Exam 2 adaptive quizing
The heartbeat assessment of four clients is given below. Which client is at an increased risk for right-sided heart failure?
client A RJVP-2.5CM LJVP-3.0CM Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. Therefore this client is at risk for right-sided heart failure. One-sided pressure elevation is caused by obstruction, as observed in clients B, C, and D.
While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure?
Older adult client The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter.
A pregnant woman at risk of preterm labor is diagnosed with hypertension. Which drug should be administered?
Magnesium sulfate Magnesium sulfate is administered to treat pregnancy-induced hypertension. Terbutaline is used to treat preterm labor, but does not reduce hypertension. Indomethacin inhibits prostaglandin activity and seizes uterine contractions. Calcium gluconate is given to reduce magnesium toxicity.
A nurse is caring for a client with a suspected endocrine tumor that presents with hypertension. Which study will the nurse prepare to monitor that best screens for this condition?
Metanephrine An endocrine tumor that presents with hypertension is pheochromocytoma. Metanephrine is the best study to screen for pheochromocytoma. Thyroglobulin is used to identify thyroid tumor cells. Although catecholamine and vanillylmandelic acid studies are used to screen for pheochromocytoma, metanephrine studies are more accurate.
Which nursing interventions should the nurse provide to an older client with hypertension? Select all that apply.
Advise the client to limit salt intake Teach stress management Instruct the client to quit smoking Proper nursing interventions for an older client with hypertension include advising the client to limit salt intake, teaching stress management, and instructing the client to quit smoking. Skin care is an appropriate intervention for clients at risk of pressure ulcers. Information about immunization is provided to older adults at a risk for developing influenza. The nurse should advise a client with dementia to eat finger foods such as sandwiches because these foods are easy to eat.
A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item should the nurse teach the mother to use when administering the medication?
Calibrated syringe A calibrated syringe or dropper provides the most accurate measurement of the medication. Using a nipple or spoon is not an accurate way to measure medication. If the dose of medication is diluted and the infant does not drink the entire ounce, the resulting dose will be insufficient.
Which nursing interventions may promote safe drug administration in a child diagnosed with heart failure who is receiving digoxin? Select all that apply.
Checking for compliance with the client's drug regimen Monitoring the client's serum potassium and magnesium levels regularly Calculating the correct dosage form, prescribed amounts, and the prescriber's order Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly Digoxin may alter the serum potassium and serum magnesium levels, which affects heart function. Calculating the correct dose according to the healthcare provider's orders helps to prevent drug toxicity. Checking for compliance with the client's drug regimen is important so that the child does not have drug to drug interactions. Monitoring and recording drug intake and output, heart rate, blood pressure, daily weight, and respiration rate is a part of general nursing care. Administering digoxin through the intramuscular route is not advised because this method is very painful.
A geriatric client with hypertension and diabetes mellitus is taking propranolol (Inderal) and insulin (Humulin N) therapy. Which interventions by health care professionals help prevent client medication errors according to the Leapfrog Group?
Using computer physician order entry The Leapfrog Group suggests using computer physician order entry (CPOE) to prevent medication errors. CPOE provides immediate information to the primary healthcare providers and nurses about the medications prescribed to the clients and helps prevent drug interactions and adverse effects. Scheduling regular follow-up visits helps prevent the side effects of the medication, but not medical errors. The Leapfrog Group does not suggest the dosage guidelines for geriatrics. Therefore the Leapfrog Group does not prescribe low dosage of medication. Closely monitoring the client for just 24 hours will not help prevent medication errors, drug interactions, and other adverse effects.
The nurse leader suffers from headaches, hypertension, and gastrointestinal problems. Which affirmative statement by the leader reflects an appropriate way to manage the stress?
"I will get enough sleep." Headache, hypertension, and gastrointestinal problems indicate physical stress in the leader. Stress can be managed by getting enough sleep. The leader should consume protein in moderate amounts. Planning a vacation would help in managing mental stress. Participating in support groups would help in managing emotional/spiritual stress.
A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The registered nurse identifies that which items on the client's care plan are appropriate for a licensed practical nurse (LPN) to perform? Select all that apply.
1. Help the client ambulate when required. 2. Monitor the client's vitals every 30 minutes. 3. Administer adequate oral fluids to the client To provide safe care, the nurse should act within the scope of practice and certification. The licensed practice nurse (LPN) can monitor the vitals, ambulate the client, and administer oral fluids to prevent dehydration. The LPN cannot administer medications intravenously and cannot formulate nursing diagnosis; therefore, these two actions do not fall within the scope of the LPN's practice.
What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.
1. The RR intervals are relatively consistent 2. One P wave precedes each QRS complex The consistency of the RR intervals indicates a regular rhythm. A normal P wave before each complex indicates the impulse originated in the sinoatrial (SA) node. Elevation of the ST segment is a sign of cardiac ischemia and unrelated to the rhythm. The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100 beats/min. Fewer than six complexes per 6 seconds equals a heart rate less than 60 beats/min. The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 second.
A nurse is weighing a client with heart failure. The client weighed 175 lb (79.4 kg) on the last visit and has had a 5% weight gain since then. The nurse suspects that the client is retaining fluid. How many liters of fluid has the client retained? Record your answer using a whole number. ___ liters
4 Multiply the client's weight by 5% (175 × 5% = 8.75 lb). Each liter of fluid is equal to 2.2 lb. Round 8.75 lb to 8.8 lb and divide by 2.2; this equals 4 liters.
A neonate diagnosed with congestive heart failure has been prescribed furosemide. What changes to the dosage or time intervals between doses should be made?
The time between doses should be lengthened. In neonates, the half-life of furosemide is increased. To avoid toxicity of the drug, the nurse should lengthen the time interval between the doses. If the time interval is shortened or the dosage is doubled, the level of drug circulating in the blood will be increased leading to toxic effects of the drug. Halving the dose is not an appropriate solution.
Which instruction would be most beneficial for an aging African-American client with hypertension?
"Have an annual urinalysis." African-American clients have 20% less blood flow to the kidneys because of high sodium consumption. This causes anatomical changes in the blood vessels, thereby increasing the risk of kidney failure. Therefore instructing the client with hypertension to have an annual urine examination would be beneficial. If the client has protein in the urine, this is a sign of high blood pressure and can signify kidney damage. Checking the pulse daily poses no harm to the individual, but does not determine if the client has hypertension. Recording the blood pressure weekly is not a good indicator of an aging African-American client with hypertension. The client's blood pressure should be taken at least daily to determine if the client has problems. If the client has an eye-related problem, visiting an ophthalmologist should be suggested.
The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse will look for potential causes. Which causes will the nurse look for in this client? Select all that apply.
Anxiety Caffeine Exercise Anemia The dysrhythmia itself is not treated, but the cause is identified and treated appropriately. Causes of sinus tachycardia include hypovolemia, heart failure, anemia, exercise, use of stimulants, fever, sympathetic response to fear or pain. Hypothermia will cause sinus bradycardia
While assessing a client with presence of neurotoxicity, lymphoma, and hypertension, the medical history reveals that the client is on immunosuppressant drug therapy. Which drug class might have caused these conditions?
Calcineurin inhibitors Calcineurin inhibitors such as cyclosporine act on T helper cells to prevent production and release of IL-2 and γ-interferon. This class of medications can cause adverse effects such as nephrotoxicity, lymphoma, hypertension, gingival hyperplasia, and hirsutism. Corticosteroids may cause peptic ulcer, osteoporosis, and hyperglycemia. Cytotoxic drugs may cause bone marrow suppression, hypertension, diarrhea, and nausea. Monoclonal antibodies may cause pulmonary edema, hypersensitivity reactions, fever/chills, and chest pain.
A lactating woman with hypertension was diagnosed with a migraine. What would be the drug combination of choice if she wishes to continue breast-feeding?
Labetalol, sumatriptan The appropriate choice is labetalol and sumatriptan. Labetalol is a safe drug to use to control hypertension during lactation; sumatriptan is the drug of choice for treating migraines in lactating woman. Tenormin is contraindicated in lactating woman. Sertraline is the drug of choice for treating depression in lactating woman.
A pregnant woman was prescribed a drug for pregnancy-induced hypertension. Later, the client developed muscle weakness, edema, and nausea for which calcium gluconate was administered. What drug was administered to the client to treat pregnancy-induced hypertension?
Magnesium sulfate Magnesium sulfate can be administered for pregnancy-induced hypertension; this medication may cause magnesium toxicity. Signs of this toxicity include muscle weakness, edema, and nausea. Calcium gluconate is co-administered along with magnesium sulfate to counteract this toxicity. Nifedipine, an antihypertensive agent, is listed as a category C drug, and can be safely used to treat pregnancy-induced hypertension. Terbutaline is a beta-adrenergic blocker used to manage preterm labor. Indomethacin is a nonsteroidal antiinflammatory drug used as a tocolytic for the management of preterm labor.
A client undergoing corticosteroid therapy is admitted with a peptic ulcer, osteoporosis, and hypertension. Which medication may have caused this condition?
Methylprednisolone Methylprednisolone is a corticosteroid that suppresses inflammatory responses and inhibits both cytokine production and T-cell activation. This drug may cause a peptic ulcer, osteoporosis, and hypertension. Everolimus may cause urinary tract infections, hyperlipidemia, and peripheral edema. Azathioprine may cause bone marrow suppression, neutropenia, and thrombocytopenia. Mycophenolate acid may cause diarrhea, neutropenia, and increased incidence of malignancies.
An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention?
Oxygen Saturation: 89% An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.
The nurse taught a client with heart failure who is scheduled for discharge about how medications, diet, and exercise improve activity tolerance. During a follow-up visit, the nurse finds that the client has learned how to adapt his or her exercise prescription to compensate for an increased tolerance. Which theory did the nurse follow to achieve this positive outcome?
Roy's theory According to Roy's theory, the goal of nursing is to help a client with a disorder adapt to changes in physiological needs by identifying the demands that are causing problems for the client. King's theory illustrates that nursing is a dynamic interpersonal process among the nurse, client, and healthcare system. Leininger's theory is about transcultural care theory, which explains that caring is the central and unifying domain for nursing knowledge and practice. Henderson's theory illustrates that nurses working interdependently with other healthcare workers can best assist the client.
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema?
Shift of fluid into the interstitial spaces Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathologic reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.
The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding?
Sinus rhythm with premature atrial contractions (PACs) A PAC is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.12 seconds. P and QRS waves are consistent in shape. Bradycardia is defined as a heart rate less than 60 beats per minute.
A pregnant client with a history of hypertension is treated with an angiotensin-converting enzyme inhibitor. Which teratogenic effect of angiotensin-converting enzyme (ACE) inhibitors is the neonate at risk for?
skull hypoplasia The use of angiotensin-converting enzyme (ACE) inhibitors in the second and third trimesters of pregnancy may cause skull hypoplasia in the newborn. Antiseizure drugs may cause neural tube defects and growth delays in the newborn. Warfarin may cause skeletal and central nervous system defects in the newborn.
The nurse is reviewing the data of clients with pre-hypertension. Which client is at risk of stage 1 hypertension based on the given data?
client B cardiac output-increased hematocrit-increased BP- 130/89 In pre-hypertension, the blood pressure will range from 120/80 to 139/89 mmHg. The blood pressure is mainly influenced by heart rate and cardiac output. When the cardiac output and hematocrit are increased, the blood pressure also increases. Client B, with an increased cardiac output and an increased hematocrit, is at a higher risk for stage 1 hypertension. In client A, only the hematocrit is increased. Client C may be at risk of hypotension because the cardiac output is decreased. Client D has a normal hematocrit and blood pressure.
A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply.
Promote dietary modifications by using varied techniques Assess the client's current lifestyle and promote lifestyle changes Monitor the client's blood pressure and weight and establish blood pressure screening programs When caring for a community-dwelling older adult with hypertension, the nurse should promote dietary modifications, assess a client's current lifestyle and promote lifestyle changes, and monitor the client's blood pressure and weight and establish blood pressure screening programs. When caring for community-dwelling older women with cancer, the nurse should perform annual Papanicolaou (Pap) smears and mammograms for older adults. When caring for a community-dwelling older adult with arthritis, the nurse should teach the client about correct body mechanics and the availability of mechanical appliances.
A nurse is assessing four clients. Which client is at the highest medical risk of coronary heart disease and hypertension?
client D height (cm)-145 weight (kg)-67 A body mass index (BMI) higher than 30 is considered obesity and puts the client at a higher medical risk of coronary heart disease, some cancers, and hypertension. Client D (who is 145 cm tall and weighs 67 kg) has a BMI of 31.9, which indicates obesity. This can lead to coronary heart disease and hypertension. Client A has a BMI of 21.6, which indicates a normal weight. Client B has a BMI of 27.77, which indicates that the client is overweight but not obese. Client C, with a BMI of 24.24, is considered as having a normal weight
A client on medication for transplant rejection is admitted with hypertension, nephrotoxicity, and gingival hyperplasia. Which medication might have caused this? Select all that apply.
tacrolimus, cyclosporine tacrolimus and cyclosporine are calcineurin inhibitors that may cause adverse effects such as hypertension, nephrotoxicity, and gingival hyperplasia. These drugs are administered to stop the production and secretion of interleukin, which then prevents the activation of lymphocytes involved in transplant rejection. Basiliximab targets the activation sites of T-lymphocytes, increasing their elimination from circulation. Sirolimus is an antiproliferative medication that may cause adverse immunosuppressive effects such as thrombocytopenia and leucopenia. Basiliximab is a monoclonal antibody that may cause adverse side effects related to the gastrointestinal system. Mycophenolate may cause adverse effects such as leukopenia, thrombocytopenia, and nausea.