Perfusion

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide concerning cast care?

"Keep your right leg elevated above heart level." R: The nurse should instruct the client to elevate the leg to promote venous return and prevent edema.

When vasoactive medications are administered, the nurse must monitor vital signs at least how often?

15 minutes R: When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).

The nurse witnesses a client go into cardiac arrest. If the nurse delays intervention, when will the death of brain cells begin?

4-6 minutes R: Unconsciousness occurs almost simultaneously with cardiac arrest, and the death of brain cells begins within 4 to 6 minutes. Interruption of blood flow also leads to the accumulation of metabolic byproducts that are toxic to neural tissue.

In which situation would blood be most likely to be rapidly relocated from central circulation to the lower extremities?

A client is helped out of bed and stands up R: During a change in body position, blood is rapidly relocated from the central circulation (when the patient is recumbent) to the lower extremities (when the patient stands up). This results in a temporary drop in blood pressure known as postural hypotension and reflects the redistribution of blood in the body.

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor exhibits the following. Which interventions would the nurse do first?

Assess the client's airway, breathing, and circulation. R: The rhythm the client is experiencing is ventricular tachycardia (VT). Although all of the options listed are appropriate for someone with stable VT, it is not yet known whether the client's VT is stable, unstable, or pulseless. Therefore, the nurse must first assess the airway, breathing, circulation, and level of consciousness to establish the client's stability. Different actions are required if the client's VT is unstable or pulseless.

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication?

Atelectasis R: Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia.

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR) R: LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels.

The nurse is evaluating a hemodynamically unstable client with an arterial line and notes that the client has tachycardia, cool and clammy skin, a pericardial friction rub, and the arterial waveform shows an inspiratory systolic pressure that is 15 mm Hg less than the expiratory systolic pressure. What is the priority intervention by the nurse?

Contact the health care provider. R: The priority action is to contact the health care provider because these symptoms are indicative of cardiac tamponade.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?

Crackles in the lower lobes R: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels.

A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have?

Essential (primary) R: Essential or primary hypertension, about 95% of cases, is sustained elevated BP with no known cause.

A client with an enlarged abdominal aorta admitted to the emergency department has severe back pain, nausea, blood pressure of 90/40 mm hg, heart rate 128 bpm, and respirations 28/min. In which order from first to last should the nurse implement these prescriptions? All options must be used.

Establish an intravenous infusion. Insert a nasogastric tube. Administer pain medication. Monitor intake and output. R: The data suggest an abdominal aortic aneurysm that is leaking or rupturing. When implementing the prescriptions the nurse should first establish an intravenous infusion with a large bore needle for immediate volume replacement. Next, the nurse should insert the nasogastric tube to relieve the nausea and vomiting and decompress the stomach. The nurse next should administer pain medication. Last, the nurse should monitor intake and output; with hypovolemia, the urine output will be diminished.

Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea R: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.

Which assessment and laboratory findings would be most closely associated with acute leukemia?

High blast cell counts and fever R: Acute leukemia is often marked by a fever as well as leukostasis.

Atherosclerosis begins in an insidious manner with symptoms becoming apparent as long as 20 to 40 years after the onset of the disease. Although an exact etiology of the disease has not been identified, epidemiologic studies have shown that there are predisposing risk factors to this disease. What is the major risk factor for developing atherosclerosis?

Hypercholesterolemia R: The cause or causes of atherosclerosis have not been determined with certainty. However, epidemiologic studies have identified predisposing risk factors, which include a major risk factor of hypercholesterolemia. Other risk factors include increasing age, family history of premature coronary heart disease, and male sex.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?

Left-sided cerebrovascular accident (CVA) R: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis.

The nurse is developing a plan of care for a client diagnosed with stable angina. Select the most important goal for this client.

Myocardial infarction prevention R: Symptom reduction for quality of life and prevention of MI are treatment goals for stable angina.

A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The client's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon assessment, which finding requires immediate intervention by the nurse?

Numbness and weakness in the left arm R: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of numbness and weakness in left arm may indicate the client is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP; immediate intervention is required.

A monitored hospitalized client with a pulmonary embolism has been in atrial fibrillation (AF) for 4 days. The nurse observes the rhythm spontaneously convert to a normal sinus rhythm. Which form of AF is this?

Paroxysmal R: AF is characterized as rapid disorganized atrial activation and uncoordinated contraction by the atria. It is classified into three categories: paroxysmal, persistent, and permanent. Paroxysmal AF self-terminates and lasts no longer than 7 days, whereas persistent lasts greater than 7 days and usually requires intervention such as a cardioversion. AF is classified as permanent when attempts to terminate are failed and the person remains in AF. The symptoms of chronic AF vary. Some people have minimal symptoms, and others have severe symptoms, particularly at the onset of the dysrhythmias.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours?

Peripheral pulses every 15 minutes after surgery R: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.

An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed Chlorothiazide and Benazepril. What will the nurse monitor this client for?

Postural hypotension and resulting injury R: Antihypertensive medication can cause hypotension, especially postural hypotension that may result in injury.

Reviewing pathology for an exam on pulmonary vasculature, the nursing student states that blood enters the right side of the heart via the vena cava, then to the right atrium, right ventricle, and then which vessel carries the deoxygenated blood into the pulmonary system?

Pulmonary artery R: Deoxygenated blood leaves the right heart through the pulmonary artery. Return of oxygenated blood to the heart occurs by way of the pulmonary vein, which empties into the left atrium.

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?

Stop smoking. R: Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities.

A client is told that she has cardiac valve leaflets, or cusps, that are floppy and fail to shut completely, permitting blood flow even when the valve should be completely closed. The nurse knows that this condition can lead to heart failure and is referred to as:

Valvular regurgitation R: When cardiac valves such as the aortic or mitral fail to close properly, blood does not efficiently exit from the left ventricle. This condition is valvular regurgitation

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. R: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

What is the most important assessment for the nurse to make when assessing peripheral pulses on a client who is post limb fracture?

amplitude and symmetry of both extremities R: Assessment of any peripheral pulse should include the characteristics of the pulse (e.g., amplitude, rhythm, and rate). The presence or lack of symmetry in the peripheral pulses must also be assessed.

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise:

decreases venous congestion. R: Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart

A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time?

ineffective tissue perfusion (cardiopulmonary) related to arrhythmia R: The client suffered a lethal arrhythmia, requiring immediate resuscitation. This arrhythmia resulted from ineffective perfusion to the heart. Therefore, the appropriate nursing diagnosis is Ineffective tissue perfusion (cardiopulmonary).

A client who is experiencing angina at rest that has been increasing in intensity should be instructed to:

see the doctor for evaluation immediately. R: Angina that occurs at rest, is of new onset, or is increasing in intensity or duration denotes an increased risk for myocardial infarction and should be seen immediately using the criteria for acute coronary syndrome (ACS).

How does the nurse describe the cardiac action potential to a new coworker?

the cycle of depolarization and repolarization R: The action potential of the cardiac muscle cell consists of five phases: Phase 0 occurs when the cell reaches a point of stimulation. This is called depolarization. Phase 2, or the plateau stage, is a process called repolarization. Phase 4 is when spontaneous depolarization begins again. The action potential involves electrolytes and polarization and does not involve timing of the cardiac cycle.

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

uterine atony R: Uterine atony is the significant cause of postpartum hemorrhage.