NSG med surg final exam hesi study guide

What is the term for shock associated with a ruptured abdominal aneurysm

hypovolemic shock

pneumatic compression devices?

used to prevent DVT, improves venous circulation improved venous blood flow

Bleeding gum, what vitamin?

K

The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first? Feel for a pulse Begin chest compressions Leave to call for assistance Perform the abdominal thrust maneuver

Begin chest compression According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, the nurse has established that the client has no pulse when cardiopulmonary arrest was determined. Therefore, chest compressions should be initiated immediately. Never leave the client to call for assistance; either call the emergency medical services (EMS) by dialing 911 in the US or 112 in Canada on a cellular phone (and leave the phone on so that EMS can find you) or shout out to others in the area for assistance in seeking EMS. The longer the client goes without circulation, the higher the risk of death, so initiating chest compressions has highest priority when cardiopulmonary arrest has been established. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

A nurse is caring for a client who was admitted to the hospital with the diagnosis of tertiary syphilis. Which system of the body should the nurse assess most closely in this stage of the disease? Reproductive Cardiovascular Lower respiratory Lower gastrointestinal

Cardiovascular Tertiary syphilis is the last stage, affecting several body systems: skin, cardiovascular, and neurological. Aortic valvular disease and aortic aneurysms can occur. Although lesions occur on the genitalia during primary and secondary syphilis, the reproductive system is not the major body system affected in tertiary syphilis. Structures of the lower respiratory tract and gastrointestinal are not the major structures involved in tertiary syphilis.

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? Call the primary healthcare provider. Check the client's pedal pulses. Take the client's blood pressure. Recognize the response is expected.

Check pedal pulses These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.

When a Schilling test is prescribed for a client suspected of having cobalamin deficiency because of pernicious anemia, what should the nurse plan to do? Give medications on time Prescribe foods low in vitamin B12 Keep an accurate intake and output Collect a 24-hour to 48-hour urine specimen

Collect a 24-hour to 48-hour urine specimen A 24-hour to 48-hour urine specimen assesses parietal cell function. After radioactive cobalamin is administered, its excretion is measured; if cobalamin cannot be absorbed, as in pernicious anemia, very little is excreted in the urine. This test is not affected by medications. The results of this test are not affected by food; with pernicious anemia there is a deficiency of intrinsic factor, which is necessary for vitamin B12 use. Intake and output records are not necessary with a Schilling test.

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Arrange for a supply of heparin for the client to take to the rehab center. Explain to the client that anticoagulant therapy will no longer be needed. Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.

Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the healthcare provider. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

What are the clinical manifestations of inhalation anthrax? Select all that apply. Fever Fatigue Rhinitis Dry cough Sore throat

Fever, fatigue, dry cough Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. Clinical manifestations include fever, fatigue, mild chest pain, and a dry cough. Rhinitis and sore throat are manifestations of many common upper respiratory infections, but are not associated with inhalation anthrax.

A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply. Collapsed neck veins Distended abdomen Dependent edema Urinating at night Cool extremities

Distended abdomen dependent edema urinating at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by a distended abdomen, dependent edema, and urinating at night. Distended, not collapsed, neck veins occur in right-sided heart failure. Cool extremities are key features of left-sided heart failure.

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan about prevention of thrombophlebitis?

Donning compression stockings before getting out of bed provides support and promotes venous return; applying stockings while the legs are horizontal ensures that the stockings are in place before dependent edema occurs. Wearing snug-fitting pants will cause constriction. Sitting with the knees flexed promotes venous stasis and the formation of thrombophlebitis. Warm soaks resolve inflammation; they do not prevent the development of thrombophlebitis.

Which leukocyte releases vasoactive amines during a client's allergic reactions? 1 Neutrophil Monocyte Eosinophil 4 Macrophage

Eosinophils release vasoactive amines during allergic reactions to limit the extent of the allergic reactions. Neutrophils are phagocytes and increase in inflammation and infection. Monocytes are involved in the destruction of bacteria and cellular debris. Macrophages are involved in nonspecific recognition of foreign protein and microorganisms.

A client states, "I feel like my heart is jumping out of my chest, and it is skipping beats." The client passes a thallium stress test; however, the healthcare provider identifies one premature ventricular complex (PVC) and several premature atrial complexes (PACs) on the 24-hour follow-up Holter monitor. Which question is most important for the nurse to ask the client? "Do you eat foods high in vitamins?" "Do you have small children at home?" "How much caffeine do you consume each day?" "How many glasses of water do you drink per day?"

How much caffein... Caffeine is a stimulant that causes the heart to become irritable; it can result in tachycardia and atrial dysrhythmias. Vitamins are unrelated to an irregular heart rhythm. Small children and water consumption are unrelated to the client's physical problem.

The primary healthcare provider prescribes a transfusion of 2 units of packed red blood cells for a client. When administering blood, what is the priority nursing intervention? Make sure the client's family has received education. Warm the blood to 98° F (36.7° C) to prevent chills. Infuse the blood at a slow rate during the first 15 minutes. Draw blood samples from the client after each unit is transfused.

Infuse the blood at a slow rate during the first 15 minutes. A slow rate provides time to recognize a reaction that is developing before too much blood is administered. Blood is not warmed to 98° F (36.7° C) to prevent chills; this could cause clotting and hemolysis. Educating the family is important but not a priority. Drawing blood samples from the client after each unit is transfused is not necessary. Test-Taking Tip: Try putting questions and answers in your own words to test your understanding.

A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? It should be elevated on a pillow. It should be kept extended while on bed rest. It will be positioned dependent to the level of the heart. It will be put through range-of-motion exercises several times an hour.

It should be kept extended while on bed rest. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. Elevating the leg on a pillow will flex the hip, which may traumatize the catheter insertion site and impede healing. The leg is kept even with the level of the heart because the client usually is placed in the supine position with the leg extended. Range of motion will flex the hip, which may traumatize the catheter insertion site and impede healing.

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Rapid pulse Deep respirations Warm, flushed skin Increased blood pressure Decreased urinary output

Rapid pulses, decreased urine output The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.

What are the clinical manifestations during the fulminant stage in a client with inhalation anthrax? Select all that apply. 1 Septic shock 2 Harsh cough 3 Mild chest pain 4 Pleural effusion 5 Body temperature of 104 °F

Septic shock; pleural effusion, high fever Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. Manifestations such as septic shock, pleural effusion, and body temperature above 103°F indicate the fulminant stage of inhalation anthrax. The prodromal stage is the early stage of inhalation anthrax; clinical manifestations include a harsh cough and mild chest pain.

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? Continue climbing." "Stand still and rest." "Walk down the stairs." "Climb but at a slower rate."

Stand 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. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse? "This test will detect your heart sounds." "This test will reflect any heart damage." "This procedure helps us change your heart's rhythm." "The ECG will tell us how much stress your heart can tolerate."

The test reflect heart damage Changes in an ECG will reflect the area of the heart that is damaged because of hypoxia. A stethoscope is used to detect heart sounds. Medical interventions, such as cardioversion or cardiac medications, not an ECG, can alter heart rhythm. An ECG will reflect heart rhythm, not change it. Identifying how much stress a heart can tolerate is accomplished through a stress test; this uses an ECG in conjunction with physical exercise.

Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? Relax in a reclining position Sit upright with legs extended Walk around at least every hour Sit in any position that relieves pressure on the legs

Walk around at least every hour Muscle contraction associated with walking prevents pooling of blood in the extremities and dependent edema. Movement is required, not inactivity (reclining or sitting). Sitting in any position that relieves pressure on the legs does not include movement, which is essential to prevent thrombus formation.

Which drug treats hay fever by preventing leukotriene synthesis? Zileuton Cromolyn sodium 3 Chlorpheniramine 4 Diphenhydramine

Zileuton is a leukotriene antagonist drug; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E.. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations.

A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? "The cause is abnormal configurations of the veins." "The cause is incompetent valves of superficial veins." "The cause is decreased pressure within the deep veins." "The cause is atherosclerotic plaque formation in the veins."

cause is incompetent valves of superficial veins Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client? Edema of the left leg Mobility of the left leg Positive left-sided Babinski reflex Presence of left arterial peripheral pulse

edema Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return. Difficulty with mobility occurs with musculoskeletal or neuromuscular problems. Positive left-sided Babinski reflex is associated with neurologic deficits in the corticospinal tracts. Presence of a left arterial peripheral pulse is made to determine the status of the arterial, not venous, system.

Holter moniror

wear it to monitor daily cardiac rhythm (it only detects/ measures abnormal rhythms and record it)