Perfusion EAQ
A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? 1 Increase left ventricular filling and improve cardiac output 2 Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias 3 Decrease the workload on the heart and promote maximum coronary artery filling 4 Increase venous return to the right atrium and increase pulmonary arterial blood flow
3 Decrease the workload on the heart and promote maximum coronary artery filling With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and therefore oxygen to reach cardiac muscle; this increases myocardial efficiency. Increasing left ventricular filling increases the workload of the heart. Oxygenation of vital organs must be maintained. Decreasing oxygen to vital organs of the body may interfere with their ability to function. Increasing venous return to the right atrium increases the workload of the heart.
nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg; the second sound is a swishing sound heard at 130 mm Hg; a tapping sound is heard at 100 mm Hg; a muffled sound is heard at 90 mm Hg; the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1 72 mm Hg 2 90 mm Hg 3 100 mm Hg 4 130 mm Hg
72
nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next? 1 Count the pulse at another site. 2 Notify the primary healthcare provider. 3 Lower the legs to increase blood flow. 4 Verify the pulse by using a Doppler.
Verify the pulse by using a Doppler.
A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition? 1 "I have abnormal platelets." 2 "I have abnormal hemoglobin." 3 "I have abnormal hematocrit." 4 "I have abnormal white blood cells."
"I have abnormal hemoglobin." The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. While it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.
What is the average systolic blood pressure in a 15 year old? Record your answer using a whole number ______________________ mm Hg
119
An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? 1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis 4 Intermittent claudication
4 Intermittent claudication Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.
What is the average diastolic pressure recorded in a 16 year old? Record your answer using a whole number. ________________ mm Hg
75
A nurse is caring for an infant with tetralogy of Fallot. What clinical finding should the nurse expect when assessing this child? 1 Slow respirations 2 Clubbing of the fingers 3 Subcutaneous hemorrhages 4 Decreased red blood cell count
Clubbing of the fingers The mixing of oxygenated and deoxygenated blood results in tissue hypoxia; clubbing occurs as a result of additional capillary development and tissue hypertrophy of the fingertips. The respirations are rapid, not slow. The child's problems are related to decreased oxygenation, not to a clotting defect. The body attempts to compensate for the hypoxemia associated with tetralogy of Fallot by increased erythropoiesis.
A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? 1 Feeling of heaviness in both legs 2 Intermittent claudication of the legs 3 Calf pain on dorsiflexion of the foot 4 Hematomas of the lower extremities
Feeling of heaviness in both legs Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.
Which Korotkoff sound represents the diastolic blood pressure in an adolescent? 1 First 2 Third 3 Fifth 4 Fourth
Fifth In adolescents, the fifth Korotkoff sound corresponds to the diastolic pressure. The first Korotkoff sound, which is sharp, represents systolic blood pressure, which is heard in all individuals. The third Korotkoff sound is a crisper, more intense tapping. The fourth Korotkoff sound is muffled and low. This sound corresponds to diastolic pressure in the toddler.
The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say that this daily information is important in determining? 1 Fluid retention 2 Kidney function 3 Nutritional status 4 Medication dosage
Fluid retention Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.
A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites? 1 Impaired portal venous return 2 Impaired thoracic lymph channels 3 Excess production of serum albumin 4 Enhanced hepatic deactivation of aldosterone secretion
Impaired portal venous return The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.
Which oxytocic drug may help to control uterine bleeding post-delivery and promote milk ejection? 1 Oxytocin 2 Mifepristone 3 Dinoprostone 4 Ergot alkaloids
Oxytocin Oxytocin is used to induce labor, control uterine bleeding after delivery, and promote milk ejection during lactation. Mifepristone is generally used to induce abortion. Dinoprostone induces labor but has no effect on milk ejection or uterine bleeding. Although ergot alkaloids control uterine bleeding after delivery, they do not cause milk ejection during lactation.
A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply. 1 Age 2 Height 3 Weight 4 Smoking 5 Family history
Weight Smoking Obesity is a modifiable risk factor that is associated with coronary artery disease (CAD); an increased fat intake contributes to an increased serum cholesterol and atherosclerosis. Smoking, which constricts the blood vessels, is a modifiable risk factor for CAD. The incidence of CAD does increase with age. However, age is not a modifiable risk factor. Height is unrelated to the incidence of CAD. Family history is not a modifiable risk factor for CAD because one cannot control heredity.
A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? 1 It should be elevated on a pillow. 2 It should be kept extended while on bed rest. 3 It will be positioned dependent to the level of the heart. 4 It will be put through range-of-motion exercises several times an hour.
It should be kept extended while on bed rest. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. Elevating the leg on a pillow will flex the hip, which may traumatize the catheter insertion site and impede healing. The leg is kept even with the level of the heart because the client usually is placed in the supine position with the leg extended. Range of motion will flex the hip, which may traumatize the catheter insertion site and impede healing.
A child returns to his room after left-side cardiac catheterization. What is involved in the postprocedure nursing care? 1 Encouraging early ambulation 2 Monitoring the insertion site for bleeding 3 Comparing blood pressures in the two extremities 4 Restricting fluids until the blood pressure has stabilized
Monitoring the insertion site for bleeding Postprocedure hemorrhage, a life-threatening complication after cardiac catheterization, is possible because arterial blood is under pressure and the catheter has entered an artery. Rest will be encouraged; flexion of the insertion site should be avoided to prevent disturbance of the clot. Comparing blood pressures in the two extremities is unnecessary; the pulse distal to the catheterization insertion site is monitored. The blood pressure will not be unstable unless a problem develops; fluid intake should be encouraged.
The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse? 1 Strong 2 Bounding 3 Expected 4 Diminished
Strong A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.
A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? 1 The client's heart may be beating faster temporarily. 2 The nurse may not know how to take an accurate pulse. 3 The radial pulse site may be surrounded by too much subcutaneous fat. 4 The client may have atrial fibrillation.
The client may have atrial fibrillation.
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? 1 A fever may lead to diaphoresis. 2 A fever increases the cardiac output. 3 An increased temperature indicates cerebral edema. 4 An increased temperature may be a sign of hemorrhage.
A fever increases the cardiac output. Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.
A client has a pulse deficit. Which documentation by the nurse supports this finding? 1 Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. 2 Capillary refill greater than 3 seconds indicating pulse deficit. 3 Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. 4 Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.
Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.
During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of large and painful varicose veins. In light of this information, what should the nurse's assessment include? 1 Monitoring daily clotting times 2 Assessing for peripheral pulses 3 Monitoring daily hemoglobin values 4 Assessing for signs of thrombophlebitis
Assessing for signs of thrombophlebitis Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? 1 Check for a pulse 2 Start cardiac compressions 3 Prepare to defibrillate the client 4 Administer oxygen via an ambu bag
Check for a pulse The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.
What intervention should the nurse implement when caring for a client 24 hours postthyroidectomy? 1 Check the back and sides of the operative site. 2 Support the head during mild range-of-motion (ROM) exercises. 3 Encourage the client to ventilate feelings about the surgery. 4 Advise the client that regular activities can be resumed immediately.
Check the back and sides of the operative site. Bleeding may occur, and blood will pool in the back of the neck because the blood will flow via gravity. ROM exercises will increase pain and put tension on the suture line. Talking should be avoided in the immediate postoperative period, except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. Activity should be resumed gradually and frequent rest periods encouraged.
Which cardiovascular adverse effect is associated with the use of clomiphene? 1 Ischemia 2 Chest pain 3 Tachycardia 4 Hypertension
Tachycardia Clomiphene is used to induce ovulation. Tachycardia is reported with the use of clomiphene. Ischemia and hypertension are not associated with clomiphene. Chest pain may occur with the use of clomiphene as a rare adverse effect.
A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client? 1 Peripherally inserted central catheter (PICC) line 2 #20 angiocatheter in either antecubital area 3 Large-gauge butterfly needle in hand 4 Femoral line
Peripherally inserted central catheter (PICC) line Dopamine hydrochloride is a vesicant, and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly needle are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.
A nurse is preparing to teach a client to apply a nitroglycerin patch as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? 1 Apply the patch on a distal extremity. 2 Remove a previous patch before applying the next one. 3 Massage the area gently after applying the patch to the skin. 4 Apply a warm compress to the site before attaching the patch.
Remove a previous patch before applying the next one Removing the previous patch before applying the next patch ensures that the client receives just the prescribed dose. Ideally, a patch should be removed after 12 to 14 hours to avoid the development of tolerance. The patch should be rotated among hair-free and scar-free sites; acceptable sites include chest, upper abdomen, proximal anterior thigh, or upper arm. The patch should be gently pressed against the skin to ensure adherence; it should not be massaged. Applying a warm compress to the site before attaching the patch is unnecessary and can result in an excessive absorption of the medication.
A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? 1 Trimming toenails so that they are short and rounded 2 Checking bathwater temperature by putting the toes in first 3 Using alcohol to rub hands, feet, legs, and arms at least two times a day 4 Seeking professional treatment for any minor injuries to the extremities
Seeking professional treatment for any minor injuries to the extremities Because diminished circulation leads to inadequate healing, early treatment of injuries is essential. Toenails should not be too short and should be trimmed straight across. Bathwater should be checked with a bath thermometer; toes of persons with peripheral artery disease (PAD) may be less sensitive to temperature change, and a burn may occur. These clients develop trophic skin changes; the drying action of alcohol will contribute to dryness and skin breakdown.
Which antihypertensive drug is contraindicated in lactating women? 1 Tenormin 2 Labetalol 3 Metoprolol 4 Propranolol
Tenormin Tenormin is contraindicated in lactating woman because it enters the breast milk and may cause adverse effects to the neonate. Labetalol and propranolol are safe to administer during lactation. Metoprolol is a safe drug to be taken during pregnancy.
Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings? 1 The stockings should reach the middle of the knee. 2 The stockings should be applied before getting out of bed. 3 The stockings should be applied at the first sign of discomfort. 4 The stockings may be substituted with loose elastic bandages.
The stockings should be applied before getting out of bed. To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches (5 cm) below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. The stockings apply uniform pressure; loose elastic bandages may slip, creating uneven, ineffective pressure. Edema also may result.
A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization? 1 To obtain the pressures in the heart chambers 2 To determine the existence of congenital heart disease 3 To visualize the disease process in the coronary arteries 4 To measure the oxygen content of various heart chambers
To visualize the disease process in the coronary arteries Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.
