UWorld Cardiovascular #3
A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? Select all that apply. a. Continue heparin infusion and recheck aPTT in 6 hours b. Prepare to administer vitamin K c. Redraw blood for laboratory tests d. Review guidelines for administration of protamine e. Stop infusion of heparin and notify the HCP
Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin). (Option 1) Continuing the heparin infusion will put the client at risk for a severe bleeding episode. (Option 2) Vitamin K is the reversal agent for warfarin. (Option 3) There is no reason to redraw blood for laboratory workup at this time as the abnormal aPTT result is consistent with the client's bleeding. Laboratory studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent. Educational objective:The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered.
The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child's parent wants to know why this treatment is required. The nurse explains that this therapy is given to: a. Fight the infection b. Minimize rash c. Prevent heart diseases d. Reduce spleen size
(KD), also known as mucocutaneous lymph node syndrome, is characterized by ≥5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling. Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms. (Option 1) KD is a vasculitis of unknown etiology, but it is not an infectious process. Because the child will often have a similar clinical presentation to that of an infection (eg, persistent fever, inflammatory immune response), KD may be mistaken for a bacterial or viral illness. (Option 2) Polymorphous rash of the trunk and extremities is an expected finding in a child with KD. Cool compresses, unscented lotions, and loose-fitting clothing can minimize discomfort. IVIG is not given to control rash. (Option 4) Lymphadenopathy (usually a single palpable anterior cervical node >1.5 cm) and splenomegaly are included in the clinical presentation of KD. IVIG therapy is not indicated to reduce incidence of these findings. Educational objective:IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.
The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply. a. Do not take car rides longer than 4 hours for at least 3-4 weeks b. Drink plenty of fluids everyday and limit caffeine and alcohol intake c. Elevate legs on a footstool when sitting and dorsiflex the feet often d. Resume your walking program as soon as possible after getting home e. Sit in a cross legged position for 5-10 minutes to improve circulation.
A deep venous thrombosis (DVT) is a blood clot (ie, thrombus) formed in large veins, generally of the lower extremities. Risk factors for DVT include venous stasis, blood hypercoagulability, and endothelial damage. Therefore, discharge teaching for a client with resolved DVT emphasizes interventions to promote blood flow and venous return (eg, exercise, smoking cessation) to prevent reoccurrence. Interventions to prevent DVT reoccurrence include: Obtain adequate fluid intake and limit caffeine and alcohol intake to avoid dehydration because dehydration increases the risk for blood hypercoagulability (Option 2). Elevate the legs when sitting and dorsiflex the feet often to reduce edema and promote venous return (Option 3). Resume an exercise program (eg, walking, swimming) and change positions frequently to promote venous return (Option 4). Stop smoking to prevent endothelial damage and vasoconstriction. Avoid restrictive clothing (eg, tight jeans), which interferes with circulation and promotes clotting. Consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels. (Option 1) Clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour). (Option 5) Clients should avoid crossing the legs at the knees or ankles because this compresses the veins and limits venous return. Educational objective:Discharge teaching for a client with resolved deep vein thrombosis includes interventions to prevent reoccurrence (eg, take in adequate fluids, elevate the extremities, exercise regularly, change positions frequently, stop smoking).
The nurse is reviewing the telemetry strips of assigned clients. The rhythm strip displayed in the exhibit is given to the nurse by the telemetry technician. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. a. Atrial fibrillation b. 1st degree atrioventricular block c. Sinus bradycardia d. Sinus rhythm
A standard electrocardiogram (ECG) traces the electrical activity of the heart at 25 mm/second on tracing paper (small boxes = 0.04 second, large boxes = 0.20 second). On a 6-second strip, the heart rate is determined by counting the number of QRS complexes on the strip and multiplying by 10. If the strip is not 6 seconds and the R-R interval is regular, the rate can be determined by counting the large boxes between QRS complexes and dividing that number into 300 (number of large boxes in 1 minute of strip). After determining the rate, the nurse should analyze the P waves, QRS complexes, and T waves (if present) and determine the rhythm. A regular heart rate of 60-100/min with normal PR intervals, QRS complexes, and QT intervals indicates that the client is in normal sinus rhythm (Option 4). (Option 1) In atrial fibrillation, there are absent P waves and fine, fibrillatory waves, indicating disorganized atrial electrical activity. The ventricular rate is usually irregular. (Option 2) In first-degree atrioventricular block, there is a prolonged (>20 seconds), regular PR interval. (Option 3) Sinus bradycardia is characterized by a rate <60/min.
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply. a. BP of 140/84 mm Hg b. HR of 98 c. Platelet count of 200,000 d. Report of Ginkgo biloba use e. Report of peptic ulcer disease
Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged. (Option 1) This blood pressure is slightly elevated, but is unaffected by antiplatelet agents. (Option 2) Normal heart rate is between 60/min-100/min. (Option 3) This is a normal platelet count (150,000/mm3-400,000/mm3 [150-400 x 109/L]). Educational objective:If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing health care provider before the client is discharged.
The nurse teaches the client taking atorvastatin to call the health care provider (HCP) if experiencing which symptom associated with a serious adverse effect of atorvastatin? a. Diarrhea b. Headache c. Muscle aches d. Numbness in the feet
Atorvastatin (Lipitor) is a statin drug, or HMG-CoA reductase inhibitor, prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. A serious adverse effect of statins, including atorvastatin and rosuvastatin (Crestor), is myopathy with ongoing generalized muscle aches and weakness. A client who develops muscle aches while on a statin drug should call the HCP who will then obtain a blood sample to assess the creatine kinase (CK) level. If myopathy is present, CK will be significantly elevated (≥10x normal), and the drug will then be discontinued. (Option 1) Diarrhea is not a side effect of statin drugs. Colchicine used for gout and acute pericarditis commonly leads to diarrhea. Many antibiotics can induce diarrhea, and some may cause Clostridium difficile infection. (Option 2) Headache is not a serious side effect of statin drugs. It is often a bothersome side effect of nitrates and calcium channel blockers as they dilate intracranial vessels; however, tolerance usually develops over time. (Option 4) Numbness in the feet (neuropathy) is not a common side effect of statin drugs. It is commonly associated with isoniazid, amiodarone, and chemotherapy agents (eg, vincristine, cisplatin). Educational objective:The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication.
The home health nurse is visiting a client discharged 2 days ago after a coronary artery bypass graft. The client reports fatigue and palpitations, and the nurse connects the client to a portable heart monitor. The nurse recognizes the displayed rhythm as which type? Click on the exhibit button for additional information. a. Atrial fibrillation b. Atrial flutter c. Complete heart block d. 2nd degree atrioventricular block, type 2
Atrial fibrillation (AF) is a common dysrhythmia after cardiac surgery. It is characterized by a total disorganization of atrial electrical activity that results in the loss of effective atrial contraction. P waves are not visible; they are replaced by fibrillatory waves. The ventricular rate varies, but the rhythm is typically irregular. AF results in decreased cardiac output due to a loss of atrial kick and/or a rapid ventricular response. Clots may form in the atria, putting the client at increased risk for stroke. Treatment goals include a decrease in ventricular rate to <100/min and adequate anticoagulation to prevent thromboembolic complications. Medications used for rate control include calcium channel blockers (eg, diltiazem, verapamil), beta blockers (eg, metoprolol), and digoxin. Medications that convert to and maintain sinus rhythm include amiodarone, flecainide, and sotalol. Electrical cardioversion may also be considered in hemodynamically unstable clients. (Option 2) Atrial flutter is characterized by recurring, regular, sawtooth-shaped flutter waves. (Option 3) Complete heart block has more P waves than QRS complexes, and PR intervals are variable. There is no communication between the atria and ventricles; each is firing independently of the other. (Option 4) Second-degree atrioventricular block, type 2 has more P waves than QRS complexes. The PR interval is constant on conducted beats; it reflects an intermittent block of atrial impulses. Educational objective:Atrial fibrillation on ECG is characterized by an irregular rhythm with fibrillatory waves instead of P waves. Treatment includes rate control and anticoagulation.
Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency? a. Brownish, hardened skin on lower extremities b. Diminished peripheral pulses c. Non healing ulcer on lateral surface of great toe d. Shiny, hairless lower extremities.
Chronic venous insufficiency (CVI) occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and into the surrounding tissues, where tissue enzymes break down red blood cells. The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery (Option 1). Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. (Options 2, 3, and 4) Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with peripheral arterial disease due to hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues. Educational objective:Chronic venous insufficiency occurs when the valves in the veins of the lower extremities fail to keep blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on the extremities and venous leg ulcers (commonly on the inside of the ankle).
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. a. I don't plan on eating any more frozen meals b. I plan to take my diuretic pill in the morning c. I will weigh myself at least every other day d. I'm going to look into joining a cardiac rehabilitation program e. Ibuprofen works best for me when I have pain
Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention (Option 5). To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of clothing, and on the same scale (Option 3). Weights should be recorded to allow for day-to-day comparisons to help identify early signs of fluid retention. (Option 1) Frozen meals are often high in sodium. Most heart failure clients are instructed to limit sodium intake. All foods high in sodium (>400 mg/serving) should be avoided. (Option 2) Diuretic medications cause clients to urinate more. Morning is the appropriate time to take this type of medication. Evening administration would cause nocturia and interrupted sleep. (Option 4) Exercise training, such as cardiac rehabilitation, improves symptoms of chronic heart failure. It has been found to be safe and improves the client's overall sense of well-being. It has also been correlated with reduction in mortality. Educational objective:Discharge education for the client with chronic heart failure should include daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention.
The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. a. I will need to take by blood thinner for about 3-6 months b. I will place small rugs on my wood floors to cushion a fall c. I will take a baby aspirin if I have a mild chest pain d. I will use a soft bristled toothbrush to clean my teeth e. I will wear a blood thinner MedicAlert tag
Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter rugs in the home to reduce the risk of tripping and falling (especially in elderly) (Option 2). Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding (Option 3). (Option 1) Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level. (Option 4) Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss may be used with care in some clients. (Option 5) Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin, heparin). Educational objective:Clients on warfarin or heparin should avoid using aspirin or nonsteroidal anti-inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake.
The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? Click on the exhibit button for additional information. Laboratory results Potassium 3.3 mEq/L (3.3 mmol/L) Sodium 149 mEq/L (149 mmol/L) Glucose 157 mg/dL (8.7 mmol/L) a. Captopril PO every 8 hours b. Morphine IV prn for pain c. Potassium chloride IVPB once d. Regular insulin SQ with meals
Clients with myocardial infarction (MI) are at risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) both during the MI and following reperfusion therapy (eg, coronary artery stenting). Myocardial ischemia damages cardiac muscle cells, causing electrical irritability (eg, premature ventricular contractions) that can be exacerbated by electrolyte imbalances (eg, hypokalemia). Hypokalemia hyperpolarizes cardiac electrical conduction pathways, increasing the risk for dysrhythmias. Therefore, prompt potassium replacement is the priority in these clients (Option 3). (Option 1) ACE inhibitors (eg, captopril, enalapril, lisinopril) help reduce the risk of future MIs by reducing blood pressure and cardiac workload and inhibiting ventricular remodeling. ACE inhibitors should be administered after MI; however, life-threatening dysrhythmias pose a higher risk to the client. (Option 2) Administering morphine is an appropriate intervention to address the client's back pain, but it is not the priority. (Option 4) Strict glycemic control in the resolution phase of an acute MI is associated with better long-term outcomes (eg, reduced morbidity/mortality), but it does not take priority. Educational objective:Prompt potassium replacement is the priority action for hypokalemic clients with myocardial infarction because they are at increased risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) and cardiac arrest.
A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching? a. I always take my Simvastatin in the evening b. I prop my legs up in the recliner and use a heating pad when feet are cold c. I've been walking on my treadmill at home for 15 minutes each day d. I've noticed that I don't have much hair on my lower legs anymore
Clients with peripheral arterial disease (PAD) have decreased sensations from nerve ischemia or coexisting diabetes mellitus. They should never apply direct heat to the extremity due to the risk for a burn wound. Wound healing is impaired in these clients. Swelling in the extremities (edema) could result from venous stasis (venous valve incompetence or varicose veins); these clients are asked to elevate their extremities during rest. However, clients with PAD usually do not have swelling, but rather have decreased blood supply. The extremities should not be elevated above the level of the heart because extreme elevation further impedes arterial blood flow to the feet. Additional teaching for the client with PAD includes the following: Smoking cessation Regular exercise Achieving or maintaining ideal body weight Low-sodium diet Tight glucose control in diabetics Tight blood pressure control Use of lipid management medications Use of antiplatelet medications Proper limb and foot care (Option 1) Most cholesterol is synthesized by the liver during the fasting state, at night. Statins (eg, simvastatin, atorvastatin) are typically taken in the evening as they are more effective during that period. This is an appropriate statement. (Option 3) Regular exercise is important for clients with PAD. The client should be encouraged to walk 30-40 minutes a day, 3-5 times a week. If claudication is present, the client should be instructed to walk to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. (Option 4) Lack of hair, brittle nails, dry skin, and skin atrophy are due to decreased blood supply to these structures and are common, expected findings in PAD. Educational objective:The nurse should instruct the client with peripheral arterial disease to never apply direct heat to extremities due to the risk of a burn from decreased sensitivity.
The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply. a. Avoid MRI scans b. Do not place cellphones directly over the pacemaker c. Notify the airport security when traveling d. Perform shoulder range of motion exercises e. Refrain from using microwave ovens
Discharge teaching for the client with a permanent pacemaker should include the following: Report fever or any signs of redness, swelling, or drainage at the incision site. Carry a pacemaker identification card and wear a medical alert bracelet. Take the pulse daily and report it to the health care provider (HCP) if below the predetermined rate. Avoid MRI scans, which can affect or damage a pacemaker (Option 1). Avoid carrying a cell phone in a pocket directly over the pacemaker and, when talking on a cell phone, hold it to the ear on the opposite side of the pacemaker (Option 2). Notify airport security of a pacemaker; a handheld screening wand should not be held directly over the device (Option 3). Avoid standing near antitheft detectors in store entryways; walk through at a normal pace and do not linger near the device. (Option 4) The client should avoid lifting the arm above the shoulder on the side of the pacemaker until approved by the HCP as this can cause dislodgement of the pacemaker lead wires. (Option 5) Microwave ovens are safe to use and do not interfere with pacemakers. Educational objective:Clients with permanent pacemakers should carry a pacemaker identification card, wear a medical alert bracelet, avoid MRI scans, avoid placing a cell phone over the pacemaker, and inform airport security personnel. Above-the-shoulder exercises should be avoided on the side of the pacemaker until cleared by the health care provider. Microwave ovens are safe to use.
The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? Select all that apply. a. BP b. BUN c. Liver enzymes d. Potassium e. WBC
Loop diuretics (furosemide, torsemide, bumetanide) are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, a medical emergency that can result in other life-threatening complications such as heart arrythmias, as well as muscle cramps and weakness (Option 4). Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. Therefore, these levels should be assessed (Options 1 and 2). (Options 3 and 5) Loop diuretics typically do not cause abnormalities in white blood cell counts or liver function tests, so these do not need to be assessed routinely. Educational objective:When administering furosemide, it is important to closely monitor the client's vital signs, serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury.
The nurse is caring for a client who, 30 minutes ago, underwent an ablation procedure for supraventricular tachycardia in the cardiac catheterization laboratory. The client has a dressing over the femoral insertion site with a small amount of oozing blood. Which action by the nurse causes the charge nurse to intervene? a. Applies pressure above the femoral insertion site b. Assessess bilateral pedal pulses frequently c. Assists client to sit on the side of the bed to use the urinal d. Reports client chest pain of 2 on a scale of 0/10 to HCP
Radiofrequency catheter ablation is an invasive procedure that may be used to treat clients with recurrent episodes of supraventricular tachycardia. A catheter is inserted through a large artery or vein (eg, femoral) and threaded to the heart. Radiofrequency waves are delivered to inactivate tissue in the area of the heart causing the dysrhythmia. After cardiac catheterization, clients must remain supine with the head of the bed at ≤30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site. The charge nurse should intervene if the nurse is assisting the client to sit on the side of the bed to use the urinal (Option 3). (Option 1) A small amount of bleeding can be expected after the catheter is removed. It is appropriate to apply pressure above the insertion site to control bleeding. The nurse should continue to closely monitor the site for further bleeding. (Option 2) It is important to verify adequate perfusion to the affected limb by frequently palpating the pedal pulses. Bilateral pulses should be palpated for comparison. (Option 4) Chest pain after ablation may be due to cardiac muscle damage but could also be caused by cardiac ischemia. This should be reported immediately to the health care provider. Educational objective:Radiofrequency catheter ablation is a cardiac catheterization procedure indicated for a client with recurrent episodes of supraventricular tachycardia. After cardiac catheterization, the client must remain supine with the head of the bed at ≤30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site.
A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply. a. Apical pulse b. Capillary refill c. Lung sounds d. Pupillary response e. Skin color and temperature
Shock is a life-threatening syndrome characterized by decreased perfusion and impaired cellular metabolism. A lack of perfusion at both the tissue and cellular level (anaerobic metabolism) occurs due to decreased cardiac output, ineffective blood flow, and inability to meet the body's demand for increased oxygen. Sustained hypoperfusion activates compensatory mechanisms (eg, neural, hormonal, biochemical) to maintain homeostasis and reverse the consequences of anaerobic metabolism. Shock will progress through 4 stages (initial, compensatory, progressive, irreversible). Early identification and intervention help to prevent stage progression. Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity temperature, and peripheral pulses. Capillary refill indicates adequacy of blood flow to the peripheral tissues. It is measured by the time taken for color (pink) to return to an external capillary bed (nail bed) after pressure is applied to cause blanching. In an adult, color should return in less than 3 seconds. Normal skin color and temperature are indicators of the adequacy of peripheral blood flow; these are usually within normal limits during the initial and compensatory stages of shock. (Option 1) Apical pulse is a central pulse and does not indicate adequacy of peripheral tissue perfusion. (Option 3) Lung sounds indicate the adequacy of ventilation and gas exchange, not peripheral tissue perfusion. (Option 4) Pupillary response is an indicator of cerebral function, not peripheral tissue perfusion. Educational objective:The adequacy of blood flow to peripheral tissues is determined by measuring capillary refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock.
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first? a. Auscultate breath sounds b. Check for peripheral edema c. Measure the client's vital signs d. Review the client's wt log over the past several days
The nurse should start assessment based on the ABCs (Airway, Breathing, Circulation). This client is at risk for acute decompensated heart failure and pulmonary edema. Pulmonary edema is an acute, life-threatening situation in which the lung alveoli become filled with serosanguineous fluid. Auscultation may include crackles, wheezes, and rhonchi if fluid has moved into the lungs. The next priority is for the nurse to measure vital signs (Option 3). This would identify if the client's heart rate or respiratory rate is elevated and if the oxygen saturation is compromised. Checking for peripheral edema (Option 2) and review of the client's weight over the past several days (Option 4) are appropriate assessments that may indicate fluid volume overload. However, they do not take priority over auscultation of the lungs. Educational objective:The nurse should follow the ABCs of assessment with the heart failure client who is short of breath and coughing. Airway, breathing, and circulation should be assessed, including auscultation of breath sounds, measurement of respiratory rate, and oxygen saturation.
A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. a. Cap refill is less than 3 seconds b. Pulse pressure is narrowed c. SBP drops only when standing d. Urine output is 360 ml in 4 hours e. Urine specific gravity is 1.020
This client's initial vital signs show tachycardia and hypotension, which are classic signs of hypovolemia. Normal capillary refill is less than 3 seconds and is an indication of normal hydration and perfusion (Option 1). Obligatory urine output is 30 mL/hr, and this client has 90 mL/hr. Urine output is one of the best indicators of adequate rehydration (Option 4). The urine specific gravity is within a normal range (1.003 to 1.030), which can indicate normal hydration (Option 5). (Option 2) Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock and would not indicate adequate rehydration. The client arrived with a narrow pulse pressure already. (Option 3) This is indicative of orthostatic vital signs. When a client stands, the body normally vasoconstricts to maintain the blood pressure from the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted, and there is no compensatory mechanism left to adjust to the position change. Educational objective:Signs of adequate hydration are normal urine specific gravity (1.003 to 1.030), adequate volume of urine output (>30 mL/hr), and capillary refill of less than 3 seconds. Pulse pressure narrows in shock, and positive orthostatic vital signs (decreasing systolic blood pressure and rising heart rate) with position change indicate dehydration.
The telemetry nurse is reviewing the cardiac monitors of 4 clients. Which cardiac rhythm is the priority for intervention by the nurse?
Ventricular fibrillation (VF) is a lethal arrhythmia characterized by disorganized electrical activity in the heart ventricles. Because of this erratic electrical activity, the heart's muscles lose the ability to contract, resulting in loss of blood flow and pulse (eg, cardiac arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation (Option 3). (Option 1) Atrial fibrillation is a cardiac arrhythmia characterized by disorganized electrical activity in the atria and an irregular pulse rate. Clients may experience this condition chronically or in response to other medical conditions (eg, electrolyte imbalance). However, a client with VF has no pulse and is the priority for care. (Option 2) Premature ventricular contractions are abnormal electrical impulses in the ventricles that may occur spontaneously or in response to heart irritants (eg, stimulant medications, electrolyte alterations, pain). This arrhythmia is typically not harmful but requires monitoring by the nurse. (Option 4) Ventricular tachycardia, a potentially lethal dysrhythmia characterized by organized, rapid firing of electrical activity within the ventricles, may impair perfusion and often leads to cardiac arrest and/or VF. However, clients may have a pulse with ventricular tachycardia, making the client with VF and no pulse the priority. Educational objective:Clients with ventricular fibrillation, a lethal arrhythmia, require immediate treatment with CPR and defibrillation. A pulse may be present in ventricular tachycardia, so it should be addressed as soon as possible. Atrial fibrillation and premature ventricular contractions are pulsatile rhythms.
