Critical Care Exam 1

Endocarditis

inflammation of the inner lining of the heart (endocardium)

Claudication

pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest. Pain develops because there is a narrowing or blockage in the main artery taking blood to the leg due to hardening of the arteries (atherosclerosis).

aPTT - definition and normal value

The aPTT is considered a more sensitive version of the PTT and is used to monitor the patient's response to heparin therapy. It is a blood test that characterizes coagulation of the blood. aPTT normal: 30-40 seconds. PTT normal: 60-70 seconds.

Bradydysrhythmia

an abnormal heart rhythm with rate less than 60 beats per minute in an adult

Venous Stasis Ulcer

an open sore on the lower legs or feet caused by poor venous blood flow; stasis ulcer

Arterial Ulcer

an open wound on the lower legs or feet caused by poor arterial blood flow - pain may be relieved by lowering legs below the heart

A nurse in an emergency room is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse monitor for? A. Confusion B. Friction Rub C. Hypertension D. Dry Skin

A. CONFUSION (Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Monitor mental status.) B. Friction Rub (The nurse should expect to hear a friction rub during cardiac auscultation on a client who has pericarditis) C. Hypertension (The nurse should monitor a client who has a bradydysrhythmia for hypotension) D. Dry skin (The nurse should monitor a client who has a bradydysrhythmia for diaphoresis)

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the client's family history of peripheral vascular disease. B. Note the presence or absence of pain at the ulcer site. C. Inquire about the presence or absence of claudication. D. Ask is the client has had a recent infection.

A. Explore the client's family history of peripheral vascular disease. (Family history is important, but it does not help to differentiate between arterial and venous ulcers) B. Note the presence or absence of pain at the ulcer site (Both arterial and venous ulcers cause varying degrees of pain or discomfort) C. INQUIRE ABOUT THE PRESENCE OR ABSENCE OF CLAUDICATION. (Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not) D. Ask is the client has had a recent infection. (Both arterial and venous ulcers have the potential to become infected)

A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds? A. Increase the heparin infusion flow rate by 2mL/hr B. Continue to monitor the heparin infusion as prescribed C. Request a prothrombin time (PT) D. Stop the heparin infusion

A. Increase the heparin infusion flow rate by 2mL/hr (An aPTT of 96 sec. indicated excessive heparin. Therefore, the nurse should not increase the heparin infusion) B. Continue to monitor the heparin infusion as prescribed (An aPTT of 96 sec. indicates excessive heparin. Therefore, the nurse should take corrective action) C. Request a prothrombin time (PT) (The nurse should monitor PT for a client who is taking an oral anticoagulant. However, it is not necessary to request a PT before taking any corrective action.) D. STOP THE HEPARIN INFUSION (The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury)

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Ventricular depolarization B. Guillian-Barré syndrom C. Myelodysplastic syndrome D. Valvular disease

A. Ventricular depolarization (Ventricular depolarization occurs during a normal cardiac cycle and is not a potential complication of endocarditis.) B. Guillian-Barré syndrome (Guillain-Barré syndrome is associated with certain bacterial and viral infections but is not a potential complication of endocarditis) C. Myelodysplastic syndrome (Myelodysplastic syndrome is a disorder of the bone marrow and is not a potential complication of endocarditis) D. Valvular disease (Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.)