Cardiac Exam 4

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply.

Contractures Pressure ulcers Venous thromboembolism Pneumonia Explanation: Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the client takes oral contraceptives. The nurse's postoperative plan of care should include what intervention?

Early ambulation and leg exercises Explanation: Oral contraceptive use increases blood coagulability; with bed rest, the client may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.

The nurse is assessing the skin graft site of a client who has undergone a radical neck dissection. The skin graft site is pink. The nurse documents which result?

Healthy graft Explanation: A healthy graft site is pink and warm to the touch. A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?

Obesity Explanation: Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.

Which adrenergic inhibitor acts directly on the blood vessels, producing vasodilation?

Prazosin Explanation: Prazosin is a peripheral vasodilator acting directly on the blood vessels. It is not used in angina and coronary artery disease, however, because it induces tachycardia if not preceded by administration of propranolol and a diuretic. Reserpine impairs synthesis and reuptake of norepinephrine. Propranolol blocks the beta-adrenergic receptors of the sympathetic nervous system, especially the sympathetics to the heart, producing a slower heart rate and lowered blood pressure. Clonidine acts through the central nervous system, apparently through centrally mediated alpha-adrenergic stimulation in the brain, reducing blood pressure.

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?

Prevention of venous thromboembolism Explanation: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?

The severity of discomfort isn't related to the size of varicosities. Explanation: Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, DVT, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is used to treat varicose veins; it doesn't cure them.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

A client's chart indicates Virchow's triad. This client is at risk for which complication?

thrombophlebitis Explanation: Virchow's triad refers to venous stasis (slowed circulation), altered blood coagulation, and trauma to the vein, and predisposes clients to thrombosis and thrombophlebitis. The diagnosis of Virchow's triad indicates the client already presents with venous stasis. The diagnosis of Virchow's triad indicates the client already presents with altered blood coagulation. Postphlebitic syndrome is a vascular complication that may occur for up to 5 years after the initial episode with thrombophlebitis. This client does not yet have thrombophlebitis, so is not at risk for postphlebitic syndrome.

A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following?

"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." Explanation: It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.

A 76-year-old client with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The client tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make?

"Kidney transplants in patients your age are as successful as they are in younger patients." Explanation: Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the elderly. However, the outcome is comparable to that of younger clients. The other listed options either belittle the client or give the client misinformation.

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Explanation: Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).

The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which measures should the nurse complete to prevent the development of deep venous thrombosis (DVT) and possible pulmonary embolism (PE)? Select all that apply.

Apply antiembolism stockings. Avoid elevating the knees on the bed. Initiate passive exercises. Explanation: Preventive measures used to prevent venous stasis include application of sequential pneumatic compression devices; discouraging crossing of legs; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; and beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?

Applying thigh-high elastic stockings Explanation: It is important to promote venous return to the heart and prevent venous stasis in a client with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The client should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

Which of the following is the most immediate danger after prostate surgery?

Bleeding Explanation: The immediate danger after prostate surgery is bleeding and hemorrhagic shock. If, after 20 minutes, the bleeding is not controlled, surgical exploration may be considered. Since bleeding is increased in the sitting position, which increases bladder and venous pressure, the patient is encouraged to rest in bed with the head of the bed slightly elevated.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?

The client will be immobile during and shortly after surgery. Explanation: Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.

The nurse explains to a patient that the primary cause of a varicose vein is:

An incompetent venous valve. Explanation: Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:

"Leg exercises help prevent blood clots in your legs." Explanation: Leg exercises improve circulation of the lower extremities by preventing venous stasis, which can lead to deep vein thrombosis in the postoperative client.

A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition?

Arterial thrombosis Explanation: A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.

A patient has developed a boil on the face and the nurse observes the patient squeezing the boil. What does the nurse understand is a potential severe complication of this manipulation?

Brain abscess Explanation: Nurses must take special precautions in caring for boils on the face because the skin area drains directly into the cranial venous sinuses. Sinus thrombosis with fatal pyemia can develop after manipulating a boil in this location. The infection can travel through the sinus tract and penetrate the brain cavity, causing a brain abscess.

Which occurs when fluid accumulates in the pericardial space and compresses the heart?

Cardiac tamponade Explanation: Cardiac tamponade is an accumulation of fluid in the pericardial space. SVCS occurs when the superior vena cava is compressed or invaded by a tumor, lymph nodes are enlarged, intraluminal thrombosis obstructs venous circulation, or drainage occurs from the head, neck, arms, and thorax. SIADH is the continuous, uncontrolled release of ADH. DIC is a complex disorder of coagulation or fibrinolysis that results in thrombosis or bleeding.

A client with paroxysmal hemoglobinuria, a deficiency of complement proteins, reports headache and weakness of the right arm and leg. Based on these symptoms, for which health complication should the nurse assess?

Cerebral venous thrombosis Explanation: Paroxysmal nocturnal hemoglobinuria is an acquired clonal stem cell disorder resulting from a somatic mutation in hematopoietic stem cells. Clinical manifestations may be indolent or life threatening. The disorder is characterized by hemoglobinuria that increases during sleep, as well as intravascular hemolysis, cytopenia, infections, bone marrow hyperplasia, and a high incidence of life-threatening venous thrombosis, which occurs most commonly in the abdominal and cerebral veins.

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)?

Cleaning the client's mouth with chlorhexidine daily Explanation: The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply.

Deep vein thrombosis Compartment syndrome Fat embolism Explanation: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?

Early ambulation Explanation: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Increased warmth of the calf Explanation: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

The nurse is taking a health history of a new client who reports pain in his left lower leg and foot when walking. This pain is relieved with rest and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address what health problem?

Intermittent claudication Explanation: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by clients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the client has CAD, arterial embolus, or Raynaud disease; none of these health problems produce this cluster of signs and symptoms.

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis. Explanation: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the client's level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.

A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the client's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the client's plan of care?

Maintain the client on complete bed rest. Explanation: Cerebral aneurysm precautions are implemented for the client with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity (such as leg exercises), pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted. The head of the bed is elevated 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the client remains flat to increase cerebral perfusion. No enemas are permitted, but stool softeners and mild laxatives are prescribed.

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?

Pulmonary embolism Explanation: Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?

Pulmonary embolism Explanation: Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

Report early calf pain. Explanation: The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration.

Which of the following are alterations noted in Virchow's triad? Select all that apply.

Stasis of blood Vessel wall injury Altered coagulation Explanation: Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad.