Midterm Adult Health II

V-Tach (Ventricular Tachycardia)

140 to 250 beats/minute or more; can lead to cardiac arrest Pulseless VT will be treated with defibrillation & CPR

1. When obtaining a health history from a 72-year-old man with peripheral arterial disease (PAD) of the lowerextremities, the nurse asks about a history of related conditions, including a. venous thrombosis. b. venous stasis ulcers. c. pulmonary embolism. d. coronary artery disease (CAD).

d. coronary artery disease (CAD). d. Regardless of the location, atherosclerosis is responsible for peripheral arterial disease (PAD) and is related to other cardiovascular disease and its risk factors, such as coronary artery disease (CAD) and carotid artery disease. Venous thrombosis, venous stasis ulcers, and pulmonary embolism are diseases of the veins and are not related to atherosclerosis.

Sinus rhythm with unifocal PVCs

(PVCs) are extra heartbeats that originate in the bottom of the heart and usually beat sooner than the next expected regular heartbeat. After the PVC beat, a pause usually occurs, which causes the next normal heartbeat to be more forceful.

aortic regurgitation

(aortic insufficiency) incompetent aortic valve that allows backward flow of blood into left ventricle during diastole

Hypovolemic shock treatment

1. Control all obvious external bleeding via direct pressure. 2.Handle the patient gently and keep him or her warm. 3. Start oxygen as soon as you suspect shock, and continue it during transport.

Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that what is the cause of the increase in the client's urinary output? 1.An expected effect of the dye used with the procedure 2. Increased cardiac output as a result of the procedure 3. An improvement of urinary functioning after the catheterization 4. A physiologic effect of the prescribed intravenous (IV) rate of 50 mL/hr

-1. An expected effect of the dye used with the procedure The dye used is hypertonic and has a diuretic effect. A cardiac catheterization is a diagnostic procedure, not a therapeutic one; it neither improves cardiac function nor increases cardiac output, and it does not improve urinary functioning. An IV rate of 50 mL/hr will not cause a urinary output three times the amount of intake.

The nurse notices sudden bursts of fast rhythm that end abruptly. The heart rate is 220 beats per minute during these bursts, but the P waves are very difficult to see. The QRS interval is normal. The nurse notifies the primary healthcare provider. Which rhythm did the nurse share with the primary healthcare provider? -Sinus tachycardia -Atrial tachycardia -Ventricular tachycardia (VT) -Paroxysmal supraventricular tachycardia (PSVT)

-Paroxysmal supraventricular tachycardia (PSVT) PSVT occurs above the ventricles, and it has an abrupt onset and cessation. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Onset is gradual rather than abrupt. PR interval is 0.12 to 0.20 seconds. P and QRS waves are consistent in shape. Atrial tachycardia is a rapid rhythm that arises from an ectopic focus in the atria. Because the P wave arises outside the sinus node, the shape is different from the sinus P wave. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The client may or may not have a pulse.

A client with seizures is prescribed phenytoin 10 mg to be taken orally two times daily. In the medicine box is phenytoin 25 mg/mL. How many mL should the nurse administer with each dose? Record the answer in milliliters (mL) and do not round.

.4 mL 10 mg x 1mL = .4 mL 25 mg

ADHF treatment

1) IV loop diuretics --> 1st line 2) IV Vasodilators 3) Vasopressin Antagonist 4) IV Positive inotropes

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? Select all that apply. 1. Canned Chili 2. Ground Beef 3. Fresh salmon 4. Luncheon meat 5. Cooked broccoli

1. Canned Chili 4. Luncheon Meat

Respiratory failure treatment

1. O2 administration 2. mobilzation of secretions (effective coughing, incentive spirometry, hydration, airway suctioning) 3. positive pressure ventilation (non invasive or intubation) 4. drug therapy relief of bronchospasm (albuterol) reduction of airway inflammation (corticosteroids) reduction of pulmonary congestion (lasix) treatment of pulmonary infection (antibiotics) reduction of severe anxiety/pain (benzos and opioids) 5. treatment of underlying cause

A home healthcare nurse is assessing a client with cardiac insufficiency. The nurse identifies that the client's pulse rate increases from 70 to 135 beats per minute while climbing the stairs. What instruction should the nurse give to the client? 1"Continue climbing." 2"Stand still and rest." 3"Walk down the stairs." 4"Climb but at a slower rate."

2"Stand still and rest." This pulse rate increase indicates that activity tolerance is exceeded. Rest limits muscle contraction and oxygen demands; these allow the heart to return to its preactivity rate. Activity should be stopped, not continued. Though descending the stairs requires less energy than climbing, rest is essential to permit the heart rate to return to normal. Climbing but at a slower rate still constitutes activity, which increases the cardiac workload.

An older client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply. 1 Taking an aspirin a day 2. Occasional cocaine use 3 Reduced hemoglobin level 4. African-American heritage 5. Increased high-density lipoprotein (HDL)

2. Occasional cocaine use 4. African-American heritage Cocaine is a stimulant that causes tachycardia and hypertension. Hypertension is more prevalent in African-Americans in the United States. Aspirin decreases platelet aggregation, thus reducing the risk for cardiovascular disease. Lowered hemoglobin may increase the heart rate, not the blood pressure. Increased HDL reduces the risk for cardiovascular disease because it helps to remove excess cholesterol from the blood, thereby preventing atheromas

An electrocardiogram (ECG) is prescribed for a client who reports chest pain. Which early finding does the nurse expect on the lead over the infarcted area. 1. Flattened T Waves 2. Absence of P waves 3. Elevated ST segments 4. Dissappearance of Q waves

3. Elevated ST segments Elevated ST segments are an early, typical finding after a myocardial infarct because of altered contractility of the heart. Flattened or depressed T waves indicate hypokalemia. Absence of P waves occurs in atrial and ventricular fibrillation. Q waves may become distorted with conduction or rhythm problems, but they do not disappear unless cardiac standstill occurs.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? A.Administer vitamins and minerals intravenously. B.Insert a feeding tube and initiate enteral feedings. C.Infuse total parenteral nutrition via a central catheter. D.Encourage an oral intake of at least 5000 kcal per day.

B.Insert a feeding tube and initiate enteral feedings.

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? A.Palpate extremities for bilateral pulses. B.Observe the patient's respiratory effort. C.Check the patient's level of consciousness. D.Examine the patient for any external bleeding.

B.Observe the patient's respiratory effort.

rheumatic fever

A bacterial infection that can be carried in the blood to the joints

Which of the following are risk factors identified in the development of an abdominal aneurysm? Choose all that apply. A. Age > 65 years B. Hx of COPD C. Being male D. Tobacco use E. Anorexia

A. Age > 65 years C. Being male D. Tobacco use

Acute Myocardial Infarction (AMI)

A heart attack; death of heart muscle following obstruction of blood flow to it. Acute in this context means "new" or "happening right now."

Which of the following are risk factors identified in the development of an abdominal aneurysm? Choose all that apply. A. Age > 65 years B. Hx of COPD C. Being male D. Tobacco use E. Anorexia

A. Age > 65 years D. Tobacco use

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? A.Assess pain level. B.Place on heart monitor. C.Check potassium level. D.Assess oral temperature.

B.Place on heart monitor.

In the assessment of a patient who has an abdominal aortic aneurysm (AAA), what is the most accurate diagnostic test that could be performed? A. CT B. Abdominal ultrasound C. MRI D. Chest x-ray

A. CT

Complications of aneurysm include which of the following. Select all A. Clot B. Ischemia C. Resection D. Misdiagnosis E. Graft

A. Clot B. Ischemia C. Misdiagnosis

After having a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? A. "What do you think caused your chest pain?" B. "Where are you planning to go for your vacation?" C. "Sometimes plans need to change after a heart attack." D. "Recovery from a heart attack takes at least a few weeks."

A. "What do you think caused your chest pain?"

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has several drugs prescribed. Which drug should the nurse discuss with the health care provider before giving? A. Gentamicin 60 mg IV B. Pantoprazole (Protonix) 40 mg IV C. Sucralfate (Carafate) 1 gram per NG tube D. Methylprednisolone (Solu-Medrol) 60 mg IV

A. Gentamicin 60 mg IV

A patient with a dissection of the arch of the aorta has a decreased LOC and a thready carotid pulse. The nurse anticipates that initial treatment of the patient will include which ONE of the following? A. Immediate surgery to replace the torn area with a graft B. Administration of anticoagulants to prevent embolization C. Administration of packed red blood cells (RBCs) to replace blood loss D. Administration of antihypertensives to maintain an MAP of 80

A. Immediate surgery to replace the torn area with a graft

For which expected response should the nurse monitor a client after a cardiac catheterization? A. Marked increase in the volume of urine output B. Decrease in blood pressure of 25% from the precatheterization blood pressure C. Complaints of heart pounding with mild chest discomfort D. Respiratory distress with an increase in respiratory rate of more than 24 respirations per minute

A. Marked increase in the volume of urine output There is increased urinary output as a result of the diuretic effect of the contrast medium. A decrease of 10% to 20% is expected because of the diuretic effect of the contrast medium; a decrease greater than 20% may be pathologic. Although heart pounding with mild chest discomfort may occur during the procedure because of trauma to the conduction system, it usually does not continue after the procedure. Respiratory distress may be an indication of a pulmonary embolus from a venous clot and should be reported immediately.

A nurse is caring for a patient with acute respiratory distress syndrome(ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? A. O2 saturation of 99% B. Heart rate 106 beats/min C. Crackles audible at lung bases D. Respiratory rate 22 breaths/min

A. O2 saturation of 99% The FIO2 of 80% increases the risk for oxygen toxicity. Because the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not need to be urgently reported to the health care provider.

When admitting a patient with possible respiratory failure and a high PaCO, which assessment information should be immediately reported to the healthcare provider? A. The patient appears somnolent. B. The patient reports feeling weak. C. The patient's blood pressure is 164/98. D. The patient's oxygen saturation is 90%.

A. The patient appears somnolent. Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

35. The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to a. walk. b. sit with the legs elevated. c. frequently rotate the ankles. d. continuously wear elastic compression stockings. 35. a. During walking, the muscles of the legs continuously knead the veins, promoting movement of venous blood toward the heart. Walking is the best measure to prevent venous stasis. The other methods will help venous return but they do not provide the benefit that ambulation does.

A. Walk During walking, the muscles of the legs continuously knead the veins, promoting movement of venous blood toward the heart. Walking is the best measure to prevent venous stasis. The other methods will help venous return but they do not provide the benefit that ambulation does.

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? A.The patient's PaO is 45 mm Hg. B.The patient's PaCO is 33 mm Hg. C. The patient's respirations are shallow. D. The patient's respiratory rate is 32 breaths/min.

A. patient's PaO is 45 mm Hg. The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? A.Auscultate the patient's lung sounds. B.Determine the extent and depth of the burns. C.Give the prescribed hydromorphone (Dilaudid). D.Infuse the prescribed lactated Ringer's solution.

A.Auscultate the patient's lung sounds.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? A.Inspect the oral mucosa. B.Listen to the lung sounds. C.Auscultate the bowel sounds. D.Check pupil reaction to light.

A.Inspect the oral mucosa.

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? A.Prepare to administer atropine IV. B.Obtain baseline body temperature. C.Infuse large volumes of lactated Ringer's solution. D.Provide high-flow O2 (100%) by nonrebreather mask. E.Prepare for emergent intubation and mechanical ventilation.

A.Prepare to administer atropine IV. C.Infuse large volumes of lactated Ringer's solution. D.Provide high-flow O2 (100%) by nonrebreather mask.

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first? A.Remove nonadherent clothing and wristwatch. B.Apply an alkaline solution to the affected area. C.Place a cool compress on the area of exposure. D.Cover the affected area with dry, sterile dressings.

A.Remove nonadherent clothing and wristwatch.

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? A.The new nurse uses clean gloves when applying antibacterial cream to a burn wound. B.The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). C.The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. D.The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated.

A.The new nurse uses clean gloves when applying antibacterial cream to a burn wound. Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? A.The patient's serum creatinine level is elevated. B.The patient complains of intermittent chest pressure. C.The patient's extremities are cool and pulses are weak. D.The patient has bilateral crackles throughout lung fields.

A.The patient's serum creatinine level is elevated.

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about A.anticoagulant therapy. B.permanent pacemakers. C.emergency cardioversion. D.IV adenosine (Adenocard).

A.anticoagulant therapy. B.permanent pacemakers.

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to A.assess the patient's current vital signs. B.give acetaminophen (Tylenol) per agency protocol. C.ask the patient to provide a clean-catch urine for urinalysis. D.tell the patient that it will be 1 to 2 hours before seeing a health care provider.

A.assess the patient's current vital signs.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? A.Monitoring urine output every 4 hours. B.Continuing to monitor the laboratory results. C.Increasing the rate of the ordered IV solution. D.Typing and crossmatching for a blood transfusion.

ANS: C. Increase the rate of the ordered IV solution. The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.

Causes of hypertensive crises

Acute aortic dissection. Exacerbation of chronic hypertension. Head injury. Monoamine oxidase inhibitors are taken with tyramine-containing foods. Aortic dissection can develop and will cause sudden, severe chest and bank pain with reduced or absent pulses in the extremities. Antihypertensive drugs given IV have a rapid onset of action. Oral drugs for hypertension include captopril, labetatlol, clonidine, catapress, amlodipine Norvasc.

ADHF

Acute decompensated heart failure (ADHF) typically manifests as pulmonary edema, an acute, life-threatening situation.

A 78-yr-old man has confusion and a temperature of 104 degrees F. He is diabetic with purulent drainage from his right heel. After an infusion of 3 L of NS, his assessment findings are BP 84/40, HR 110, resp rate 42 and shallow; CO 8 L/min; PAWP4 mm Hg. This patient's symptoms are most likely indicative of A.sepsis B.Septic Shock C.MODS D.SIRS

B.Septic Shock

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? A. Serum troponin B. Arterial blood gases C. B-type natriuretic peptide D. 12-lead electrocardiogram

B-type natriuretic peptide

The nurse is evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery. Which patient statement indicates that additional teaching is needed? A. "They will circulate my blood with a machine during surgery." B. "I will have incisions in my leg where they will remove the vein." C. "They will use an artery near my heart to go around the area that is blocked." D. "I will need to take aspirin every day after the surgery to keep the graft open."

B. "I will have incisions in my leg where they will remove the vein."

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse is best? A. "Most patients are able to enjoy intercourse without any complications." B. "Sexual activity uses about as much energy as climbing two flights of stairs." C. "The doctor will provide sexual guidelines when your heart is strong enough." D. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

B. "Sexual activity uses about as much energy as climbing two flights of stairs."

Which of these patients admitted to the emergency room should the nurse assess first? A. 62 y/o who has gangrenous ulcers on both feet B. 50 y/o who is complaining of tearing chest pain C. 45 y/o who is taking anticoagulants and notes blood in the stool D. 36 y/o who has right calf tenderness, redness, and swelling

B. 50 y/o who is complaining of tearing chest pain This could be aortic dissection, symptoms include sudden severe chest or upper back pain described as tearing, ripping or shearing sensation that radiates to the neck or down the back.

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? A. A patient who reported dizziness after receiving the first dose of captopril. B. A patient who has new-onset confusion and restlessness and cool, clammy skin. C. A patient who is receiving oxygen and has crackles bilaterally in the lung bases. D. A patient who is receiving IV nesiritide (Natrecor), with a blood pressure of100/62.

B. A patient who has new-onset confusion and restlessness and cool, clammy skin.

client has serially decreasing blood pressures after surgery. Which mechanisms involved in the regulation of blood pressure should the nurse consider? Select all that apply. A. Dilation of arterioles to increase peripheral resistance B. Activation of regulators that control renal angiotensin II C. Release of vasodilators, for example antidiuretic hormone D. Increase of left ventricular stroke volume to maintain blood volume E. Enervation of the sympathetic nervous system to constrict arterioles

B. Activation of regulators that control renal angiotensin II D. Increase of left ventricular stroke volume to maintain blood volume E. Enervation of the sympathetic nervous system to constrict arterioles When the kidney senses a decreased circulating blood volume, angiotensin I is released, which produces angiotensin II, a powerful vasoconstrictor; also, it stimulates the adrenal cortex to release aldosterone, which causes active reabsorption of sodium and water. Baroreceptors in the aortic arch and carotid sinus respond to altered arterial pressure, initiating events that ultimately stimulate peripheral vasoconstriction, thus increasing cardiac output. Alpha 1-adrenergic receptors are located in vascular smooth muscles and, when stimulated, cause vasoconstriction of the blood vessels. Arterioles will constrict, not dilate, to increase peripheral resistance. Antidiuretic hormone (vasopressin) will cause vessels to constrict, not dilate.

The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increases the patient's risk for respiratory complications after surgery. HX: Age 81; Med surg HX: Recent 15lb weight loss, knee arthroscopy 3 months ago Lab Data: Hemoglobin 11.8 g/dl; hematocrit 38%; Albumin 2.7 mg/dL Physical assessment: Lungs clear to auscultation. Mildly confused: disoriented to date, oriented to persona and place. A.Older age and anemia B. Albumin level and weight loss C.Recent arthroscopic procedure D.Confusion and disorientation to time

B. Albumin level and weight loss

A patient with a small abdominal aortic aneurysm (AAA) is not a good surgical candidate. The nurse teaches the patient that one of the best ways to prevent expansion of the lesion is to... A. Avoid exercise B. Control hypertension with prescribed therapy C. Comply with prescribed anticoagulant therapy D. Maintain a low calcium diet to prevent calcification of the vessel

B. Control hypertension with prescribed therapy Increased systolic blood pressure (SBP) continually puts pressure on the diseased area of the artery, promoting its expansion. Small aneurysms can be treated by decreasing blood pressure (BP), modifying atherosclerosis risk factors, and monitoring the size of the aneurysm. Anticoagulants are used during surgical treatment of aneurysms but physical activity is not known to increase their size. Calcium intake is not related to calcification in arteries.

A client is admitted with a tentative diagnosis of pneumonia. On admission the client is not in respiratory distress, but later develops chest pain and a fever of 103° F (39.4° C). A productive cough produces rust-colored sputum. How should the nurse interpret these findings? A. Onset of pulmonary edema B. Expected course of pneumonia C. Prsence of a pulmonary embolus Dr. Insidious onset of tuberculosis (TB)

B. Expected course of pneumonia Chest pain, fever, productive cough, and rust-colored sputum are cardinal signs of pneumonia [1] [2]. Chest pain results from excessive coughing; fever, increased sputum, and rust-colored sputum result from the infectious process. Dependent edema, respiratory distress, and crackles on auscultation of the lungs are associated with pulmonary edema. Although chest pain is expected with a pulmonary embolus, rust-colored sputum and a high fever are not. Pulmonary TB is associated with a low-grade fever, nonproductive or mucopurulent blood-tinged sputum, night sweats, and fatigue.

A patient admitted with acute respiratory failure has ineffective airway clearance from thick secretions. Which nursing intervention would specifically address this patient problem? A. Encourage use of the incentive spirometer. B. Offer the patient fluids at frequent intervals. C. Teach the patient the importance of ambulation. D. Titrate oxygen level to keep O saturation above 93%.

B. Offer the patient fluids at frequent intervals.

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? A. Urine output over 8 hours is 250 mL less than the fluid intake. B. The patient cannot move the left arm and leg when asked to do so. C. Tremors are noted in the fingers when the patient extends the arms. D. The patient reports a headache with pain at level 7 of 10 (0 to 10 scale).

B. The patient cannot move the left arm and leg when asked to do so.

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. What should teaching for this patient include today? A.Typical emotional responses to AMI B.When cardiac rehabilitation will begin C.Pathophysiology of coronary artery disease D.Information regarding discharge medications

B. When cardiac rehabilitation will begin

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? A.Take the patient's blood pressure. B.Check the respiratory rate and effort. C.Assess the Glasgow Coma Scale score. D.Send the patient for a computed tomography (CT) scan.

B.Check the respiratory rate and effort.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? A.Monitor white blood cells (WBCs). B.Continue to measure the urine output. C.Assess that blisters and edema have subsided. D.Encourage the patient to eat an adequate number of calories.

B.Continue to measure the urine output. The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? A.Skin cool and clammy B.Heart rate of 118 beats/min C.Blood pressure of 92/56 mm Hg D.O2 saturation of 93% on room air

B.Heart rate of 118 beats/min

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? A.Blood pressure is 95/48 per arterial line. B.Urine output of 41 mL over past 2 hours. C.Serous exudate is leaking from the burns. D.Heart monitor shows sinus tachycardia of 108.

B.Urine output of 41 mL over past 2 hours. The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phas

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of A.peritoneal lavage. B.abdominal ultrasonography. C.nasogastric (NG) tube placement. D.magnetic resonance imaging (MRI).

B.abdominal ultrasonography.

The nurse in the emergency department (ED) cares for the client in the image who has a 24-hour history of excessive vomiting. Along with the vomiting, what additional assessment finding indicates the client may be at risk for hypovolemic shock? A.Decreased urine specific gravity. B.Increased urine output. C.Hemoglobin 6 g/dL. D.Hematocrit 60%

C. Hemoglobin 6 g/dL. Rationale: Rationale: Hypovolemic shock is caused by conditions where the client loses body fluids. This can be as a result of burns, excessive diarrhea, excessive vomiting, and profuse sweating, among other causes. Therefore, with the 2-day history of vomiting, the client is at risk for hypovolemic shock. Additional assessment finding of low hemoglobin indicates the client's risk for hypovolemic shock. Signs and symptoms of hypovolemic shock include low blood pressure, fast heart rate, low hemoglobin, and hematocrit, decreased urine output, increased urine specific gravity, among others Clinical Tip: There are several types of shock, each with different signs and symptoms. The nurse must be aware of the differences so that the right nursing intervention might be implemented. Subtopic: Managing clients with hypovolemic shock

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient? A. "Heparin enhances platelet aggregation at the plaque site." B. "Heparin decreases the size of the coronary artery plaque." C. "Heparin prevents the development of new clots in the coronary arteries." D. "Heparin dissolves clots that are blocking blood flow in the coronary arteries."

C. "Heparin prevents the development of new clots in the coronary arteries."

18. Priority Decision: Following an ascending aortic aneurysm repair, what is an important finding that the nurse should report immediately to the health care provider? a. Shallow respirations and poor coughing b. Decreased drainage from the chest tubes c. A change in level of consciousness (LOC) and inability to speak d. Lower extremity pulses that are decreased from the preoperative baseline

C. A change in level of consciousness (LOC) and inability to speak During repair of an AAA, the blood supply to the carotid arteries may be interrupted, leading to neurologic complications manifested by a decreased level of consciousness (LOC) and altered pupil responses to light as well as changes in facial symmetry, speech, and movement of the upper extremities. The thorax is opened for ascending aortic surgery and shallow breathing, poor cough, and decreasing chest drainage are expected. Often, lower limb pulses are normally decreased or absent for a short time following surgery.

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? A. Assess both feet for pedal edema. B. Palpate the radial pulses bilaterally. C. Auscultate for a pericardial friction rub. D. Check the heart monitor for dysrhythmias.

C. Auscultate for a pericardial friction rub.

Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? A. Inform the patient about a diet containing no saturated fat and minimal salt. B. Emphasize the increased cardiac risk unless the patient makes dietary changes. C. Help the patient modify favorite high-fat recipes by using monounsaturated oils. D. Give the patient a list of low-sodium, low-cholesterol foods to include in the diet.

C. Help the patient modify favorite high-fat recipes by using monounsaturated oils.

Which information about a patient receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? A. An increase in troponin levels from baseline B. A large bruise at the patient's IV insertion site C. No change in the patient's reported level of chest pain D. A decrease in ST-segment elevation on the electrocardiogram

C. No change in the patient's reported level of chest pain

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? C. Obtain oxygen saturation using pulse oximetry.

C. Obtain oxygen saturation using pulse oximetry.

The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? A. Persistent cough of blood-tinged sputum. B. Scattered crackles in the posterior lung bases. C. Oxygen saturation 90% on 100% O2 by non-rebreather mask. D. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

C. Oxygen saturation 90% on 100% O2 by non-rebreather mask. The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

Which of the following most accurately describes the anatomical changes in the heart in the presence of cor pulmonale A. Left ventricular dilation B. Mitral valve prolapse C. Right ventricular hypertrophy D. Elevated systemic vascular resistance

C. Right ventricular hypertrophy

The nurse cares for a client who has partial focal seizures and is newly prescribed valproate. The nurse includes which priority instruction when educating the client on valproate? Select all that apply. A. Keep a seizure diary to identify factors associated with seizures. B. Take medication with 8 ounces of orange juice for maximum absorption. C. Talk with your healthcare provider should you choose to begin exploring pregnancy. D. Practice safe sexual practices for the first 90 days of your treatment regimen. E. If you notice more hair in the drain after a shower, let your healthcare provider know.

C. Talk with your healthcare provider should you choose to begin exploring pregnancy. E. If you notice more hair in the drain after a shower, let your healthcare provider know

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department reporting shortness of breath on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider? A. The patient has bibasilar lung crackles. B. The patient is sitting in the tripod position. C. The patient's respiratory rate is 10 breaths/min. D. The patient's pulse oximetry shows a 91% O2 saturation.

C. The patient's respiratory rate is 10 breaths/min.

A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? A."Do you have any allergies?" B."Do you take aspirin daily?" C."What time did your pain begin?" D."Can you rate the pain on a 0 to 10 scale?"

C."What time did your pain begin?"

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? A.219 mL/hr B.625 mL/hr C.938 mL/hr D.1875 mL/hr

C.938 mL/hr

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? A.Interrupted family processes related to effects of illness of a family member B.Situational low self-esteem related to increasing dependence on spouse for care C.Disabled family coping related to inadequate understanding by patient's spouse D.Impaired nutrition: less than body requirements related to hemiplegia and aphasia

C.Disabled family coping related to inadequate understanding by patient's spouse

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? A.Placing the pulse oximeter on the ear for a patient with septic shock B.Keeping the head of the bed flat for a patient with hypovolemic shock C.Maintaining a cool room temperature for a patient with neurogenic shock D.Increasing the nitroprusside infusion rate for a patient with a very high SVR

C.Maintaining a cool room temperature for a patient with neurogenic shock

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? A.Bananas B.Orange gelatin C.Vanilla milkshake D.Whole grain bagel

C.Vanilla milkshake

While caring for a 23-yr-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to A.take antibiotics before any dental appointments. B.limit physical activity to avoid stressing the heart. C.avoid over-the-counter (OTC) drugs that contain stimulants. D.take an aspirin a day to prevent clots from forming on the valve.

C.avoid over-the-counter (OTC) drugs that contain stimulants.

When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of A.flank pain. B.splenomegaly. C.shortness of breath. D.mental status changes.

C.shortness of breath.

A nurse evaluates a client with weakness to one side of the body for the ability to safely ambulate with a quad cane. The nurse assesses for the correct steps of walking, from start to finish. Rank order the options. Please only place the letter of the option in the blanks provided. A - Place body weight on both lower extremities. B - Place the affected leg forward. C - Move the cane ahead about 9 inches. D - Hold the cane on the unaffected side of the body. E - Place the unaffected leg ahead of the cane.

D - Hold the cane on the unaffected side of the body. C - Move the cane ahead about 9 inches. A - Place body weight on both lower extremities. B - Place the affected leg forward. E - Place the unaffected leg ahead of the cane.

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? A. "The pain wakes me up at night." B. "The pain is level 3 to 5 (0 to 10 scale)." C. "The pain has gotten worse over the last week." D. "The pain goes away after a nitroglycerin tablet."

D. "The pain goes away after a nitroglycerin tablet."

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first ? A. A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain. B. A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia). C. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge. D. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).

D. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).

The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary disease (COPD). Which action should the nurse take first? A. Observe for facial symmetry. B. Notify the health care provider. C. Attempt to calm and reorient the patient. D. Assess oxygenation using pulse oximetry.

D. Assess oxygenation using pulse oximetry. Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? A. Administer anticoagulant drug therapy. B. Notify the patient's health care provider. C. Prepare patient for a spiral computed tomography (CT). D. Elevate the head of the bed to a semi-Fowler's position.

D. Elevate the head of the bed to a semi-Fowler's position.

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. What procedure should the nurse anticipate assisting with to determine whether the patient has acute respiratory distress syndrome(ARDS) or pulmonary edema caused by heart failure? A. Obtaining a ventilation-perfusion scan B. Drawing blood for arterial blood gases C. Positioning the patient for a chest x-ray D. Insertion of a pulmonary artery catheter

D. Insertion of a pulmonary artery catheter

When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) A.isoelectric ST segment. B.PR interval of 0.18 second. C.QT interval of 0.38 second. D.QRS interval of 0.14 second.

D. QRS interval of 0.14 second. Normal QRS interval is 0.08-0.10 seconds

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client? A. Warm, flushed skin B. Increased pulse pressure C. Lethargy with confusion D. Reduced peripheral pulses

D. Reduced peripheral pulses Hypovolemia results in decreased cardiac output and decreased arterial pressure, which are reflected by a weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. The pulse pressure narrows with decreased cardiac output associated with hypovolemic shock. Lethargy with confusion is a late sign of shock.

Which of the following groups of symptoms indicates a ruptured aneurysm has occurred? A. Lower back pain, increased BP, decreased RBC, increased WBC B. Severe lower back pain, decreased BP, decreased RBC, decreased WBC C. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC D. Severe lower back pain, decreased BP, decreased RBC, increased WBC

D. Severe lower back pain, decreased BP, decreased RBC, increased WBC --Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it can't be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn't increase. For the same reason, the RBC count is decreased - not increase. The WBC count increases as cells migrate to the site of injury.

During the assessment of a patient with an acute distal descending aortic dissection, the nurse would expect the patient to manifest which of the following? A. A cardiac murmur characteristic of aortic valve insufficiency B. Altered level of consciousness (LOC) with weak carotid pulses C. Severe hypertension D. Severe ripping back or abdominal pain with decrease in urine output

D. Severe ripping back or abdominal pain with decrease in urine output

A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving A.tetanus immunoglobulin (TIG) only. B.TIG and tetanus-diphtheria toxoid (Td). C.tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. D.TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

D.TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? A.Stay at the bedside and reassure the patient. B.Administer the ordered morphine sulfate IV. C.Assess orientation and level of consciousness. D.Use pulse oximetry to check oxygen saturation.

D.Use pulse oximetry to check oxygen saturation. Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing. A.a relative hypervolemia B.an absolute hypovolemia C.neurogenic shock from low blood flow D.neurogenic shock from massive vasodilation

D.neurogenic shock from massive vasodilation

Neurogenic shock treatment

General treatment & Atropine for bradycardia & stabilize C-spine & methylprednisolone within 8 hours of injury

ADHF drug therapy

Diuretics: Decrease volume overload (preload) [Furosemide (Lasix), bumetanide (Bumex)] Vasodilators: Reduce circulating blood volume and improve coronary artery circulation [IV nitroglycerin, Sodium nitroprusside (Nipride)] [Nesiritide (Natrecor): studies showed this doesn't work)] Morphine: Reduces preload and afterload, relieves dyspnea (dilates pulmonary blood vessels, improving gas exchange), pain and anxiety Positive inotropes: increases myocardial contractility β-adrenergic agonists (dopamine [Intropin], dobutamine [Dobutrex]-IDEAL) Phosphodiesterase inhibitors (inamrinone [Inocor], milrinone [Primacor]) Digitalis (not recommended for initial tx)

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses? -Bladder spasms -Polycythemia vera -Hypovolemic shock -Pulmonary hypertension

Hypovolemic shock These signs occur with hypovolemic shock because less blood is being circulated to vital centers in the brain. A large loss of blood may occur during and after orthopedic surgery. Urinary retention, not bladder spasms, may occur after general anesthesia. Bladder spasms are associated with intermittent suprapubic pain. Anemia and deep vein thrombosis, not an increase in the total red blood cells (polycythemia vera), tend to occur after a total hip replacement. Polycythemia vera is associated with headache, irritability, and paresthesias of the hands and feet. Atelectasis and pneumonia, not pulmonary hypertension, tend to occur after general anesthesia. Pulmonary hypertension is associated with dyspnea, substernal chest pain, and fatigue

A client is admitted to the coronary intensive care unit. Which is the first step the nurse should take when developing a discharge teaching plan for this client?

Identifying the client's needs For teaching to be meaningful, the client must have a need to learn; also, readiness to learn is part of this assessment

Signs of impending death

Increased heart rate then slowing and weakening of pulse; irregular rhythm, decreased BP. Distention and nausea. Mottling on hands, feet, arms, legs. Cold, clammy skin, cyanosis of nose, mail beds, knew. Waxlike skin. Sagging of jaw, difficulty speaking. Swallowing. Jerking seen. Increased respiratory rate. Cheyne-Stokes respiration.

A client who presents to the emergency department with symptoms of a stroke is sent to imaging for an immediate CT scan of the head. Imaging calls the nurse to report that the client has a hemorrhagic stroke. As the nurse awaits the client's return, what must be included in the client's immediate plan of care? A. Oral anticoagulant therapy. B. Oral administration of baby aspirin. C. Intravenous blood pressure medications. D. Intravenous tissue plasminogen activator (tPA).

Intravenous blood pressure medications.

Cardiogenic shock treatment

Intravenous fluids then vasopressors: NE, dopamine, dobutamine, nitro IV if ischemia

AMI Treatment pneumonic Mona Tass

M-Morphine O-Oxygen N-Nitroglycerin A-Aspirin T-Thrombolytics A-Anticoaculants S-Stool Softners S-Sedatives

Septic shock treatment

Manage Airway and correct Hypoxemia; Fluid resuscitation, Vasopressors, Treat infection

Care of the client who is dying

Neuro assessment very important. Presence of reflexes and pupil responses. In the last hours limit assessments to only those that you need to determine patient comfort.

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first?

Raise the client to high-Fowler position Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary healthcare provider immediately would not be useful without having a full set of vital signs. The vital signs should include the oxygen saturation, which the healthcare provider would expect the nurse to provide.

Which of the following most accurately describes the anatomical changes in the heart in the presence of cor pulmonale

Right ventricular hypertrophy

. During a routine physical exam, an EKG is obtained and the nurse notes an occasional altered p wave that presents earlier than the normal p-p interval, creating an early complex and an irregular rhythm. The p wave occurs prior to the QRS, and the QRS complex is normal. Identify this rhythm

Sinus Rhythm with occasional PAC

Atrial Fibrillation (A-Fib)

an irregular and often very fast heart rate originating from abnormal conduction in the atria. Causes: Hypoxia, CHF, Hypertension, Pericarditis. TX: Digoxin Beta-adrenergic, Calcium channel

28. The patient is admitted with pain, edema, and warm skin on her lower left leg. What test should the nurse expect to be ordered first?a. Duplex ultrasound b. Complete blood count (CBC) c. Magnetic resonance imaging (MRI) d. Computed venography (phlebogram)

a. Duplex ultrasound With manifestations of a VTE, the D-dimer is drawn to determine if a VTE exists and the duplex ultrasound is most widely used to diagnose VTE by identifying where a thrombus is located and its extent.

23. A patient with a dissection of the arch of the aorta has a decreased LOC and weak carotid pulses. What should thenurse anticipate that initial treatment of the patient will include? a. Immediate surgery to replace the torn area with a graft b. Administration of anticoagulants to prevent embolization c. Administration of packed red blood cells (RBCs) to replace blood loss d. Administration of antihypertensives to maintain a mean arterial pressure of 70 to 80 mm Hg

a. Immediate surgery to replace the torn area with a graft Although most initial treatment for aortic dissection involves a period of lowering the BP and myocardial contractility to diminish the pulsatile forces in the aorta, immediate surgery is indicated when complications (such as occlusion of the carotid arteries) occur. Anticoagulants would prolong and intensify the bleeding and blood is administered only if the dissection ruptures.

Priority Decision: A patient has atrial fibrillation and develops an acute arterial occlusion at the iliac arterybifurcation. What are the six Ps of acute arterial occlusion the nurse may assess in this patient that require immediatenotification of the physician? a.b.c.d.e.f. 7. a. Pain; b. pallor; c. pulselessness; d. paresthesia; e. paralysis; f. poikilothermia. The physician requires immediate notification to begin immediate intervention to prevent tissue necrosis and gangrene.

a.b.c.d.e.f. 7. a. Pain; b. pallor; c. pulselessness; d. paresthesia; e. paralysis; f. poikilothermia. The physician requires immediate notification to begin immediate intervention to prevent tissue necrosis and gangrene.

Atrial Flutter (A-Flutter)

an arrhythmia caused by rapid but regular contractions in the atria of the heart

20. Priority Decision: A patient who is postoperative following repair of an AAA has been receiving IV fluids at 125 mL/hr continuously for the last 12 hours. Urine output for the last 4 hours has been 60 mL, 42 mL, 28 mL, and 20 mL, respectively. What is the priority action that the nurse should take? a. Monitor for a couple more hours. b. Contact the physician and report the decrease in urine output. c. Send blood for electrolytes, blood urea nitrogen (BUN), and creatinine. d. Decrease the rate of infusion to prevent blood leakage at the suture line.

b. Contact the physician and report the decrease in urine output. The decreasing urine output is evidence that either the patient needs volume or there is reduced renal blood flow. The physician will want to be notified as soon as possible of this change in condition and may order laboratory tests. The other options are incorrect.

25. What are characteristics of arterial disease (select all that apply)?a. Pruritus b. Thickened, brittle nails c. Dull ache in calf or thigh d. Decreased peripheral pulses e. Pallor on elevation of the legs f. Ulcers over bony prominences on toes and feet

b. Thickened, brittle nails d. Decreased peripheral pulses e. Pallor on elevation of the legs f. Ulcers over bony prominences on toes and feet Arterial disease is manifested in thick, brittle nails; decreased peripheral pulses; pallor when the legs are elevated; and ulcers over bony prominences on the toes and feet, as well as paresthesia. The other options are characteristic of venous disease and paresthesia could occur with venous thromboembolism (VTE).

Following teaching about medications for PAD, the nurse determines that additional instruction is necessary when the patient makes which statement? a. "I should take one aspirin a day to prevent clotting in my legs. "b. "The lisinopril I use for my blood pressure may help me walk further without pain. c. "I will need to have frequent blood tests to evaluate the effect of the Coumadin I will be taking." d. "Pletal should help me increase my walking distance and help prevent clots from forming in my legs."

c. "I will need to have frequent blood tests to evaluate the effect of the Coumadin I will be taking." Oral anticoagulants (warfarin) are not recommended for treatment of PAD but all of the other statements are correct in relation to treatment of PAD.

Priority Decision: During care of the patient following femoral bypass graft surgery, the nurse immediately notifiesthe health care provider if the patient experiences a. fever and redness at the incision site. b. 2+ edema of the extremity and pain at the incision site. c. a loss of palpable pulses and numbness and tingling of the feet. d. increasing ankle-brachial indices and serous drainage from the incision.

c. Loss of palpable pulses, numbness and tingling of the feet. extremity, extremity pallor, cyanosis or cold, and decreasing ankle-brachial indices are indications of occlusion of the bypass graft and need immediate medical attention. Pain, redness, and serous drainage at the incision site are expected postoperatively.

. A surgical repair is planned for a patient who has a 5.5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, what should the nurse expect to find? a. Hoarseness and dysphagia b. Severe back pain with flank ecchymosis c. Presence of a bruit in the periumbilical area d. Weakness in the lower extremities progressing to paraplegia

c. Presence of a bruit in the periumbilical area. Although most abdominal aortic aneurysms (AAAs) are asymptomatic, on physical examination a pulsatile mass in the periumbilical area slightly to the left of the midline may be detected and bruits may be audible with a stethoscope placed over the aneurysm. Hoarseness and dysphagia may occur with aneurysms of the ascending aorta and the aortic arch. Severe back pain with flank ecchymosis is usually present on rupture of an AAA and neurovascular loss in the lower extremities may occur from pressure of a thoracic aneurysm.

Care of the client who has HTN Crisis

crisis occurs at systolic BP greater than 180 and diastolic BP greater than 120. BPs often can be grater tan 220/140

To help prevent embolization of the thrombus in a patient with a VTE, what should the nurse teach the patient to do? a. Dangle the feet over the edge of the bed q2-3hr. b. Ambulate around the bed three to four times a day. c. Keep the affected leg elevated above the level of the heart. d. Maintain bed rest until edema is relieved and anticoagulation is established.

d. Maintain bed rest until edema is relieved and anticoagulation is established. Prevention of emboli formation can be achieved by bed rest and limiting movement of the involved extremity until the clot is stable, inflammation has receded, and anticoagulation is achieved. Dangling the legs promotes venous stasis and further clot formation and elevating the affected limb will promote venous return but it does not prevent embolization.

cardiomyopathy

disease of the heart muscle

Patients with an electrical injury have ________ than normal _____ needs. They require osmotic diuretic (mannitol or Osmitrol) to increase urine output and overcome high levels of hemoglobin and myoglobin in the urine.

greater; fluid For the 1st 24 hours it is recommended 2-4 mL lactated Ringer's/kg%TBA burned. Colloidal solutions such as albumin may be given.Example: 4 mL x 70 kg x 50(%TBSA) burned = 14,000 mL in 24 hours

endocarditis

inflammation of the inner lining of the heart

pericarditis

inflammation of the pericardium

mitral valve stenosis

narrowing of the mitral valve from scarring, usually caused by episodes of rheumatic fever

Thoracic Aortic Aneurysm (TAA)

widening or bulging of the upper portion of the aorta that may occur in the descending thoracic aorta, the ascending aorta, or the aortic arch.