cardiac/circulatory

what should the nurse do when entering a heart failure patient's room, the client is agitated, gasping for air, attempting to sit up, and says 'i cant catch my breath.' ? select all 1. elevate HOB to sitting position 2. elevate clients legs on two pillows 3. initiate oxygen at 2 liters per nasal cannula 4. initiate IV of LR administer morphine 2 mg IV

1,3,5- patient is in acute distress most likely from pulmonary edema (from HF!), o2 increases available o2 for myocardial uptake, morphine helps with venous return and reduce myocardial workload and anxiety 2,4- dangling legs wont help with breathing and IV fluids would make problem worse since pulmonary edema likely

which statements by the client indicates to the nurse that teaching regarding how to prevent venous stasis ulcerations for a client who has been diagnosed with chronic venous insufficiency has been effective? select all: 1. 'stationary standing should be kept to a minimum' 2. 'its important to avoid wearing constricting clothes longer than 2 hours' 3. 'protecting my legs from trauma is very important' 4. 'i will wear compression stockings every day' 5. 'i will elevate the foot of my bed 6 inches when i sleep'

1,3,4,5- common sense, elastic compression stockings are recommended for these clients to prevent pooling and promote venous return 2. the client should avoid wearing any tight clothing at all times

what additional s/s should the nurse monitor for in a client who reported squeezing pain in the chest? select all: 1. dyspnea 2. dry, flushed skin 3. indigestion 4. restlessness 5. tachycardia

1,3,4,5- indigestion could mean MI in women! duh! 2. skin should be cool and clammy instead duh no blood circulating

what clinical manifestations does the nurse expect to find when assessing a client with a stroke on the left side of brain? select all 1. right sided hemiplegia 2. impaired judgment 3. depression 4. impaired language comprehension 5. impulsiveness 6. impaired speech

1,3,4,6- left side stroke so right side of body probs 2,5- seen with right sided brain damage

what s/s would indicate to the nurse that the primary healthcare provider should be notified for a client post heart catheterization with a left femoral stick? select all: 1. cap refill of 6 seconds to left toes 2. epigastric discomfort 3. paresthesia to left leg 4. left pedal pulse 0/4; right pedal pulse 2+/4 5. temp of 99.9 F

1,2,3,4- all is common sense and epigatric pain could indicate that client is having an MI...always assume the worse! 5. not that high so not that worried

what assessment findings would indicate to the nurse that the treatment for a client on bed rest and diagnosed with new onset HF is effective? select all: 1. CVP is 6 mmhg 2. 3.8 kg weight loss in 24 hours 3. pink, frothy sputum 4. S3 heart sound 5. urinary output 320 ml/8 hours 6. dyspnea on exertion

1,2,5- CVP is within normal range, weight loss of 3.8 kg is good to reduce FVE, and UO is good... 30-50 ml/hr 3. not good duh 4. not good duh 6. not good to be SOB

what s/s would the nurse expect to assess in a client diagnosed with acute pericarditis? select all: 1. distended neck veins 2. muffled heart sounds 3. narrowed pulse pressure 4. pain worsens when sitting up and leaning forward 5. pulsus paradoxus 6. stabbing chest pain

1,2,6- is an infection of the pericardium which is the sac around the heart, so that can restrict volume of the heart so heart cant fill up properly which leads to distended neck veins, fluid fills up in pericardium so muffled tones, and that is type of pain felt 3. wont happen in this case, but will in HF, blood loss, aortic stenosis and cardiac tamponade 4. thats the opposite 5. that is an exaggerated decrease of systolic BP during inspiration exceeding 12 mmhg, which is a sign of cardiac tamponade so no

what is expected with the assessment finding of the monitor showing sinus tachycardia in a client's heart rhythm? select all: 1. regular rhythm 2. rate of 101-200 3. absent P waves 4. PR interval not measurable 5. QRS complex greater than 0.20 seconds

1,2- sinus is normal and tachy is more than 100 duh 3. if it is sinus, then there is still a P wave! 4. false, PR interval would not be measurable in atrial flutter, afib, vtach, or vfib 5. so false, QRS complex should be no more than 0.12 seconds in tachy

what assessment finding would indicate to the nurse that further treatment is needed for a client hospitalized with systolic heart failure? select all: 1. S3 heart sound 2. CVP of 6 mmhg 3. one day weight loss of 2 pounds 4. hepatomegaly 5. increasing BNP level 6. urine output at 50 ml/hr

1,4,5- S3 is not good, enlarged liver is not good, and increased BNP level is not good and increased that HF is worsening 2. normal range 3. good for weight loss for HF 6. is good amount of UO... 30-50 ml/hr

what info should the pre-op nurse include when educating a client about preventing a deep vein thrombus (DVT) formation after abdominal surgery? select all: 1. anticoagulant medication may be prescribed 2. caffeinated beverages will be allowed once able to drink in order to promote hydration 3. bed rest will be required for at least 5 days 4. move feet in a circle 10 times an hour 5. a sequential compression device (SCD) will be wrapped around the legs

1,4,5- want meds to prevent blood clots, moving legs and feet will help prevent clots by improving blood circulation and so will SCDs 2. alcohol and coffee contribute to dehydration, which can lead to thickened blood and increased risk for clot formation! 3. that is so false

which cardiac change noted on the monitor would be of GREATEST concern for a client who was admitted to coronary care with a diagnosis of myocardial infarction? 1. ventricular tachycardia > 100 bpm 2. atrial fibrillation with atrial rate > 300 bpm 3. four premature ventricular contractions within one minute 4. ST segment depression of 0.5 mm

1. vtach can lead to vfib and then asystole so thats more life-threatening! 2. afib is not that threatening 3. PVCs are bad but not that bad 4. ST segment depression of 1 mm or more signifies myocardial ischemia

which client teachings would the nurse initiate to a client with arterial disease of the lower extremities? select all: 1. elevate extremities above the level of the heart 2. discourage use of caffeine 3. protect extremities from cold exposure 4. maintain a warm environment at home 5. encourage isometric exercise

2,3,4,5- caffeine, stress and nicotine can vasoconstrict! warmth prevents vasoconstriction, isometric exercise and walking helps promote collateral circulation 1. NEVER ELEVATE! Arteries down, Veins up!

which statements made by the client would indicate to the nurse that teaching a client who has recovered from MI about the prescribed diet of low sodium, low saturated fat, and low cholesterol has been successful? select all: 1. 'i should drink fruit juices rather than soft drinks' 2. 'a good snack to eat would be unsalted popcorn' 3. 'when making homemade tomato sauce, i should not add salt' 4. 'i should use 2% milk when cooking' 5. 'there is no restriction on egg white consumption'

2,3,5- no salt is good and there is no restriction on egg white smh 1. eat actual veggies and fruits rather than fruit juices bc of added sugar and lack of fiber 4. use skim milk or 1% milk

what topics should the nurse include in presenting a seminar to a group of senior citizens on ways to reduce the risks of a peripheral artery disease (PAD)? select all: 1. daily strenuous exercise 2. how to read food labels 3. maintaining a BMI less than 30 kg/m2 4. managing diabetes 5. use of anti-embolic stockings

2,4- always good to read labels, poorly managed diabetes leads to vessel damage 1. clients can increase collateral circulation with a moderate exercise program of at least 30 mins 3x a week 3. want to achieve a body mass index of 18.5-24.9 kg/m2! 5. those are ordered to improve venous return in clients with restricted or limited mobility!