Cardiovascular Q's
A client experiences anginal chest pain on and off for 3 days before admission. The nurse completes discharge medication, activity, and follow up teaching. Which client statement indicates the client requires further teaching about angina-related activity instructions? A. "I should not engage in sexual activity for 6 weeks." B. "I can return to my usual activities, but should rest if the pain comes back." C. "I should not use nitroglycerin as a substitute for rest if I have chest pain." D. "I should take a nitroglycerin tablet before activities that usually give me chest pain."
A. "I should not engage in sexual activity for 6 weeks." The question is asking which option means you need to correct the client on something. The client may resume sexual activity in 1 weeks or less as long as the client is feeling well. Continued anginal pain after the hospitalization should be reported to the provider, but being hospitalized for angina without myocardial infarction is not an indication to abstain from sexual activity for 6 weeks. The other statements don't need to be corrected, they reflect appropriate understanding of the situation.
The nurse admits a client to the unit from the post anesthesia care unit (PACU) immediately after an abdominal aortic aneurysm repair. Which is the nurse's priority observation? A. Blood pressure reading B. Blood chemistry laboratory report C. Intake and output measurements D. Rectal temperature reading
A. Blood pressure reading Electrolyte balance can be monitored with blood chemistry and intake and output data. Temperature can help with monitoring infection. Patency of the aortic graft can be assured with maintenance of an adequate systemic blood pressure. An abdominal aortic aneurysm is the localized enlargement of the abdominal aorta's wall. It may be asymptomatic or the client may complain of abdominal and low back pain. Other symptoms include pulsating mass in the periumbilical area, bruit over the aorta, and blood pressure may be lower in legs than arms. Nursing considerations include monitoring blood pressure frequently, monitoring kidney function, CBC, and instructing the client to avoid bending, lifting, and constipation.
The nurse understands which factor is the most important to maintain adequate circulation? A. Blood volume B. White blood cell count C. Aerobic exercise D. Effective respiration
A. Blood volume White blood cells (leukocytes) provide immunity and protect the body from infection. They don't contribute to maintaining circulation. During exercise, oxygen is metabolized to produce energy. It does not play a role in maintaining adequate circulation. Effective respiration is required to oxygenate the body, but not maintain circulation. An adequate transport medium, blood, is needed to carry nutrients and gases throughout the body. Enough of this is needed to maintain circulation, that being volume.
The nurse expects which laboratory test results to be elevated for a client following an acute myocardial infarction? A. Creatine kinase (CK), troponin, and myoglobin B. Blood urea nitrogen (BUN), serum creatinine, and protein-bound iodine C. Aspartate aminotransferase (AST), RBC count, and platelets D. Lactic dehydrogenase (LDH), thyroxine, and endorphin levels
A. Creatine kinase (CK), troponin, and myoglobin Each of these values are increased after MI. Creatine kinase (CK-MB) is a cardiac specific enzyme that begins to increase an hour after MI and peaks in 24 hrs. Troponin is myocardial muscle protein that's released into the bloodstream when heart muscle is damaged. It starts rising 6-12 hrs after MI peaking at 24 hrs, followed by a gradual decline for up to 2 weeks. Myoglobin is protein found in cardiac and skeletal muscle, that rises 1 hr post MI and peaks at 4-6 hrs. BUN gets elevated bc of dehydration, AKI, or CKD. Serum creatinine gets elevated bc of AKI, CKD, shock, cancer, HTN, acute MI. Protein-bound iodine was an early test used to estimate thyroid hormone concentration in serum blood levels, so it has nothing to do with indicating cardiac health status. AST is an enzyme found in the heart and liver and can be elevated post MI or also d/t liver damage (not cardiac specific). RBCs carry hemoglobin, but aren't indicative of MI. Plts are used to dx hemorrhagic dzs and thrombocytopenia. LDH is an indicator of cardiac damage and is elevated longer than other cardiac enzymes. Thyroxine (T4) is a major hormone secreted by the thyroid. Endorphins are produced by brain and act as opiate and produce analgesic effect.
The nurse provides care for a client diagnosed with hypothermia as a result of a diving accident. The client's pupils are fixed and dilated, temperature is 27.2 C (80 F), and the client is not breathing. Cardiopulmonary resuscitation (CPR) is started in the emergency department. The client is intubated and IV access is obtained. Which action is most essential for the nurse to take now? A. Initiate core rewarming. B. Administer diazepam (Valium) to reduce shivering. C. Apply warm compresses to the axilla and groin. D. Place heating pads on each of the client's extremities.
A. Initiate core rewarming. If hypothermia is the issue, this is the tx option that's going to correct that problem. Core rewarming would be done by using oxygen and gastric bladder/peritoneal lavage so the core temp is gradually raised. Shivering is your body contracting its muscles in order to generate heat. Bc this patient is hypothermic, you wouldn't stop this from happening since that body mechanism is conducive to your ultimate tx goal for them. Warm compresses heating pads are external heat sources that are viable tx options for other cases, but are not appropriate here bc core rewarming focuses on getting the person's body temp up from the inside out, and like said above, that'll be done w oxygen and lavages given to the patient. These are internal heating options. External heat is also not applied to hypothermic clients bc it causes vasodilation and can further cardiovascular collapse.
Which postoperative intervention does the nurse include in a client's plan of care for repair of an abdominal aortic aneurysm (AAA)? A. Performing circulation checks distal to the graft B. Elevating extremities during rest periods C. Instructing the client on application of warm soaks to the lower extremities D. Placing the client on a high protein and low carbohydrate diet
A. Performing circulation checks distal to the graft D/t the nature of the aortic repair, distal pulses should be marked postoperatively. Hourly circulation checks should be performed to document the rate, rhythm, and character of distal pulses. An AAA is a localized enlargement of the abdominal aorta wall. It can be asymptomatic or the client may complain of abdominal and low back pain. Other sx include a pulsating mass in the periumbilical area, bruit over the aorta, and the BP may be lower in the legs than in the arms. Nursing considerations include monitoring the BP frequently, monitoring kidney function and CBC values, and instructing the client to avoid bending, lifting, and constipation. Do not elevate extremities. The client should remain flat in bed w/o flexion of the extremities to avoid compression of the LE arteries. Warm soaks aren't indicated/useful here. Instead, the nurse should focus on preventing thrombophlebitis by applying elastic or sequential compression stockings. You shouldn't be on a high protein and low carbohydrate diet, you should instead be on a low cholesterol and low fat diet.
A client is scheduled for coronary artery bypass grafting surgery. The nurse instructs the client that a tube assisting with breathing will be in place for a short time after surgery. Why is it important that the nurse share this information with the client? A. The client will be unable to talk while the endotracheal tube is in place B. The client's family will not be permitted to see the client while the client is intubated C. The client needs to be prepared for the extreme pain caused by the endotracheal tube D. The client can pull the endotracheal tube out if it is irritating
A. The client will be unable to talk while the endotracheal tube is in place Not being allowed to see a patient while they are intubated is not a rule. Endotracheal intubation is uncomfortable but rarely painful (??). The client cannot independently decide when to be extubated, when to pull out their tube. Not being able to talk while the trach is in place is true. Clients appreciate being forewarned that they won't be able to talk while intubated. It prepares them and decreases their frustration postoperatively.
The nurse provides care for a client after a coronary artery bypass graft (CABG). Which observation during the postoperative period most concerns the nurse? A. The heavy chest tube drainage suddenly stops. B. The client is confused, disoriented, and agitated. C. The temperature of the client is 97.6 F (36.5 C). D. The client is coughing poorly.
A. The heavy chest tube drainage suddenly stops. Sudden cessation of the mediastinal chest tube drainage after a CABG, especially when the drainage was heavy, is a hallmark manifestation of cardiac tamponade. Cardiac tamponade occurs when blood and/or fluid collects in the pericardial sac, presses on the heart, and prevents atria and ventricles from filling adequately. Cardiac output is thus reduced and an emergency sternotomy and volume expanders are used to stabilize the client if possible. Cardiac tamponade is a medical emergency. Because temporary or permanent LOC changes usually happen after CABGs, of the options provided it wouldn't be most concerned if the patient started being confused, agitated, disoriented. When your patients start exhibiting these mental status changes though, you need to reorient them, allow them rest, and secure any lines or tubes that they could possibly pull out. The temperature reading is closer to the lower side of normal, so it's a little concerning but not something you need to act on right now. Nurses should know that CABG patients frequently become hypothermic postop (T < 96.8 F, 36.0 C). Hypothermia may occur after the client leaves the surgical area, even though the client was rewarmed prior to removal from the bypass. Hypothermia will cause vasoconstriction and increased afterload and result in depressed cardiac contractility. Gradual rewarming is done with blankets and/or rewarming lights. Care is taken not to rewarm too quickly to decrease risk of acute hypoxia. It's slightly concerning if the client is coughing poorly because coughing is used as a way to clear the airway after an ET tube and ventilator are removed. Incisional pain can make deep breathing and coughing difficult. Splinting the surgical site and pain meds can help improve the client's ability to deep breathe and cough.
The emergency department nurse provides care for a client experiencing myocardial infarction with no dysrhythmias. Which intervention does the nurse anticipate carrying out? Select all that apply. A. administer oxygen B. establish an intravenous line C. monitor the electrocardiogram D. administer lidocaine E. administer aspirin F. insert an indwelling urinary catheter
A. administer oxygen B. establish an intravenous line C. monitor the electrocardiogram E. administer aspirin You give oxygen to maximize the amount of it the patient's getting into circulation thru gas exchange, which'll hopefully increase the amount the heart is getting despite the occlusion it's experiencing. This decreases risk of dysrhythmias, minimizes ischemia, and helps prevent dyspnea/SOB. You gotta have an intact IV for all the IV meds that an MI patient needs to get for tx (want all meds to act fast and bypass any absorption methods, these patients won't be getting meds any other way). MI patients would be on telemetry, allowing you to monitor their ECG and see if their condition worsens or improves, or monitor for dysrhythmias. Aspirin is a platelet inhibitor that'll prevent clotting and facilitate further blood flow, which you want bc the patient's having heart perfusion issues - less clots means that blood flows more easily in the whole body which means that the heart will get blood more easily. Lidocaine is only warranted for people w ventricular dysrhythmias, not for MI. Indwelling urinary catheters aren't inherently indicated for MI patients unless they have another condition that has to be addressed. No other one is mentioned here so you wouldn't choose this answer.
The nurse provides care for a client after a carotid endarterectomy. Which signs and symptoms does the nurse observe that indicate cranial nerve impairment? A. facial drooping, tongue deviation, and dysphasia B. swelling and tightness at the operative site C. unstable blood pressure D. increase respiratory rate, rhythm, and effort
A. facial drooping, tongue deviation, and dysphasia Facial movements, tongue movements, and speech are all cranial nerve functions, so these sx indicate something's wrong w them. CN can be stretched during surgery, leading to deficits in their functioning. A carotid endartectomy is a procedure removing plaques and other substances built up impeding flow thru the carotids. The operative site would be the carotids. If the option had discussed impaired neck movements a/w the operative side, that would be an appropriate answer to the question of CN impairment since CN control neck movements. But inflammation of the operative site alone doesn't mean that there's a CN issue. Inflammation to an extent is expected as part of the healing process but swelling and tightness should be monitored as signs of possible hemorrhage. Unstable blood pressure can happen after a surgery like this bc your carotid sinuses help regulate your BP, but CN aren't the ones innervating this area, so that doesn't answer the question. Increased respiratory rate, rhythm, and effort are signs of respiratory distress that can happen after a surgery like this d/t edema and hematoma formation in and around the trachea.
The nurse provides care for a client diagnosed with hypertension. The client states, "I no longer have headaches, so my blood pressure must be normal now." Which is the best response for the nurse to give? A. "If you no longer have headaches, then your blood pressure probably is normal." B. "High blood pressure is usually asymptomatic and symptoms do not reliably indicate blood pressure levels." C. "Since you have lost weight, your blood pressure is probably lower." D. "It is good to avoid strenuous exercise to keep your blood pressure lower."
B. "High blood pressure is usually asymptomatic and symptoms do not reliably indicate blood pressure levels." This answer is right - people w HTN don't always have sx of it. Just bc you don't have sx doesn't mean you don't have HTN, it might just mean you're earlier in the dz process or that your body is compensating properly w/o showing any problems. The first option is wrong bc not having sx doesn't mean BP is normal. Obesity is a RF for HTN, but losing weight or looking subjectively skinny doesn't mean you can't have high BP. Genetics, physical activity, and lots of other factors also play roles in determining your BP. Losing weight is good for the patient in many ways, but that doesn't inherently make your BP lower. The question also doesn't talk about weight to begin w, so choosing this answer would imply a relationship btwn weight, HA, and BP, which isn't good form. Avoiding exercise will make your BP worse long term. Short term, you should avoid stressors that'll trigger your fight or flight and increase your BP, and strenuous exercise (like too intense in a very short time) counts under that umbrella here. What the client needs to do is exercise isotonically regularly in order to help control BP and weight.
The health care provider prescribes a clonidine patch for a client with a blood pressure that continues to be regularly above 160/100 mm Hg. Which statement is most important for the nurse to include in the teaching? A. "You can apply the patch to any area of your body that you can easily reach." B. "Rotate the sites you apply the patch to, avoiding scarred or irritated areas." C. "Avoid milk and other dairy foods, due to their high calcium content." D. "You can continue to drink alcohol, but you should not smoke cigarettes."
B. "Rotate the sites you apply the patch to, avoiding scarred or irritated areas." The patch depends on the medication being absorbed through intact skin, and scarred areas might prevent absorption; irritated areas might become even more uncomfortable and itchy. You can't just put the patch on any part of your body that you can easily reach because some parts of your body are hairy and medication patches shouldn't be placed on hairy areas of the body since the hair would interfere with absorption. Clonidine patches have no effect on calcium levels, so you don't need to be conscious of your calcium intake. However, it does affect sodium. Avoid foods high in sodium like canned soups, lunch meats, and cheese. You CANNOT drink alcohol while you're on this medication d/t risk of stroke, coma, heart attack, death. So don't drink alcohol and it's never okay to smoke cigarettes d/t the health risk.
The nurse teaches a class about cardioversion. The nursing student asks, "How does cardioversion differ from defibrillation?" Which is the best response for the nurse to give? A. "The application of conductive materials to the chest is different." B. "The position of the synchronizer switch on the defibrillator is different." C. "The placement of paddles on the chest wall is different." D. "The application of pressure to defibrillator paddles is different."
B. "The position of the synchronizer switch on the defibrillator is different." A synchronizer switch should be turned on for cardioversion in order to deliver the electrical shock during the QRS complex of the EKG. For defibrillation, the synchronizer switch should be turned off. However, the synchronizer/defibrillator machine is used in both cases (cardioversion, defibrillation). Each of the other options describe similarities btwn cardioversion and defibrillation. Cardioversion can either be done thru meds or thru electric shock. If you're talking about the latter, both cardioversion and defibrillation involve the application of conductive materials to the chest where the paddles/pads will be placed. You have to position the pads/paddles the same way for both procedures (the first to the right of the sternum just below the clavicle, the second to the left of the precordium). You also have to apply the same amount of pressure to the paddles when using them, that being 20-25 lbs.
The nurse is teaching a client diagnosed with heart failure about the prescribed medication. The nurse explains the purpose of digoxin includes which reason? A. Dilate the coronary arteries B. Increase the strength of the heart's contractions C. Prevent premature ventricular contractions D. Increase the rate of myocardial contractions
B. Increase the strength of the heart's contractions Digoxin increases the force of the heart's contractions by slowing the heart rate and conduction through the AV node. Thinking about cardiac medications, nitroglycerin dilates coronary arteries. Lidocaine and procainamide prevent premature ventricular contractions. Atropine increases heart rate, or rate of myocardial contractions.
The nurse provides care for a client receiving a blood transfusion. The nurse observes which symptoms if fluid overload occurs during the transfusion? A. Decreased pulse rate, increased BP, decreased respirations B. Increased pulse rate, increased BP, increased respirations C. Increased pulse rate, increased BP, decreased respirations D. Decreased pulse rate, decreased BP, increased respirations
B. Increased pulse rate, increased BP, increased respirations If a blood transfusion infuses too quickly, fluid overload can occur and signs of heart failure will be seen. Symptoms include increased respirations (dyspnea), increased pulse rate (rapid and irregular), and increased blood pressure.
Which is the primary goal of the nurse in performing cardiopulmonary resuscitation (CPR) on a client experiencing púlseles ventricular dysrhythmias? A. Correct fluid volume deficit B. Maintain circulation to vital organs C. Return the heart to normal rhythm D. Maintain acid-base balance
B. Maintain circulation to vital organs CPR doesn't achieve any of the other goals. Defibrillation (AED) is necessary to possibly to restore normal rhythm. Although circulation and ventilation help maintain acid-base balance, that's not the primary purpose of CPR. The goal of CPR is to maintain circulation to vital organs until more advanced forms of life support can be initiated. It achieves aid with circulation and respiration via mechanical pushing of the heart and breathing into the patient's airway.
A client is taking verapamil in the sustained-release form that was prescribed one month ago. The client reports having a mild headache since starting the medication. Which information does the nurse provide to the client? A. This is an unrelated symptom and should be reported. B. This medication often causes headache which may improve with time. C. This medication should be stopped until the headache disappears. D. The client should go immediately to the emergency department.
B. This medication often causes headache which may improve with time. Verapamil is a calcium channel blocker used to tx angina, certain dysrhythmias, and HTN. Common adverse fx of this medication include HA, constipation, fatigue, and dizziness. D/t the vasodilation of blood vessels, verapamil can cause headache. Remember that one possible underlying pathology causing headaches is the swelling of blood vessels in the brain. A non-narcotic analgesic is often rxed to tx the HA. HA sx may diminish over time. If it's severe and persistent, the patient and the nurse need to talk to the provider. As shown above, HA is a sx r/t verapamil. Stopping the medication until the HA means that you'd be stopping it abruptly, and you should never go cold turkey on a HTN med even if you're not taking it for HTN bc it can cause a severe and rapid rise in BP. An ER visit is unwarranted for mild HAs. Reasons r/t to HTN to go to the ER would be rash, dyspnea, swelling of the hands and feet, severe HA, nosebleed.
The nurse provides care for a client with acute chest pain. The client's skin is cool and clammy, and blood pressure and heart rate are elevated. The client appears short of breath as well as restless and anxious. Which action does the nurse take first? A. takes a 12 lead electrocardiogram B. assesses pain and administers analgesia C. administers anticoagulants as prescribed D. gives a brief orientation to the unit
B. assesses pain and administers analgesia Even though you should suspect MI for this kind of presentation and start to act quickly, txing your patient's pain would still come first, especially since morphine works to reduce preload and consequently decrease the workload of the heart - precisely the sort of thing you want for a possible MI patient. Decreasing workload could also initiate a cycle of reducing the patient's pain bc if the heart isn't being perfused properly, this causes pain, which activates the stress response and increases cardiac workload, which will only make your pain worse since the oxygen supply your heart's getting isn't compatible w its metabolic demands. If you hold off on pain management/tx, specifically w the morphine, the amount of affected heart tissue only increases. Morphine both txs pain and starts alleviating the stress on the heart, other meds will still be used to tx this kind of patient later tho. Pain management comes first for patients!! An ECG would be the next thing you do for a patient like this. It'll allow you to identify the occurrence and location of ischemia or necrosis. Anticoags would also be given to a patient like this to better facilitate perfusion. Anticoags prevent an existing occlusion from worsening, and thrombolytics break the occlusion up altogether. Both improve/restore perfusion, but these txs will come after pain management. Orientation to the unit is like the last thing you'd do for this kind of patient. It helps w patient comfort to get them used to new surroundings but their physiological needs come first, this is more psychological (Maslow's hierarchy).
The nurse provides care for a client diagnosed with angina. Which question is essential for the nurse to ask the client before a cardiac catheterization? A. "Have you ever had this procedure before?" B. "Do you have a strong family history of cardiac disease?" C. "Are you allergic to anything?" D. "Do you have comfortable shoes and clothes with you?"
C. "Are you allergic to anything?" Cardiac caths involve dyes that has to be injected into the person's circulation in order for the cardiologists to see the tube/balloon on their monitor during the procedure. So you should always know your patient's allergies, but especially here, you wanna be sure that your patient doesn't have an allergy to iodine products bc the dyes used here may contain iodine. Knowing if the patient's had the procedure before or what their family hx is like for CVD helps inform you about the patient's case, but isn't important info that you need to know before doing this kind of procedure. Having comfy shoes and clothes isn't needed for a cardiac cath, that would be more helpful if the patient's going thru a stress test.
The nurse instructs a client diagnosed with atrial fibrillation receiving lisinopril. Which statement, if made by the client to the nurse, indicates the need for further teaching? A. "I have to limit the amount of canned soups, lunch meats, and cheese I eat." B. "I will decrease the number of oranges, bananas, and apricots in my diet." C. "I have switched to a salt substitute instead of iodized salt." D. "I do not include as much broccoli, potatoes, and leafy green vegetables in my diet."
C. "I have switched to a salt substitute instead of iodized salt." Remember that lisinopril is an ACE inhibitor, which blocks ACE in the lungs from converting AT I to AT II. This affects the RAAS system, ultimately resulting in lower BP, lower aldosterone secretion, and sodium and fluid loss. Clients should avoid high sodium foods when taking ACE inhibitors bc that will increase your serum sodium levels, which in turn promotes fluid retention via osmosis, and then your BP and BV increase bc of that. I.e, it contradicts your goal of taking lisinopril to begin w. Bc of this, you should NOT have high sodium foods like salt or salt substitutes whe taking lisinopril. This is a further teaching question, so the right answer is the option that's actually wrong. So each of the other answers here are appropriate considerations when taking lisinopril. Canned soups, lunch meats, and cheese have lots of sodium, so they should be avoided. High potassium/potassium rich foods should also be avoided when you're on an ACE inhibitor. While ACE inhibitors cause sodium and fluid loss, it also means that the body keeps more potassium (NA-K pump). If you have potassium rich foods, you could become hyperkalemic from the extra K that's already in your body d/t the effects of the medication. Oranges, bananas, apricots, broccoli, potatoes, and leafy green veggies are all high in K.
The nurse identifies that which set of vital signs is within the normal range for an adult? A. BP 80/50 mm Hg, P 110 bpm, R 32 breaths/minute B. BP 110/80 mm Hg, P 56 bpm, R 20 breaths/minute C. BP 120/70 mm Hg, P 68 bpm, R 16 breaths/minute D. BP 130/90 mm Hg, P 72 bpm, R 24 breaths/minute
C. BP 120/70 mm Hg, P 68 bpm, R 16 breaths/minute Normal BP is <120/80 mm Hg. Normal pulse is 60-100 bpm for adults. Normal respiratory rate is 12-20 breaths/minute. Elevated BP and decreased pulse indicate shock, like in the first option. The rest of the options have abnormal values for the vitals being assessed.
To assess the pulse during adult cardiopulmonary resuscitation (CPR), which site does the nurse use? A. Femoral artery B. Radial artery C. Carotid artery D. Brachial artery
C. Carotid artery The carotid's the most accessible artery, which is why we use it during CPR. Specifically used for adults and children 1-8 y/o. Never assess the pulse for more than 10 sec during CPR. The femoral artery is considered a central pulse but it's less accessible and likely buried under clothes, not the ideal option for CPR. Radial artery is more accessible, but this is considered a peripheral pulse and it can be hard to pick up a pulse here in someone w perfusion issues. Brachial artery is in the groove btwn your biceps and triceps, at the antecubital fossa. This is the one you go for when you're doing CPR on a baby.
The nurse provides care for a client diagnosed with angina. The nurse discovers the client in cardiac arrest and begins to perform cardiopulmonary resuscitation (CPR). The nurse evaluates that the client has a pulse and is breathing independently. Which is the most appropriate position in which to place the client? A. Supine B. Supine with lower extremities elevated C. In side lying position D. Trendelenburg
C. In side lying position The recovery position for CPR is a side lying position bc it decreases risk of aspiration. Basic CPR is the process of externally supporting circulation and respiration. Failure to institute ventilation within 4-6 min results in brain damage. A CPR sequence consists of compression-airway-breathing (CAB). If the rescuer starts with step 2 listed below and if the rescuer doesn't witness the collapse of the victim, start w step 1. If the person is a drowning victim, start w 2 min of CPR before activating EMS and if the victim is a child, the rescuer starts with 2 min CPR before activating EMS. Step 1: establish unresponsiveness, breathing, and pulse. Step 2: rescuer activates EMS. Step 3: start compressions and allow for complete recoil at a rate of at least 100/min (depth depending on age). Adult compression-ventilation rate is 30:2. Step 4: establish airway by using the head-tilt chin lift. If trauma's suspected, use the jaw thrust method. Step 5: begin breathing at 8-10 breaths/min, watch for visible chest rise. All chest compressions are done a rate of 100/min at least. Sternum should be depressed at least 2 in (5 cm) for an adult, compression-ventilation rate 30:2. When recovering from CPR, supine is contraindicated d/t risk of aspiration. Supine with LE elevated would be used for clients who are hypotensive and feeling faint. Trendelenburg is also used for hypotensive clients.
The nurse provides care for a client receiving methyldopa. The nurse instructs the client about common adverse effects of methyldopa. Which information does the nurse include? A. Bronchospasm B. Loss of potassium C. Loss of libido D. Tachycardia
C. Loss of libido None of the others are adverse effects of methyldopa. Methyldopa is a centrally acting sympathyolytic that reduces peripheral vascular resistance. Adverse effects include drowsiness, sedation, orthostatic hypotension, bradycardia, weight gain, nightmares, and loss of libido. It is an anti-hypertensive, so its action results in a decrease in BP, peripheral resistance, and slight decrease in heart rate. Tachycardia wouldn't occur.
The nurse provides care for a client diagnosed with arterial insufficiency. Which sign or symptom does the nurse expect when obtaining the client's history or performing a physical assessment? A. Bounding peripheral pulses B. Relief of pain when walking C. Pain in the hip, buttock, thighs, or calf D. Excessive growth of hair on the lower extremities
C. Pain in the hip, buttock, thighs, or calf Decreased arterial blood flow leads to pain in the hip, buttock, thighs, calf. Classic sx of arterial dz is intermittent claudication and ischemic muscle dz. Indications of peripheral arterial dz include rubor, cool and shiny skin, cyanosis, ulcers, gangrene, impaired sensation, and decreased peripheral pulses. Predisposing factors include smoking exposure to cold, emotional stress, DM, high fat diet, HTN, and obesity. Tx includes sympathectomy, grafting, vasodilators, anticoagulants, and enarterectomy. Nursing considerations include monitoring peripheral pulses, good foot care, teaching the client not to cross their legs, encouraging regular exercise and cessation of smoking. With arterial insufficiency, pulses won't be bounding, they'll be diminished or absent. Because blood flow to the area is lower than normal, pain will result at rest and will interfere with one's ability to walk; that's what's called intermittent claudication. You won't experience relief when walking, but rest can help. Because epithelial cells in the extremities aren't being properly perfused with nutrients, the skin will become hairless, shiny, and taut.
The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's blood pressure is 150/96, serum albumin is 3 g/dL (30 g/L), 3+ protein is found in the urine, and the client's face and hands are edematous. Which instruct by the nurse is most important? A. The client should decrease caloric intake. B. The client should eliminate all salt from the diet. C. The client should ensure adequate protein. D. The client should increase the intake of iron.
C. The client should ensure adequate protein. These sx - HTN, decreased protein, during pregnancy - indicate preeclampsia. The client will be placed on bedrest lying on the left side and will be instructed to maintain adequate intake of fluids and protein. Proteins restore osmotic pressure. Altering salt and iron intake is irrelevant in addressing preeclampsia. Though high salt can cause edema, the edema from preeclampsia is d/t decreased colloidal osmotic pressure from protein loss, not excess dietary sodium. If the client has chronic HTN controlled by a low salt diet before pregnancy, decreased salt would be an dietary intervention implemented.
The nurse understands that intermittent claudication is which description? A. found in venous insufficiency B. pain caused by cold C. pain caused by walking D. found only in the elderly
C. pain caused by walking This is a knowledge question. Intermittent claudication refers to an aching pain in the legs when walking or exercising that goes away at rest. It's an arterial problem - the arteries of the legs aren't circulating blood properly, and the pain happens bc the legs don't have the oxygen supply to meet the metabolic demands a/w physical activity. If the condition is very severe, the pain happens at rest, too. Venous insufficiency is when the veins have difficulty sending blood back from the legs to the heart, that's not what intermittent claudication is. It's caused by HTN, which, over time, weakens the vein walls and damages the venous valves. Sx include edema, discoloration of ankles, and stasis ulcers. Pain caused by cold is a finding a/w Raynaud's disease/syndrome, it doesn't describe intermittent claudication. That's a vascular d/o where a person's blood vessels start constricting excessively if the environment is cold or the person is feeling stressed. They're called vasospasms. When these vasospasms happen, the blood is unable to get to the surface of the skin and the affected areas turn white and blue. While it's true that intermittent claudication happens most commonly in people over 70, anyone 50+ y/o is at risk for it if they smoke or have DM.
The nurse teaches a client diagnosed with myocardial infarction. The client's choice of which cooking oil indicates that the nurse needs to review instructions for managing a diet low in saturated fat? A. olive B. safflower C. palm D. corn
C. palm Tropical oils like palm and coconut oils are high in saturated fat, so you wouldn't want your patient eating this if they just had an MI. A low saturated fat diet is designed to decrease the proportion of calories you're taking in of fat and minimizing cholesterol intake. It's best for patients with conditions like atherosclerosis, CHD, obesity, and cystic fibrosis. Stuff you should predominantly eat in this kind of diet include fruits, veggies, cereals, and lean meat. Prohibited foods are marbled meats, avocados, whole milk, bacon, egg yolks, and butter. You would also avoid cooking w animal fats like lard. Vegetable oils like corn, safflower, and olive oils are all okay when you're on a low saturated fat diet.
The nurse provides care for a client who had an open reduction and internal fixation of the right hip and femur. On the second postoperative day, the client becomes confused and disoriented and reports sharp stabbing pain in the chest. The client's respiratory rate is 32 and the pulse is 110. Which action does the nurse take initially? A. Places the client in high Fowler position B. Medicates the client for chest pain C. Retakes the client's vital signs in 15 minutes D. Applies oxygen and notifies the health care provider
D. Applies oxygen and notifies the health care provider The first step in this question is trying to identify the patient's problem, which is probably, in this case, pulmonary embolism. High Fowler promotes lung inflation, which would be good for a dyspneic client. However, that's not the issue here. Circulation to the lung via the pulmonary vasculature is the problem (embolus is a blood clot that's traveled from somewhere else in the body). Confusion, disorientation, and sharp chest pains are signs of pulmonary embolism. When dealing with patients who have pulmonary embolisms, the first step should be applying oxygen.
The nurse assesses the apical heart rate in an infant client. Where does the nurse locate the point of maximum intensity (PMI)? A. Between the third and fourth left intercostal space B. At the fifth intercostal space to the right of the midclavicular line C. In the aortic area D. Between the fourth and fifth intercostal space, medial to the left midclavicular line
D. Between the fourth and fifth intercostal space, medial to the left midclavicular line The first and third options are too high. The second answer describes the pulmonic area. The apical pulse is where the impulse of the left ventricle is felt most strongly. This is the point of maximal impulse (PMI). The PMI is located between the fourth and fifth intercostal space to the left of the midclavicular line in the infant.
A client comes to the cardiac clinic for a medication check, and reporting symptoms of anorexia, nausea, headache, mild confusion, and blurred vision. The nurse understands these symptoms indicate the client may be experiencing which condition? A. Cardiac tamponade B. Hypokalemia C. Myocardial infarction D. Digitalis toxicity
D. Digitalis toxicity Sx of digitalis toxicity include the following: visual disturbances, n/v/d, anorexia, headaches, confusion, hallucinations, anxiety, restlessness, and depression. Visual disturbances are the hallmark sx that should've brought you to digitalis toxicity here. Be sure to check an apical heart rate and hold the digoxin if the apical HR is < 60 bpm. If you noted these assessments in a patient, you'd wanna run labs, specifically for their digoxin levels. Normal range of digoxin is 0.5-2.0 ng/mL. Cardiac tamponade is the compression of the heart due to fluid inside the pericardial sac, which impairs cardiac function (can't contract properly with the pressure being placed on it). Sx of this would be Beck's triad: low arterial BP, distended neck veins, and distant/muffled heart sounds. Hypokalemia is low serum potassium levels. Normal potassium is 3.5-5.5 mEq/L. Any lower and you'll see anorexia, n/v, and muscle weakness. Hypokalemia can cause increased sensitivity to digitalis and may be a factor in this patient's dx, but this isn't the most correct answer. There are lots of sx of MI: dyspnea, acute and/or unrelenting chest pain/pressure/tightness that may radiate down the left arm, n/v, diaphoresis, apprehension. Atypical sx are indigestion, jaw pain, dizziness, lightheadedness, and fatigue. Visual disturbances usually don't happen w MI.
The nurse provides care for a client diagnosed with a Stage III pressure injury on the coccyx. At this time the wound has no purulent drainage. Which intervention is the most appropriate for the nurse to implement? A. Massage the area carefully. B. Cover the area with a transparent dressing. C. Irrigate the wound with a sodium hypochlorite solution. D. Irrigate the wound and apply a hydrocolloid dressing.
D. Irrigate the wound and apply a hydrocolloid dressing. Stage III pressure injuries are usually irrigated daily and a hydrocolloid dressing may be applied. Both transparent and hydrocolloid dressings are contraindicated for an infected pressure injury or one with exposed muscle, tendon, bones. A pressure injury is a localized area of necrotic tissue that develops when soft tissue is compressed over a bony prominence. Risk factors include impaired sensory perception, impaired mobility, altered LOC, shear, friction, and moisture. Prevention includes frequent assessment of pressure areas for non-blanching reactive hyperemia, keeping moisture away from the client's skin, repositioning client using a draw-sheet, implementing a turning schedule, and providing adequate nutrition and fluids. Massaging the area will only increase tissue trauma. Transparent dressings that are impermeable to water and bacteria but permeable to moisture vapor and oxygen. They're usually used for stages I and II pressure injuries, not III. Irrigation with sodium hypochlorite isn't indicated here.
The nurse discovers an unconscious person in the street. The nurse notes the person is not breathing but has a pulse. The nurse should take which action first? A. Lift the back of the person's neck. B. Using the thumbs on the chin, move the person's lower jaw backward toward the neck. C. Turn the person's head to the left. D. While maintaining the cervical spine, roll the person supine to ensure the person is in position for cardiopulmonary resuscitation (CPR) if needed.
D. While maintaining the cervical spine, roll the person supine to ensure the person is in position for cardiopulmonary resuscitation (CPR) if needed. Making sure the person is in supine position means that they're automatically ready for any resuscitation efforts that may need to be used. This is because resuscitation efforts and evaluation efforts are only effective when the person is supine and on a firm, flat surface. If they're lying face down, roll the victim as a unit so that the head, shoulders, and torso move simultaneously without twisting. The head and neck should remain in the same plane as the torso, and the body should be moved as a unit. The non-breathing victim should be supine with the arms alongside the body making them ready for CPR if needed.
