Perfusion questions
what type of scale is used to systemically assess and qualify a clients risk for pressure ulcer PULSES profile Braden scale Barthel index FIM
Braden scale
what is an embolism
a blocked artery caused by a foreign body, such as a blood clot or an air bubble
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? Intubation of the airway BP and pulse measurements every 15 to 30 minutes Insertion of a central venous catheter Hourly administration of a fluid bolus
bp and pulse measurements every 15-30mins beside ECG, O2, BP, and Pulse are standard
A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. Administer warfarin. Check the postoperative CBC, INR, PTT, and platelet levels. Confirm availability of blood products. Monitor the mediastinal chest tube drainage. Start a dopamine drip for a systolic BP less than 100 mm Hg.
check postoperative CBC, INR, PTT and platelets confirm availability of blood products monitor the mediastinal chest tube drainage
What is a cardiac tamponade?
compression of the heart by an accumulation of fluid in the pericardial sac
what are defined as intermittent vessel vasospasms
epinephrine norepinephrine dopamine angiotensin II vasopressin
what is coronary obstruction
gradual narrowing or closing of arteries that supply the heart with blood
The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition? heart failure ventricular hypertrophy pulmonary edema myocardial infarction
heart failure BNP of 100 pg/ml or higher suggests heart failure, testing for BNP is a fast test and used commonly in the ED
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of Hemorrhage. Thrombosis of the graft. Decreased motor function. Stent dislodgement.
hemorrhage all options require medical/surgical attention but hemorrhage is priority
The nurse caring for a client 12 hours after a coronary bypass graft notes a sudden decrease in the amount of chest tube drainage, a rapidly narrowing pulse pressure, paradoxical pulse, and shortened amplitude of the QRS complex on the electrocardiogram monitor. Which action should the nurse take next? Prepare for pericardiocentesis Administer IV corticosteroids Provide pain medications Encourage deep breathing
prepare for pericardiocentesis this may occur after cardiac surgery or a result from trauma/infection, the volume and speed of fluid accumulating in the pericardial sac determines how critical the situation is
A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) Jugular vein distention Ascites Pulmonary crackles Dyspnea Cough
pulmonary crackles dyspnea cough
Priapism (a prolonged painful erection not associated with sexual excitement) can occur at any age. In boys, ages 5 to 10, what are the most common causes of priapism? Neoplasms or hemophilia Sickle cell disease or neoplasms Hemophilia or sickle cell disease Hypospadias or neoplasms
sickle cell disease or neoplasms most common in boys between 5-10 years old
An IV drug abuser walks into the ED telling the nurse, "I am sick." The client looks feverish with flushed, moist skin; dehydrated with dry lips/mucous membranes; and fatigued. The assessment reveals a loud murmur. An echocardiogram was ordered that shows a large vegetation growing on the client's mitral valve. The client is admitted to ICU. The nurse will be assessing this client for which possible life-threatening complication? -Systemic emboli, especially to brain. -Petechial hemorrhages under the skin and nail beds. -GI upset from the massive amount of antibiotics required to kill the bacteria. -Pancreas enlargement due to increased need for insulin secretion.
systemic emboli, especially to brain systemic emboli develop and break off the mitral valve and travel into the vascular system, with a high probability it could get lodged into the brain/kidneys
how does a coronary obstruction occur
usually caused by a build up of plaque (atherosclerosis) that can begin as early as teens
a patient is diagnosed with systolic heart failure, what is the patients ejection fraction % 5% 30% 55% 65%
30%
What are petechial hemorrhages?
-areas of pericapillary bleeding that occur in a wide spectrum of disorders -tiny round brown-purple spots due to bleeding under the skin
how do you treat arteriovenous malformation (AVM)
-depending on where it is found, symptoms and risk determines the treatment, surgery can happen if there is a high risk of bleeding -endovascular embolization -stereotactic radiosurgery
what are the phases in the sinoatrial node SA
-phase four is spontaneous depolarization -phase zero is depolarization -phase three is repolarization
What is BNP?
B-type natriuretic peptide. This is secreted by the ventricular tissues in the heart when ventricular volumes and pressure in the heart are increased. Sensitive indicator
what is the normal order of conduction through the heart -Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers -AV node, SA node, bundle of His, right and left bundle branches, and the Purkinje fibers -SA node, AV node, right and left bundle branches, bundle of His, and the Purkinje fibers -SA node, AV node, bundle of His, the Purkinje fibers, and the right and left bundle branches
Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers
An autopsy is being performed on a 44-year-old female who died unexpectedly of heart failure. Which components of the pathologist's report is most suggestive of a possible history of poorly controlled blood pressure? "Scarring of urethra suggestive of recurrent urinary tract infections is evident." "Bilateral renal hypertrophy noted." "Vessel wall changes suggestive of venous stasis are evident." "Arterial sclerosis of subcortical brain regions noted."
arterial sclerosis of subcortical brain regions noted neurological consequences include narrowing and sclerosis of subcortical regions
elevated INR/PTT and decreased platelet count increase risk for what
bleeding can occur
The hemoglobin and hematocrit should be assessed to evaluate what
blood loss
Chronic stable angina, associated with inadequate blood flow to meet the metabolic demands of the myocardium, is caused by: Fixed coronary obstruction Increased collateral circulation Intermittent vessel vasospasms Excessive endothelial relaxing factors
fixed coronary obstruction chronic stable angina is caused by fixed coronary obstruction that produces an imbalance between blood flow and metabolic demands of the myocardium
A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? "You are experiencing leg pain because of venous congestion." "You are experiencing pain due to inadequate removal of carbon dioxide from the tissues in the legs." "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." "The pain is related to atherosclerosis, which is the same problem causing your angina."
the pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs when the person has a history of atherosclerosis affecting the heart and resulting in intermittent claudication, there is arterial insufficiency, which then results in inadequate provision of oxygenated blood to the muscles
Which of the following is associated with stasis of blood, increased blood coagulability, and vessel wall injury? Venous thrombosis Varicose veins Chronic venous insufficiency Peripheral artery disease (PAD)
venous thrombosis
What is the QRS complex?
ventricular depolarization and atrial repolarization
what are the three coagulation cascade components
vessel spasm platelet aggregation hemostatic process
Which statement describes phase 4 of the action potential of cells in the sinoatrial (SA) node? --A slow depolarization occurs when Na+ is transported out of the cell and K+ moves back in, resulting in resting membrane potential. --The cells are capable of responding to a greater-than-normal stimulus before the resting membrane potential is reached. --The fast sodium channels in the cellular membranes close, causing an abrupt decrease in intracellular positivity. --Potassium permeability is allowing the cell membrane to remain depolarized and the Ca++ channel opens, moving Ca++ back into the cell.
A slow depolarization occurs when Na+ is transported out of the cell and K+ moves back in, resulting in resting membrane potential. during stage 4 of the SA node, a slow leakage through the slow channels leads to spontaneous depolarization and this enables pacemaker function
what is priapism
A prolonged and painful erection
what is a systemic emboli
an emboli travel through the systemic arterial circulatory system
what is an arteriovenous malformation
When major arteries and veins don't develop normally. The capillary bed is missing and brain tissue is not normal.
what is pericardiocentesis
a procedure done to remove fluid that built up in the sac around the heart (pericardium)
The nurse must administer a unit of packed red blood cells to a 4-year-old child. The child's blood type is Type B Rh factor positive. When the unit of blood arrives, it is labeled as Type O Rh factor negative. What is the appropriate action for the nurse to take? Begin the administration of the blood as ordered. Return the blood and order a new unit of Type B. Document the error with an incident report. Have the child's blood retested for blood type.
begin the administration of the blood as ordered type O Rh negative blood is universal donor
A college student has been experiencing frequent headaches that he describes as throbbing; he is reporting difficulty concentrating while studying. Upon cerebral angiography, he is found to have an arteriovenous malformation. Which pathophysiologic concept is likely responsible for his symptoms? Increased tissue perfusion at the site of the malformation Hydrocephalus and protein in the cerebrospinal fluid High pressure and local hemorrhage of the venous system Localized ischemia with areas of necrosis noted on CT angiography
high pressure and local hemorrhage of the venous system
