Aug 30 Practice
!!!!!!!!!!! When performing cardiac compression on an adult client, how far would the nurse depress the lower sternum? 0.75 to 1 inch (2-2.5 cm) 0.5 to 0.75 inch (1.3-2 cm) 1 to 1.4 inches (2.5-3.6 cm) 2 to 2.4 inches (5-6 cm)
2 to 2.4 inches (5-6 cm) Current adult cardiopulmonary resuscitation (CPR) guidelines indicate that the sternum should be depressed at least 2 inches (5 cm) and not more than 2.4 inches (6 cm) to compress the heart adequately between the sternum and vertebrae. In infants, the recommendation is that the sternum be compressed by approximately one-third of the anteroposterior diameter of the chest, which is about 1.5 inches (3.8 cm). In children up to the age of puberty, compressions should be about one-third of the anteroposterior diameter of the chest, which is about 2 inches (5 cm). In postpubertal adolescents, recommended compression depth is at the adult range of 2 to 2.4 inches (5-6 cm).
Which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply. One, some, or all responses may be correct. Weight Inactivity Cholesterol Tobacco use Homocysteine
All of the above
How can the nurse describe heart failure to a client? A cardiac condition caused by inadequate circulating blood volume An acute state in which the pulmonary circulation pressure decreases An inability of the heart to pump blood in proportion to metabolic needs A chronic state in which the systolic blood pressure drops below 90 mm Hg
An inability of the heart to pump blood in proportion to metabolic needs As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients, and it will result in the heart's inability to pump blood in proportion to metabolic needs. Heart failure is related to an increased, not decreased or inadequate, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure may be decreased with heart failure, but a systolic blood pressure below 90 mm Hg can occur in healthy clients or be caused by many other diagnoses.
Which action would the nurse take to prevent venous thrombus formation after abdominal surgery?
Encourage the client to ambulate multiple times daily. Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client in a gatch bed to elevate the knees or having the client dangle the legs off the side of the bed cause increased popliteal pressure and impair venous return, which will increase risk for venous thrombosis in the legs. Having the client use an incentive spirometer every hour helps prevent atelectasis, not thrombi.
When a client is admitted to the postanesthesia care unit after surgery, how frequently will the nurse plan to assess the blood pressure?
Every 10 to 15 minutes During the first 2 postoperative hours, the blood pressure is monitored every 10 to 15 minutes to detect unstable vital signs that might indicate shock. Checking every 3 to 5 minutes is unnecessary, unless the client becomes hemodynamically unstable. Checking every 20 minutes or longer is unsafe because it is too long a period of time between blood pressure readings for a client who just had surgery.
!!!!!!!!!! When a child is newly diagnosed with hemophilia A, the nurse will teach family members that hemophilia A is linked to a deficiency in which clotting factor? Factor II Factor XII Factor IX Factor VIII
Factor VIII Hemophilia type A, the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and XII are part of the clotting cascade, but they are not associated with hemophilia. Factor IX is associated with hemophilia type B.
When a client is experiencing acute coronary syndrome, which factor would the nurse identify as the cause of the pain experienced by a client? Arterial aneurysm Heart muscle ischemia Blocking of the coronary veins Irritation of nerve endings in the cardiac plexus
Heart muscle ischemia Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial aneurysms are not a common cause of myocardial ischemia or infarction. Arteries, not veins, are involved in the pathology of an acute coronary syndrome. Tissue injury and pain occur in the myocardium, not the cardiac plexus.
Which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count? Increased blood pH Decreased hematocrit Increased blood viscosity Decreased immune response
Increased blood viscosity Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. The number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity.
How would anxiety affect outcomes for a client with heart failure? Increases the cardiac workload Interferes with usual respirations Produces an elevation in temperature Decreases the amount of oxygen used
Increases the cardiac workload Anxiety increases sympathetic nervous system activity, leading to increases in heart rate, vasoconstriction, and increased metabolic rate, which increase cardiac workload and worsen outcomes in clients with heart failure. Anxiety does not directly interfere with respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen needed for body functions.
!!!!!!!!!!!! Which group of clients would the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas?
Older adults The incidence of non-Hodgkin lymphoma increases with age; the disease is more common in men and older adults. Younger individuals have a lower incidence of non-Hodgkin lymphomas.
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery?
Prevent clot formation Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Active ROM exercises will not improve wound healing.
When hypokalemia is suspected, which diagnostic test will the nurse use to confirm the diagnosis?
Serum potassium level A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood cell count, x-ray film of long bones, and blood cultures ×3 will have no significance in the diagnosis of a potassium deficit.
Based on an electrocardiogram (ECG), a client is suspected to have hypokalemia. Which test will be used to confirm hypokalemia? Complete blood count Serum potassium level Arterial blood gas panel Urine osmolality test
Serum potassium level Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and urine osmolality testing have no significance in diagnosing a potassium deficit.
Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure?
Sodium Restriction of sodium reduces the amount of water retention, thus reducing cardiac workload. Calcium is restricted in individuals who develop renal calculi. Potassium is not restricted, especially if a diuretic is prescribed, because diuresis facilitates the loss of potassium in the urine. Magnesium is not restricted.
!!!!!!!!! Which action will the nurse take to determine a client's pulse pressure? Multiply the heart rate by the stroke volume. Subtract the diastolic from the systolic reading. Average the systolic and diastolic pressure readings. Calculate the difference between apical and radial pulse rates.
Subtract the diastolic from the systolic reading. Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.
!!!!! In what order does normal cardiac conduction occur through the heart?
The cardiac cycle begins with an impulse generated from a small concentrated area of pacemaker cells high in the right atria called the sinus or sinoatrial node. The impulse quickly reaches the AV node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The electrical impulse then is conducted rapidly through the bundle of His to the ventricles via the left and right bundle branches. The bundle branches divide into smaller and smaller branches, finally terminating in tiny fibers called Purkinje fibers that reach the myocardial muscle cells or myocytes.
Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage? Peripheral vasoconstriction Elevation of serum cortisol level Release of immature erythrocytes Increased antidiuretic hormone (ADH)
The initial response to hemorrhage is activation of the sympathetic nervous system, leading to increases in heart rate and peripheral vasoconstriction, which shunts blood to essential core organs. The other responses also occur, but more slowly. Cortisol increases as part of the stress response, leading to fluid retention, but this process occurs more slowly. Immature red blood cells (erythrocytes) are released from the bone marrow, but this occurs more slowly than vasoconstriction. An increase in ADH causes fluid retention, but this occurs more slowly.
After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? "I have abnormal platelets." "I have abnormal hemoglobin." "I have abnormal hematocrit." "I have abnormal white blood cells."
"I have abnormal hemoglobin." The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. Although it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.
!!!!!!! Which electrical activity of the cardiac conduction system is reflected in the P wave? Atrial depolarization Atrial repolarization Ventricular depolarization Ventricular repolarization
Atrial depolarization The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, the QRS complex obscures visualization of atrial repolarization. The T wave represents ventricular repolarization.
Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct. Providing oxygen Assessing vital signs Obtaining a 12-lead EKG Drawing blood for cardiac enzymes Auscultating heart sounds Administering nitroglycerin
All of the above, The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital signs, obtain a 12-lead EKG, and auscultate heart sounds to determine rhythm changes related to cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enzymes. Changes in the levels of these enzymes (including troponin, creatine kinase, and myoglobin) can indicate damage to heart tissue. Nitroglycerin is administered to promote coronary vasodilation.
Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? P wave T wave PR interval QRS interval
QRS interval --- Figure 31-4? Atrial and ventricular depolarization and repolarization are represented on the ECG as a series of waves: the P wave followed by the QRS complex and the T wave. The QRS represents ventricular depolarization. The P wave occurs with depolarization of the atria. The T wave represents ventricular repolarization. The PR interval represents depolarization of the atria and of the atrioventricular node.
When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin? Vitamin K Vitamin D Vitamin B 1 Vitamin B 12
Vitamin K Warfarin causes inhibition of vitamin K-dependent clotting factors, and use of vitamin K would affect the therapeutic effect of warfarin. Vitamin D has no effect on warfarin. Vitamin B 1 does not affect warfarin or clotting. Vitamin B 12 does not affect warfarin effectiveness.
How is hemophilia inherited? X-linked recessive trait Y-linked recessive trait X-linked dominant trait Y-linked dominant trait
X-linked recessive trait Hemophilia A is an X-linked recessive trait, not a dominant trait, meaning daughters who have the gene are carriers, and sons with the gene have the condition. The trait is not carried on the Y chromosome.