Week 9 4.0 Principles

Obtain an order to change the route of the demerol

A client develops a deep vein thrombosis following a total hip replacement and is placed on a continuous heparin infusion. The client has an order for hydromorphone 2mg intramuscular injection every 6 hours for pain. Which of the following actions would the nurse implement? Answer Options * Keep vitamin K on hand in case the client has signs of bleeding Obtain an order to change the route of the demerol Instruct the client that petechiae is a normal finding Assess the pedal pulses and leg circumference every shift

Initiating cardiac defibrillation for the client.

A client is found unresponsive and without a pulse. The client's electrocardiogram (ECG) shows ventricular tachycardia. The nurse knows the most effective treatment to increase this client's chance for survival is which of the following? Answer Options * Intubating and providing mechanical ventilation. Initiating cardiac defibrillation for the client. Giving epinephrine 1 mg intravenous administration. Performing adequate quality chest compressions.

Tachycardia

A client presents to the emergency department complaining of dizziness. The client has a history of atrial fibrillation and is on Coumadin. Which of the following assessment findings indicates bleeding? Answer Options * Hypertension Tachycardia INR of 2.0 Bradypnea

Sudden onset of epistaxis

A client presents to the emergency department with a pulmonary embolus. The client has been started on a heparin drip. Which of the following observations by the nurse should be immediately reported to the health care provider? Answer Options * Sudden onset of epistaxis Insomnia and constipation Polyuria and depression New onset of diabetes

Vagal maneuvers.

A client presents with complaints of palpitations and dizziness. The electrocardiogram (ECG) shows Sinus Tachycardia with a heart rate of 180 beats per minute. The nurse expects which of the following treatments may be ordered for this client? Answer Options * Oral nitrates. Defibrillation. Vagal maneuvers. Oral aspirin.

Lower extremity edema

A client receiving chemotherapy for cancer treatment reports a lack of appetite that has resulted in reduced dietary intake. The client has an albumin level that has dropped to 2.0 g/dL. Which of the following clinical manifestations should the nurse assess for when determining the validity of this lab? Answer Options * Conjunctival pallor Lower extremity edema Urinary frequency Increased bowel sounds

Elevated cholesterol can increase your risk for CAD'

A client returns to the doctor's office to discuss the laboratory results. The client said to the nurse all my blood results are normal except for my cholesterol. Why is it such a big deal. Which response made by the nurse is most appropriate? Answer Options * ' Try not to worry, things will work out just fine' ' Elevated cholesterol is an indication of heart failure' ' I am sure the doctor will put you on a diet with medications' 'Elevated cholesterol can increase your risk for CAD'

Check the client's heart rate and blood pressure

A client who had a thoracoscopy performed returns to the unit and is requesting breakfast. Which of the following actions is a nursing priority? Answer Options * Assess the previous 24 hour intake and output Give the client ice chips to determine fluid tolerance Check the client's heart rate and blood pressure Give the client pain medication prior to eating

Keep the client in bed with the left leg elevated.

A client who had a total knee replacement two days ago complains of an aching pain to the left leg. The nurse notes that the distal part of the left leg is warm, erythematous and swollen. Which action by the nurse is a priority? Answer Options * Apply a sequential compression device. Assess for a positive Homan's sign in each leg. Obtain an order for a broad spectrum antibiotic. Keep the client in bed with the left leg elevated.

Heart rate of 48 and dizziness

A client who has a pacemaker inserted 10 years ago complains of shortness of breath, fatigue, and weakness. Which of the following assessment findings suggests a complication related to the pacemaker? Answer Options * Heart rate of 48 and dizziness Hypertension and irritability Oxygen saturation of 98% and heart rate 120 bpm Headache, vomiting, nausea, and tachycardia

Elevated serum C-reactive protein

A client who has osteoarthritis complains of increased shoulder pain. Which of the following findings best supports inflammation? Answer Options * Daily use of extra-strength acetaminophen Elevated serum C-reactive protein Facial grimacing noted by the nurse A decrease in prostaglandin activity

Coumadin could cause significant bleeding'

A client who is scheduled for a colonoscopy was instructed to stop taking warfarin (Coumadin) five days before the procedure. The client asks the nurse the reason for stopping the medication? Which of the following statements made by the nurse is appropriate? Answer Options * 'It was a mistake please don't stop coumadin' 'Coumadin could cause significant bleeding' 'Coumadin can affect the accuracy of the test' 'This procedure can't be done with coumadin'

Black tea Hot chocolate Caffeinated energy drinks

A client's diet is modified to eliminate foods that act as cardiac stimulants. What should the nurse teach this client to avoid? (Select all that apply.) Answer Options * Black tea Red meat Club soda Hot chocolate Caffeinated energy drinks

Principle:

A decrease in cardiac output may result in dizziness, fatigue, chest pain, and palpitations ; Page# 731

Internal bleeding

A male client has been on warfarin (Coumadin) for three days and is still receiving intravenous heparin. The nurse notes that the blood pressure is 110/60, heart rate 136 and red blood cell (RBC) count of 3.9 cells/mcL. Based on the findings, the nurse anticipates which of the following complications? Answer Options * Drug overdose Thrombocytopenia Tachycardic crisis Internal bleeding

A client who is having ventricular fibrillations

A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority? Answer Options * A client with a 102.1 temperature A client with a recent fractured femur A client who is having ventricular fibrillations A client who complains of severe abdominal pain

Right-sided chest discomfort 4 days postoperatively

A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. Which of the following clinical findings require the nurse to notify the practitioner? Answer Options * Lack of a productive cough 2 days postoperatively Rectal temperature of 100.2F 2 days postoperatively Right-sided chest discomfort 4 days postoperatively Pain to the operative site 4 days postoperatively

Principle:

A priority action in the setting of dysrhythmias is to maintain cardiac output ; Page# 730

Principle:

Adenosine must be administered rapidly and is used to abort tachycardia in the setting of atrial flutter or sinus tachycardia with hemodynamic instability ; Page# 720

Principle:

Alcohol, caffeine or nicotine could contribute to premature ventricular contractions ; Page# 729

Principle:

Ambulation, sequential compression devices, and anti-embolism stockings promote venous return ; Page# 872

Principle:

Anticoagulants can be given to prevent clots from getting larger but they do NOT dissolve clots ; Page# 869

Principle:

Apply compression stockings prior to the patient getting out of bed and remove at night ; Page# 873

Principle:

Aslsess heart rate by counting the R-R intervals in 6 seconds and multiply by 10 or count the number of large boxes within the R-R interval and divide 300 by that number ; Page# 714

Principle:

Assess pulses using light palpation ; Page# 847

Principle:

Atropine (an anticholinergic) is given to block vagal stimulation and increase heart rate during sinus bradycardia ; Page# 718

Principle

Avoid raising the hands over the head for 2 weeks or heavy lifting followng the insertion of a cardiac device ; Page# Pacemakers are typically monitored every 4 weeks ; Page# 740

Principal

Bleeding is a key complication of anticoagulant therapy ; Page# 872

Principle:

Bleeding is a key complication of anticoagulant therapy ; Page# 872

Principle:

Bleeding is always a risk of angiograpy and procedures ending in oscopy (ex. bronchoscopy)! ; Page# 849

Principle:

Cancer, pregnancy, immobility and clotting disorders increase the risk for deep vein thrombosis and pulmonary embolism ; Page# 864

Principle:

Capillaries are a single layer which allows for gas and nutrient exchange ; Page# 842

Principle:

Cholesterol levels greater than 200 mg/dL increases the risk for coronary artery disease ; Page# 850

Principle:

Classic signs of deep vein thrombosis include edema to the extremity, warmth, tenderness or fullness in the leg ; Page# 868

Principle:

Constricting blood vessels under the knees increases the risk for deep vein thrombosis ; Page# 853

Principle:

Defribillation safety consists of maintaining good contact between the skin and paddles (use a conductive medium) and confiming that no one is touching the patient ; Page# 731

Principle:

Determine changes in arterial blood flow by assessing for pain, pallor, paresthesia, paralysis, poikilothermia/polar, pulselessness and capillary refill ; Page# 864

Principle:

Dysrhythmias can impair the heart rate and rhythm and result in a decrease in blood pressure ; Page# 714

Principle:

Edema could result from an increase in hydrostatic pressure or a decrease in oncotic pressure ; Page# 844

Principle:

Elevated C-reactive protein levels suggests inflammation ; Page# 851

Principle:

Elevating the legs promotes venous return but is contraindicated with arterial insufficiency ; Page# 853

Principle:

Exercise, fever, and catecholamines increase sympathetic stimulation and could result in dysrhythmias ; Page# 714

Principle:

Heparin and coumadin may be given together until the international normalized ration (INR) is therapeutic between 2-3 ; Page# 869

Principle

High-density lipoproteins bring cholesterol from the blood to the liver to be broken down while Low-density lipoproteins invade the wall of vessels contributing to plaque formation and a narrowed lumen ; Page# 754

Principle:

Hydrostatic pressure moves fluid from the intravascular compartment to the intercellular ; Page# 844

Principle:

Illicit drugs like amphetamines and cocaine can increase the heart rate and lead to dysrhythmias ; Page# 717

Principle

Impaired cardiac conduction between the sinoatrial node, atrial ventricular node, bundle of His, right and left bundle branch and the Purkinje fibers contributes to dysrhythmias ; Page# 715

Principle:

Instruct patients to place cell phones 6-12 inches away from the pacemaker generator and handheld screening devices used in airports may interfere with the pacemaker ; Page# 740

Principle:

Instruct patients to take the anticoagulant at the same time every day and to notify their provider with any signs of bleeding (reddish or brownish urine, epistaxis, tarry stools) ; Page# 870

Principle:

Instruct the patient to lower the extremities below the level of the heart in the setting of arterial insufficiency and to raise the extremity in the setting of venous insufficiency ; Page# 849

Protamine sulfate

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? Answer Options * Vitamin K Protamine sulfate Glucagon Calcium Gluconate

Principle:

On an EKG, the p wave represents atrial depolarization, the QRS represents ventricular depolarization, the T wave represents ventricular repolarization, the ST segment indicates early ventricular repolarization, U wave is sometimes seen in the setting of hypokalemia ; Page# 714

Principle:

Pacemaker malfunction could result in bradycardia and a decrease in heart rate ; Page# 739

Principle:

Peripheral vascular disease is marked by an inability of arterial blood flow to meet the oxygen demand of tissue in the periphery or an impaired ability to bring venous blood flow back to the heart ; Page# 870

Principle:

Prepare to administer vitamin K for coumadin toxicity or protamine sulfate for heparin toxicity ; Page# 870

Principle:

Proteins like albumin create an oncotic pressure which pulls fluid from the interstitial compartment into the intravascular compartment to maintain volume. ; Page# 845

Two-days post-operative client with swelling and tenderness in left calf when ambulating

Several clients on a surgical unit have had surgery. Who should the nurse see first after receiving report? Answer Options * One-day post-operative client who is not ambulating enough One-day post-operative client who wants a pain pill two hours before it is scheduled Two-days post-operative client with swelling and tenderness in left calf when ambulating Two-days post-operative client scheduled for discharge who has colostomy care questions

Principle:

Stimulation of the parasympathetic nervous system results in vagal nerve innervation and a slowing of the heart rate ; Page# 714

Principle:

The ankle-brachial index is used to determine the degree of stenosis in the extremities ; Page# 847

Blood pressure.

The client complains of feeling heart palpitations at rest. The nurse notes frequent premature ventricular contractions (PVCs) on the electrocardiogram (ECG). What is the priority nursing assessment for this client? Answer Options * Capillary refill. Lung sounds. Respiratory rate. Blood pressure.

Caffeine Alcohol Tobacco

The client presents to the health clinic with a complaint of feeling skipped beats. The electrocardiogram (ECG) shows normal sinus rhythm with occasional premature ventricular contractions (PVCs). The nurse should assess the client's intake of which of the following? Select all that apply. Answer Options * Milk Caffeine Water Alcohol Tobacco

IV rapid push of Adenocard (adenosine)

The client presents with hypotension, dyspnea, and decreasing level of consciousness. The client's electrocardiogram (ECG) shows a heart rate 190 beats per minute with QRS complexes measuring 0.06 seconds. The nurse prepares to perform which of the following actions? Answer Options * IV slow push of atropine IV rapid push of Adenocard (adenosine) IV slow push of Cordarone (amiodarone) IV rapid push of Procainamide

Avoid reaching for objects above the head for 2 weeks. Pacemaker should be monitored every month.

The nurse includes which of the following discharge instructions for a client following pacemaker insertion? Select all that apply. Answer Options * Avoid reaching for objects above the head for 2 weeks. Lifting up to 10 pounds is allowed three days after insertion. Wear a lead shield if you have to have an MRI. Pacemaker should be monitored every month. Swelling, pain, and redness at insertion site expected for up to 5 days.

Use cell phones on the opposite side of insertion site

The nurse includes which of the following discharge instructions for a client who had pacemaker insertion? Answer Options * Increase your intake of fluids if you begin to hiccup Redness and swelling at the insertion site is expected Use cell phones on the opposite side of insertion site Avoid using the microwave while the pacemaker is on

Check the client's apical pulse

The nurse interprets the client's electrocardiogram (ECG) rhythm as Ventricular Tachycardia (VT). Which nursing intervention takes first priority? Answer Options * Start cardiopulmonary resuscitation (CPR) Prepare to defibrillate Assess the client's level of pain Check the client's apical pulse

Lightly palpate the pulses in the right lower extremity

The nurse is assessing the neurovascular status of a client who has just returned from having a cardiac catheterization where the right femoral artery was used. Which action performed by the nurse is appropriate? Answer Options * Compare the rate of the right carotid and right pedal pulse Lightly palpate the pulses in the right lower extremity Assess the right and the left leg for any signs of hair loss Massage the right lower extremity before assessing capillary refill

Assess client's potassium level

The nurse is caring for a client on telemetry. The nurse observe a U wave on the client's electrocardiogram strip. The client denies any chest pain or palpitations. Which action should the nurse take next? Answer Options * Associate the finding to artifacts Assess client's potassium level Perform a 12 lead electrocardiogram Notify the rapid response team immediately

Sinus Tachycardia

The nurse is caring for a client who had a cocaine overdose. The nurse anticipates which dysrhythmia would be consistent with this situation? Answer Options * Sinus Bradycardia Sinus Tachycardia Atrial Fibrillation Atrial Flutter

Swelling to the right calf

The nurse is caring for a client who had an open reduction internal fixation two days ago to repair a right hip fracture. The nurse is concerned that the client may have developed a deep vein thrombosis. Which of the following clinical manifestations best supports the diagnoses. Answer Options * Positive Homan's sign Cold and tender extremity Shortness of breath Swelling to the right calf

Determine the degree of stenosis in the client's leg

The nurse is caring for a client with a history of peripheral arterial disease. The health care provider has ordered an ankle-brachial index test. The nurse understands that this exam will Answer Options * Help promote blood return and relieve any edema Determine the degree of stenosis in the client's leg Help promote arterial dilation in the lower extremity Determine if there is venous insufficiency as well

Brown discolored skin to legs

The nurse is caring for a client with chronic venous insufficiency. Which assessment finding is consistent with this disorder? Answer Options * Pedal pulses 1+ Intermittent claudication Brown discolored skin to legs Lower extremities without hair

+1 pedal pulse

The nurse is caring for a client with peripheral vascular disease. Which of the following findings is consistent with arterial insufficiency? Answer Options * Pitting edema Skin hot and dry +1 pedal pulse Capillary refill less than 3 seconds

Reduced cardiac output

The nurse is caring for a client with severe bradycardia and frequent syncopal episodes. The client complains of being too tired to get out of bed or eat. Which of the following is the priority nursing diagnosis? Answer Options * Reduced cardiac output Impaired nutrition Altered gas exchange Activity intolerance

Obesity Damage to blood vessels Blood pooling in the extremities Crosses legs when sitting

The nurse is completing a preoperative assessment on a female client who is scheduled for kidney surgery. Which of the following findings increases the client's risk for deep vein thrombosis? Select all that apply: Answer Options * Orthostatic hypotension Elevated creatinine Obesity Damage to blood vessels Blood pooling in the extremities Crosses legs when sitting

State 'All Clear' and verify no one has contact with client or bed.

The nurse is part of a code team caring for a client in cardiac arrest. The nurse has correctly applied the defibrillator pads to the client's chest and determined that the client is in ventricular fibrillation. What is the nurse's next action? Answer Options * Administer epinephrine 1 mg intravenous (IV) push. Deliver the shock and immediately resume chest compressions. State 'All Clear' and verify no one has contact with client or bed. Insert airway and begin bag valve mask ventilations.

Take warfarin at the same time each day. Use a soft-bristled tooth brush for oral care. Notify health care provider if tarry stools occur.

The nurse is preparing a client who started on warfarin (Coumadin) for discharge. Which of the following teaching points must the nurse include in the discharge instructions? Select all that apply. Answer Options * Avoid any green leafy vegetables. Report burning or pain while voiding. Take warfarin at the same time each day. Use a soft-bristled tooth brush for oral care. Notify health care provider if tarry stools occur.

Check heart rate.

The nurse is preparing to administer atropine. Which action should the nurse perform prior to administering the medication? Answer Options * Auscultate bowel sounds. Assess blood sugar. Check heart rate. Assess lung sounds.

Ineffective peripheral tissue perfusion.

The nurse notes that the client has a capillary refill time greater than 3 seconds. Which of the following nursing diagnoses is most appropriate for this client? Answer Options * Ineffective cerebral tissue perfusion Ineffective peripheral tissue perfusion. Ineffective renal tissue perfusion. Ineffective gastrointestinal perfusion.

40-60 beats per minute

The nurse observes an absence of P waves on the client's electrocardiogram (ECG). When auscultating the client's apical pulse, the nurse expects the heart rate will be in which of the following ranges? Answer Options * 40-60 beats per minute 60-100 beats per minute 100-120 beats per minute 120-140 beats per minute

Engage in regular physical activity and exercise. Adhere to a smoking cessation program.

The nurse provides discharge instructions to a client who smokes, has a body mass index of 23 and has coronary artery disease by teaching the client to help increase high density level (HDL) lipoproteins in which of the following ways? Select all that apply. Answer Options * Take antihypertensive medication as prescribed. Engage in regular physical activity and exercise. Get at least 10 hours of sleep each night. Adhere to a smoking cessation program. Follow a supervised weight-loss plan.

Edema to the extremity Warmth to palpation Tenderness to palpation

The nurse suspects a client has a deep vein thrombosis (DVT). Which of the following assessment findings supports the possibility of a DVT. Select all that apply Answer Options * Edema to the extremity Warmth to palpation Capillary refill > 3 seconds Tenderness to palpation Absent pedal pulse

Principle

The sinoatrial (SA) node initiates the impulse that causes atrial contraction which is observed by a p wave on the electrocardiogram (EKG) ; Page# 713

Principle:

The treatment of choice for unconscious patients with pulseless ventricular tachycardia is defibrillation! ; Page# 730

Principle:

Three or more continuous premature ventricular contractions at a rate greater than 100 beats per minute is defined as ventricular tachycardia ; Page# 730

Principle:

Use a doppler to evaluate blood flow following vascular surgery ; Page# 860

Principle:

Ventricular fibrillation causes ineffective quivering of the ventricles and is not compatible with life ; Page# 731

Principle:

Virchow's triad consists of three risk factors for venous thromboembolism, venous stasis, blood vessel damage, altered coagulation ; Page# 849

Apply compression stockings with legs elevated prior to getting out of bed

When applying compression stockings to a post-surgical client, the nursing actions include which of the following? Answer Options * Apply compression stockings before bed and remove in the morning Apply compression stockings with legs elevated prior to getting out of bed Compression stockings should be worn 24 hours per day except for showering Compression stockings should be worn when legs ache or feel heavy

Pink, frothy sputum. Crackles. Orthopnea.

When assessing a client in pulmonary edema, the nurse understands increased pulmonary hydrostatic pressure is responsible for which of the following clinical signs observed during assessment? Select all that apply. Answer Options * Pink, frothy sputum. Ankle edema. Decrease in right atrial pressure. Crackles. Orthopnea.

Keep legs below the level of the heart

When assessing a client who has arterial insufficiency to the lower extremities, the nurse knows that which of the following is important to teach the client? Answer Options * Elevate legs if cramping occurs Massage the legs when painful Avoid reusing razors when shaving legs Keep legs below the level of the heart

Count the number of R waves in 6 seconds, multiply by 10

When assessing the heart rate of a client , the nurse uses which of the following methods to measure the number of heartbeats per minute? Answer Options * Count the number of large squares between the R-R intervals and multiply by 2 Count the number of little squares between the R-R intervals and multiply by 6 Count the number of R waves in 6 seconds, multiply by 10 Count the number of T waves in 6 seconds, multiply by 20

Your fluid volume has increased resulting in fluid being pushed into your tissue

When completing an assessment on a client with severe heart failure, the client asks the nurse why the lower extremities are swollen. Which of the following responses by the nurse is most appropriate? Answer Options * Your fluid volume has increased resulting in fluid being pushed into your tissue A diet that is low in protein could increase your risk for developing edema Once you begin the diuretic you will see that the swelling in your legs will diminish Could you tell me what you have been eating and drinking for the last 24 hours

Doppler ultrasound

When evaluating blood flow through the major arteries following vascular surgery, the nurse expects which of the following will be used as part of the assessment?

Applying sequential compression devices

When preparing a client for surgery, the nurse knows that which of the following interventions best helps to decrease the client's risk for deep vein thrombosis? Answer Options * Placing the client in a high-Fowlers position Sitting the client up in a chair that reclines Instructing the client on range of motion Applying sequential compression devices

'If electrical activity to my heart stops, the ICD will send electrical charges to my heart.'

When preparing a client with a history of ventricular fibrillation and who recently had an implantable cardioverter defibrillator (ICD) inserted, the nurse knows the client understands the purpose of the device when which of the following statements is made? Answer Options * 'If I have a heart attack the ICD will not be able to work.' 'The ICD will generate my heartbeat all of the time from now on instead of my heart.' 'If electrical activity to my heart stops, the ICD will send electrical charges to my heart.' 'Now that I have the ICD, I won't have any more dysrhythmias.'

Do not elevate your legs above the level of your heart

When teaching disease management for a client with peripheral vascular disease, which of the following actions should the nurse recommend to the client to help prevent complications from arterial insufficiency? Answer Options * Wear anti-embolism stockings daily to prevent clots Avoid crossing the legs for more than thirty minutes at a time Place a pillow behind the knees when lying in a supine position Do not elevate your legs above the level of your heart

Decreased cardiac output

Which nursing diagnosis is a priority when planning the care for a client with a cardiac dysrhythmia? Answer Options * Decreased cardiac output Activity intolerance Fluid volume excess Knowledge deficit

'If I get a blood clot the warfarin will help my body dissolve it.'

Which of the following statements made by the client on warfarin (Coumadin) indicates to the nurse that the client needs additional instruction before discharge? Answer Options * 'The warfarin makes it take longer for my blood to clot.' 'I need to report any unusual bleeding while I'm on warfarin.' 'I should have frequent blood work to check therapeutic levels of the warfarin.' 'If I get a blood clot the warfarin will help my body dissolve it.'