UWorld Questions
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. 1. "I will apply moisturizing lotion on my legs every day." 2. "I will elevate my legs at night when I am sleeping." 3. "I will keep my legs below heart level when sitting." 4. "I will start walking outside with my neighbor." 5. "I will use a heating pad to promote circulation."
1, 3, 4 Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene). Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development (Option 2) Elevating the legs promotes venous return, but does not promote arterial circulation. (Option 5) Heating pads should not be used in clients with altered perfusion or sensation due to the increased risk for burns. Educational objective: Peripheral artery disease increases the risk of tissue necrosis and limb loss. Management focuses on improving blood flow and circulation to the extremities through lifestyle changes and medications.
What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg? Select all that apply. 1. Crackles in lungs 2. Dry mucous membranes 3. Hypotension 4. Jugular venous distension 5. Pedal edema
1, 4, 5 CVP is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid volume problems. The normal CVP is 2-8 mm Hg. An elevated CVP can indicate right ventricular failure or fluid volume overload. Clinical signs of fluid volume overload include the following: Peripheral edema Increased urine output that is dilute Acute, rapid weight gain Jugular venous distension S3 heart sound in adults Tachypnea, dyspnea, crackles in lungs Bounding peripheral pulses
A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply. 1. Blood pressure of 90/70 mm Hg 2. Bounding peripheral pulses 3. Decreased breath sounds on left side 4. Distant heart tones 5. Jugular venous distension
1, 4, 5 Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Signs and symptoms of cardiac tamponade include: Hypotension with narrowed pulse pressure (Option 1) Muffled or distant heart tones (Option 4) Jugular venous distension (Option 5) Pulsus paradoxus Dyspnea, tachypnea Tachycardia (Option 2) Bounding pulses may be present during fluid overload or hypertension. They may also be present with anxiety or fever. The client with possible tamponade will have evidence of decreased cardiac output and is more likely to have weak, thready pulses. (Option 3) Decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax. Educational objective:The client with a moderate to large pericardial effusion is at risk for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, narrowed pulse pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The nurse should report these findings to the health care provider immediately and prepare for a pericardiocentesis.
The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker? 1. Auscultate the client's apical pulse rate 2. Measure the client's blood pressure 3. Obtain a 12-lead ECG 4. Palpate the client's radial pulse rate
1. Auscultate the client's apical pulse rate Clients with an implanted permanent pacemaker should be assessed for both electrical capture of heart rhythm and mechanical capture of heart rate. In atrial pacing, pacer spikes precede P waves, whereas in ventricular pacing, pacer spikes precede QRS complexes. Pacing spikes should be immediately followed by their appropriate electrical waveform, indicating electrical capture. Checking for mechanical capture is essential to ensure that the electrical activity of the heart corresponds to a pulsatile rhythm. The best method for checking for a pulsatile rhythm is to assess a central pulse (eg, auscultation of apical, palpation of femoral) (Option 1). This rate should be compared to the electrical rate displayed on the cardiac monitor to assess for pulse deficit. (Option 2) Blood pressure is an important assessment relating to cardiac output and organ perfusion, but it does not determine if the client's pacemaker is capturing the mechanical activity of the heart. (Option 3) A 12-lead ECG does not assess mechanical capture of cardiac activity via the client's pacemaker. (Option 4) Peripheral pulses (eg, radial, pedal, popliteal) are not the best indicators of mechanical action of the heart. Peripheral vasculature may have anatomical changes that impair pulse quality, leading to false perception of a pulse deficit. Educational objective: For clients with a newly implanted permanent pacemaker, the nurse should assess for electrical capture of heart rhythm (eg, ECG) and mechanical capture of heart rate (eg, pulse). A central pulse (eg, auscultation of apical, palpation of femoral) should be assessed to determine mechanical capture
The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply. 1. No sexual activity for at least 6 weeks postoperatively 2. Notify health care provider (HCP) of redness, swelling, or drainage at the incision site 3. Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP 4. Take a shower daily without soaking chest and leg incisions 5. Use lotion on incision sites with dressing changes if the area is dry
2, 3, 4 The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. Clarify no driving for 4-6 weeks or until the HCP approves. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). Notify the HCP if the following symptoms occur:Chest pain or shortness of breath that does not subside with restFever >101 F (38.3 C)Redness, drainage, or swelling at the incision sites (Option 2). Educational objective:Discharge teaching for a client recovering from a CABG should include instructions related to medications, activity level, driving, sexual activity, and symptoms to report to the HCP.
A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP? 1. Blood pressure (BP) of 140/86 mm Hg 2. Difficulty swallowing 3. Dry, hacking cough 4. Low back pain
2. Difficulty swallowing Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment. (Option 1) This BP reading is slightly elevated. The nurse would need to assess further to find out if this is a typical BP for this client. Given the client's history of aneurysm, this elevated BP may warrant treatment. (Option 3) The nurse would need to assess the client further as there are multiple causes of cough. (Option 4) Low back pain would be a concern if the client had a history of abdominal aortic aneurysm. Educational objective:The nurse should report swallowing difficulty immediately in a client with a thoracic aortic aneurysm. This could indicate that the aneurysm has increased in size and may require treatment.
The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which finding is most important to report to the health care provider (HCP)? 1. Nausea and vomiting 2. New S3 heart sound 3. Occasional unifocal premature ventricular contractions (PVCs) 4. Temperature of 100.4 F (38 C)
2. New S3 heart sound A large anterior wall MI can affect the pumping ability of the left ventricle, putting the client at risk for developing heart failure and cardiogenic shock. The new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension can signal heart failure and should be reported immediately to the HCP. (Option 1) Clients may experience nausea and vomiting during an MI resulting from stimulation of the vomiting center by severe pain or from vasovagal reflexes initiated from the area of the infarction. This finding is not as high a priority as the S3 heart sound. (Option 3) Dysrhythmias are a common complication after an MI. Occasional PVCs are not significant, but the nurse should further assess the client's potassium level and assess the apical-radial pulse for the presence of a pulse deficit. (Option 4) An increase in temperature following a MI is usually due to a systemic inflammatory process caused by myocardial cell death. The elevation may last as long as a week. This finding is not as significant as the S3 heart sound. Educational objective: The nurse should immediately report the new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension in the post MI client to the HCP. These findings may indicate the development of heart failure or cardiogenic shock.
The nurse receives handoff of care report on four clients. Which client should the nurse see first? 1. Client with atrial fibrillation who reports feeling palpitations and has an irregular pulse of 122/min 2. Client with liver cirrhosis who reports bleeding from an IV insertion site and has a platelet count of 48,000 mm3 (48 x 109/L) 3. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour 4. Client with pneumonia whose white blood cell count has increased from 14,000 mm3 (14 x 109/L) 8 hours ago to 30,000 mm3 (30 x 109/L)
3. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Cardiac tamponade decreases atrioventricular filling and impairs the heart's ability to contract and eject blood; it is life-threatening without prompt recognition and treatment. Clinical features of cardiac tamponade include hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) (Option 3). In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, and tachycardia may be present. (Option 1) Palpitations, tachycardia, and irregular pulse are expected findings in atrial fibrillation. Atrial fibrillation is usually a chronic arrhythmia. The heart rate must be controlled, but this is not a priority over tamponade. (Option 2) Liver cirrhosis causes portal hypertension and splenomegaly. An enlarged spleen sequestrates platelets, causing thrombocytopenia. Spontaneous bleeding requires further investigation after addressing a client with possible cardiac tamponade. (Option 4) Increased white blood cell count in a client with infection may indicate ineffective treatment and/or progression to sepsis, both of which require follow-up. However, this finding is not immediately life-threatening. Educational objective: Cardiac tamponade is a possible complication of acute pericarditis that impairs cardiac output and is life-threatening without immediate intervention. Clinical features of cardiac tamponade include hypotension, muffled heart sounds, and neck vein distension (Beck triad).
The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? 1.Assess incision for bleeding or hematoma formation 2. Auscultate bilateral anterior and posterior lung sounds 3. Initiate continuous cardiac monitoring 4. Reestablish IV fluids and postoperative antibiotics
3. Initiate continuous cardiac monitoring When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker. If the atrioventricular (dual-chambered) pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes (electrical capture). If the pacemaker is not working properly (eg, failure to capture, failure to sense), the health care provider should be contacted immediately (Option 3). The nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure.
A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action? 1. Auscultate the client's lungs 2. Check the client's capillary refill 3. Measure the client's blood pressure 4. Review the client's electrocardiogram (ECG)
3. Measure the client's blood pressure Sodium nitroprusside is a highly potent vasodilator (both venous and arteriolar). Venous dilation reduces preload (volume of blood in ventricles at the end of diastole), and arterial dilation reduces afterload (resistance ventricle must overcome to eject blood during systole). Sodium nitroprusside is commonly used in hypertensive emergencies and for conditions in which blood pressure control is of utmost importance (eg, aortic dissection, acute hypertensive heart failure). Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely due to hypotension. Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally develop fatal cyanide toxicity. Educational objective: Sodium nitroprusside is given as an infusion for the short-term treatment of acute decompensated heart failure, especially in clients with markedly elevated blood pressure. It is a potent vasodilator and reduces preload and afterload. The main adverse effect is symptomatic hypotension, necessitating close monitoring of blood pressure.
The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client? 1. A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg 2. A client just admitted from the emergency department with a BP of 150/72 mm Hg 3. A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin 4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg
4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg The MAP refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is between 70-105 mm Hg. If the MAP falls below <60 mm Hg, vital organs may be underperfused and can become ischemic. MAP can be calculated using the formula below: Mean Arterial Pressure =Systolic Blood Pressure + (Diastolic Blood Pressure × 2)3 A normal MAP is 70-105 mm Hg. The client with the BP of 106/42 mm Hg has a MAP of 63 mm Hg, in the abnormal range. The nurse should report this to the HCP and monitor the client closely. (Options 1, 2, and 3) These MAPs are within the 70-105 mm Hg normal range. Educational objective: Mean Arterial Pressure =Systolic Blood Pressure + (Diastolic Blood Pressure × 2)3 A normal MAP is 70-105 mm Hg. A MAP <60 mm Hg will not allow for adequate perfusion of vital organs.
The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time? Click on the exhibit button for additional information. 1. Call a code and begin chest compressions 2. Call the rapid response team and prepare for cardioversion 3. Document the findings in the chart and continue to monitor 4. Notify the cardiologist and prepare for temporary pacing
4. Notify the cardiologist and prepare for temporary pacing Radiofrequency ablation is performed through transvenous cardiac catheterization to ablate (ie, burn) electrical pathways causing supraventricular or ventricular tachydysrhythmias. Ablation performed near the atrioventricular (AV) node can damage conduction, causing varying degrees of AV block. Third-degree AV block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). On ECG, third-degree AV block presents as a regular rate and rhythm with disassociated P waves and QRS complexes. This type of AV block requires temporary or permanent pacing to restore electrical conduction and hemodynamic stability. Educational objective: Third-degree AV block results in disassociation of atrial and ventricular contraction due to blocked electrical conduction pathways. Temporary or permanent pacing is necessary to stabilize the client.
Which client should the nurse assess first? 1. client with afib with a new prescription of warfarin 2. client with COPD and O2 sat of 91% 3. client with postoperative pain rated 8 out of 10 4. client with third-degree heart block with a pulse of 42/min
4. client with third-degree heart block with a pulse of 42/min Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole (Option 4). Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed. (Option 1) Atrial fibrillation puts clients at risk for development of atrial thrombi, which can embolize and cause a stroke. Administration of warfarin (a long-term anticoagulant) is important to prevent thrombus formation; however, symptomatic third-degree AV block is a higher priority. (Option 2) Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal (eg, 91%). The goal in this client population is to keep the oxygen saturation 88-92%. (Option 3) The client experiencing severe postoperative pain should be assessed for surgical complications (eg, infection), and the pain should be treated (eg, with hydrocodone). However, severe pain does not take priority over third-degree AV block. The nurse can see the client as soon as possible or ask another nurse for help. Educational objective:Clients with third-degree atrioventricular (AV) block should be assessed immediately due to the potential for life-threatening consequences (eg, shock, syncope, asystole) caused by decreased cardiac output and severe bradycardia. The client with third-degree AV block requires a permanent pacemaker.
The nurse is caring for a client in the intensive care unit who has delirium. Which of the following client factors should the nurse identify as potential contributors to delirium? Select all that apply. 1. Blood cultures positive for gram-positive cocci 2. Continuous IV sedation 3. Elevated serum ammonia 4. Frequent monitor alarms 5. Serum glucose 45 mg/dL (2.5 mmol/L)
Delirium is a cognitive disorder characterized by an acute or fluctuating change in mental status, usually due to an underlying medical condition, that is often reversible with intervention. Factors contributing to the development of delirium include infection (eg, positive blood cultures); sedating medications; underlying disorders of major organs (eg, liver disease causing elevated serum ammonia); mechanical ventilation; sleep deprivation (eg, monitor alarms frequently waking the client); metabolic alterations (eg, hypoglycemia); and admission to an intensive care unit (Options 1, 2, 3, 4, and 5).
An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP goes back to assist the client with a shower, the client curses at and tries to hit the UAP. Which of the following is the most appropriate response by the registered nurse? Click on the exhibit button for additional information. 1. "I need to assess the client." 2. "It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable." 3. "Just leave the client alone now and try again later." 4. "The client probably has dementia and is under a lot of stress with the change of environment."
This client is exhibiting behaviors that are concerning for delirium. Therefore, the nursing priority is to perform a targeted assessment to determine whether the client has delirium and its cause. Delirium is characterized by behavior changes and confusion that have an acute onset, and it is usually reversible. Common causes in older adults include infection, medications, and hypoxia. This client's vital signs (mildly elevated temperature, respiratory rate, and hypoxia) and recent surgery suggest pulmonary infection as the cause of the delirium. Although a temperature of 98.7 F (37 C) is normal for younger adults, it may indicate fever in an 81-year-old as mean body temperature decreases with age. Other signs of pulmonary infection include crackles in the lungs, productive cough, and pleuritic chest pain. (Option 2) The nurse is making an assumption and there is not enough information to support dissatisfaction as the cause of this client's behavior. Further assessment is needed. (Option 3) This client is exhibiting signs of delirium, which is a medical emergency. Leaving the client alone without further assessment and appropriate, timely intervention would constitute negligence. (Option 4) The nurse is assuming that the client has dementia based on age. However, only 1 of every 8 older adults has dementia. Educational objective: Delirium is a common manifestation of a serious physiologic instability in older adults and is characterized by acute changes in cognition and behavior. When a client is suspected of having delirium, the nursing priority is assessment for the cause of the delirium to guide interventions.