Hesi NCLEX: Med Surg: Cardiac
The nurse encourages a client with Raynaud disease to stop smoking. Which primary goal is the nurse trying to achieve? Prevent pain and tingling Prevent cyanosis and necrosis Prevent peripheral vasoconstriction Prevent excessive blood oxygen content
Prevent peripheral vasoconstriction. Nicotine causes spasms and constriction of the smooth muscles of the arterial vasculature, compromising blood flow to the distal extremities. Nicotine does not directly cause pain and tingling, although these may occur as consequences of nicotine-induced vasoconstriction. Vasoconstriction from nicotine will not result in such severe effects as cyanosis and necrosis. Smoking increases the carboxyhemoglobin level in the blood; carbon monoxide combines with hemoglobin and occupies the sites on the hemoglobin molecule that bind with oxygen, thus decreasing oxygen content.
A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best response by the nurse? "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." "Those spots indicate a high glucose content in the skin that may get infected if left untreated." "They are the result of diseased small vessels in the shins and may spread if not treated soon." "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."
"Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot." "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the definition of a xanthoma. A high glucose content in the skin that has become infected is not the cause of brown spots on the skin; increased glucose in the skin is not observable by inspection. Brown spots result from the deposition of hemosiderin. Blood vessels may become diseased with diabetes, but this does not cause brown spots.
A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essential nursing intervention? "Maintain elevation of both legs." "Massage the legs when they are painful." "Apply a hot water bottle to the legs." "Check pulses in the legs regularly."
"Check pulses in the legs regularly." Altered quantity and quality of pulses are the earliest indications of increasingly limited circulation. Maintaining elevation of both legs prevents the use of gravity to carry arterial blood to the legs and feet. Massaging the legs when painful can release an embolus into the circulation and cause tissue trauma. Altered sensation may limit sensitivity to heat, which can result in burns.
A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction (MI). Which statement by the client indicates the nurse needs to follow up? "I want to stay as pain-free as possible." "I am not good at remembering to take medications." "I should not have any problems in reducing my salt intake." "I wrote down my dietary information for future reference."
"I am not good at remembering to take medications." Not adhering to the treatment regimen may interfere with effective resolution of the MI, and further intervention is necessary. The other statements, such as "I want to stay as pain-free as possible," "I should not have any problems in reducing my salt intake," and "I wrote down my dietary information for future reference," are appropriate responses related to teaching concerning self-care after an MI.
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? A fever may lead to diaphoresis. A fever increases the cardiac workload. An increased temperature indicates cerebral edema. An increased temperature may be a sign of hemorrhage.
A fever increases the cardiac workload Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.
An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. What does the nurse expect the primary healthcare provider to prescribe to confirm the presence of hypokalemia? A complete blood count A serum electrolyte level An arterial blood gas panel An x-ray film of long bones
A serum electrolyte level Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and an x-ray film of long bones have no significance in diagnosing a potassium deficit. K+ range: 3.5-5
A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. Which behavior by the client demonstrates an increase in client autonomy? Active participation in providing self-care Verbalizing realistic expectations of caregivers Discussing necessary lifestyle changes with family members Listing the indicators of recovery after a myocardial infarction
Active participation in providing self-care Planning self-care demonstrates decision-making by the client; participating in care enhances feelings of self-worth and autonomy. Expectations do not reflect autonomy. Discussing necessary lifestyle changes with family members does not reflect autonomy; it may be intellectualization. Listing the indicators for recovery after a myocardial infarction does not reflect autonomy; it may be intellectualization.
The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? Apples Broccoli Cherries Cauliflower
Broccoli Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? Check for a pulse Start cardiac compressions Prepare to defibrillate the client Administer oxygen via an ambu bag
Check for a pulse The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.
Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Arrange for a supply of heparin for the client to take to the rehab center. Explain to the client that anticoagulant therapy will no longer be needed. Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.
Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the healthcare provider.
What should the nurse do to prevent thrombus formation after most surgeries? Keep the client's bed gatched to elevate the knees. Have the client dangle the legs off the side of the bed. Have the client use an incentive spirometer every hour. Encourage the client to ambulate with assistance every few hours.
Encourage the client to ambulate with assistance every few hours. Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client's bed gatched to elevate the knees or having the client dangle the legs off the side of the bed cause increased popliteal pressure and impair venous return. Having the client use an incentive spirometer every hour helps prevent atelectasis, not thrombi.
A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? Hypokalemia Hypocalcemia Hyponatremia Hypomagnesemia
Hypokalemia Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.
A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? International normalized ratio (INR) Accelerated partial thromboplastin time (APTT) Bleeding time Sedimentation rate
International normalized ratio (INR) Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.
A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? Cataracts Esophagitis Kidney failure Diabetes mellitus
Kidney failure Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures, such as tubules, glomeruli, and nephrons, leading to kidney failure. Retinopathy, resulting in blurred vision, retinal hemorrhage, and blindness, occurs with a long history of hypertension because of increased intravascular pressure, not cataracts. Esophagitis is caused by esophageal reflux disease, not a long history of hypertension. Hypertension does not cause diabetes mellitus; however, chronic elevations of serum glucose accelerate atherosclerosis, resulting in the development of hypertension.
The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily Give 1 L of 0.9% normal saline (NS) bolus over 4 hours Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr No prescription change
No prescription change The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.
A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension? Mild but persistent depression Transient temporary memory loss Occipital headache in the morning Cardiac palpitation during periods of stress
Occipital headache in the morning Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged. Mild but persistent depression is a nonspecific response; it is not physiologically related to increased arterial blood pressure. Transient temporary memory loss occurs with transient ischemic attacks, which may be a later consequence of prolonged hypertension. Cardiac palpitation during periods of stress is a common physiologic effect; it is not specific to hypertension.
A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure? Fear of dying Skipped heartbeats Pain at the insertion site Anxiety in response to intensive monitoring
Pain at the insertion site Pain at the arterial puncture site is attributable to entry and cannulation of the artery and is a common complaint after a cardiac catheterization. Fear of dying might occur during the precatheterization period. Although skipped heartbeats may occur during the procedure because of trauma to the conduction system, usually it does not continue after the procedure. Although some clients may be anxious, many feel safe when receiving ongoing monitoring.
A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. Which recommendation by the nurse will help the client maintain blood vessel patency? Practice relaxation techniques. Lead a more sedentary lifestyle. Limit cardiovascular exercise. Increase saturated fats in the diet.
Practice relaxation techniques. Research has shown that decreasing stress will slow the rate of atherosclerotic development. Exercise is thought to decrease atherosclerosis and the formation of lipid plaques. Saturated fats in the diet are contraindicated because they increase the risk for atherosclerosis.
A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? "Do you have chest pain?" "Are you feeling anxious?" "Do you have any palpitations?" "Are you feeling short of breath?"
"Do you have chest pain?" Females may present with atypical symptoms of myocardial infarction, such as absence of chest pain, overwhelming fatigue, and indigestion. Anxiety, palpitations, and shortness of breath are common clinical manifestations in both males and females who are experiencing a myocardial infarction.
A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? "You must be quite frightened about having high blood pressure." "I'm glad to hear you have felt well enough to stop the medication." "It is important to take your medications daily to achieve optimal results." "You will need to document daily whether you took your medication or not."
"It is important to take your medications daily to achieve optimal results." "It is important to take your medications daily to achieve optimal results" is a nonjudgmental response that does not pressure the client but does indicate clearly that treatment is necessary. The response "I'm glad to hear you felt well enough to stop the medication" is not supported by the client's statement. The response "You must be quite frightened about having high blood pressure" does not address the correlation between blood pressure medication and controlling hypertension. Although it is important to document medication taking, the initial response should address the importance of medication to control the client's hypertension.
A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, "What can I do to help myself?" How should the nurse respond? "Limit walking to as little as possible." "Reduce fluid intake to 1 L of liquid a day." "Apply moisturizing lotion on your legs several times a day." "Put on compression hose before getting out of bed in the morning."
"Put on compression hose before getting out of bed in the morning." As valves become incompetent, they allow blood to pool in the veins, which increases hydrostatic pressure and leads to further valve destruction. Compression hose provide external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. The legs are less congested after sleeping, and therefore the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Prolonged sitting, standing, or crossing the legs should be avoided because they reduce venous return. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin more supple, it will not treat enlarged and tortuous veins.
The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would be the best reply by the nurse? "Why do you want to be out of bed?" "Bed rest plays a role in most therapy." "Rest helps your body direct energy toward healing." "Would you like me to ask your primary healthcare provider to change the prescription?"
"Rest helps your body direct energy toward healing." A client's knowledge about the treatment program enhances compliance and reduces stress. The response "Why do you want to be out of bed?" does not answer the client's question and might produce frustration. The response "Bed rest plays a role in most therapy" does answer the client's question, but does not explain specifically why. The response "Would you like me to ask your primary healthcare provider to change the prescription?" does not support the treatment regimen; the client needs education.
A primary healthcare provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse? "The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." "I wouldn't bother. For this diet all that you need to do is to reduce the amount of salt you use and fry foods in peanut oil." "You're right. Be careful to cook a small portion for each of you to eat to not waste food." "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen."
"The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals. Fried foods are not advocated on a heart-healthy diet; peanut oil is a monounsaturated fatty acid, and these acids should not exceed 15% of the calories of the diet. The responses "You're right. Be careful to cook a small portion for each of you to eat to not waste food" and "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen" can be discouraging and encourage noncompliance.
The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? A loss of atrial kick No physiologic changes Increased cardiac output Decreased risk of pulmonary embolism
A loss of atrial kick Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The atrioventricular (AV) node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. This irregularity is called "irregularly irregular." The ineffectual contraction of the atria results in loss of "atrial kick." If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The client may or may not be aware of the atrial fibrillation. If the ventricular response is rapid, the client may show signs of decreased cardiac output or worsening of heart failure symptoms.
The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? Except with rare blood disorders, hemoglobin seldom affects oxygenation status. There are many other factors that affect oxygenation status more than hemoglobin does. A low hemoglobin level causes reduced oxygen-carrying capacity. Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status.
A low hemoglobin level causes reduced oxygen-carrying capacity. Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. Higher levels of hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. Hemoglobin does not reflect clotting ability.
A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? Obtain vital signs Initiate a cardiac arrest code Administer oxygen using a face mask Encourage the use of an incentive spirometer
Administer oxygen using a face mask The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted. The client is not experiencing a cardiac arrest, and therefore a code should not be initiated. After more definitive medical intervention, deep breathing and coughing or use of an incentive spirometer may be done to prevent or treat atelectasis.
A client has a pulse deficit. Which documentation by the nurse supports this finding? Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. Capillary refill greater than 3 seconds indicating pulse deficit. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.
Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses. pulse deficit (difference between heart beats and pulsations at the periphery) is determined by simultaneous palpation at the radial artery and auscultation at the PMI, near the heart apex. It may be present in case of premature beats or atrial fibrillation.
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? Arteriolar constriction occurs. The cardiac workload decreases. Contractility of the heart decreases. The parasympathetic nervous system is triggered.
Arteriolar constriction occurs The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.
When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? Interview the client for a health history. Assess the client's heart and lung sounds. Monitor the client's pulse and temperature. Obtain the client's blood specimen for electrolytes.
Assess the client's heart and lung sounds. With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.
A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take? Loosen the dressing slightly. Notify the primary healthcare provider. Assess the pulses distal to the dressing. Have the client flex the joints of the right leg.
Assess the pulses distal to the dressing Assessing the circulatory status of the extremity will determine whether the dressing is too tight. Loosening the dressing slightly may result in bleeding from the catheter insertion site and is contraindicated. Notifying the primary healthcare provider is premature; the primary healthcare provider should be notified if circulation to the leg is compromised. Having the client flex the joints of the right leg may result in bleeding from the catheter insertion site and is contraindicated. The leg should remain extended for several hours.
The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first? Feel for a pulse Begin chest compressions Leave to call for assistance Perform the abdominal thrust maneuver
Begin chest compressions According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, the nurse has established that the client has no pulse when cardiopulmonary arrest was determined. Therefore, chest compressions should be initiated immediately. Never leave the client to call for assistance; either call the emergency medical services (EMS) by dialing 911 in the US or 112 in Canada on a cellular phone (and leave the phone on so that EMS can find you) or shout out to others in the area for assistance in seeking EMS. The longer the client goes without circulation, the higher the risk of death, so initiating chest compressions has highest priority when cardiopulmonary arrest has been established. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.
Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? Call the primary healthcare provider. Check the client's pedal pulses. Take the client's blood pressure. Recognize the response is expected.
Check the client's pedal pulses These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.
A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? Client pushes the airway out. Client has snoring respirations. Client's respirations are 16 breaths per minute and unlabored. Client's systolic blood pressure drops from 130 to 90 mm Hg.
Client's systolic blood pressure drops from 130 to 90 mm Hg A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Respirations of 16 breaths per minute is a common response postoperatively. If the client is experiencing a depressant effect of anesthesia, the nurse will assess shallow and slow respirations.
A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? The furosemide is causing dehydration. Cloudy urine may be indicative of infection. The client has inadequate hourly urine output. All of the indications are within normal findings.
Cloudy urine may be indicative of infection Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.
A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? Deficient fluid volume Impaired skin integrity Inadequate nutritional intake Decreased participation in activities
Deficient fluid volume The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.
What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)? Deflate the balloon as soon as the PCWP is measured. Have the client bear down when measuring the PCWP. Place the client in a supine position before measuring the PCWP. Flush the catheter with a heparin solution after the PCWP is determined.
Deflate the balloon as soon as the PCWP is measured Although the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lung. Bearing down will increase intrathoracic pressure and alter the reading. Although a supine position is preferred, it is not essential. Agency protocols relative to flushing of unused ports must be followed.
The primary healthcare provider prescribes two units of packed red blood cells for a client who is bleeding. Before blood administration, what is the nurse's priority? Obtaining the client's vital signs Letting the blood reach room temperature Monitoring the hemoglobin and hematocrit levels Determining proper typing and crossmatching of blood
Determining proper typing and crossmatching of blood. Determining proper typing and crossmatching of blood is absolutely necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. Although important, obtaining the client's vital signs is not the highest priority. Blood must be kept cool until ready to use. If blood is at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within 4 hours. Monitoring the hemoglobin and hematocrit levels is not the highest priority; these laboratory results were part of the data used to determine the need for the blood.
A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? Asthma Anemia Endocarditis Reye syndrome
Endocarditis Streptococcal infection can be spread through the circulation to the heart; endocarditis results and affects the valves of the heart. Asthma, anemia, and Reye syndrome are not caused by beta-hemolytic streptococcus.
A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? Feeling of heaviness in both legs Intermittent claudication of the legs Calf pain on dorsiflexion of the foot Hematomas of the lower extremities
Feeling of heaviness in both legs Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.
A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take? Double the dose of potassium chloride and administer it with the prescribed digoxin. Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately. Give the digoxin and potassium chloride as prescribed and report the laboratory results to the primary healthcare provider. Administer the prescribed digoxin and potassium chloride with a glass of orange juice and continue to monitor the client.
Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately. A low potassium level with the administration of digoxin can cause digitalis toxicity, resulting in life-threatening dysrhythmias. Doubling the dose of potassium chloride and administering it with the prescribed digoxin has the potential of causing digitalis toxicity. In addition, changing the dose of a medication is not within the legal role of the nurse and requires a primary healthcare provider's prescription. Giving the digoxin and potassium chloride as prescribed and reporting the laboratory results to the primary healthcare provider has the potential of causing digitalis toxicity, especially when the potassium level is less than 3 mEq/L (3 mmol/L). Administering the prescribed digoxin and potassium chloride with a glass of orange juice and continuing to monitor the client has the potential of causing digitalis toxicity. One glass of orange juice and one dose of potassium chloride will not change the potassium level significantly.
A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session? Elevated blood pressure Increased blood viscosity Fragility of the blood cells Immaturity of red blood cells
Increased blood viscosity Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation. Hypertension usually is related to narrowing or sclerosing of arteries, not to an increased number of blood cells. The fragility of blood cells does not affect the viscosity of the blood. Erythrocyte immaturity is not related to increased viscosity.
The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest? It prevents the further aggregation of platelets. It enhances the peripheral circulation in the deep vessels. It decreases the potential for further dislodgment of emboli. It maximizes the amount of blood available to damaged tissues.
It decreases the potential for further dislodgment of emboli. Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation or the circulation of blood to damaged tissues.
A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? It should be elevated on a pillow. It should be kept extended while on bed rest. It will be positioned dependent to the level of the heart. It will be put through range-of-motion exercises several times an hour.
It should be kept extended while on bed rest. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. Elevating the leg on a pillow will flex the hip, which may traumatize the catheter insertion site and impede healing. The leg is kept even with the level of the heart because the client usually is placed in the supine position with the leg extended. Range of motion will flex the hip, which may traumatize the catheter insertion site and impede healing.
A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do? Keep a record of the day's activities. Avoid going through laser-activated doors. Record the pulse and blood pressure every 4 hours. Delay taking prescribed medications until the monitor is removed.
Keep a record of the day's activities The purpose of monitoring is to correlate dysrhythmias with the client's reported activity. Laser-activated doors have no effect on a Holter monitor and will not affect the readings. Recording the pulse and blood pressure every 4 hours is not required for interpretation of the test. The client should take medication as prescribed and note it in the activities diary.
An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I'm sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do? Suppress fears Deny the illness Maintain independence Reassure the adult child
Maintain independence The client's statement is really saying, "I can manage this myself. I am capable." None of the information given leads to the conclusion that the client is suppressing fears. Nothing in the statement can be interpreted as denial; the client has stated, "I know I'm sick." Telling the adult child that self-care is possible will not be reassuring to a family member who brought the client to the hospital and who probably is more reassured by having the client hospitalized.
A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? Normal sinus rhythm Sinus tachycardia Sinus bradycardia Sinus arrhythmia
Normal sinus rhythm Normal sinus rhythm reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.
The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? Notify the primary healthcare provider immediately Apply a warm, moist compress to the incision site Increase the intravenous fluid rate by 20 mL/hr Monitor vital signs more frequently
Notify the primary healthcare provider immediately The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, then warm, moist compresses may be applied. Increasing the intravenous fluid rate by 20 mL hourly will not resolve an embolus. Although monitoring vital signs is appropriate, it is an insufficient intervention; the healthcare provider must be notified so that anticoagulants can be prescribed.
A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? Hematocrit 46% Hemoglobin 14.1 g/dL (141 mmol/L) Potassium 3.0 mEq/L (3.0 mmol/L) White blood cell 9200/mm 3 (9.2 × 10 9/L)
Potassium 3.0 mEq/L (3.0 mmol/L) A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm 3is within the normal range of 4000 to 11,000 cells/mm 3 (4 to 11 × 10 9/L).
While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every 2 hours. What does the nurse explain that these exercises will help to do? Prevent clot formation Reduce leg discomfort Maintain muscle strength Limit venous inflammation
Prevent clot formation Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. Active ROM exercises help prevent, not limit, venous inflammation.
What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? Wear support hose continuously. Lie down for 30 minutes after taking medication. Avoid tasks that require high-energy expenditure. Sit on the edge of the bed for 5 minutes before standing.
Sit on the edge of the bed for 5 minutes before standing. Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.
A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? Poached eggs Spinach salad Sweet potatoes Cheese sandwich
Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet. if at risk for blood clots, avoid leafy greens rich in Vitamin K Vitamin K is in the clotting cascade
While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? Administer nitroglycerin and aspirin. Slow the rate and monitor the vital signs. Stop the transfusion and administer normal saline. Ask the client to further describe the feeling and rate the pain.
Stop the transfusion and administer normal saline. The chest tightness or pressure and impending doom indicate the presence of an acute hemolytic reaction; other signs and symptoms include low back pain, tachycardia, tachypnea, and anxiety. The transfusion must be stopped immediately. The intravenous tubing must be changed and infusion of normal saline begun. Administering nitroglycerin and aspirin is appropriate for a possible myocardial infarction but not for a hemolytic reaction. Slowing the rate and monitoring the vital signs will increase the severity of symptoms and may increase morbidity or mortality. Exploring feelings will delay appropriate action.
A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? Support systems that can assist the client at home Potential nursing homes in which the client can recuperate Agencies that can help the client regain activities of daily living Ways that the client can develop relationships with neighbors
Support systems that can assist the client at home The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.
A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations? Long-term use of an irritant-type laxative Emotional response resulting in physical symptoms Inadequate dietary practices resulting in altered bowel function Systemic responses of the body to a localized inflammatory process
Systemic responses of the body to a localized inflammatory process With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).
The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? Refer the client to a nutritionist after providing health teaching about a low-sodium diet. Place the client in a recumbent position and call the paramedics for transport to the hospital. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.
Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible. According to the United States Department of Health and Human Services (Canada: Canadian Heart and Lung Association), both of these readings indicate hypertension and thus require further evaluation by a healthcare provider; having a baseline for both arms can assist the healthcare provider with the medical diagnosis. Teaching about a low-sodium diet is an inadequate intervention. An appointment with a healthcare provider, not a nutritionist, should be scheduled as soon as possible. There are insufficient data to support this emergency intervention (calling the paramedics). The client's elevated blood pressure needs to be evaluated by a healthcare provider and then medical therapy implemented. Although emotional stress can precipitate hypertension, physical causes should be ruled out first.
A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? "The cause is abnormal configurations of the veins." "The cause is incompetent valves of superficial veins." "The cause is decreased pressure within the deep veins." "The cause is atherosclerotic plaque formation in the veins."
The cause is incompetent valves of superficial veins. Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.
A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? The client's heart may be beating faster temporarily. The nurse may not know how to take an accurate pulse. The radial pulse site may be surrounded by too much subcutaneous fat. The client may have atrial fibrillation.
The client may have atrial fibrillation Clients who have atrial fibrillation have a pulse deficit caused by reduction of preload. An accelerated heart rate is known as tachycardia, not a pulse deficit. It is unlikely the nurse does not know how to take a pulse accurately; nurses are trained in assessment. If a pulse deficit identified at a pulse site is attributed to the presence of excessive subcutaneous fat, the nurse should obtain the peripheral pulse at a different site.
A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea Increased urinary output
Unusual fatigue Dependent edema Nocturnal dyspnea Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia; women more commonly report unusual fatigue than men. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure. Orthopnea, a compensatory mechanism, limits venous return, which decreases pulmonary congestion and promotes ventilation, easing the dyspnea. Weight gain, not loss, occurs because of fluid retention. Urinary output decreases, not increases, with heart failure because the sympathetic nervous system and the renin-angiotensin-aldosterone system stimulate the retention of sodium and water in the kidneys.
A client is admitted to the hospital for a total hip replacement. Included in the primary healthcare provider's prescriptions is a prescription for digoxin 2.5 mg by mouth daily. The nurse knows that digoxin is supplied in 0.125 mg tablets. What should the nurse do? Give half a tablet. Administer two tablets. Ask the client what dose was taken at home. Verify the prescription with the primary healthcare provider.
Verify the prescription with the primary healthcare provider The usual dose of digoxin is 0.125 mg to 0.25 mg daily. A dose of 2.5 mg is excessive, and the prescription should be questioned. Half a tablet and two tablets are not the prescribed dose; the prescribed dose is excessive and must be questioned. Asking the client what dose was taken at home might be done, although it is not as important as verifying the prescription. The nurse should not administer medication that is outside therapeutic parameters.
Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? Relax in a reclining position Sit upright with legs extended Walk around at least every hour Sit in any position that relieves pressure on the legs
Walk around at least every hour Muscle contraction associated with walking prevents pooling of blood in the extremities and dependent edema. Movement is required, not inactivity (reclining or sitting). Sitting in any position that relieves pressure on the legs does not include movement, which is essential to prevent thrombus formation.
A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply. Age Height Weight Smoking Family history
Weight Smoking Obesity is a modifiable risk factor that is associated with coronary artery disease (CAD); an increased fat intake contributes to an increased serum cholesterol and atherosclerosis. Smoking, which constricts the blood vessels, is a modifiable risk factor for CAD. The incidence of CAD does increase with age. However, age is not a modifiable risk factor. Height is unrelated to the incidence of CAD. Family history is not a modifiable risk factor for CAD because one cannot control heredity.
A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to reeducate the client? Whole milk with oatmeal Garden salad with olive oil Tuna fish with a small apple Soluble fiber cereal with yogurt
Whole milk with oatmeal An overall heart healthy diet includes a variety of fruits and vegetables, whole grains, low-fat dairy products, skinless poultry and fish, nuts, legumes and non-tropical vegetable oils. Whole milk is high in saturated fat and should be avoided.
