NGN Adult Health Cardiovascular

The following scenario applies to the next 1 times The nurse cares for a client four hours postoperative after laparoscopic gastric bypass surgery Item 1 of 1 Nurses' NoteMedical History 31-year-female postoperative laparoscopic Roux-en-Y procedure. The client is fully alert and oriented. Glasgow Coma Scale was 15. The client reports pain at the incision as a '4' out of 10. Four surgical incisions were assessed as clean, dry, and approximated with skin glue. Bowel sounds were hypoactive in all four quadrants. The indwelling catheter was secured to the bed frame without kinks or loops. Clear, yellow urine was observed. Capillary blood glucose (CBG) was 268 mg/dL. Morbid obesity (BMI 42) Uncontrolled Diabetes Mellitus Metabolic Syndrome ➢ Select the anticipated provider orders from each of the following categories. Each category must have at least one option selected, and each category may have more than one option selected. CategoriesPotential Orders Activity Strict Bed Rest Head of Bed Restrictions Out of Bed to Chair Diet Clear Liquids Full Liquids Nothing by Mouth (NPO) Medications Multivitamin Hydrocodone-Acetaminophen Docusate Consultations Registered Dietician Diabetic Educator Ostomy Venous Thromboembolism (VTE) Prophylaxis None Sequential Compression Stockings Prophylactic Anticoagulant Therapy Submit Answer

Explanation A significant complication following any bariatric surgery is venous thromboembolism (VTE). The client will be expected to ambulate within the first several hours after surgery. Mobilizing the client early will present complications such as VTE and pneumonia. Strict bed rest would be detrimental to the post-op care of this client as it may allow for a VTE to form. HOB restrictions are not necessary following this surgery. Clear liquids are introduced slowly if the client can tolerate water, and 1-ounce cups are used for each serving. A full liquid diet follows tolerance of the clear liquid diet. The nurse should defer to the primary healthcare provider's (PHCP) orders regarding diet advancement. The client has a GCS of 15 and keeping the client NPO would be unnecessary as aspiration is not a risk. A multivitamin is a common prescription following bariatric surgery because of the risk of vitamin and mineral deficiencies caused by the altered absorption of nutrients and decreased intake of calories. It is expected for a client to have post-operative pain. Opioids such as hydrocodone (often combined with acetaminophen) are commonly prescribed to help with the discomfort. Docusate is a stool softener used to prevent opioid-related constipation. The client has undergone a significant surgery and will need extensive education on nutritional choices. The client consulting with a dietician is the standard of care following this procedure. Additionally, this client has uncontrolled diabetes mellitus, and consulting with a diabetic educator would be beneficial. This surgery does not involve the placement of an ostomy, and consultation with an ostomy nurse would be unnecessary. VTE is a significant risk factor following this procedure. The nurse should work to mitigate this risk by applying sequential compression stockings and administering prophylactic anticoagulant therapy. This, combined with early mobilization, will decrease this complication. Additional Info Bariatric surgery is a life-altering procedure that requires a coordinated effort to prevent post-operative complications. Complications of bariatric surgery include venous thromboembolism, pneumonia, severe vitamin and mineral deficiencies, and dumping syndrome. Bariatric surgery may be indicated if one of the following clinical criteria has been met: The client has not responded to traditional interventions Has a body mass index (BMI) of 40 or greater Has a BMI of 35 or greater, with other health risk factors

15-21 The following scenario applies to the next 6 times 27-year-old female presents to the clinic who is presumptively pregnant Item 1 of 6 History And Physical A 27-year-old nulliparous female presented to the clinic stating that she took an over-the-counter urine pregnancy test, which was positive. She states that she is two weeks late for her menstrual period. Her symptoms include nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness. She is not in a committed relationship and uses no contraceptive methods. She reports having multiple sexual partners. She has a negative gynecological and medical history. ➢ Which two (2) client findings in the history and physical require further investigation? Select all that apply Nausea Breast tenderness Fatigue Burning with urination Vaginal discharge Amenorrhea Submit Answer ➢ For each client finding, click to specify if the finding is consistent with pregnancy, gonorrhea, or cystitis. Each client finding may support more than one (1) condition or disease process. Each row must have at least one, but may have more than one, response option selected. Client FindingPregnancyGonorrheaCystitis Malodorous vaginal discharge Increased urinary frequency Breast tenderness Burning with urination Amenorrhea Submit Answer The nurse reviews the client's laboratory results ➢ The nurse understands that the client is most likely experiencing which condition? Select all that apply Pyelonephritis Chlamydia Cystitis Gonorrhea Pre-eclampsia Submit Answer ➢ Click to specify whether the planned intervention is appropriate or not appropriate InterventionAppropriateNot Appropriate Obtain a prescription for antivirals Obtain an order to screen for additional sexually transmitted infections Obtain an order for a transvaginal ultrasound Review the client's current medications, including any over-the-counter supplements or vitamins. Submit Answer ➢ The nurse is teaching the client about the treatment plan. Which information should the nurse include? If your HIV testing comes back positive, your baby will be infected. Let's discuss some options for notifying your sexual partners. You may notice dark urine and a metallic taste caused by ceftriaxone. After you take the azithromycin, do not consume any calcium rich foods. Submit Answer The nurse verifies the client's understanding ➢ Which statement, if made by the client, would require additional teaching? "It would be best for me not to have sexual intercourse during my pregnancy." "I should abstain from sexual intercourse until I have been fully treated." "It is important for me to increase my fluid intake while being treated." "If I develop a fever or pain in my side, I should come back right away." Submit Answer

Explanation Based on the client's symptoms, she is presumptively pregnant. Expected presumptive pregnancy signs include nausea, vomiting, frequent urination, breast tenderness, and amenorrhea. The client also has one probable sign of pregnancy, which is the positive home pregnancy test. The two symptoms reported by the client of burning with urination and vaginal discharge are not expected signs of a presumptive pregnancy. Thus, the nurse should investigate these reported symptoms further because they are concerning. Explanation The symptoms that the client is reporting (nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness) may be categorized as a manifestation belonging to pregnancy, gonorrhea, or cystitis. Malodorous vaginal discharge is a classic manifestation associated with gonorrhea. Increased urinary frequency is commonly seen in the first trimester of pregnancy and is also classically found with gonorrhea and cystitis. The fluctuating hormones cause the woman to experience breast tenderness and would be an expected finding with presumptive pregnancy. Burning with urination is not a manifestation associated with pregnancy (only increased urinary frequency) this manifestation of dysuria is associated with cystitis and gonorrhea. The cessation of menses is a classic presumptive pregnancy sign and not associated with cystitis or gonorrhea. Explanation The client's urine analysis, urine gonorrhea and chlamydia screening, and serum human chorionic gonadotropin (HCG) return with several findings requiring follow-up. The findings requiring follow-up are in red. Based on the findings, the client has cystitis supported by the bacteria and nitrites in the urine. The client not having any flank pain, fever, or any other systemic symptoms excludes pyelonephritis. Pyelonephritis is an ascending urinary tract infection that results when causative organism invades the kidney. Pre-eclampsia is excluded because this client has yet to have a confirmatory pregnancy screening such as an ultrasound, additionally, if pre-eclampsia were to occur, it would typically have an onset after 20 gestational weeks. Explanation It would be inappropriate for the nurse to obtain a prescription for antivirals. The client's infections (cystitis, gonorrhea, and chlamydia) are bacterial. Appropriate antibiotics such as ceftriaxone and azithromycin are likely to be prescribed. Additional screening tests are necessary for a client with a sexually transmitted infection. A significant risk factor for an STI is previous STIs. Thus, the client will need to be screened for syphilis and human immunodeficiency virus (HIV). The client's positive HCG test effectively makes pregnancy probable, and a confirmatory test such as a transvaginal ultrasound would help view the embryo and potentially obtain a fetal heart rate. This method may be done as early as three to four weeks of gestation. Explanation It is quite plausible for a client infected with HIV to deliver a baby who is HIV negative. Robust antiretrovirals have made this possible. This is not a statement that should be made to the client because it is not true. A client needs to notify her sexual partners of her exposure. This does not mean that she is obligated to do this herself, as public health services may assist her with contact tracing. Gonorrhea is a reportable health condition to the public health department. Dark urine and a metallic-like taste is not a finding associated with ceftriaxone; rather, this is a feeding most commonly seen with metronidazole. Azithromycin does not have an interaction with calcium. This would be an appropriate teaching point if the client were discharged with doxycycline. Explanation Sexual intercourse is not prohibited during pregnancy. Unless a complication is evident, the client is free to have sexual intercourse. Abstaining seven days following treatment of an STI is recommended. The client is receiving treatment for gonorrhea, and she should be instructed to postpone sexual activity until this time. The client should be instructed to increase her fluid intake as she has cystitis, which is a mainstay treatment for this condition. Fever and pain in her side are concerning and reportable as this is a classic manifestation of pyelonephritis, a complication of cystitis (the infection has ascended at this point).

8-14 The following scenario applies to the next 6 times The nurse is caring for a client directly admitted from the physician's office Item 1 of 6 History And PhysicalNurses' NotesVital Signs 48-year-old African American male was directly admitted from his physician's office to the intensive care unit (ICU) after his blood pressure was 210/114 mmHg, and the client reported dizziness, headache, and fatigue. The client takes antihypertensives but lost his insurance and was unable to afford refills. He states his symptoms started two days ago after his last dose of clonidine. Prior to this episode, the client reported that his hypertension was well controlled with his medications. The client has a medical history of hypertension, hyperlipidemia, and overflow urinary incontinence. Current medications include clonidine, hydrochlorothiazide, tamsulosin, and atorvastatin. 1400: Client arrived at ICU orientated to the room. The client is alert and completely oriented. Glasgow Coma Scale 15. He reports dizziness that is worse when he moves. Normal peripheral pulses were palpable. S1/S2 heart tones auscultated. 2+ lower extremity edema. Clear lung sounds. Reports a generalized headache that was described as 'throbbing' and rated as a '8' on a scale 0-10. Vital signs were obtained. 1400 Blood Pressure 209/111 mm Hg Temperature 98° F (36.7° C) Heart rate 90/minute Respiratory rate 17/minute Oxygen saturation 96% on room air ➢ Select four (4) findings from the nurses' notes and vital signs that require follow-up? Blood pressure Heart tones Lung sounds Dizziness Generalized headache Lower extremity edema Submit Answer The nurse is concerned about the client's symptomatic hypertension ➢ The nurse identifies which factor that most likely causing this condition? Knowledge deficit Impaired physical mobility Ineffective health maintenance Nonadherence to medications Submit Answer ➢ The nurse understands that this client is most likely experiencing Hypertensive crisis Pulmonary embolism Myocardial infarction Left-sided heart failure Submit Answer The nurse is planning care for this client ➢ Please select the interventions that are indicated and not indicated for this client Possible InterventionIndicatedNot indicated Place patient in a supine position Establish peripheral vascular access Obtain a prescription for intravenous antihypertensives Prepare the client for percutaneous coronary intervention (PCI) Monitor the blood pressure every 5 to 15 minutes Submit Answer The nurse receives orders from the physician ➢ Upon receiving orders from the physician, highlight which orders should be prioritized Orders Initiate peripheral vascular access Consult case management for home prescription management Labetalol 10 mg intravenous (IV) push x 1 Initiate continuous cardiac monitoring q15-minute blood pressure monitoring Submit Answer Discharges Prescription clonidine TTS-1 (0.1 mg/24 hours) spironolactone 25 mg PO Daily labetalol 100 mg PO BID Two days later, the client recovers, and the nurse reviews the discharge prescriptions. The nurse is educating the client on the newly prescribed medications ➢ Complete the following sentences by using the list of options The client should be instructed to change the clonidine patch every 3/5/7 days and apply it to a clean and dry area. Additionally, the client should have a low K/ high carb/ high K diet while taking the spironolactone and take it in the morning. Finally, the client should be instructed to monitor their weight/ pulse/ blood gluc while taking the prescribed labetalol. Submit Answer

Explanation Both the heart tones and lung sounds were normal. They do not require follow-up. The client's blood pressure is highly elevated, combined with the client's symptoms (dizziness and headache), which is strongly suggestive of a hypertensive crisis. The client's lower extremity also requires follow-up because this is showing fluid retention, likely raising the blood pressure. Explanation The client reported that his symptoms started after abruptly stopping his clonidine. Clonidine can cause significant rebound hypertension if it is abruptly stopped. It is the nonadherence to his antihypertensives that is causing his symptomatic hypertension and fluid retention. The client did not indicate any knowledge deficit as he was able to recall his symptoms, when they started, and appropriate adherence prior to him losing his insurance. The client does not state that they are not physically mobile or are ineffectively maintaining their health. These would not be causative factors for the client's rebound hypertension. Explanation The client is suffering from a hypertensive crisis which is a medical emergency. Hypertensive crisis is a severe elevation in blood pressure (greater than 180/120), which can cause damage to organs such as the kidneys or heart. No evidence suggests heart failure despite the client's peripheral edema. The client's heart tones do not have an S3 sound. An S3 heart sound is one of the earliest signs of a client developing heart failure. The client has clear lung sounds, does not have tachypnea, or apprehension and thus, a pulmonary embolism is unlikely. The client does not endorse chest pain or dyspnea and thus, a myocardial infarction is excluded. Explanation Not indicated: For the client experiencing a hypertensive crisis, the client should be positioned semi-Fowler's. This position decreases intracerebral blood pressure, thereby, decreasing the client's risk of a stroke. If the client is supine, this increases the cerebral blood pressure to a dangerously high level. The client does not need to be prepared for a PCI; this would be appropriate if the client was experiencing an acute myocardial infarction. Indicated: Establishing peripheral vascular access is important because this client's blood pressure needs to be emergently decreased. Once the vascular access is secured, the nurse should anticipate the prescription of parenteral antihypertensives along with close blood pressure monitoring. Explanation The nurse needs to establish peripheral vascular access to deliver the necessary intravenous labetalol. Labetalol is a nonselective beta-blocker and useful in the treatment of a hypertensive crisis. Because labetalol may lower both the blood pressure and heart rate, the nurse should establish continuous cardiac monitoring as well as q15 minute blood pressure monitoring. Consulting case management for home prescription management is a low priority item that will not immediately impact the client's physical health. Explanation The clonidine patch is an effective way to a set amount of antihypertensive over 24 hours. The patch should be applied to a clean and dry area with no hair. The patch should be changed every seven days. Spironolactone is a potassium-sparing diuretic, and the client should consume a diet low in potassium because if this medication was combined with a high potassium diet, it could cause the potassium to become critically high. Labetalol is a nonselective beta-blocker, and the client should be instructed to take their radial pulse prior to each dose. If the pulse is less than 60/minute, the physician should be notified.

The following scenario applies to the next 1 times The nurse cares for a client following a cardiac arrest Item 1 of 1 Admission Notes 2000 - 36-year-old was found unresponsive and with no pulse after collapsing at his job. Cardiopulmonary resuscitation (CPR) was started at the scene. The client was successfully resuscitated in the emergency department. The client was intubated, and central vascular access was established. 2130 - The client was transferred to the intensive care unit. Shortly after the transfer, the client converted to ventricular fibrillation. Code blue was called. CPR was delivered over 2 minutes, and a palpable carotid pulse was not assessed. The client's current cardiac monitor shows asystole. ➢ Complete the sentence below by choosing from the list of options The next essential intervention is the administration of epi/ amiodarone/ Na Bicarbonate followed by defib/ resuming CPR/ cardioversion Submit Answer

Explanation Epinephrine is utilized in asystole to assist in restoring the vascular tone, thereby increasing the perfusion to the brain and the heart. Thus, the next essential action to complete after a cycle of CPR has been completed is to administer intravenous epinephrine. Amiodarone is not indicated for asystole. This medication is indicated for ventricular and atrial dysrhythmias. In cardiac arrest, sodium bicarbonate is utilized only if acidosis is suspected or confirmed. No information is provided in the scenario suggesting the utilization of this drug. The next action after the administration of epinephrine is resuming high-quality CPR. Asystole cannot be cardioverted or defibrillated because an underlying dysrhythmia is absent. Additional Info Asystole is a complete cessation of a ventricular rhythm. This produces no cardiac output. Using defibrillation or cardioversion is not an effective remedy for this arrhythmia because the heart has nothing to shock as it is at a complete standstill. The treatment recommended for asystole is high-quality CPR at a rate of 100-120 compressions per minute followed by intravenous epinephrine.

The following scenario applies to the next 1 times The nurse cares for a client admitted for a myocardial infarction Item 1 of 1 Nurses' Note 0800 - Client was found in bed pale and diaphoretic, stating, 'I do not feel well.' Approximately two minutes later, the cardiac monitor showed ventricular tachycardia. Upon assessment, the client became unresponsive and did not have a pulse. ➢ For each potential intervention, click to specify if it is essential or contraindicated InterventionEssentialContraindicated Call a code blue Cardiovert the client Defibrillate the client Anticipate a prescription for intravenous digoxin Perform chest compressions Submit Answer

Explanation Essential Actions - If a cardiac monitor should show a lethal dysrhythmia like ventricular tachycardia, the nurse should immediately assess the client. This includes establishing the level of consciousness, breathing, and if they have a carotid pulse. Ventricular tachycardia without a pulse is a dysrhythmia where cardiac output ceases. The nurse should then call a code blue. The priority treatment for ventricular tachycardia without a pulse is defibrillation. Defibrillation is essential as the countershock helps terminate this lethal arrhythmia. Once defibrillation is given, the nurse should resume chest compressions at a rate of 100-120 per minute. Contraindicated Actions - Cardioverting the client and obtaining a prescription for intravenous digoxin. Cardioversion is only used if the client has a pulse. This client has no pulse. Cardioversion would be reserved for dysrhythmias such as atrial fibrillation or SVT. Digoxin would be contraindicated during ventricular tachycardia because of its negative effects on cardiac output. The medication necessary is intravenous epinephrine and amiodarone (or lidocaine). IV epinephrine is necessary because it assists with restoring vascular tone.

The nurse is caring for a client who was admitted for an exacerbation of congestive heart failure. ➢ Click to highlight the findings in the nurses' note which indicate that the client is progressing towards discharge. Nurses' Notes Day 1 - 0900 - The client was ambulated 25 feet and did not tolerate the ambulation reporting dyspnea. Gait was unsteady. Provided education on aerobic exercise and the benefits for heart failure. Client verbally taught back the education with understanding. Day 3 - 0915 - The client ambulated 30 feet in the hallway without assistance. Gait was steady. The oxygen saturation after ambulation was 95% on room air. Scheduled furosemide was refused by the client. Educated the client on the purpose of the medication and its benefits. Submit Answer

Explanation On day one, the client did not tolerate a 25 feet ambulation as there was a report of dyspnea. Additionally, the client's gait was unsteady. These findings do not indicate that the client is not ready for discharge. The nurse providing education is a nursing responsibility and does not determine if the client is progressing towards discharge; however, their ability to verbally teach back the education provided on exercise and heart failure indicates engagement and a reassuring finding. On day three, the client being able to ambulate 30 feet in the hallway, with a steady gait, and without any assistance, is an improvement in their clinical progress compared to the ambulation trial on day one. This is a marked improvement in their progress towards discharge. A concerning finding is the client's refusal of their prescribed furosemide. Clients have the right to refuse their medications; however, the nurse understands that refusal of this medication will lead to a decline in their health status. This decline may cause serious complications such as pulmonary edema and hospital readmission. This is not a finding that indicates that the client is ready for discharge. Additional Info For a client with congestive heart failure, aerobic exercises are encouraged to maintain the client's strength and cardiovascular conditioning. Since congestive heart failure is a risk factor for venous thromboembolism, the client's ambulation is essential in avoiding this complication. When teaching a client with congestive heart failure, it is also important to know the prescribed medication regimen involving agents such as diuretics. Adherence to the treatment plan is critical to avoid further decline and readmission. Suppose a client should refuse a portion of their treatment plan. In that case, the nurse is obligated to actively listen to the client's refusal, educate the client on the purpose of the prescribed treatment, and work with the healthcare provider to find a suitable alternative.

The following scenario applies to the next 1 times The nurse cares for a 58-year-old client in the emergency department Item 1 of 1 History & PhysicalVital SignsLaboratoryOrdersDiagnostic Testing 1600 - 58-year-old client with a history of hypertension and diabetes mellitus type I reports headaches and elevated blood pressure. The client reported the headaches started one day ago and have worsened. The client reports not taking his prescribed medications because he lost his health insurance. His prescribed antihypertensive medications were clonidine and enalapril. The client has a flushed appearance on exam, endorses a generalized headache, and blurred vision. Oral temperature 99.5 F (37.5o C); Pulse 114 bpm; Respirations 16. BP 207/124 mm Hg; Oxygen saturation 95% on room air. Nitroprusside via continuous infusion Timolol 0.25% to both eyes ➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress. Administer prescribed timolol ophthalmic Blood Pressure Angle Closure Glaucoma Administer prescribed nitroprusside Intraocular pressure (IOP) Action to Take Obtain hourly blood glucose levels Obtain a prescription for regular insulin infusion Position the client Semi-fowler's Potential Conditions Myocardial infarction Hypertensive Emergency Migraine Headache Diabetic ketoacidosis Parameters to Monitor Troponin Blood Glucose Thiocyanate levels Submit Answer

Explanation Potential Conditions This client is experiencing a hypertensive emergency is at risk for end-organ damage. The client is hypertensive and is symptomatic (headache, blurred vision, flushing). This is supported by the client reporting that he was unable to take his prescribed medications and likely is experiencing rebound hypertension from abrupt discontinuation of the medication. The hypertension is causing end-organ damage, as evidenced by the increased creatinine. It is unlikely that the client is experiencing a myocardial infarction. The client did not endorse any angina, nor is the client reporting atypical manifestations such as indigestion or profound fatigue. Diabetic ketoacidosis is not a condition experienced by the client because the blood sugar is not hyperglycemic (greater than 250 mg/dL). The client reporting blurred vision and a headache is a concern for acute angle-closure glaucoma, but the tonometry reading, which measures intraocular pressure was normal. For acute angle-closure glaucoma, the intraocular pressure would be greater than 30 mmHg. Migraine headaches are not likely because having a headache with this significantly elevated blood pressure is uncommon for a migraine. Action to Take Priorities for a client experiencing a hypertensive emergency/crisis is to administer the prescribed antihypertensive. A prescription was provided for nitroprusside, and the nurse should administer the drug via an infusion pump. The nurse should also position the client semi-Fowlers. This position is preferred because this position slightly decreases the intracerebral blood pressure. The supine position would not be recommended because this increases blood flow to the brain and is not recommended for a client with extremely high blood pressure. Parameters to Monitor The client taking nitroprusside should have their blood pressure carefully watched. Nitroprusside is a potent vasodilator and monitoring the blood pressure every five to fifteen minutes is required. A complication of not watching the blood pressure closely during this therapy would be significant hypotension. The nurse should also monitor the client's thiocyanate levels. This client's elevated creatinine makes him at risk of having this drug accumulate and causing cyanide toxicity. Symptoms of cyanide toxicity include metabolic acidosis, confusion, and hyperreflexia.

21-27 The following scenario applies to the next 6 times The nurse cares for a 41-year-old female in the emergency department (ED) Item 1 of 6 Nurses' NoteVital Signs 0900 - Client reports a concern for increased swelling and pain in her left lower extremity. The onset of the symptoms was yesterday evening and when she woke up the pain and swelling had increased. Two days prior, the client sustained abrasions and bruising on the extremity while attempting to get out of a swimming pool. 2+ edema was evident in the left lower extremity; area was warm to touch. Several abrasions on leg noted which were dry and appeared to be healing. Erythema noted. Peripheral pulse and sensation were intact, toe movement was evident along with distal and sensation. Pain reported with leg movement. Pain rated a '7' on a scale 0-10. Current daily medications include ortho tri-cyclen, bupropion, and a multivitamin. She denies any alcohol or drug use. Smokes 2-3 cigarettes per day. Oral Temperature 98o F (36.7o C) Pulse 66/minute Respirations 16/minute Blood pressure 130/72 mm Hg O2 saturation 96% on room air ➢ Which assessment finding is the nurse most concerned with? Select all that apply. Healing abrasions Left lower leg edema Pain with movement Vital signs Peripheral pulse Left lower leg temperature ➢ For each client finding, click to specify if it is consistent with deep vein thrombosis, compartment syndrome, or cellulitis. Each finding may support more than one condition FindingCompartment SyndromeCellulitisVenous Thromboembolism Pain in the affected extremity Swelling to the affected area Intact sensation Warmth and erythema to the extremity Submit Answer ➢ Complete the sentences below from the list of options The client is at greatest risk for venous thromboembolism/ cellulitis/ compartment syndrome The primary healthcare provider (PHCP) will likely order a venous duplex ultrasonography/ ankle-brachial index/ radiography to confirm this diagnosis. Submit Answer Diagnostics Results Venous Duplex Ultrasonography: Proximal deep vein thrombosis in the left popliteal vein The nurse reviews the diagnostic results ➢ For each possible physician order/prescription, click to indicate if it is anticipated or not anticipated Physician Order/PrescriptionAnticipatedNot Anticipated Splint the affected extremity Clopidogrel Strict bed rest Elevate the affected extremity Submit Answer Orders Admit to Med/Surg Activity as tolerated Initiate peripheral vascular access Oxycodone 5 mg PO q 6 hours, PRN pain Laboratory (aPTT, CBC, CMP, PT/INR) Warfarin 2 mg PO, Daily Heparin 5000 units intravenous (IV) bolus x1 Heparin infusion at 18 units/kg/hr; follow heparin protocol The nurse reviews the physician's orders and prescriptions ➢ Complete the sentences from the list of options below Prior to administering heparin, the nurse should obtain the client's aPTT/ complete metabolic panel/ PT/INR and blood type/ weight/ height While the client is receiving the prescribed heparin, the nurse will also need to monitor the client's blood gluc/ platelet count/ sodium level Submit Answer Three days later, the routine laboratory data is reviewed by the nurse ➢ Click to highlight the laboratory result(s) that requires follow-up LaboratoryResultReference Range Hemoglobin 12.4 g/dL 12-16 g/dL Platelets 155,000 150,000 - 400,000 International Normalized Ratio (INR) 2.7 0.9-1.2 Activated Partial Thromboplastin Time (aPTT) 110 seconds 30-40 seconds Blood Urea Nitrogen 17 mg/dL 10-20 mg/dL Creatinine 1.0 mg/dL 0.6-1.2 mg/dL Submit Answer

Explanation The assessment findings of left lower leg edema, pain during movement, and the temperature of the affected extremity are concerning. These assessment findings are abnormal; the client's vital signs, peripheral pulses, and healing abrasions are not of concern because they are normal findings. Explanation Most of these clinical findings overlap for compartment syndrome, cellulitis, and venous thromboembolism. The three differing clinical features are the intact sensation, warmth, and erythema to the extremity. One of the earliest findings associated with compartment syndrome is paresthesia, and because of the lack of perfusion, coolness to the extremity develops. Cellulitis is an infectious process that does not cause impairment in sensation. Finding 1Compartment Syndrome 2Cellulitis 3Venous Thromboembolism Pain in the affected extremity123 Swelling to the affected area123 Intact sensation23 Warmth and erythema to the extremity23 Explanation This client most likely has venous thromboembolism. The triggering event of the VTE was likely the injury to her leg. Combined with the oral contraceptives and her tobacco use, these are substantial risk factors for her developing VTE. The gold standard diagnosis for VTE is using a venous duplex ultrasonography which is a non-invasive test that may be performed at the bedside. Explanation Splinting the affected extremity would not be anticipated as this is ordered for orthopedic injuries. Clopidogrel is antiplatelet and treatment for VTE is anticoagulants such as rivaroxaban, heparin, or warfarin. Strict bed rest is not indicated in the management of a VTE. No credible evidence exists that this degree of immobility decreases the risk of a pulmonary embolism. Further, strict bed rest would increase the risk of the client developing pneumonia. Elevating the extremity to promote venous return is a standard intervention in the care of a client with a VTE. Explanation Heparin infusions require an actual and accurate weight of the client. This information, along with the baseline labs, is necessary prior to administering heparin. Platelet count also needs to be monitored during the duration of the heparin infusion because of the potential adverse event of heparin-induced thrombocytopenia (HIT). Explanation While a client receives a heparin infusion, the goal is to prolong the control (baseline) aPTT 1.5 to 2.5 times. 110 seconds is too prolonged and requires the nurse to review the heparin protocol to hold the infusion for a specified period or reduce the rate. The other labs are within normal limits. The client was prescribed warfarin, whose INR is now 2.7, which is therapeutic as the goal is to have the INR between 2-3. Additional Info Risk factors for venous thromboembolism include active cancer, reduced mobility, hormonal treatment, obesity, recent trauma/surgery, and a known thrombophilic condition. Classic symptoms of a VTE include pain, erythema, warmth, and swelling. Diagnosing a VTE is commonly done through non-invasive venous duplex ultrasonography. Treatment is either through oral or parenteral anticoagulants, and the nurse must surveil for pulmonary embolism, which can be fatal if not promptly recognized.

The following scenario applies to the next 6 times The nurse is caring for a 41-year-old in the outpatient clinic Item 1 of 6 Nurses' NoteVital SignsMedical History 1345 - Client presents with a concern for intermittent palpitations. He reports they come on suddenly and that he also gets dizzy, short of breath, and fatigued. He indicated that they last anywhere from twenty to thirty minutes. He reports experiencing three episodes of palpations in the past week. He reports he has not taken any new medications or an increase in stress. He reports full adherence to all his prescribed medications. The client is alert and oriented. Denies any pain. Skin is dry and flaky, especially around the elbows and knees. Lungs are clear bilaterally. S1/S2 heart tones auscultated. Peripheral pulses are palpable and irregular. He reports feeling fatigued. Normoactive bowel sounds in all quadrants. Denies any nausea or vomiting. No edema was observed—no jugular venous distention. Oral Temperature 99.2 o F (37.3o C) Heart rate 73/minute; irregular rhythm Respirations 15/minute Blood pressure 139/78 mm Hg Oxygen saturation 95% on room air Myocardial infarction Psoriasis Hypertension Urolithiasis Hemorrhoids ➢ Which two (2) client findings require follow-up? Blood pressure Irregular pulse S1/S2 heart tones Palpable peripheral pulses Reports of palpitations Dry and flaky skin Submit Answer ➢ Which potential problems is the client at risk for developing? Select all that apply. Atrial fibrillation Bacteremia Cerebrovascular accident (CVA) Infective endocarditis Congestive heart failure Pneumothorax Submit Answer ➢ Complete the following sentence by choosing from the list of options The client is at highest risk of developing a fib/ infective endocarditis/ pneumothorax/ CHF as evidenced by irregular pulse/ lung sounds/ S1 and S2/ temp Submit Answer The nurse is collaborating with the physician ➢ For each potential prescription, click to specify whether it is anticipated or not indicated Potential PrescriptionIndicatedNot Indicated Perform a 12-lead electrocardiogram Obtain Blood Cultures Obtain Complete Metabolic Panel (CMP) Nothing by mouth (NPO) status Computed tomography (CT) scan of the chest Submit Answer The nurse reviews the diagnostic result and the medication orders from the physician The nurse plans to administer the prescribed warfarin and diltiazem-XR to the client ➢ For each prescribed medication, specify the appropriate nursing intervention Prescribed MedicationNursing Intervention Diltiazem-XR Select Warfarin Select Submit Answer Diagnostics 12-lead electrocardiogram: Atrial fibrillation Physicians order Diltiazem-XR 120 mg PO Daily Warfarin 2 mg PO Daily The nurse reviews the diagnostic result and the medication orders from the physician The nurse plans to administer the prescribed warfarin and diltiazem-XR to the client ➢ For each prescribed medication, specify the appropriate nursing intervention Prescribed MedicationNursing Intervention Diltiazem-XR Select Warfarin Select Submit Answer The nurse reinforces the discharge instructions with the client ➢ Complete the following sentences by choosing from the list of options Prior to discharge, the nurse should review the client's current medication list for Saw Palmetto/ Vit B12/ Mag Oxide as it could interact with the prescribed warfarin. The dietary education that should be reinforced is that the client should have a consistent intake of folic acid rich food/ vit K rich food/ iron rich food The nurse should remind the client that they will need a follow-up appointment to monitor their international normalized ratio (INR) as the treatment goal is for it to be between 2-3/ 3-4/ 2.5-3.5 Submit Answer

Explanation The irregular pulse requires follow-up because this, combined with the client having palpitations, indicates a significant change in the cardiovascular status. The client's blood pressure is normal, S1/S2 heart tones are normal, and the remaining clinical data. Explanation This is consistent with atrial fibrillation based on the provided clinical data of an irregular pulse, palpitations, and fatigue. In atrial fibrillation, there is a decrease in cardiac output because of the decline of the atrial kick. This causes the client to feel fatigued and may even result in the client having a syncopal episode. CVA is a concern because in atrial fibrillation a thrombus can dislodge and become an embolus which may cause an ischemic stroke. Explanation This client has an irregular pulse is a finding associated with atrial fibrillation because atrial fibrillation is an irregular dysrhythmia in which the atria beat 150-200 times faster than the ventricles. Explanation The client is experiencing an irregular rhythm, and a 12-lead electrocardiogram is necessary to determine the client's cardiovascular status definitively. A CMP is also necessary because electrolyte abnormalities may trigger cardiac dysrhythmias. Blood cultures are not indicated because this client exhibits no signs of bacteremia. NPO status is also unnecessary, as well as a chest CT scan. A chest x-ray is more likely to be ordered to determine any structural defects of the heart. Explanation Diltiazem is a calcium channel blocker commonly prescribed for individuals with atrial fibrillation to attain (and maintain) rate control. This medication will decrease blood pressure and pulse; the nurse should obtain both before administering. Warfarin is an anticoagulant indicated in atrial fibrillation to prevent a stroke. The client will need their baseline INR obtained with the goal INR being between 2-3. Explanation Supplements such as Garlic, Ginko Biloba, and Saw Palmetto should be questioned because this, taken concurrently with warfarin, will potentiate the anticoagulant effects. When taking warfarin, the client should maintain a consistent intake of Vitamin K-rich foods because this will help decrease fluctuations in the INR. The target INR for this client will be between 2-3. A consistent intake would be helpful because no intake of Vitamin K-rich foods would cause the INR to go too high. Too much intake would cause a decrease in the INR. By the client having a consistent intake of Vitamin K-rich foods, they will stabilize their INR and not miss out on the nutritional benefits of these foods.

27-33 The following scenario applies to the next 6 times The nurse cares for a 56-year-old in the emergency department experiencing epigastric pain, shortness of breath, and dizziness Item 1 of 6 Nurses' Notes 1900 - A 56-year-old female presents to the emergency department (ED) with reports of epigastric pain, shortness of breath, and dizziness. The client reports that the symptoms started eight hours ago and have progressively worsened. The client arrives pale and diaphoretic. The client has a medical history of type II diabetes mellitus and stated that her blood glucose has been 'very high.' The blood glucose was taken, and it was 110 mg/dL. ➢ Which five (5) client findings require follow-up by the nurse? Reports of epigastric pain Blood glucose of 110 mg/dL History of diabetes mellitus type II Reports of shortness of breath Progressive worsening of symptoms Reports of dizziness Pale skin and diaphoresis Submit Answer ➢ Which statement, if made by the nurse, would help interpret the client's findings? Why did you wait to come to the emergency department? What was your last hemoglobin A1C result? Does the epigastric pain radiate anywhere? When was the last time you were seen by your physician? Submit Answer ➢ Based on the clinical data, which problem is the client most likely experiencing? Pancreatitis Acute Coronary Syndrome Peptic Ulcer Disease Esophagitis Submit Answer Vital SignsDiagnostics Oral temperature 99.0° F (37° C) Pulse 119 bpm Respirations 22 BP 92/58 mm Hg Oxygen saturation 91% on room air 12-Lead Electrocardiogram - Rate: 112 beats-per-minute Rhythm: Sinus Tachycardia with ST elevations ➢ For each possible intervention, click to specify if it is indicated or not indicated InterventionIndicatedNot Indicated Establish continuous cardiac monitoring Obtain a prescription for albuterol via nebulizer Establish intravenous (IV) access Prepare the client for a chest computed tomography (CT) scan Apply supplemental oxygen Submit Answer Physicians Order Diagnosis: Unstable Acute Coronary Syndrome - Myocardial Infarction NPO 325 mg Aspirin PO STAT Nitroglycerin via intravenous infusion, titrate to a pain level of '2' or less Clip the groin area for cardiac catheterization Obtain medication history The physician provides orders for the nurse The nurse obtains assistance from a licensed practical/vocational nurse (LPN/VN) ➢ Click to specify which physician order should or should not be delegated to the licensed practical/vocational nurse (LPN/VN) Physician OrderDelegateDo Not Delegate Administer 325 mg Aspirin PO Titrate nitroglycerin via intravenous infusion Clip the groin area Obtain the client's medication history Submit Answer The nurse assesses the client two hours after undergoing percutaneous coronary intervention (PCI) via the femoral artery. The nurse updates the nursing note with the following entry: 2200 - Client was restless and feeling 'not good'. The femoral catheter site remained clean and dry. Extensive bruising noted over the flank area with some induration. Reported no pain. Vital signs obtained and the primary healthcare provider was notified. Vital Signs: Oral temperature 97.0° F (36° C); Pulse 110 bpm; Respirations 19; BP 100/67 mm Hg; Oxygen saturation 95% on room air. ➢ Based on the 2200 nurses' notes, complete the sentences below to fill in the blanks The client may is showing early signs of Conditions based on the Assessment Findings and Assessment Findings . Conditions diabetic ketoacidosis shock myocardial infarction atrial fibrillation Assessment Findings heart rate blood glucose blood pressure restlessness. Assessment Findings heart rate blood glucose blood pressure restlessness. Submit Answer

Explanation This client presented with atypical signs of acute coronary syndrome that are unstable, as evidenced by the ST changes on the 12-lead electrocardiogram. The client reports progressively worsening angina accompanied by shortness of breath. Typical clinical features of ACS include - Substernal chest pain with a gradual onset. Pain that radiates to the arm or jaw. Chest pain that is not relieved with rest. Diaphoresis and pallor may be additional findings. Atypical clinical features of ACS include - Nausea and vomiting Dyspnea Significant fatigue Epigastric pain Atypical features are found in women and individuals with diabetes mellitus. Individuals with diabetes mellitus have attenuated chest pain because of neuropathy. The client in this scenario is over the age of 50, which makes her at high risk for developing a myocardial infarction. The findings demonstrated by the client that require follow-up include the client reporting epigastric pain, shortness of breath, the worsening of symptoms, dizziness, and diaphoresis are all findings consistent with atypical and unstable ACS. The client has a history of diabetes, and blood glucose of 110 mg/dL would not be pertinent clinical findings related to ACS symptoms. However, the client being a woman and a diabetic make it likely for her to have atypical clinical features of ACS. Explanation It would be helpful for the nurse to gather a more comprehensive pain assessment, such as inquiring if the pain radiates anywhere. Pain radiating to the upper extremities is highly suggestive of ischemic pain. This is an essential question to ask for the nurse to narrow down if the client is experiencing unstable acute coronary syndrome. The other options would not validate acute coronary syndrome, which the client is experiencing. Explanation It would be helpful for the nurse to gather a more comprehensive pain assessment, such as inquiring if the pain radiates anywhere. Pain radiating to the upper extremities is highly suggestive of ischemic pain. This is an essential question to ask for the nurse to narrow down if the client is experiencing unstable acute coronary syndrome. The other options would not validate acute coronary syndrome, which the client is experiencing. Explanation The client is experiencing unstable acute coronary syndrome, and the nurse should act quickly to recognize if complications are being experienced by establishing continuous cardiac monitoring. Further, prescribed treatments such as vascular access should be obtained to administer treatments. A CT scan is not indicated in acute coronary syndrome, as a chest radiograph will be obtained. Additionally, the client is showing signs of hemodynamic instability, which would not be a priority. Supplemental oxygen should be applied as the oxygen saturation is 91%. Albuterol breathing treatments are contraindicated, making the myocardium demand more perfusion. This, in turn, could cause lethal arrhythmias. Explanation If the nurse is to work with an LPN/VN, the nurse can safely delegate tasks such as aspirin administration and the clipping of the groin, which is done in preparation for the client to go to the cath lab for intervention. Obtaining the client's medical history can be done by the LPN/VN. Tasks that should not be delegated include the titration of the nitroglycerin infusion, which requires frequent assessment of the blood pressure, which the RN can only do. Explanation Following percutaneous coronary intervention, the client goes to intensive care. If access were obtained via the femoral artery, the provider would typically order head-of-the-bed restrictions up to thirty degrees for up to six hours. The client should keep the affected extremity straight. Nursing care involves frequent assessment of the vital signs and the site for any bleeding. Shock and dysrhythmias are common complications following this procedure. The nurse should report any induration associated with bruising at the site or flank area. This client is in the early stages of shock, which are classically manifested by restlessness and tachycardia. The extensive bruising further supports this finding in the client's flank area, which indicates a retroperitoneal bleed. This client is not exhibiting signs of any pain; therefore, the client is not experiencing a myocardial infarction. DKA is not a concern, considering the blood glucose is elevated but not hyperglycemic.