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Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?
Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child. Based on the symptoms the child is exhibiting (irritability, confusion), hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death. (Option 2) Buttock abscess, although painful, is not an emergency. Incision and drainage are needed. (Option 3) Immune thrombocytopenia (idiopathic thrombocytopenic purpura) can be a serious condition due to the risk for bleeding. A client with this condition should be assessed for internal bleeding following an injury, especially to the head. Shoulder pain is not a symptom associated with life-threatening bleeding; therefore, this client is not the top priority. (Option 4) This child with brassy (barking) cough most likely has croup, which can be life threatening and needs urgent assessment. However, because this client seems to be stable, the child with possible glyburide ingestion should be seen first. This child has mild retractions, a sign that the child is still moving air but work of breathing has increased. The presence of stridor or severe suprasternal, subcostal, and intercostal retractions would make this client a higher priority. Educational objective: Ingestion of antidiabetic drugs (eg, glyburide, glipizide, glimepiride) by a nondiabetic client (eg, child) is an emergency as severe hypoglycemia can result in coma and/or death.
The nurse is preparing to administer 40 mg of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters? Select all that apply
Loop diuretics (furosemide, torsemide, bumetadine) 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
The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention?
New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment. (Option 1) Loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening. (Option 2) A painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly. (Option 4) Strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly. Educational objective: New onset of dependent edema in an elderly client could be due to heart failure; the client needs further assessment for characteristic signs such as lung crackles and increased body weight (fluid retention).
Postprocedure care of a client who has undergone cardiac catheterization should focus on monitoring
Postprocedure care of a client who has undergone cardiac catheterization should focus on monitoring hemodynamics (eg, blood pressure, heart rate, strength of distal pulses, temperature of extremities). The client should be also assessed several times per hour (eg, approximately every 15 minutes) for active bleeding or hematoma formation at the incision. Any report of back or flank pain should be investigated for possible retroperitoneal bleeding. Back pain, tachycardia, and hypotension may be the only indications of bleeding as it can take up to 12 hours before a significant drop in hematocrit can be measured. Hemorrhage after cardiac catheterization is particularly dangerous due to the frequent use of anticoagulant prescriptions in these clients. (Option 1) A heparin infusion is used to treat deep venous thrombosis. An activated partial thromboplastin time of 60 seconds is a therapeutic value. The therapeutic range for a client on anticoagulation is usually 46-70 seconds (1½ -2 times the normal value). (Option 3) A client with a head injury should be evaluated hourly for any change in neurological status. However, the highest possible score on the Glasgow Coma Scale is 15 for a fully alert person; a client with a score of 14 does not require urgent attention. (Option 4) The report of incisional pain on postoperative day 2 would take second priority for further assessment, but evaluating a client with possible internal bleeding is the priority. Educational objective: Clients with any indication of compromised airway, breathing, or circulation always take priority. The onset of back pain after angiography always requires further assessment to monitor for retroperitoneal bleeding.
A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information.
The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client. (Option 1) Atropine is administered to clients with symptomatic bradycardia; however, this client's symptoms are caused by failure to capture. Therefore, obtaining capture via transcutaneous pacing should resolve the client's symptoms. (Option 2) Dopamine is an inotrope used to treat hypotension due to bradycardia. This client is bradycardic and hypotensive due to failure to capture. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. (Option 4) The health care provider needs to be notified, but the nurse should first use the transcutaneous pacemaker to stabilize the client.
The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip?
The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks). (Option 2) In first-degree atrioventricular block, every impulse is conducted to the ventricles, but the time of atrioventricular conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option 3) Normal sinus rhythms do not have pacer spikes. Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option 4) Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations (eg, pacer spike on the T wave). It should not be confused with failure to capture, in which pacer spikes are located appropriately but there is no electrical response elicited from the heart (eg, no QRS complex after a pacer spike).
A client with ST segment elevation myocardial infarction (MI) is due for 9:00 AM medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply. Click on the exhibit button for additional information.
he client should receive aspirin (Option 1), docusate sodium (Option 2), and lisinopril (Option 3). Antiplatelet agents (eg, aspirin, clopidogrel) are administered to clients with heart disease to reduce inflammation and inhibit platelet aggregation. The client's platelet count (normal 150,000-400,000/mm3 [150-400 X 109/L]), hemoglobin, and hematocrit are normal, so it is safe to administer this medication (Option 1). Docusate sodium is a stool softener. The client who has had an MI should not strain during bowel movements due to the risk of producing a vagal response, putting the client at risk for bradycardia and other dysrhythmias (Option 2). Angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, benazepril, captopril) are commonly given to clients post MI to prevent the progression of heart failure. Because ACE inhibitors have the potential to cause hyperkalemia and hypotension, the nurse should assess the potassium level and blood pressure (BP) prior to administration. This client's BP and potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) are within normal range (Option 3). (Option 4) Beta blockers (eg, metoprolol, propranolol, atenolol) are given to clients post MI to reduce the risk of reinfarction and the occurrence of heart failure. A side effect of this medication is bradycardia (<60/min). This client is experiencing bradycardia with a heart rate of 52/min. The nurse should hold this medication and report findings to the registered nurse. (Option 5) Simvastatin is a lipid-lowering medication prescribed to clients to reduce triglycerides and LDL cholesterol. This medication is not due at 9:00 AM. Educational objective: BP and serum potassium levels are checked prior to administration of ACE inhibitors. Heart rate should be checked prior to administration of beta blockers. Aspirin is given to clients with normal platelet counts. Stool softeners reduce straining during defecation which helps prevent a vagal response
The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities. Client instructions include the following: Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances Do not bathe or shower during the test period (Option 4) Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record (Option 3) (Option 1) The data are not generally transmitted over the phone. The client simply takes the monitor back to the HCP's office.
The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse?
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). Increased pericardial fluid places pressure on the heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-threatening without immediate intervention. When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest. (Option 1) In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside table) to lean on for comfort. (Option 3) ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in only localized leads (depending on which vessel is occluded). (Option 4) Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium rubbing together to create a characteristic high-pitched, leathery, and grating sound.
A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor? Click on the exhibit button for additional information.
An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.
Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium
The client is scheduled to have a cardiac catheterization. Which of the following findings would cause the nurse to question the safety of the test proceeding? Select all that apply.
Cardiac catheterization involves injection of IV iodinated contrast to assess for obstructed coronary arteries. Potential complications of IV iodinated contrast include: Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast medium (Option 2). Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore, health care providers may discontinue metformin 24-48 hours before administration of contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option 4). Contrast-induced nephropathy: Iodinated contrast can cause acute kidney injury in clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]). Therefore, clients with renal impairment should not receive iodinated contrast unless absolutely necessary (Option 5)
A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which client statement regarding digoxin toxicity indicates that teaching reinforcement is needed?
Drug toxicity is common with digoxin use due to its narrow therapeutic range. Many contributing factors (eg, hypokalemia) can cause toxicity. However, in the absence of other factors, potassium intake does not need to be increased when a client is taking digoxin. If the client also takes other potassium-depleting medications (eg, diuretics), potassium supplements may be needed. Signs and symptoms of digoxin toxicity include the following: Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms (Option 2) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness Cardiac arrhythmias are the most dangerous
The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply.
Hypertension is referred to as the "silent killer" as many clients are asymptomatic. Untreated chronic hypertension can result in damage of various organs and tissues and increases the risk for renal failure, coronary artery disease, stroke, and heart failure. Appropriate client screening based on risk factors is key to preventing complications. This client has both nonmodifiable (eg, African American ethnicity) and modifiable (eg, diabetes mellitus type 2, chronic stress, smoking) risk factors (Options 1, 2, 3, and 5). To prevent future comorbidities, the nurse should educate the client on smoking cessation, appropriate diabetes management, and therapeutic strategies for stress management at work. (Option 4) Clients should be screened for potential hyperlipidemia. An LDL laboratory value of 94 mg/dL (2.43 mmol/L) is within recommended parameters (<100 mg/dL [<2.6 mmol/L]).
A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? Click the exhibit button for additional information.
In heart failure, cardiac output is reduced because the heart is unable to pump blood adequately. This reduction in cardiac output reduces perfusion to the vital organs, including the kidneys. Decreased renal blood flow triggers the kidneys to activate the renin-angiotensin system as a compensatory mechanism, which increases blood volume by increasing water resorption in the kidneys. This compensatory mechanism results in fluid volume excess and dilutional hyponatremia (more free water than sodium). Dilutional hyponatremia can be treated with fluid restriction, loop diuretics, and ACE inhibitors (eg, lisinopril, captopril). Furosemide works to resolve hyponatremia by promoting free water excretion, allowing for hemoconcentration and increased sodium levels (Option 3).
home management for a client with peripheral arterial disease
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
Discharge teaching for a client who had deep venous thrombosis (DVT) emphasizes minimization of risk factors and interventions to promote blood flow and venous return and prevent reoccurrence.
Teaching points include the following: Drink plenty of fluids and limit caffeine and alcohol intake to avoid dehydration, which predisposes to blood hypercoagulability and venous thromboembolism (Option 2). Elevate legs when sitting, and dorsiflex the feet often to reduce venous hypertension and edema and to promote venous return (Option 3). Begin or resume a walking/swimming exercise program as soon as possible to promote venous return through contraction of the calf and thigh muscles (Option 4). Change position frequently to promote venous return and circulation and prevent venous stasis. Stop smoking to prevent endothelial damage and vasoconstriction as this promotes clotting. Avoid wearing restrictive clothing (eg, Spanx, tight jeans) that interferes with circulation and promotes clotting. The nurse would suggest consultation with a nutritionist or enrollment in a weight-loss program to overweight/obese clients as excess weight contributes to venous insufficiency and hypertension by compressing large pelvic vessels
The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened, and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: Wear gloves when handling cold objects (Option 5). Dress in warm layers, particularly in cold weather. Avoid extremes and abrupt changes in temperature. Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). Avoid excessive caffeine intake (Option 1). Refrain from use of tobacco products (Option 4). Implement stress-management strategies (eg, yoga, tai chi) (Option 3). If conservative management is unsuccessful, calcium channel blockers may be prescribed to relax arteriole smooth muscle and prevent recurrent episodes. (Option 2) Cold water causes vasoconstriction and worsens the condition.
The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document? Listen to the audio clip.(Headphones are required for best audio quality.)
S1 and S2 are the normal "lub-dub" heart sounds that result from closure of valves. Systole occurs between S1 and S2, with S1 indicating closure of the atrioventricular (tricuspid, mitral) valves and S2 indicating closure of the pulmonic and aortic valves. S3 is an adventitious (extra) heart sound heard as "DUB" immediately following S2 (Option 3). S3 occurs during early diastole as a result of rapid ventricular filling and is a normal finding in children and young adults. In older adults, S3 is an abnormal finding that often indicates heart failure because the sound results from decreased ventricular compliance. S3 can be difficult to distinguish from S4. S4 is a "LUB" sound that occurs immediately before S1, during late diastole, and indicates ventricular hypertrophy. (Option 1) A pericardial friction rub is a creaky, grating sound heard throughout systole and diastole. Friction rub occurs with pericarditis and is due to friction between inflamed layers of pericardium. (Option 2) S1 and S2 are the normal heart sounds heard during cardiac auscultation. (Option 4) A murmur is a swooshing, blowing, or rumbling sound caused by turbulent blood flow (eg, from valve regurgitation or stenosis). Educational objective: S3, the third heart sound, is a "DUB" sound that immediately follows S2. It is a normal finding in children and young adults. S3, an abnormal finding in older adults, often indicates heart failure.
A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply.
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 client is admitted to the emergency department after a fall with dizziness and light-headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the exhibit. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.
Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate of <60/min. SB is classified as symptomatic if, in addition to a heart rate <60/min, the client experiences such symptoms as dizziness, syncope, chest pain, and hypotension. The clinical significance of SB depends on how the client tolerates it. The client with symptomatic SB is first treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine is considered. A permanent pacemaker may be needed. If SB is the result of a medication (eg, beta blocker, digoxin), the drug may need to be held, discontinued, or given in a reduced dosage. (Option 1) Complete heart block, or 3rd-degree atrioventicular (AV) block, is a form of AV dissociation in which no impulses from the atria are conducted to the ventricles. The atria are stimulated and contract independently of the ventricles. The ventricular rhythm is an escape rhythm. (Option 2) In 1st-degree AV block, every impulse is conducted to the ventricles, but the time of AV conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. (Option 4) Sinus rhythm has a rate of 60-100/min.
The practical nurse is performing a cardiac assessment in collaboration with the registered nurse. Where does the nurse expect to feel the client's point of maximal impulse?
The point of maximal impulse (PMI) is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular line, the heart may be enlarged.
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).
The practical nurse is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis?
Venous thromboembolism includes both deep venous thrombosis (DVT) and pulmonary embolism (PE). DVT is more common and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common theories behind the pathophysiology of venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: Trauma (endothelial injury and venous stasis from immobility) Major surgery (endothelial injury and venous stasis from immobility) Prolonged immobilization (eg, stroke, long travel) causing venous stasis Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) Oral contraceptives (estrogen is thrombotic) Underlying malignancy (cancer cells release procoagulants) Smoking (produces endothelial damage by inflammation) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase in blood viscosity from an increase in one or more blood cell types) such as polycythemia vera The 80-year-old 4-day postoperative client is at greatest risk for developing DVT due to having the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age. (Option 1) Smoking cigarettes and using oral contraceptives increase plasma fibrinogen and coagulation factors and cause hypercoagulability of blood; however, this client is not at greatest risk. Hormonal contraceptives are not recommended if the client is age >35 and smokes. (Option 2) An elevated hemoglobin/hematocrit level (erythrocytosis) causes increased blood viscosity and hypercoagulability of blood, which increase the risk for DVT. However, this client is not at greatest risk. (Option 3) Anticoagulants and antiplatelet agents are administered before and after coronary stent placement. This client is at increased risk due to endothelial damage and advanced age but is not at greatest risk. Educational objective: Deep venous thrombosis (DVT) is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.
Clinical manifestations of a lower-extremity DVT include
unilateral edema, calf pain or tenderness to touch, warmth, erythema, and low-grade fever
The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding?
A pharmacologic nuclear stress test uses vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected to allow a special camera to produce images of the heart. Based on these images, the health care provider (HCP) can determine whether there is adequate coronary perfusion. Preprocedure client instructions include: Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours) (Options 1 and 2). Avoid caffeine (including decaffeinated products) 24 hours before the test (Option 3). If insulin/pills are prescribed for clients with diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 4). Some medications can interfere with test results by masking angina. Do not take certain cardiac medications (eg, nitrates, dipyridamole, beta blockers) unless the HCP directs otherwise or unless needed to treat chest discomfort on the day of the test. Educational objective: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; they should avoid caffeinated products for 24 hours before the test and avoid taking certain cardiac medications (eg, nitrates, beta blockers) unless otherwise instructed by the health care provider.
A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? Click on the exhibit button for additional information.
A premature ventricular contraction (PVC) is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement). (Option 1) Atrial fibrillation is a total disorganization of atrial electrical activity. P waves are replaced by fibrillatory waves. Ventricular rate varies and the rhythm is usually irregular. (Option 2) A premature atrial contraction (PAC) is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave of a PAC has a different shape than the P wave that originated in the sinus node. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle.
The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the highest priority to report to the registered nurse?
In infective endocarditis (IE), the vegetations growing on the valves can break off and embolize to various organs, resulting in life-threatening complications, including: Stroke: Paralysis on one side Spinal cord ischemia: Paralysis of both legs Ischemia to the extremities: Pain, pallor, and cold foot or arm Intestinal infarction: Abdominal pain Splenic infarction: Left upper quadrant pain (Options 2 and 4) IE commonly presents with fever, arthralgias (multiple joints pains), weakness, and fatigue. These are expected and do not need to be reported during the initial stages of treatment. IE clients typically require IV antibiotics for 4-6 weeks. Fever may persist for several days after treatment is started. If the client is febrile persistently after 1-2 weeks of antibiotics, this must be reported as it may indicate ineffective antibiotic therapy. (Option 3) Splinter hemorrhages can occur with infection of the heart valves (endocarditis). They may be caused by damage from swelling of the blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli). The presence of splinter hemorrhages is not as critical as the macroemboli causing a stroke or painful cold leg.
The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?
The basic life support sequence is compressions, airway, and breathing (mnemonic - CAB). High-quality CPR is associated with improved client outcomes and begins with high-quality chest compressions (ie, 100-120/min, 2-2.4 in [5-6 cm] deep). Any unwitnessed collapse should be treated with 2 minutes of CPR, followed by activating the emergency response system and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume high-quality chest compressions immediately (Option 3). (Option 1) Chest compressions should not be interrupted for more than 10 seconds when assessing for a pulse and chest rise/fall. (Option 2) Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to clients who have a pulse but are not breathing normally. For clients with no pulse, the nurse should deliver cycles of 30 compressions followed by 2 rescue breaths. (Option 4) The jaw-thrust maneuver is used instead of the head-tilt/chin-lift method in clients who may have a head/spinal injury. Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing. Assessing the airway is not indicated at this time.
The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.
VF is characterized on the ECG by irregular waveforms of varying shapes and amplitudes. This represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover. VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization procedures due to catheter stimulation of the ventricle. Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine, vasopressin, amiodarone). (Option 1) Asystole is the total absence of ventricular electrical activity. (Option 2) Atrial fibrillation is characterized by total disorganization of atrial, not ventricular, activity. QRS complexes are usually normal in morphology. P waves are not seen. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. Educational objective: The nurse should recognize VF, a potentially lethal dysrhythmia. The ECG shows irregular waveforms of varying shapes and amplitudes. The client is unresponsive, pulseless, and apneic. Rapid treatment should include CPR, defibrillation, and drug therapy (eg, epinephrine, vasopressin, amiodarone)
An implantable cardioverter defibrillator (ICD) is a
medical device that is surgically implanted underneath the skin that can sense life-threatening arrhythmia and discharge electrical shocks directly into the cardiac muscle to correct the arrhythmia. Clients typically receive ICDs after a history of sustained or recurrent ventricular tachycardia (VT), including personal or family history of sudden cardiac death and severe heart failure. When caring for a client with an ICD, it is critical that the nurse monitor for ICD firings (eg, client report, observation on cardiac monitors). After firings, the nurse should monitor for resolution of the arrythmia, indications of hemodynamic compromise (eg, hypotension, chest pain, altered mentation), and additional ICD discharges. Occasionally, an ICD may be unable to convert the arrythmia to a hemodynamically stable rhythm and will repeatedly shock the client. If the client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should promptly obtain a manual external defibrillator and initiate measures to prevent hemodynamic instability and cardiac arrest (Option 4)
