4510: Concept Synthesis, Exam 1 - Oxygenation, Perfusion, Elimination, Fluid and Electrolyte, Infection

A with stage 3 CKD is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? 1. Apple, green beans, and a roast beef sandwich 2. Granola made with dried fruits, nuts, and seeds 3. Watermelon and ice cream with chocolate sauce 4. Bran cereal with ½ banana and milk and orange juice

1 When the patient selects an apple, green beans, and a roast beef sandwich, the patient shows understanding of the low-potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have high levels of potassium, at or above 200 mg per 1/2 cup.

Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI)? (Select all that apply.) 1. Dehydration 2. Hypokalemia 3. Hypernatremia 4. BUN increases 5. Urine output increases 6. Serum creatinine increases

1, 2, 5 The hallmark of entering the diuretic phase is the production of copious amounts of urine. Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Serum BUN and serum creatinine levels begin to decrease.

A client is admitted with a temperature of 103.2 F and signs of SIRS. The client complains of shortness of breath and fatigue. On assessment, you note a mitral murmur which is new for the client. The patient has a history of IV drug use in the past. What diagnostic test is most likely able to confirm the presence of infective endocarditis? 1. Heart catheterization 2. Transesophageal echocardiogram 3. White blood cell count 4. Abdominal ultrasound

2. TEE

To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply) a. monitor the BP in the affected arm. b. irrigate the graft daily with low-dose heparin. c. palpate the area of the graft to feel a normal thrill. d. listen with a stethoscope over the graft to detect a bruit. e. assess the pulses and neurovascular status distal to the graft.

C, d, e Rationale: A thrill can be felt on palpation of the area of anastomosis of the arteriovenous graft, and a bruit can be heard with a stethoscope. The bruit and thrill are created by arterial blood rushing into the vein. The BP should not be taken in the arm with the AV graft

After receiving the change-of-shift report, which patient should you assess first? A. 18-month-old with coarctation of the aorta who has decreased pedal pulses B. 3-year-old with rheumatic fever who reports severe knee pain C. 5-year-old with endocarditis who has crackles audible throughout both lungs D. 8-year-old with Kawasaki disease who has a temperature of 102.2° F (39° C)

C. 5-year-old with endocarditis who has crackles audible throughout both lungs

The nurse is caring for a patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? A. Observe stools for frank bleeding and occult blood. B. Maintain head of the bed elevation at 30 to 45 degrees. C. Begin enteral feedings as soon as bowel sounds are present. D. Administer prescribed lorazepam (Ativan) to reduce anxiety.

C. Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

Which condition unrelated to cardiac disease is the major cause of right ventricular failure? Hypovolemic shock Chronic obstructive pulmonary disease Chronic kidney disease Systemic inflammatory response syndrome

COPD COPD causes destruction of capillary beds around the alveoli, interfering with blood flow to the lungs from the right side of the heart. As the heart continues to strain against this resistance, heart failure eventually results. Renal disease causes stress on the left side of the heart. Hypovolemic shock will not cause stress on the right side of the heart. Severe systemic infection probably will produce greater stress on the left side of the heart.

When teaching a patient about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of a. valvular heart disease. b. pulmonary hypertension. c. superior vena cava syndrome. d. hypertrophy of the right ventricle.

Correct answer: a Rationale: Rheumatic heart disease is a chronic condition resulting from rheumatic fever. It is characterized by scarring and deformity of the heart valves.

A client presents to the emergency department with a heart rate of 180. An EKG reveals that the client's heart rhythm is supraventricular tachycardia (SVT). The client is given diltiazem. Which assessment indicates to the nurse that the diltiazem is effective? Client no longer complaining of heart palpitations Prevention of heart dysrhythmias Heart rate of 120 beats/minute Blood pressure of 90/60 mmHg

Heart rate of 120 beats/minute

What would be covered in the discharge teaching for a 32-year-old client who has had mitral valve replacement with a mechanical valve? Daily aspirin use Care of leg incisions Low fat and low cholesterol diet Anticoagulation therapy

Anticoagulation therapy

T/F Acute pericarditis most often is idiopathic.

True • Acute pericarditis most often is idiopathic. Other causes include uremia, viral or bacterial infection, acute myocardial infarction (MI), heart surgery, tuberculosis, cancer, inflammation from radiation to the chest, and trauma.

What respiratory test is preferred when differentiating between obstructive and restrictive pulmonary issues? a) Chest radiographs b) MRI c) Pulmonary function test d) Serial arterial blood gases

a) Pulmonary function test

Which laboratory value would the nurse monitor when determining whether a client's newly transplanted kidney works effectively? a) Serum creatinine b) Renal ultrasound c) 24 hour urine output d) Serum potassium

a) Serum creatinine

What is the priority nursing intervention for a client on a continuous intravenous morphine sulfate infusion at 3mg/hr whose respiratory rate is 8 breaths per minute? a) Stop administering the medication and assess the client b) Elevate the head of the bed and provide oxygen via nasal cannula c) Intranasal administration of 0.4mg Narcan d) Report to the primary care provider

a) Stop administering the medication and assess the client

SATA: Which of the following statements are TRUE? a. The most common cause of death in AKI is infection. b. Postrenal AKI is the most common cause of AKI c. All patients with AKI experience the oliguric phase d. Hyperkalemia is one of the most serious complications of AKI

a, d The most common cause of death in AKI is infection. The most common sites of infection are the urinary and respiratory systems. Hyperkalemia is one of the most serious complications in AKI because it can cause life threatening dysrhythmias. b. Postrenal AKI is the least common, accounting for <10% of AKI cases d. About 50% of patients will be non-oliguric, making the diagnosis difficult. Non-oliguric AKI occurs with acute interstitial nephritis and ATN

Which assessment finding in a client with a history of chronic obstructive pulmonary disease indicates that the client's hypercapnia is increasing? a) Client reports feelings of anxiety b) Respirations between 30-40 breaths per minute c) Client's incentive spiromentry volume increases from 500ml to 1500mls. d) Altered mental status

d) Altered mental status

During a focused cardiac assessment, the nurse auscultates a murmur at the second left intercostal space along the sternal border. Which valve is being auscultated? Mitral Tricuspid Pulmonic Aortic

Pulmonic

While educating a group of nursing students about the stages of acute kidney injury, a student asks how long the oliguric stage lasts. You explain to the student this stage can last? A. 1-2 weeks B. 1-3 days C. Few hours to 2 weeks D. 12 months

The answer is A. The oliguric stage can last 1-2 weeks. Regarding the other stages of AKI: Initiation: few hours to several days, diuresis: 1-3 weeks, and recovery: 12 months or more.

A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by the physician is most appropriate for this patient? A. Low-sodium, high-protein, and low-potassium B. High-protein, low-potassium, and low-sodium C. Low-protein, low-potassium, and low-sodium D. High-protein and high-potassium

The answer is C. The patient with AKI, especially in the oliguric stage of AKI, should eat a low-protein, low-potassium, and low-sodium diet. This is because the kidneys are unable to filter out waste products, excessive water, and maintain electrolyte balance. The patient will have a buildup of waste (BUN and creatinine). Remember these waste products are the byproduct of protein (urea) and muscle breakdown (creatinine). So the patient should avoid high-protein foods. In addition, the patient is at risk for hyperkalemia and fluid overload (needs low-potassium and sodium foods).

When caring for older adult patients with respiratory failure, the nurse will add which intervention to individualize care? A. Assess frequently for manifestations of delirium. B. Position the patient in the supine position primarily. C. Provide early endotracheal intubation to reduce complications. D. Delay activity and ambulation to provide additional healing time.

A. Older adult patients are more predisposed to delirium and health care-associated infections. Individualizing the older patient's care plan to address these factors will improve care. Older adult patients are not required to remain in a supine position only and should increase activity as soon as stability is determined. Endotracheal intubation is not provided early, and noninvasive positive pressure ventilation may be considered as an alternative. The nurse should consider that the aging process leads to decreased lung elastic recoil, weakened lung muscles and reduced gas exchange, which may make the patient difficult to wean from the ventilator.

A patient with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the provider would the nurse to question? A. Increase PEEP from 10 to 15 cm H2O. B. Start a dobutamine infusion at 3 mcg/kg/min. C. Give 1 unit of packed RBCs over the next 2 hours. D. Change the maintenance IV rate from 75 to 125 mL/hr.

A. Patients on PPV and PEEP often have decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, giving crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.

The patient with pulmonary fibrosis has hypoxemia during exercise but not at rest. To plan patient care, the nurse identifies the patient is experiencing which physiologic mechanism of respiratory failure? A. Diffusion limitation B. Intrapulmonary shunt C. Alveolar hypoventilation D. Ventilation-perfusion mismatch

A. The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, so hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease, pulmonary embolus).

Which of the following statements regarding treatment for hyperkalemia is true? SATA a. insulin and sodium bicarb are temporary measures for treating hyperkalemia by promoting transient shift of K+ into cells, K= will eventually diffuse back out. b. Calcium gluconate raises the dysrythmia threshold by temporarily stabilizing the myocardium c. Sodium polystyrene sulfonate (Keyexalate), patiromer, and dialysis are the treatments that actually remove potassium from the body.

All of the above are true

A patient is receiving treatment for infective endocarditis. The patient has a history of intravenous drug use and underwent mitral valve replacement a year ago. The patient is scheduled for a transesophageal echocardiogram tomorrow. On assessment, you find tender, red lesions on the patient's hands and feet. You know that this is a common finding in patients with infective endocarditis and is known as? A. Janeway Lesions B. Roth Spots C. Osler's Nodes D. Trousseau's Sign

Answer is C...Osler's Nodes. They are TENDER, red lesions on the hands and feet. Don't get this confused with Janeway Lesions which are NON-TENDER, red lesions on the PALMS of the hands and SOLES of the feet. Roth spots are retinal hemorrhages with white centers and Trousseau's Sign is found in hypocalcemia.

Interventions used in managing the patient with ARDS include (select all that apply) a. IV injection of surfactant. b. aggressive IV fluid resuscitation. c. giving adequate analgesia and sedation. d. elevating the head of bed 30 to 45 degrees when supine. e. monitoring hemodynamic parameters and daily weights.

B, c, d, e Management strategies for patients with ARDS include administration of analgesia and sedation for comfort, ETT tolerance, and to help prevent ventilator dyssynchrony. Management of fluid balance includes maintaining normovolemia or keeping the patient on the "dry" side. Avoid aggressive IV fluid resuscitation as the lungs are already fluid overloaded. Measures to help reduce ventilator associated pneumonia include head of bed elevated 30 to 45 degrees and, strict infection control measures. Surfactant replacement therapy in adults is experimental at this time.

While working on the cardiac step-down unit, you are serving as preceptor to a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? A. 19-year-old with rheumatic fever who needs discharge teaching before going home with a roommate today B. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV C. 50-year-old with newly diagnosed stable angina who has many questions about medications and nursing care D. 75-year-old who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

B. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. B. Initiate oxygen via a nasal cannula, and begin at a flow rate of 2 L/min. C. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). D. Encourage coughing and deep breathing to clear the airway.

B. The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would diminish his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? A. Arterial pH is 7.32. B. PaO2 is greater than or equal to 60 mm Hg. C. PEEP increased to 20 cm H2O caused BP to fall to 80/40. D. No change in PaO2 when patient is turned from supine to prone position.

B. The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60 mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? A. Biologic valves will require immunosuppressive drugs after surgery. B. Mechanical mitral valves need to be replaced sooner than biologic valves. C. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. D. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

C Mechanical valves are made from artificial materials. They consist of combinations of metal alloys, pyrolytic carbon, and Dacron. Biologic valves are made from bovine, porcine, and human (cadaver) heart tissue. They usually contain some human-made materials. A "decellularizing" process removes the cadaver cells from the valve to lower the risk for tissue rejection. Biologic valves are asymmetric in shape. They produce a more natural pattern of blood flow compared with mechanical valves. Mechanical valves are more durable and last longer than biologic valves. However, they have an increased risk for thromboembolism. Patients need long-term anticoagulation therapy, which increases the risk of bleeding. 13 Anticoagulation therapy is not needed with biologic valves because of their low thrombogenicity. However, they are less durable and tend to cause early calcification, tissue degeneration, and stiffening of the leaflets. Both valve types are subject to leaking and risk of IE

The nurse is caring for a patient with multiple fractured ribs from a motor vehicle crash. Which assessment findings would be early indications that the patient is developing respiratory failure? A. Tachycardia and pursed lip breathing B. Kussmaul respirations and hypotension C. Frequent position changes and agitation D. Cyanosis and increased capillary refill time

C. A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next? A. Lower the client's left foot below heart level. B. Administer oxygen at 4 L/min to the client. C. Notify the client's physician about the change in status. D. Reassure the client that embolization is common in endocarditis.

C. Notify the client's physician about the change in status.

When evaluating the concept of gas exchange, how should the nurse best describe the movement of oxygen and carbon dioxide? A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. C. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.

C. Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas.

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with a BP of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure because of diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure because of increased airway resistance

C. The patient's respiratory rate is decreased because of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.

The nurse is admitting a patient with asthma in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding suggest to the nurse? A. Spontaneous resolution of the acute asthma attack B. An acute development of bilateral pleural effusions C. Airway constriction requiring immediate interventions D. Overworked intercostal muscles resulting in poor air exchange

C. When a patient in respiratory distress has inspiratory wheezing and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore airway patency. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress.

A kidney transplant recipient has had fever, chills, and dysuria over the past 2 days. What is the first action that the nurse should take? a. Assess temperature and initiate workup to rule out infection. b. Reassure the patient that this is common after transplantation. c. Provide warm covers to the patient and give 1 gram oral acetaminophen. d. Notify the nephrologist that the patient has manifestations of acute rejection.

Correct answer: a Rationale: The nurse must be astute in the observation and assessment of kidney transplant recipients because prompt diagnosis and treatment of infections can improve patient outcomes. Fever, chills, and dysuria indicate an infection. Assess the temperature. The patient should undergo diagnostic testing to rule out an infection

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In helping the patient decide about treatment, the nurse informs the patient that a. successful transplantation usually provides better quality of life than that offered by dialysis. b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available. c. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection. d. the immunosuppressive therapy after transplantation makes the person ineligible to receive other treatments if the kidney fails.

Correct answer: a Rationale: Kidney transplantation is extremely successful, with 1-year graft survival rates of about 90% for deceased donor organs and 95% for live donor organs. An advantage of kidney transplantation over dialysis is that it reverses many of the pathophysiologic changes associated with renal failure when normal kidney function is restored. It also eliminates the dependence on dialysis and the need for the accompanying dietary and lifestyle restrictions. Transplantation is less expensive than dialysis after the first year.

A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys. b. a rapid decrease in urine output with an elevated BUN. c. an increasing creatinine clearance with a decrease in urine output. d. prostration, somnolence, and confusion with coma and imminent death.

Correct answer: a Rationale: Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function. A focus on stages 1 through 4 before the need for dialysis (stage 5) includes the control of hypertension, hyperparathyroid disease, CKD-MBD, anemia, and dyslipidemia.

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia

Correct answer: c Rationale: In the diuretic phase of AKI, the kidneys have recovered the ability to excrete wastes but not the ability to concentrate urine. Hypovolemia and hypotension can result from massive fluid losses. Because of the large losses of fluid and electrolytes, monitor the patient for hyponatremia, hypokalemia, and dehydration.

Priority nursing management for a patient with myocarditis includes interventions related to a. meticulous skin care. b. antibiotic prophylaxis. c. tight glycemic control. d. oxygenation and ventilation

Correct answer: d Rationale: General supportive measures for management of myocarditis include interventions to improve ventilation and oxygenation (oxygen therapy, bed rest, and restricted activity).

Nutritional support and management are essential across the entire continuum of chronic kidney disease. Which statements are true related to nutritional therapy? (select all that apply) a. Sodium and salt may be restricted in someone with advanced CKD. b. Fluid is not usually restricted for patients receiving peritoneal dialysis. c. Decreased fluid intake and a low-potassium diet are part of the diet for a patient receiving hemodialysis. d. Decreased fluid intake and a low-potassium diet are part of the diet for a patient receiving peritoneal dialysis. e. Decreased fluid intake and a diet in protein-rich foods are part of a diet for a patient receiving hemodialysis.

Correct answers: a, b, c Rationale: Water and any other fluids are not routinely restricted before Stage 5 end-stage renal disease (ESRD). Patients receiving hemodialysis have a more restricted diet than do patients receiving peritoneal dialysis. Patients receiving hemodialysis are taught about the need for a dietary restriction of potassium- and phosphate-rich foods. Patients receiving peritoneal dialysis may actually need potassium replacement because of the higher losses of potassium with peritoneal dialysis. Sodium and salt restriction is common for all patients with CKD. For those receiving hemodialysis, as their urinary output decreased, fluid restrictions are enhanced. Intake depends on the daily urine output. In general, 600 mL (from insensible loss) plus an amount equal to the previous day's urine output is allowed for a patient receiving hemodialysis. Patients are taught to limit fluid intake so that weight gains between dialysis sessions (i.e., interdialytic weight gain) are no more than 1 to 2 kg. For the patient who is undergoing dialysis, protein is not routinely restricted. For CKD stages 1 through 4, many clinicians encourage a diet with normal protein intake. However, patients are taught to avoid high-protein diets and supplements because they may overstress the diseased kidneys.

Which signs and symptoms should the nurse expect to find when assessing a patient with infective endocarditis who uses IV cocaine? (select all that apply) a. Retinal hemorrhages b. Splinter hemorrhages c. Presence of Osler's nodes d. Painless nodules over bony prominences e. Erythematous macules on the palms and soles

Correct answers: a, b, c, e Rationale: Clinical manifestations of infective endocarditis may include hemorrhagic retinal lesions (Roth's spots), splinter hemorrhages (black, longitudinal streaks) that may occur in the nail beds, Osler's nodes (painful, tender, red or purple, pea-size lesions) on the fingertips or toes, and Janeway's lesions (flat, painless, small, red spots) seen on the fingertips, palms, soles of feet, and toes.

Patients with chronic kidney disease have an increased incidence of cardiovascular disease related to (select all that apply) a. hypertension. b. vascular calcifications. c. a genetic predisposition. d. hyperinsulinemia causing dyslipidemia. e. increased high-density lipoprotein levels.

Correct answers: a, b, d Rationale: CKD patients have traditional cardiovascular (CV) risk factors, such as hypertension and high lipid levels. Hyperinsulinemia stimulates hepatic production of triglycerides. Most patients with uremia develop dyslipidemia. CV disease may be related to nontraditional CV risk factors, such as vascular calcification, which are major contributors to CV disease in CKD. Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial and incompletely understood, but they include (1) change of vascular smooth muscle cells into chondrocytes or osteoblast-like cells, (2) high totalbody amounts of calcium and phosphate from abnormal bone metabolism, (3) impaired renal excretion, and (4) drug therapies to treat the bone disease (e.g., calcium phosphate binders).

Nurses can screen patients at risk for developing chronic kidney disease. Those considered to be at increased risk include (select all that apply) a. older black patients. b. patients more than 60 years old. c. those with a history of pancreatitis. d. those with a history of hypertension. e. those with a history of type 2 diabetes.

Correct answers: a, b, d, e Rationale: Risk factors for CKD include diabetes, hypertension, age older than 60 years, cardiovascular disease, ethnic minority (e.g., Black, Native American), family history of CKD, and exposure to nephrotoxic drugs.

A patient is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which interventions could the nurse delegate to unlicensed assistive personnel (UAP)? (select all that apply) a. Obtain and record daily weight. b. Determine apical-radial pulse rate. c. Observe for overt signs of bleeding. d. Teach the patient how to get a Medic Alert device. e. Obtain and record vital signs, including pulse oximetry.

Correct answers: a, c, e Rationale: The nurse may delegate routine procedures, such as measuring weights and vital signs. The nurse may give specific directions to the unlicensed assistive personnel (UAP) to observe and report obvious signs of bleeding. The nurse cannot delegate teaching, assessment, or activities that require clinical judgment. Obtaining an apical-radial pulse rate is an assessment.

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply) a. hypotension. b. ECG changes. c. hypernatremia. d. pulmonary edema. e. urine with high specific gravity.

Correct answers: b, d Rationale: The nurse monitors the patient in the oliguric phase of acute renal injury for the following: • Hypertension and pulmonary edema: When urinary output decreases, fluid retention occurs. The severity of the symptoms depends on the extent of the fluid overload. In the case of reduced urine output (i.e., anuria, oliguria), the neck veins may become distended with a bounding pulse. Edema and hypertension may develop. Fluid overload can eventually lead to HF, pulmonary edema, and pericardial and pleural effusions. • Hyponatremia: Damaged tubules cannot conserve sodium. Consequently, the urinary excretion of sodium may increase, which results in normal or below-normal serum levels of sodium. • Electrocardiographic changes and hyperkalemia: Initially, signs of hyperkalemia are apparent on electrocardiogram (ECG), including peaked T waves and a widening of the QRS complex. • Urinary specific gravity: Urinary specific gravity is fixed at about 1.010

Which patient would most benefit from noninvasive positive pressure ventilation (NIPPV) to promote oxygenation? A. A patient whose cardiac output and blood pressure are unstable. B. A patient with cystic fibrosis who is currently producing copious secretions. C. A patient with respiratory failure due to a head injury with loss of consciousness. D. A patient who has respiratory failure because of the progression of myasthenia gravis.

D. NIPPV such as continuous positive airway pressure (CPAP) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.

RIFLE defines the first 3 stages of AKI based on changes in a. blood pressure and urine osmolality. b. fractional excretion of urinary sodium. c. estimation of GFR with the MDRD equation. d. serum creatinine or urine output from baseline.

D. The RIFLE classification describes the stages of AKI. RIFLE standardizes the diagnosis of AKI. Risk (R) is the first stage of AKI, followed by injury (I), which is the second stage, and then increasing in severity to the last or third stage of failure (F). The 2 outcome variables are loss (L) and end-stage renal disease (E). The first 3 stages are characterized by the serum creatinine level and urine output.

A patient with aspiration pneumonia develops severe respiratory distress. The PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first? A. Stat portable chest radiography. B. Give lorazepam (Ativan) 1 mg IV push. C. Place the patient in a prone position on a rotational bed. D. Position the patient with arms supported away from the chest.

D. The nurse will first position the patient to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio < 200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. Lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety.

T/F: A hallmark finding in Infective Endocarditis is a pericardial friction rub.

FALSE A hallmark finding of acute pericarditis is a pericardial friction rub.

T/F: Aortic Valve stenosis is usually a benign condition with no symptoms

FALSE Aortic Valve Stenosis has a poor prognosis if left untreated ▪Congenital aortic stenosis (AS) usually found in childhood, adolescence, or young adulthood ▪In adults, can be degenerative or caused by rheumatic fever; Most common degenerative valve disorder ▪AS due to rheumatic heart disease accompanies mitral valve disease. Isolated AS is usually nonrheumatic. ▪Obstruction of blood flow from left ventricle to aorta during systole--> L ventricular hypertrophy & increased myocardial O2 consumption ▪Decreased CO--> decreased tissue perfusion, pulmonary HN, and HF ! Poor prognosis if left untreated !

True or False: All patients with acute renal injury will progress through the oliguric stage of AKI but not all patients will progress through the diuresis stage.

FALSE. Some patients will skip the oliguric stage of AKI and progress to the diuresis stage.

true or false: Hemodialysis is the real replacement therapy (RRT) of choice for hemodynamically unstable patients

False. CRRT is used the unstable patient who cannot tolerate large/fast shifts of fluid Continuous renal replacement therapy (CRRT) is a method for treating AKI. It provides a means by which uremic toxins and fluids are removed while acid-base status and electrolytes are adjusted slowly and continuously in a hemodynamically unstable patient. The principle of CRRT is to dialyze patients in a more physiologic way (over 24 hours), just like the kidneys. CRRT is contraindicated if a patient has life-threatening manifestations of uremia (hyperkalemia, pericarditis) that need rapid treatment. CRRT can be used in conjunction with HD.

True or False: The pericardium layer consists of a fibrous layer that is made up of two layers called the parietal and visceral layers.

False: The pericardium layer consists of a fibrous layer and SEROUS layer that is made up of two layers called that parietal and visceral layers.

What is the difference between hypoxemic and hypercapnic respiratory failure?

Hypoxemic respiratory failure is a PaO2 less than 60 mm Hg when the patient is receiving an inspired O2 concentration of 60% or more. In hypoxemic respiratory failure (aka oxygenation failure), the main problem is inadequate exchange of O2 between the alveoli and pulmonary capillaries. The PaO2 level shows inadequate O2 saturation. A less than optimal PaO2 level exists despite supplemental O2. Hypercapnic respiratory failure (or ventilatory failure) is a PaCO2 greater than 50 mm Hg with acidemia (arterial pH less than 7.35). 2 The main problem is insufficient CO2 removal. This causes the PaCO2 to be higher than normal. For whatever reason, the body is unable to compensate for the increase. This allows acidemia to occur. Patients may have both types of respiratory failure at the same time.

Which of the following patients are MOST at risk for developing endocarditis? Select-all-that-apply: A. A 25 year old male who reports using intravenous drugs on a daily basis. B. A 55 year old male who is post-opt from aortic valve replacement. C. A 63 year old female who is newly diagnosed with hyperparathyroidism and is taking Aspirin. D. A 66 year old female who recently had an invasive dental procedure performed 1 month ago and is having a fever.

Options A, B, and D are all risks for developing endocarditis. Remember that any thing that allows entry of bacteria into the system can potentially cause endocarditis. Option C is not relevant.

A 2 year old client with a congenital cardiac condition is awaiting corrective surgery. Prophylactic antibiotics are prescribed. Which condition is likely to be prevented? 1. Bacterial pneumonia 2. Subacute bacterial endocarditis 3. Upper respiratory infections 4. Laryngotracheobronchitis

Subacute bacterial endocarditis There is evidence that antimicrobial prophylaxis effectively prevents infective endocarditis.

T/F: Most patients with Mitral Valve prolapse will be asymptomatic for life.

TRUE Most patients asymptomatic for life Only 10% with symptoms: -Murmur regurgitation heard during systole; ***midsystolic CLICK; Heard best at apex -Severe Mitral Regurgitation uncommon -Dysrhythmias can cause palpitations, light-headedness, and syncope -Infective endocarditis may occur -Chest pain: ▪due to Papillary muscle tension ▪Noticeable during emotional distress; occur in clusters ▪Unresponsive to nitrates Treatment: ▪Treat symptoms with β-blockers; Controls palpitations and Reduced workload on heart ▪Valve surgery for MR ▪Diet/lifestyle modification: Hydrate, exercise regularly, avoid caffeine

Select-all-that-apply: What are the typical signs and symptoms of infective endocarditis? A. Hyperthermia B. S4 gallop C. Enlarged Spleen D. Hyperkalemia E. Substernal pain that radiates to the back F. Heart failure G. Cardiac Murmur

The answer is A, C, F, and G. These are classic signs and symptoms of IE.

Which patient below with acute kidney injury is in the oliguric stage of AKI: A. A 56 year old male who has metabolic acidosis, decreased GFR, increased BUN/Creatinine, hyperkalemia, edema, and urinary output 350 mL/day. B. A 45 year old female with metabolic alkalosis, hypokalemia, normal GFR, increased BUN/creatinine, edema, and urinary output 600 mL/day. C. A 39 year old male with metabolic acidosis, hyperkalemia, improving GFR, resolving edema, and urinary output 4 L/day. D. A 78 year old female with respiratory acidosis, increased GFR, decreased BUN/creatinine, hypokalemia, and urinary output 550 mL/day.

The answer is A. During the oliguric stage of AKI the patient will have a urinary output of 400 mL/day or LESS. This is due to a decreased GRF (glomerular filtration rate), which will lead to increased amounts of waste in the blood (increased BUN/Creatinine), metabolic acidosis (decreased excretion of hydrogen ions), hyperkalemia, hypervolemia (edema/hypertension), and urinary output of <400 mL/day.

A family member, who is caring for a 2-year-old with Tetralogy of Fallot, asks you why the child will periodically squat when playing with other children. Your response is: A. "Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." B. "Squatting helps to decrease systemic vascular resistance, which will decrease the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels." C. "Squatting helps to decrease systemic vascular resistance, which will increase the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." D. "Squatting helps to normalize systemic vascular resistance, which will increase the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels."

The answer is A. Squatting is common in patient with TOF. Why? Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels.

A 30 year old female is being treated for infective endocarditis with IV antibiotics. At the beginning of the hospitalization, the patient's symptoms were severe and sudden with a high fever but are now controlled. She has no significant health history other than 2 cesarean sections in the past. She is being prepped for a central line placement so she can be discharged home with home health to continue the 4 week antibiotic regime. What is type of infective endocarditis this classified as based on the information listed? A. Acute Infective Endocarditis B. Subacute Infective Endocarditis C. Non-infective Endocarditis D. Pericarditis

The answer is A. This is acute infective endocarditis. The key clues in this question are patient has no significant health history and signs and symptoms were sudden/severe. In subacute infective endocarditis, the patient will have a pre-existing condition that caused them to develop the IE and the symptoms are gradual and subtle.

. You're assessing morning lab values on a female patient who is recovering from a myocardial infraction. Which lab value below requires you to notify the physician? A. Potassium level 4.2 mEq/L B. Creatinine clearance 35 mL/min C. BUN 20 mg/dL

The answer is B. A normal creatinine clearance level in a female should be 85-125 mL/min (95-140 mL/min males). A creatinine clearance level indicates the amount of blood the kidneys can make per minute that contain no amounts of creatinine in it. Remember creatinine is a waste product of muscle breakdown. Therefore, the kidneys should be able to remove excessive amounts of it from the bloodstream. A patient who has experienced a myocardial infraction is at risk for pre-renal acute injury due to decreased cardiac output to the kidneys from a damaged heart muscle (the heart isn't able to pump as efficiently because of ischemia). All the other labs values are normal.

______________ is solely filtered from the bloodstream via the glomerulus and is NOT reabsorbed back into the bloodstream but is excreted through the urine. A. Urea B. Creatinine C. Potassium D. Magnesium

The answer is B. Creatinine is a waste product from muscle breakdown and is removed from the bloodstream via the glomerulus of the nephron. It is the only substance that is solely filtered out of the blood but NOT reabsorbed back into the system. It is excreted out through the urine. This is why a creatinine clearance test is used as an indicator for determining renal function and for calculating the glomerular filtration rate.

You're developing a nursing care plan for a patient in the diuresis stage of AKI. What nursing diagnosis would you include in the care plan? A. Excess fluid volume B. Risk for electrolyte imbalance C. Urinary retention D. Acute pain

The answer is B. During the diuresis stage of AKI, the patient will be losing an excessive amount of urine (3-6 Liters/day) and is at risk for fluid volume deficient and electrolyte imbalance. The nurse must monitor the patient's electrolyte levels, especially potassium (hypokalemia).

You are assessing the heart sounds of a patient with a severe case of Tetralogy of Fallot. You would expect to hear a __________ murmur at the _______ of the sternal border? A. diastolic; right B. systolic; left C. diastolic; left D. systolic; right

The answer is B. The patient will have a harsh systolic murmur due to pulmonary stenosis, which would lead you to find the murmur at the LEFT of the sternal border (the sound location of the pulmonary valve).

You're providing discharge teaching to a patient being treated for endocarditis. Which statement by the patient demonstrated they understood your teaching about this condition? A. "I will stop taking the antibiotics once my fever is gone in order to prevent antibiotic resistance." B. "I will only wash my hands with soap and water." C. "I will inform my dentist about my history of endocarditis prior to any invasive procedures." D. "I will avoid eating fish and organ meats."

The answer is C. Patients should finish all antibiotics doses and never stop taking them in the middle of treatment because this increases antibiotic resistances. Also, the patient should maintain good oral hygiene and should go to the dentist regularly for cleanings. However, it is very important the patient inform all other healthcare practitioners about their history of endocarditis because they will need prophylactic antibiotics therapy prior to any invasive procedures to prevent acquiring endocarditis again. Option D is incorrect.

You are providing care to a patient with pericarditis. Which of the following is NOT a proper nursing intervention for this patient? A. Monitor the patient for complications of cardiac tamponade. B. Administer Ibuprofen as scheduled. C. Place the patient in supine position to relieve pain. D. Monitor the patient for pulsus paradoxus and muffled heart sounds.

The answer is C. Placing the patient in supine position is not a proper nursing intervention for a patient experiencing pericarditis because this increases pain. The high Fowler's position or leaning forward is the best position for a patient with pericarditis.

A 55-year-old male patient is admitted with a massive GI bleed. The patient is at risk for what type of acute kidney injury? A. Post-renal B. Intra-renal C. Pre-renal D. Intrinsic renal

The answer is C. Pre-renal injury is due to decreased perfusion to the kidneys secondary to a cause (massive GI bleeding...patient is losing blood volume). This leads to a major decrease in kidney function because the kidneys are deprived of nutrients to function and the amount of blood it can filter. Pre-renal injury can eventually lead to intrarenal damage where the nephrons become damaged.

A patient with endocarditis has listed in their medical history "Roth Spots". You know that this is a complication of infective endocarditis and presents as? A. Non-tender spots found on the feet and hands B. Red and tender lesions found in the eyes C. Retinal hemorrhages with white centers D. Purplish spots found on the forearms and groin

The answer is C. Roth spots are found in the eyes as retinal hemorrhages with white centers.

While feeding a 3-month-old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to? A. Continue feeding the infant and place the infant on oxygen. B. Stop feeding the infant and provide suction. C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. D. Assess the infant's heart rate and rhythm.

The answer is C. The patient is experiencing a "tet spell". This is where during any type of activity like feeding, crying, playing etc. the child's heart (due to Tetralogy of Fallot) is unable to maintain proper oxygen levels in the blood (these activities place extra work on the heart and it can't keep up). Therefore, there are low amounts of oxygen in the blood, and the skin will become cyanotic (bluish tint) and the respiratory rate will increase (this is the body's way of trying to increase the oxygen levels in the body but it doesn't work because it's not a gas exchange problem in the lungs but a heart problem). The nurse would want to place the infant in the knee-to-chest position. WHY? This increases systemic vascular resistance (which will help decrease the right to left shunt that is occurring in the heart...hence helps replenish the body with oxygenated blood). In addition, the nurse would want to place the patient on oxygen.

A patient is admitted with sepsis. The patient has a temperature of 104.2 'F and is experiencing chills. On assessment, you note a mitral murmur which the patient states they've never had before, and dark, small lines on the patient's fingernails. The patient has a history of IV drug use in the past. However, the patient states they are no longer using drugs. The physician suspects possible infective endocarditis. What diagnostic test do you expect the physician to order in order to confirm the presence of infective endocarditis? A. Abdominal ultrasound B. Heart catheterization C. Transesophageal echocardiogram D. White blood cell count

The answer is C. Transesophageal echocardiogram (TEE) is an ultrasound performed to look at the back side of the heart and assesses the valve structure. It is a test used to diagnose vegetations found on the valves. All the other options do not confirm endocarditis.

On physical assessment of a patient with pericarditis, you may hear what type of heart sound? A. S3 or S4 B. mitral murmur C. pleural friction rub D. pericardial friction rub

The answer is D. A common sign of pericarditis is being able to auscultate a pericardial friction rub.

A patient with severe pericarditis has developed a large pericardial effusion. The patient is symptomatic. The physician orders what type of procedure to help treat this condition? A. Pericardiectomy B. Heart catheterization C. Thoracotomy D. Pericardiocentesis

The answer is D. The physician will probably order a pericardiocentesis. This is a procedure to remove excessive fluid from the pericardial sac.

A patient being treated for infective endocarditis is complaining of very sharp radiating abdominal pain that goes to the left shoulder and back. As the nurse familiar with complications of infective endocarditis, what do you suspect is the cause of this patient finding? A. Renal embolic event B. Pulmonary embolic event C. Central nervous system embolic event D. Splenic embolic event

The answer is D. These are classic signs and symptoms of a splenic embolic event. The patient with endocarditis is at risk for renal, pulmonary, central nervous system, or spleen emboli. Renal emboli would present with flank pain with pus or blood in the urine. Pulmonary emboli would present with dyspnea, chest pain, or shortness of breath, and CNS emboli would present with confusion or difficulty speaking.

A patient with acute kidney injury has the following labs: GFR 92 mL/min, BUN 17 mg/dL, potassium 4.9 mEq/L, and creatinine 1 mg/dL. The patient's 24 hour urinary output is 1.75 Liters. Based on these findings, what stage of AKI is this patient in? A. Initiation B. Diuresis C. Oliguric D. Recovery

The answer is D. This patient is in the recovery stage of AKI. The patient's labs and urinary output indicate the renal function has returned to normal. Remember the recovery stages starts when the GFR (glomerular filtration rate) has returned to normal (normal GFR 90 mL/min or higher), which will allow waste levels and electrolyte levels to be maintained.

A patient with acute renal injury has a GFR (glomerular filtration rate) of 40 mL/min. Which signs and symptoms below may this patient present with? Select all that apply: A. Hypervolemia B. Hypokalemia C. Increased BUN level D. Decreased Creatinine level

The answers are A and C. The glomerular filtration rate indicates how well the glomerulus is filtering the blood. A normal GFR tends to be 90 mL/min or higher. A GFR of 40 mL/min indicates that the kidney's ability to filter the blood is decreased. Therefore, the kidneys will be unable to remove waste and excessive water from the blood...hence hypervolemia and an increased BUN level will present in this patient. The patient will experience HYPERkalemia (not hypo) because the kidneys are unable to remove potassium from the blood. In addition, an INCREASED creatinine level (not decreased) will present because the kidneys cannot remove excessive waste products, such as creatinine.

As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply: A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." C. "Tetralogy of Fallot is treated with only palliative surgery." D. "Many patients with this condition will experience clubbing of the nails."

The answers are A, B, and D. Option C is wrong because this condition can be treated with both palliative surgery (used to help alleviate symptoms until the child is old enough for complete repair) and complete repair. All the other options are correct.

Select-all-that-apply: Which of the following are NOT typical signs and symptoms of pericarditis? A. Fever B. Increased pain when leaning forward C. ST segment depression D. Pericardial friction rub E. Radiating substernal pain felt in the left shoulder F. Breathing in relieves the pain

The answers are B, C, and F. These are findings NOT found in pericarditis. B is wrong because leaning forward actually helps relieve pain felt in pericarditis (supine position makes it worst). C is wrong because ST segment ELEVATION is seen not depression. F is wrong because inspiration (breathing in) increases the pain felt with pericarditis.

A 36-year-old male patient is diagnosed with acute kidney injury. The patient is voiding 4 L/day of urine. What complication can arise based on the stage of AKI this patient is in? Select all that apply: A. Water intoxication B. Hypotension C. Low urine specific gravity D. Hypokalemia E. Normal GFR

The answers are: B, C, and D. This patient is in the DIURESIS stage of AKI. The nephrons are now starting to filter out waste but cannot concentrate the urine. There is now a high amount of urea in the filtrate (because the nephrons can filter the urea out of the blood) and this causes osmotic diuresis. Urinary output will be excessive (3 to 6 L/day). Therefore, the patient is at risk for hypotension, diluted urine (low urine specific gravity), and hypokalemia (waste potassium in the urine). The patient is not at risk for water intoxication and will not have a normal GFR until the recovery stage.

A 4-month-old is diagnosed with Tetralogy of Fallot. You're providing an illustration to the parent to help him understand the pathophysiology of this condition. What defects must be present in the illustration to help the parent understand their child's condition? Select all that apply: A. Aortic stenosis B. Ventricular septal defect C. Coarctation of aorta D. Right ventricular hypertrophy E. Displacement of the aorta F. Pulmonic stenosis G. Patent ductus arteriosus

The answers are: B, D, E, and F. Let the condition's name help you: "TETRAOLOGY"...this means there will be FOUR problems with this heart defect. Remember from the lecture the mnemonic RAPS: Right ventricular hypertrophy, Aorta displacement, Pulmonary stenosis, Septal defect (ventricular)

Select all the patients below that are at risk for acute intra-renal injury? A. A 45 year old male with a renal calculus. B. A 65 year old male with benign prostatic hyperplasia. C. A 25 year old female receiving chemotherapy. D. A 36 year old female with renal artery stenosis. E. A 6 year old male with acute glomerulonephritis. F. An 87 year old male who is taking an aminoglycoside medication for an infection.

The answers are: C, E, and F. These patients are at risk for an intra-renal injury, which is where there is damage to the nephrons of kidney. The patients in options A and B are at risk for POST-RENAL injury because there is an obstruction that can cause back flow of urine into the kidney, which can lead to decreased function of the kidney. The patient in option D is at risk for PRE-RENAL injury because there is an issue with perfusion to the kidney.

True or False: Endocarditis only affects the atrioventricular and semi-lunar valves in the heart.

This statement is FALSE. Endocarditis can affect not only the heart valves but the interventricular septum and chordae tendineae as well.

T/F: Risk factors for Pericarditis include MI, autoimmune conditions, infections, or cancer

True Causes of Pericarditis: -Infectious: virus, bacteria, IE -Noninfectious: post MI 2 days- 4 weeks, Cancer (-Dresler syndrome: post-MI syndrome pericarditis occurs 4-6 weeks after transmural MI) -Trauma: heart surgery, physical trauma -Autoimmune: RA, SLE, Scleroderma -****MOST COMMONLY Idiopathic or VIRAL (coxsackievirus B)

T/F: •Most Common Valve affected by Infective Endocarditis is the Mitral Valve

True IE on the MV may eventually cause Mitral Valve Stenosis (MVS. •Mitral valve IE--> Mitral valve stenosis (MVS)--> blood backs up into lungs!--> low pitched rumbling diastolic murmur **New or worsening murmur is a sign of IE and MVS

True or false. Hyperkalemic ECG changes include peaked T waves, widened QRS complexes, and st segment depressions

True While patients with hyperkalemia are often asymptomatic, some may have weakness with sever hyperkalemia. Because cardiac muscle is intolerant of acute increases in K+, emergency treatment of hyperkalemia is needed. Acute of rapid development of hyperkalemia may result in signs that are apparent on the ECG.

A client with pericarditis may have elevations in which inflammatory markers? WBC, K+, BNP WBC, BUN, Creatinine WBC, ESR, CRP WBC, troponin, AST

WBC, ESR, CRP Harding, p. 783: Common laboratory findings include leukocytosis and increased CRP and ESR. Troponin levels may be increased in patients with ST segment elevation and acute pericarditis, which could indicate concurrent heart damage. Fluid obtained during pericardiocentesis or tissue from a pericardial biopsy may be studied to determine the cause of the pericarditis.

The nurse is caring for an elderly client admitted to the progressive care unit for pneumonia. Which finding would be most important to report to the health care provider? a) There are expiratory wheezes bilaterally in the upper lung lobes b) The client exhibits kyphosis with a barrel-shaped chest c) There are decreased lung sounds at bases d) The client is alert and oriented to person, place, time, and situation

a

Which are expected findings in a client with acute respiratory distress syndrome? a) Crackles, hypoxemia, severe dyspnea b) Hyperventilation, wheezes, bradypnea c) Tachycardia, RR 22, SPO2 of 93% ? d) Temp 38.2, HR 98 bpm, coarse crackles

a

A client is admitted for sepsis and acute kidney injury. 10 days after their admission they progress into the diuretic phase of AKI. During this phase, which clinical indicators would the nurse be alert for? a) Skin rash b) Hypovolemia c) Metabolic acidosis d) Hyperkalemia

a) Hypovolemia During the diuretic phase of AKI, daily urine outcome is usually around 1-3 L, but may reach >5L. Hypovolemia and Hopotension can occur from massive fluid losses. Monitor for Hyponatremia, Hypokalemia, and dehydration.

Which priority intervention would the nurse anticipate when caring for a client with pneumonia whose arterial blood gases are pH 7.21, PaCO 2 70 mm Hg, HCO 3 17 mEq/L, PaO 2 54 mm Hg, and O 2 saturation 84% on 15L oxygen via non-rebreather? (respiratory acidosis, partly compensated) a) Intubation and mechanical ventilation b) Stat nebulized albuterol treatment c) Placing the client on a BiPap machine d) Administration of sodium bicarbonate intravenously

a) Intubation and mechanical ventilation

Which of the following defects are included in Tetralogy of Fallot? a) Mitral valve insufficiency, atrial septal defect, patent ductus, and right ventricular hypertrophy b) Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta c) Aortic stenosis, patent ductus arteriosus, mitral valve insufficiency and overriding of the aorta, d) Tricuspid atresia, atrioventricular canal, and coarctation of the aortaventricular septal defect

a) Right ventricular hypertrophy, VSD, pulmonic stenosis, and overriding of the aorta

Which mechanism of action explains how diuretics reduce blood pressure? a) They facilitate vasodilation b) They block the sympathetic nervous system c) They reduce the circulating blood volume d) They promote smooth muscle relaxation

a) They reduce the circulating blood volume

A client is experiencing anxiety about an upcoming surgery and begins to hyperventilate. How would this reflect in their arterial blood gas? a) Respiratory failure b) Compensated respiratory alkalosis c) Uncompensated respiratory alkalosis d) Uncompensated respiratory acidosis

a) Uncompensated respiratory alkalosis

Which assessment finding would the nurse recognize as indicating improvement in a 4-year-old child being treated for nephrotic syndrome? a) Urine specific gravity decreases b) Urine specific gravity increases c) The child's hemoglobin and hematocrit increase d) The child gains weight

a) Urine specific gravity decreases

The nurse is providing care for an older adult patient who has a low partial pressure of oxygen in arterial blood (PaO2) due to worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? A. Augmented coughing or huff coughing B. Positioning the patient side-lying on his left side C. Frequent and aggressive nasopharyngeal suctioning D. Application of noninvasive positive pressure ventilation

a. Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

While admitting a patient with pericarditis, the nurse will assess for what manifestations of this disorder? 1. Pulsus paradoxus 2. Prolonged PR intervals 3. Widened pulse pressure 4. Clubbing of the fingers

a. Pericarditis can lead to cardiac tamponade, an emergency situation. Pulsus paradoxus greater than 10 mm Hg is a sign of cardiac tamponade that should be assessed at least every 4 hours in a patient with pericarditis. Prolonged PR intervals occur with first-degree AV block. Widened pulse pressure occurs with valvular heart disease and increased intracranial pressure. Clubbing of fingers may occur in subacute forms of infective endocarditis and valvular heart disease.

3. The most common early clinical manifestations of ARDS that the nurse may see are a. dyspnea and tachypnea. b. cyanosis and apprehension. c. respiratory distress and frothy sputum. d. bradycardia and increased work of breathing

a. The initial presentation of acute respiratory distress syndrome (ARDS) is often subtle. At the time of the initial injury and for up to 48 hours, the patient may not have respiratory symptoms, or the patient may have only dyspnea, tachypnea, cough, and restlessness.

The nurse is caring for a 12 year old child who presents to the emergency department with an acute asthma exacerbation. Which assessment finding would require immediate action by the nurse? a) Pulse rate of 110 beats per minute b) Diminished breath sounds in the upper lung lobes c) Pulse oximetry reading of 92% d) Respiratory rate of 32 breaths per minute

b

Which clinical finding is often encountered for a client admitted to an intensive care unit with a diagnosis of ARDS? a) Blood pressure of 173/43 b) Altered mentation c) Copious amounts of blood-tinged sputum d) Slowed rate of breathing

b

Which instruction would the nurse give to a client with renal calculi? a) "Tea is a good substitute for coffee." b) "Drink plenty of water." c) "Make sure you get a lot of spinach in your diet." d) "Consume foods rich in omega-3 fatty acids."

b

Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? a) metabolic alkalosis caused by excessive production of acid metabolites b) Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid c) respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide d) metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formations

b

Which primary intervention is used to treat anemia secondary to chronic kidney disease? a) Interleukin-2 b) Erythropoietin c) Antidiuretic hormone d) Blood transfusion

b) Erythropoietin Anemia in CKD is due to decrease in Erythropoietin by kidneys

Arterial blood gas results are reported to the nurse for a patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first? A. Administer albuterol inhaler PRN. B. Start oxygen at 2 L/min by nasal cannula. C. Increase fluid intake to 2500 mL per 24 hours. D. Perform chest physical therapy 4 times per day.

b. The arterial blood gas results show the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be given next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.

A client is experiencing acute respiratory distress. Which of the following would be an expected finding? a) Hypothermia b) Bradypnea c) Tachycardia d) Elevated ST segment on EKG

c

Which medical intervention is most likely needed for a client admitted with a diagnosis of acute respiratory distress syndrome (ARDS)? a) Aggressive diuretic therapy b) Insertion of a pleural chest tube c) Mechanical ventilation and positive end-expiratory pressure d) Administation of beta-blockers to control tachycardia

c

Which assessment finding in a hospitalized client with a history of chronic kidney disease would lead the nurse to suspect worsening kidney function? a) Dribbling after voiding b) Facial flushing c) Edema and pruritus d) Diminished force of urination

c) Edema and pruritus

Which symptom is indicative of the need for dialysis in the child with chronic kidney disease? a) Hypotension b) Hypokalemia c) Hypervolemia d) Hypercalcemia

c) Hypervolemia

Which integumentary assessment findings may be present in a client with a serum creatinine value of 7.4 mg/dL and a blood urea nitrogen value of 245 mg/dL? a) Hyperpigmentation of the hands and feet b) Cyanosis and diaphoresis c) Pruritus and uremic frost d) Pruritus and clubbing

c) Pruritus and uremic frost A small number of patients with CKD develop refractory pruritus that can have a devastating impact on their well-being and quality of life. Pruritus has multiple causes, including dry skin, calcium-phosphate deposition in the skin, and sensory neuropathy. It is more common in patients receiving dialysis than in the earlier stages of CKD. The itching may be so intense that it can lead to bleeding or infection from scratching. Uremic frost is an extremely rare condition in which urea crystallizes on the skin. This is usually seen only when BUN levels are extremely high (e.g., over 200 mg/dL).

Which complication may be present in a client hospitalized with end-stage kidney disease? a) jaundice b) shortness of breath c) anemia d) hypoglycemia

c) anemia Normocytic, normochromic anemia is associated with CKD due to inability of kidneys to make erythopoietin.

Which intervention is most likely to prevent or limit volutrauma in the patient with ARDS who is mechanically ventilated? a. Increasing PEEP b. Increasing the inspiratory flow rate c. Use of low tidal volume ventilation d. Suctioning the patient via endotracheal tube hourly

c. Low-tidal volume ventilation helps avoid the risk of volutrauma. The delivery of large tidal volumes of air into stiff, non-compliant lungs is associated with volutrauma and barotrauma. Volutrauma causes damage or tears in the alveoli and movement of fluids and protein into the alveolar spaces. Suctioning the patient is done as needed and has no effect on volutrauma. Increasing PEEP and inspiratory flow increase the risk of barotrauma.

A client has been in the ICU for 8 days with acute respiratory distress syndrome (ARDS). The nurse assesses the client and notes signs of decreased lung compliance and increased pulmonary vasculature. Which phase of ARDS is the client exhibiting? a) Exudative b) Fibrotic c) Injury d) Proliferative

d

Which diagnosis would the nurse suspect when caring for a client with acute kidney injury who complains of tingling of the extremities and tetany in the arm when the blood pressure cuff cycles? a) build up of lactic acid b) retention of potassium c) Calcium depletion d) loss of sodium

d

Which statement regarding kidney ultrasound is correct? a) "Kidney ultrasonography primarily makes use of iodinated contrast dye." b) "Kidney ultrasonography is performed on an empty bladder." c) "Kidney ultrasonography provides three-dimensional information regarding kidneys." d) "Kidney ultrasonography makes use of sound waves and has minimal risk."

d is true

What education would the nurse perform regarding pulmonic stenosis to the parent of a recently diagnosed 4-year-old child? a. "Pulmonic stenosis is the narrowing of the valve between the left atrium and left ventricle." b. "Pulmonic stenosis is the hardening of the valve between the right ventricle and the arch of the aorta." c. "Pulmonic stenosis is the hardening of the valve between the right atrium and right ventricle." d. "Pulmonic stenosis is the narrowing of the valve between the right ventricle and the pulmonary artery."

d. "Pulmonic stenosis is the narrowing of the valve between the right ventricle and the pulmonary artery."

Which abnormal finding would be a priority for a client who is in the oliguric phase of acute kidney injury? a) Hypocalcemia b) Hypernatremia c) Hypophosphatemia d) Hyperkalemia

d. Cardiac muscle is intolerant of acute increases of potassium

An important consideration in selecting an O2 delivery device for the patient with acute hypoxemic respiratory failure is to a. always start with noninvasive positive pressure ventilation. b. apply a low-flow device, such as a nasal cannula or face mask. c. be able to correct the PaO2 to a normal level as quickly as possible. d. base the selection on the patient's condition and amount of FIO2 needed.

d. The selected O2 delivery system must be able to deliver oxygen in enough concentration to maintain partial pressure of O2 in arterial blood (PaO2) at 55 to 60 mm Hg or higher and arterial O2 saturation (SaO2) at 90% or higher (at the lowest O2 concentration possible). This might range from a simple face mask to intubation and mechanical ventilation. Several methods are available to provide O2 to patients in ARF. The device selected depends upon the patient's overall physiological condition, degree of respiratory failure, ability to maintain a patent airway, the amount of FIO2 that the device can delivered, and most importantly, the patient's ability to sustain spontaneous ventilation

Causes of VQ mismatch:

diseases that: -increase secretions in the airways e.g., COPD -increase secretions in the airways e.g., pneumonia -increase bronchospasm e.g., asthma V/Q mismatch may result from -pain intereferes with chest/abd wall movement and may compromise ventilation, also may increase SNS response and increases O2 and ventilation demand -alveolar collapse (atelectasis) -pulmonary emboli affect perfusion by limiting blood flow distal to oclusion *O2 therapy is an appropriate first step to reverse hypoxemia caused by V/Q mismatch. O2 therapy increases the PaO2 in the blood leaving normal gas exchange units, causing a higher-than-normal PaO2. This blood mixes with the poorly oxygenated blood from damaged areas, raising the overall PaO2 level in the blood leaving the lungs. The best way to treat hypoxemia caused by a V/Q mismatch is to treat the cause.* Shunts are extreme forms of VQ mismatch -anatomic shunts e.g., VSD -intrapulmonary shunts e.g., pneumonia or other conditions when alveoli are filled with fluid *O2 therapy alone is not effective at increasing the PaO2 if hypoxemia is due to shunt. Patients with a shunt are usually more hypoxemic than patients with V/Q mismatch. They often need mechanical ventilation with a high fraction of inspired O2 (FIO2) to improve gas exchange.*

T/F: A symptom of Mitral Valve Stenosis is a malar rash

true MVS Clinical manifestations: -Exertional dyspnea -Loud S1; Opening snap; Low-pitched mid-diastolic murmur/rumble; Best auscultated at apex with bell -Fatigue -Palpitations -Hoarseness (Compression of the laryngeal nerve) -Hemoptysis From pulmonary hypertension -Atrial fibrillation with risk for stroke -Malar flushing "MALAR" acornym; MVS symptoms: •Malar flush across the cheeks (low CO from pulmonary HTN) •Afib •L HF •Apex beat displaces •R HF

T/F: Treating the cause of infective endocarditis is the main goal of IE treatment

true •****Treatment - 4-6 weeks of antibiotics

• Guidelines for the diagnosis of Infective Endocarditis are based on Duke Criteria. The patient must have 2 major criteria and 1 minor criterion, or 1 major and 3 minor, or 5 minor criteria. What are the major and minor criteria?

• Major criteria include: positive blood cultures, typical microorganism for IE from 2 separate blood cultures, evidence of endocardial involvement, and new valvular vegetation. • Minor criteria include: predisposing heart condition or IV drug use, vascular phenomena, immunologic phenomena, microbiologic evidence, or echocardiographic findings consistent with IE but not meeting major criteria• Patients with specific heart conditions undergoing certain invasive procedures (e.g., dental work that perforates the oral mucosa) need antibiotic prophylaxis.

When the nurse is obtaining the health history for a client with suspected mitral valve stenosis, which question will be most relevant to ask? "Do you have a family history of heart attacks or angina?" "Have you recently had a bought of pneumonia?" "Did you ever have strep throat during childhood?" "Do you frequently get urinary tract infections?"

"Did you ever have strep throat during childhood?" Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart.

A nurse is doing discharge teaching to a client who has had a mitral valve replacement. Which client statement indicates a need for more education? "I will start a vigorous aerobic exercise program." "I will take antibiotics when I have my teeth repaired." "I should go to the doctor when I have a respiratory illness." "I should wear a medical alert bracelet."

"I will start a vigorous aerobic exercise program." It is advisable for this patient to wear a Medic Alert device to provide information in case of an emergency. Antibiotic prophylaxis prior to invasive dental procedures (such as extraction) is necessary to prevent endocarditis. Respiratory infections should be treated with antibiotics because some microorganisms may damage the valves of the heart. Also, valve surgery only relieves the symptoms and does not cure the disease; therefore, regular follow-up is important to monitor the disease progression. Strenuous physical exercise should be avoided because the valve may be unable to accommodate the associated increase in cardiac output. The extent of physical exercise should be prescribed by the health care provider.

***Heart murmurs as they relate to stenosis and regurgitation:

*Stenosis: with a stenosed valve, you will hear murmurs when VALVE IS OPEN, bc valve does not open all the way--> hard to force blood through eg. Mitral stenosis murmur is low pitched rumbling diastolic murmur at apex of heart (this murmur occurs during diastole, when mitral valve is open) *Regurgitation: with a regurgitant valve, you will hear murmurs when VALVE SHOULD BE CLOSED, bc valves do not close all the way (=gurgling)--> leaky e.g. Mitral regurgitation murmur is a holosystolic blowing murmur heard at the apex of the heart (this mumur accurs during systole, when the mitral valve should be closed)

Normal V/Q ratio:

0.8 to 1.2 In normal lungs, the volume of blood perfusing the lungs and the amount of gas reaching the alveoli are almost identical. So, when you compare normal alveolar ventilation (4 to 6 L/min) to pulmonary blood flow (4 to 6 L/min), you have a V/Q ratio of 0.8 to 1.2. 3 In a perfect match, ventilation and perfusion would yield a V/Q ratio of 1:1, expressed as V/Q = 1. When the match is not 1:1, a V/Q mismatch occurs.

When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations? (Select all that apply.) 1. Osler's nodes 2. Janeway's lesions 3. Splinter hemorrhages 4. Subcutaneous nodules 5. Erythema marginatum lesions

1, 2, 3 Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Subcutaneous nodules and erythema marginatum lesions occur with rheumatic fever.

Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD)? (Select all that apply.) 1. Anemia 2. Dehydration 3. Hypertension 4. Hypercalcemia 5. Increased fracture risk 6. Elevated white blood cells

1, 3, 5 When the kidney fails, erythropoietin is not excreted, so anemia is expected. Dehydration and hypercalcemia are not expected in chronic renal disease. Fluid volume overload with hypertension and hypocalcemia are expected. Hypocalcemia from chronic renal disease stimulates the parathyroid to release parathyroid hormone, causing calcium liberation from bones increasing the risk of pathological fracture. Although impaired immune function should be expected, elevated white blood cells would indicate inflammation or infection not associated with chronic renal failure itself but a complication.

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? 1. Regurgitant murmur at the mitral valve area 2. Point of maximal impulse palpable in fourth intercostal space 3. Heart rate of 94 beats/min and capillary refill time of 2 seconds 4. Respiratory rate of 18 breaths/min and heart rate of 90 beats/min

1. A regurgitant murmur of the aortic or mitral valves would indicate valvular disease, which is a complication of endocarditis. All the other findings are within normal limits.

A patient with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform? 1. Assess the patient's hydration status. 2. Insert a urinary catheter for the expected diuresis. 3. Evaluate the patient's lower extremities for edema. 4. Check the patient's urine for the presence of ketones.

1. Preexisting kidney disease is the most important risk factor for the development of contrast-associated nephropathy and nephrotoxic injury. If contrast media must be administered to a high-risk patient, the patient needs to have optimal hydration. The nurse should assess the hydration status of the patient before the procedure is performed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.

The nurse is teaching a community group about preventing rheumatic fever. What information should the nurse include? 1. Prompt recognition and treatment of streptococcal pharyngitis 2. Avoiding respiratory infections in children born with heart defects 3. Completion of 4 to 6 weeks of antibiotic therapy for infective endocarditis 4. Requesting antibiotics before dental surgery for individuals with rheumatoid arthritis

1. Prompt recognition and treatment of streptococcal pharyngitis

The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? 1. Monitor the patient's cardiac status. 2. Teach the patient about hand washing. 3. Obtain a serum specimen for electrolytes. 4. Increase direct observation of the patient.

1. The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

The student nurse notices reddish linear streaks in the nail bed of the client during a head-to-toe assessment. Which systemic condition would the preceptor suspect in the client based on these assessment findings? 1. Subacute bacterial endocarditis 2. Iron-deficiency anemia 3. Chronic obstructive pulmonary disease 4. Syphilis

1. splinter hemorrhages may be caused by tiny clots that damage the small capillaries under the nails. Splinter hemorrhages can occur with infection of the heart valves (infective endocarditis)

A patient donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is having significant pain and refuses to get up to walk. How should the nurse respond? 1. Allow the patient to rest and try again tomorrow. 2. Encourage a short walk around the patient's room. 3. Have the transplant psychologist convince her to walk. 4. Tell the patient she is lucky she did not have an open nephrectomy.

2 Because ambulating will improve bowel, lung, and kidney function with improved circulation, even a short walk with assistance should be encouraged after pain medication. The transplant psychologist or social worker's role is to determine if the patient is emotionally stable enough to handle donating a kidney; postoperative care is the nurse's role. Telling the patient she is lucky she did not have an open nephrectomy (implying how much more pain she would be having if it had been open) will not be beneficial to the patient or her postoperative recovery. Early ambulation should be encouraged, waiting until tomorrow is too long

Which statement about continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? 1. "Maintain a daily written record of blood pressure and weight." 2. "It is essential that you maintain aseptic technique to prevent peritonitis." 3. "You will be allowed a more liberal protein diet once you complete CAPD." 4. "Continue regular medical and nursing follow-up visits while performing CAPD."

2 Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of prevention. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality that peritonitis does.

A client is admitted with a diagnosis of infective endocarditis. She calls the nurse, complaining of sharp radiating abdominal pain that goes to the left shoulder and back and rates it 8/10 on the visual acuity pain scale. What is the most likely cause of the client's chest pain? 1. Pulmonary embolic event 2. Splenic embolic event 3. Central nervous system embolic event 4. Renal embolic event

2. -These are classic signs and symptoms of a splenic embolic event. The patient with endocarditis is at risk for renal, pulmonary, central nervous system, or spleen emboli. Renal emboli would present with flank pain with pus or blood in the urine. Pulmonary emboli would present with dyspnea, chest pain, or shortness of breath, and CNS emboli would present with confusion or difficulty speaking.

A patient with end-stage renal disease (ESRD) secondary to diabetes has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? 1. Level of consciousness 2. Blood pressure and fluid balance 3. Temperature, heart rate, and blood pressure Assessment for signs and symptoms of infection

2. Although all the assessments are relevant to the care of a patient receiving hemodialysis, fluid removal during the procedure will require monitoring blood pressure and fluid balance prior, during, and after.

The nurse is caring for a patient who is in the oliguric phase of acute kidney disease. Which action would be appropriate to include in the plan of care? 1. Provide foods high in potassium. 2. Restrict fluids based on urine output. 3. Monitor output from peritoneal dialysis. 4. Offer high-protein snacks between meals.

2. Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.

Which patient has the most significant risk factors for CKD? 1. A 50-yr-old white woman with hypertension 2. A 61-yr-old Native American man with diabetes 3. A 28-yr-old black woman with a urinary tract infection 4. A 40-yr-old Hispanic woman with cardiovascular disease

2. The nurse identifies the 61-year-old Native American with diabetes as the most at risk. Diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD 6 times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. Blacks have the highest rate of CKD because hypertension is significantly increased in blacks. A UTI will not cause CKD unless it is not treated or UTIs occur recurrently.

What should the nurse teach the patient who has had a valve replacement with a biologic valve? 1. Long-term anticoagulation therapy 2. Antibiotic prophylaxis for dental care 3. Exercise plan to increase cardiac tolerance 4. β-Adrenergic blockers to control palpitations

2. The patient will need to use antibiotic prophylaxis for dental care to prevent endocarditis. Long-term anticoagulation therapy is not used with biologic valve replacement unless the patient has atrial fibrillation. An exercise plan to increase cardiac tolerance is needed for a patient with heart failure. Taking β-adrenergic blockers to control palpitations is prescribed for mitral valve prolapse, not valve replacement.

The home care nurse visits a patient receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse? 1. "Drain time is faster if I rub my abdomen." 2. "The fluid draining from the catheter is cloudy." 3. "The drainage is bloody when I have my period." 4. "I wash around the catheter with soap and water."

2. The primary manifestation of peritonitis is a cloudy peritoneal effluent. Blood may be present in the effluent of women who are menstruating, and no intervention is indicated. Daily catheter care may include washing around the catheter with soap and water. Drain time may be facilitated by gently massaging the abdomen.

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. Which strategy is used to achieve ultrafiltration in peritoneal dialysis? 1. Increasing the pressure gradient 2. Increasing osmolality of the dialysate 3. Decreasing the glucose in the dialysate 4. Decreasing the concentration of the dialysate

2. Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis, the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream.

Which patients are most at risk for developing endocarditis? (Select all that apply.) 1. Older woman with histoplasmosis 2. Man with reports of chest pain and dyspnea 3. Man who is homeless with history of IV drug use 4. Patient with end-stage renal disease on peritoneal dialysis 5. Adolescent with exertional palpitations and clubbing of fingers 6. Female with peripheral intravenous site for medication administration

3, 4 Intravenous drug use, especially if reusing or sharing needles are at risk of developing sepsis. In addition, risk for infection is increased in the elderly, homeless, and those with chronic illness. Peritoneal dialysis requires strict sterile technique to prevent peritonitis. Chest pain, shortness of breath, and palpitations may be signs of endocarditis. Clubbing of the fingers indicates long-term hypoxia. Central venous catheters, not peripheral, increase risk to for infective endocarditis. Patients with fungal infections, such as histoplasmosis and candida, are at risk for pericarditis.

Which statement made by the client indicates a need for further understanding regarding the use of Colchicine after being hospitalized with pericarditis? 1. "This medication is also used to treat patients with gout." 2. "I can take this medication with or without food." 3. "I like to take all my medications in the morning with grapefruit juice." 4. "I will notify the doctor immediately if I start experiencing nausea, vomiting, or stomach pain while taking this medication."

3. "I like to take all my medications in the morning with grapefruit juice." (no, avoid grapefruit juice with colchicine)

A 72-yr-old man with a history of aortic stenosis is admitted to the emergency department. He reports severe left-sided chest pressure radiating to the jaw. Which medication, if ordered by the health care provider, should the nurse question? 1. Aspirin 2. Oxygen 3. Nitroglycerin 4. Morphine sulfate

3. Aspirin, oxygen, nitroglycerin, and morphine sulfate are all used to treat acute chest pain suspected to be caused by myocardial ischemia. However, nitroglycerin should be used cautiously or avoided in patients with aortic stenosis as a significant reduction in blood pressure may occur. Chest pain can worsen because of a decrease in blood pressure.

The provider has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? 1. Hemodialysis (HD) three times per week 2. Automated peritoneal dialysis (APD) 3. Continuous venovenous hemofiltration (CVVH) 4. Continuous ambulatory peritoneal dialysis (CAPD)

3. CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD three times per week would not be used for this patient because fluid and solutes build up and then are rapidly removed. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not as rapidly remove large amounts of fluid as CVVH can do.

A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery? 1. Hypokalemia 2. Hyponatremia 3. Large urine output 4. Leukocytosis with cloudy urine output

3. Patients often have diuresis in the hours and days immediately after a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.

A 25-yr-old patient with a group A streptococcal pharyngitis does not want to take the antibiotics prescribed. How should the nurse respond? 1. "You will not feel well if you do not take the medicine and get over this infection." 2. "Once you have been treated for a group A streptococcal infection, you will not get it again." 3. "Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." 4. "You may not want to take the antibiotics for this infection, but you will be sorry if you do not."

3. Rheumatic fever (RF) is not common because of effective use of antibiotics to treat streptococcal infections. Without treatment, RF can occur and lead to rheumatic heart disease, especially in young adults. Saying that the patient will not feel well or that the patient will be sorry if the antibiotics are not taken is threatening to the patient and inappropriate for the nurse to say. Patients may have reoccurring infection of group A streptococcus.

A patient with a history of coronary artery disease is being treated for a myocardial infarction (MI). During treatment, acute mitral valve regurgitation occurs. What is the most likely cause of the acute mitral valve dysfunction?Please choose from one of the following options. 1. Ventricular fibrillation 2. Infective endocarditis 3. Rupture of the chordae tendinae 4. Atherosclerosis

3. Rupture of the chordae tendinae

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? 1. Give hypertonic saline. 2. Initiate a blood transfusion. 3. Decrease the rate of fluid removal. 4. Administer antiemetic medications.

3. The patient is having hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea but would not help the hypovolemia.

A 55-yr-old female patient develops acute pericarditis after a myocardial infarction. Which assessment finding indicates a possible complication? 1. Presence of a pericardial friction rub 2. Distant and muffled apical heart sounds 3. Increased chest pain with deep breathing 4. Decreased blood pressure with tachycardia

4 Cardiac tamponade is a serious complication of acute pericarditis. Signs and symptoms include narrowed pulse pressure, tachypnea, tachycardia, a decreased cardiac output, and decreased blood pressure. The other symptoms are consistent with acute pericarditis.

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? 1. IV tobramycin 2. Incompatible blood transfusion 3. Poststreptococcal glomerulonephritis 4. Dissecting abdominal aortic aneurysm

4 A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststreptococcal glomerulonephritis are intrarenal causes of AKI.

Which is an expected finding in a client with pericarditis? 1. dull, throbbing chest pain that is intermittent and relieved by NSAIDS 2. Dyspnea upon exertion 3. Pericardial rub upon auscultation of the patient's back 4. sharp, rapid onset chest pain that is relieved when the client leans forward

4.

A frail 86-yr-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid? 1. Aspirin 2. Acetaminophen 3. Diphenhydramine 4. Aluminum hydroxide

4. Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.

The patient with pericarditis is reporting chest pain. After assessment, which intervention should the nurse expect to implement to provide pain relief? 1. Corticosteroids 2. Morphine sulfate 3. Proton pump inhibitor 4. Nonsteroidal antiinflammatory drugs

4. Nonsteroidal antiinflammatory drugs (NSAIDs) control pain and inflammation. Corticosteroids are reserved for patients already taking corticosteroids for autoimmune conditions and those who do not respond to NSAIDs. Morphine is not necessary. Proton pump inhibitors are used to decrease stomach acid to avoid the risk of gastrointestinal bleeding from the NSAIDs.

When caring for a patient during the oliguric phase of acute kidney injury (AKI), which nursing action is appropriate? 1. Weigh patient three times weekly. 2. Increase dietary sodium and potassium. 3. Provide a low-protein, high-carbohydrate diet. 4. Restrict fluids according to previous daily loss.

4. Patients in the oliguric phase of AKI will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times each week.

The nurse is caring for a patient who received a mechanical aortic valve replacement 2 years ago. Current lab values include an international normalized ratio (INR) of 1.5, platelet count of 150,000/µL, and hemoglobin of 8.6g/dL. Which nursing action is most appropriate? 1. Assess the vital signs. 2. Start intravenous fluids. 3. Monitor for signs of bleeding. 4. Contact the health care provider.

4. Patients with mechanical valve replacement are placed on anticoagulants and should be in a therapeutic INR range of 2.5 to 3.5. Administration of Coumadin (Warfarin) prolongs clotting time and prevents clot formation on the valve. The low INR would require a call to the health care provider for an order increase the medication dose. Vital signs would be unchanged related to the low INR. Intravenous fluids are not indicated. The patient is at risk of forming clots, not bleeding.

The nurse preparing to give a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? 1. Sodium 2. Potassium 3. Magnesium 4. Phosphorus

4. Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore, administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. Calcium acetate will not have an effect on sodium, potassium, or magnesium levels.

An 80-yr-old patient with uncontrolled type 1 diabetes is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to do or have what done? 1. Aortic valve replacement 2. Have a pacemaker inserted 3. Open commissurotomy (valvulotomy) procedure 4. Percutaneous transluminal balloon valvuloplasty (PTBV) procedure

4. The PTBV procedure is best for this older adult patient who is a poor surgery candidate related to the uncontrolled type 1 diabetes. Aortic valve replacement would probably not be tolerated well by this patient, although it may be done if the PTBV fails and the diabetes is controlled in the future. Open commissurotomy procedure is used for mitral stenosis. The patient is not a candidate for a pacemaker.

A patient with a 25-year history of type 1 diabetes is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood glucose levels. Which diagnostic study is most indicative of chronic kidney disease (CKD)? 1. Serum creatinine 2. Serum potassium 3. Microalbuminuria 4. Calculated glomerular filtration rate (GFR)

4. The best study to determine kidney function or CKD that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

Which physical examination finding would the nurse expect when assessing an infant with a ventricular septal defect (VSD)? (low CO, blood shunts from LV RV) 1. Bradycardia at rest 2. Bounding peripheral pulses 3. Activity-related cyanosis 4. Murmur at the left sternal border

4. With ventricular septal defects, there is often a characteristic holosystolic harsh murmur along the left sternal border. Right ventricular heave, fixed split-second heart sound, and systolic ejection murmur are typically found with atrial septal defects.

Which signs and symptoms distinguish hypoxemic from hypercapnic respiratory failure? (select all that apply) a. Cyanosis b. Tachypnea c. Morning headache d. Paradoxical breathing e. Use of pursed-lip breathing

A, B, D. Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxical chest or abdominal wall movement with the respiratory cycle. Manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased respiratory rate with shallow breathing.

As the pediatric unit charge nurse, you are working with a newly-graduated RN who has been on orientation in the unit for 2 months. Which patient should you assign to the new RN? A. 2-year-old with a ventricular septal defect for whom digoxin (Lanoxin) 90 mcg by mouth has been prescribed B. 4-year-old who had a pulmonary artery banding and has just been transferred in from the intensive care unit C. 9-year-old with mitral valve endocarditis whose parents need teaching about IV antibiotic administration D. 16-year-old with a heart transplant who was admitted with a low-grade fever and tachycardia

A. 2-year-old with a ventricular septal defect for whom digoxin (Lanoxin) 90 mcg by mouth has been prescribed

The nurse is caring for a patient with a systolic heart murmur. Which of these valve disorders are associated with a systolic murmur? A. Aortic stenosis and mitral regurgitation B. Aortic and tricuspid stenosis C. Pulmonic and mitral regurgitation D. Pulmonic regurgitation and tricuspid stenosis

A. Aortic stenosis and mitral regurgitation Stenosis of the aortic or pulmonic valves will result in a systolic murmur as blood is ejected through the narrowed orifice. Conversely, regurgitation of the same valves will result in a diastolic murmur as blood flows backward through the diseased valve when ventricular pressures drop during relaxation.

The nurse is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? A. Morphine B. Albuterol C. Azithromycin D. Methylprednisolone

A. For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.

A patient is in acute respiratory distress syndrome (ARDS) from sepsis. Which measure would be implemented to maintain cardiac output? A. Administer IV crystalloid fluids. B. Place the patient on a strict fluid restriction. C. Position the patient in Trendelenburg position. D. Perform chest physiotherapy and assist with staged coughing.

A. Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or giving inotropes. The Trendelenburg position is not recommended to treat hypotension. Chest physiotherapy is unlikely to relieve decreased cardiac output. Fluid restriction would be an inappropriate intervention.