Answer: Respiratory Acidosis or Metabolic Acidosis (pg. 181)

The following IV fluids are considered to be a hypertonic solution: A. 5% Dextrose Lactate Ringers B. Lactate Ringers C. Dextran D. 5% Dextrose and water

Correct Answer: A &C 5% Dextrose Lactate Ringers and Dextran

A nurse is reviewing the laboratory values for a client who is taking an ACE inhibitor and spironolactone for heart failure. The nurse should notify the provider for which of the following laboratory values? A. Creatinine 1.8 mg/dL B. Potassium 4.2 mEq/L C. BNP 98 pg/mL D. d-Dimer 0.3 mcg/mL

Correct Answer: A. Creatinine 1.8 md/dL Rationale: The nurse should notify the provider of a creatinine 1.8 mg/dL. Clients receiving an ACE inhibitor and spironolactone together, may develop hyperkalemia and dysrhythmias.

A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which of the following actions should the nurse take? A. Use a transfusion set that has a short tubing and small filter. B. Verify the client's blood type with a second nurse. C. Allow platelets to sit at room temperature for 1 hour prior to infusion. D. Infuse the platelets over a period of 2 hours.

Correct Answer: A. Use a transfusion set that has a short tubing and a small filter. Rationale: The nurse should administer platelets with a special transfusion set that has a smaller filter and shorter tubing. If a standard blood administration set is used, the filter can trap the platelets and the longer tubing increases platelet adherence to the lumen.

A nurse is planning care for a client who has heart failure. Which of the following interventions should the nurse include in the plan of care? A. Maintain sodium intake at 3.5 gm daily. B. Limit fluid intake to 2L per day. C. Administer NSAIDs for minor discomfort D. Place the client in a lateral recumbent position.

Correct Answer: B. Limit fluid intake to 2L per day. Rationale: The nurse should plan to limit the client's fluid intake to 2 L daily to decrease fluid retention, which decreases the workload of the heart.

A nurse is assessing a client who has left-sided heart failure with decreased cardiac output. Which of the following manifestations should the nurse expect? A. Flushing of the skin on exertion B. Nocturia at night C. Warm lower extremities D. Respiratory rate of 16/min

Correct Answer: B. Nocturia at night Rationale: The client who has left-sided heart failure with decreased cardiac output can have oliguria during the day and nocturia at night due to poor tissue perfusion to the kidneys.

A nurse is monitoring a client who has received enalapril for heart failure. The nurse should identify which of the following findings as an adverse effect? A. Bradycardia B. Orthostatic Hypotension C. Increased Perspiration D. Somnolence

Correct Answer: B. Orthostatic Hypotension Rationale: Enalapril, which is an angiotensin-converting enzyme, prevents conversion of angiotensin I to angiotensin II, causing dilation of the arterial and venous vessels. This can lead to the client developing orthostatic hypotension.

A nurse is assessing a client who is restricted to bedrest for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? A. Weak peripheral pulses B. Angina C. Sacrum edema D. Crackles in the lungs

Correct Answer: C. Sacrum edema Rationale: A client who has right-sided heart failure and is restricted to bedrest will often have fluid accumulation in the sacral area when compared to a client who is ambulatory. The edema is due to increased systemic venous pressures and congestion.

A nurse is providing teaching to a client who is scheduled to receive one unit of packed RBCs. Which of the following information should the nurse include in the teaching? A."It will take approximately 6 hours for this unit of blood to infuse." B. "You can expect to experience some back discomfort during the infusion." C. "You will need to lie on your left side while the blood is infusing." D. "I will remain with you for the first 15 minutes of the transfusion process."

Correct Answer: D. "I will remain with you for the first 15 minutes of the transfusion process." Rationale: The nurse should inform the client that he will remain with the client for the first 15 min of the transfusion. It is during the first 50 mL of the transfusion that a severe reaction is most likely to occur.

A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take? A. Monitor vital signs every hour during the transfusion. B. Infuse each unit of blood slowly over 6 hours to avoid flush overload. C. Use the same transfusion set to infuse both units of packed RBC's. D. Wait 2 hours between infusing the two units of packed RBC's.

Correct Answer: D. Wait 2 hours between infusing the two units of packed RBC's. Rationale: If possible, the nurse should wait 2 hr to elapse after the administration of the first unit of packed RBCs before beginning to infuse the second unit. This will decrease the client's risk of fluid overload.

S/S: Elevated Hgb and Hct; Specific gravity of 1.301; Elevated sodium, BUN, and serum osmolarity

Correct Answer: Dehydration or fluid volume deficit (pg. 229)

Signs and symptoms: Thready, increased pulse rate; decreased blood pressure and postural hypotension; flat neck & hand veins; diminished peripheral pulses; increased temperature

Correct Answer: Dehydration or fluid volume deficit (pg. 229)

S/S: Fever, chills, low back pain, chest pain, dyspnea, or hemoglobinuria

Correct Answer: Hemolytic transfusion reaction

The intracellular compartments swells with this type of IV fluid:

Correct Answer: Hypotonic solution

S/S: Excessive alcohol or antifreeze ingestion

Correct Answer: Metabolic acidosis

S/S: Diarrhea

Correct Answer: Metabolic acidosis

S/S: Diabetic ketoacidosis (DKA) or starvation

Correct Answer: Metabolic acidosis (pg. 180)

S/S: Kussmaul's respirations

Correct Answer: Metabolic acidosis (pg. 181)

S/S: Tingling in the fingers, toes and mouth

Correct Answer: Metabolic or Respiratory Alkalosis (pg. 181)

Signs and symptoms: Behavioral changes such as lethargy and confusion

Correct Answer: Respiratory Acidosis or Metabolic Acidosis (pg. 181)

S/S: Positive Chvostek's sign

Correct Answer: Respiratory or Metabolic Alkalosis (pg. 184)

What is one of the main reasons for heart failure?

Hypertension

What are the typical causes of left sided heart failure?

Hypertension Coronary artery disease Valvular disease

What are the typical causes of right-sided heart failure (increased volume and pressure in the venous system & peripheral edema) ?

Left ventricular failure Right ventricular MI Pulmonary hypertension