Medical-Surgical Nursing - Cardiovascular System, Blood, and Lymphatic Systems

What client response indicates to the nurse that a vasodilator medication is effective?

Answer: Blood pressure changes from 154/90 to 126/72 Rationale: Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg, the second sound is a swishing sound heard at 130 mm Hg, a tapping sound is heard at 100 mm Hg, a muffled sound is heard at 90 mm Hg, and the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure?

Answer: 72 mmHg Rationale:When the sound disappears at 72 mm Hg it is known as phase five of Korotkoff sounds; this reflects the diastolic pressure when the artery is no longer compressed and blood flows freely. 90 mm Hg is recorded as the diastolic pressure in adolescents and adults. The muffled sound heard at 90 mm Hg is phase four of Korotkoff sounds; the muffled sound represents the point at which the cuff pressure falls below the pressure within the arterial wall. This number is recorded as the diastolic pressure in infants and children. The tapping sound heard at 100 mm Hg is known as phase three of Korotkoff sounds; this reflects blood flow through an increasingly open artery as constriction of the cuff decreases. The swishing sound heard at 130 mm Hg is phase two of Korotkoff sounds; this is caused by blood turbulence.

A nurse provides teaching regarding vitamin B12 injections to a client with pernicious anemia. The nurse concludes that the teaching was understood when the client states, "I must take the drug:

Answer: Monthly, for the rest of my life. Rationale: Because the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client's life. The drug must be taken on a regular basis for the rest of the client's life.

A client who has a hemoglobin of 6 gm/dL is refusing blood because of religious reasons. What is the most appropriate action by the nurse?

Answer: Notify the primary health care provider of the client's refusal of blood products Rationale: The nurse serves as an advocate for clients to uphold their wishes. Synthetic blood products are available but must be prescribed by the primary health care provider. Therefore, the primary health care provider needs to be notified of the client's refusal for blood so alternatives can be considered. The chaplain's role is to offer support, not to convince the client to go against their beliefs. It is an HIPAA violation to discuss the case with coworkers unless they are involved in the care of the client. The nurse should not use threats or fear to coerce the client.

A client experiences angina and is admitted to the telemetry unit for observation. Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain. Which instruction should the nurse include when teaching the client about the correct use of sublingual nitroglycerine?

Answer:Hold the tablet under the tongue until it is dissolved. Rationale: A rich vascular supply is present under the tongue; this ensures quick delivery of medication into the blood. Usually, relief of pain will occur within 5 minutes. Sublingual nitroglycerine is taken during an episode of anginal chest pain, not at preset intervals. The prescribed nitroglycerine is administered sublingually, not orally.

A client with a tentative diagnosis of pernicious anemia is scheduled for a Schilling test. Which body process associated with vitamin B12 is assessed with the Shilling test?

Answer: Absorption Rationale: With the Schilling test, radioactive vitamin B12 is administered, and its absorption and excretion are ascertained. Storage is not measured by this test. Digestion is not measured by this test. Vitamin B12 is not produced in the body. Pernicious anemia is caused by an inability to absorb vitamin B12 as a result of a lack of intrinsic factor in gastric juices

Metoprolol (Toprol-XL) is prescribed for a client with hypertension. For which side effect should the nurse monitor the client?

Answer: Bradycardia Rationale: Beta blockers block stimulation of beta1 (myocardial) adrenergic receptors, which decreases the heart rate and blood pressure. The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest. Excessive growth of hair or presence of hair in unusual places does not occur with this medication; however, absence or loss of hair (alopecia) may occur. A side effect of this medication is fatigue, not restlessness. This medication may produce hypotension, not hypertension.

The nurse is providing care for a client that had an endarterectomy one month ago. The nurse explains the reason that clopidogrel (Plavix) is being prescribed. The nurse concludes that the teaching is understood when the client says, "The medication will:

Answer: Help prevent further clogging of my arteries." Rationale: Clopidogrel interferes with platelet aggregation, which impedes the formation of thrombi. Clopidogrel is a platelet aggregation inhibitor, not an anti-inflammatory. Clopidogrel is a platelet aggregation inhibitor, not an antipyretic. Clopidogrel is a platelet aggregation inhibitor, not an analgesic

The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" The nurse explains that the primary purpose of early ambulation is to:

Answer: Keep blood from pooling in the legs to prevent clots Rationale: The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.

A client with type 1 diabetes asks what causes the several brown spots on the skin. The nurse's best response is, "The brown spots:

Answer:Result from small blood vessel damage; the blood contains iron, which leaves a brown spot." Rationale: Brown spots "result from small blood vessel damage; the blood contains iron, which leaves a brown spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the definition of a xanthoma. A high glucose content in the skin that has become infected is not the cause of brown spots on the skin; increased glucose in the skin is not observable by inspection. Brown spots result from the deposition of hemosiderin. Damaged blood vessels may occur with diabetes but they do not cause brown spots.