JSRCC NSG-170, PrepU 2. Perfusion

A client is hospitalized following a report of dizziness, shortness of breath, and chest pain. Based on the ECG rhythm, the client is scheduled for a transesophageal echocardiogram (TEE) today. Which nursing interventions would be appropriate at this time? A. Administer oxygen via nasal cannula as prescribed. B. Encourage deep breathing exercises. C. Initiate a heparin drip. D. Prepare the client for immediate electrical cardioversion.

A. Administer oxygen via nasal cannula as prescribed. After analyzing the waveform, it is noted that the client is experiencing atrial fibrillation and is symptomatic; therefore, because of the client's symptoms, the nurse would administer oxygen. Initiating a medication such as a heparin requires a health care provider order. Deep breathing exercises assist to open airways and reestablish lung function following surgery. A TEE is sometimes prescribed before electrical cardioversion to ensure that there are no clots in the atria; if none are found, then the cardioversion can be safely performed.

Which colloid is expensive but rapidly expands plasma volume? A. Albumin B. Lactated Ringer solution C. Dextran D. Hypertonic saline

A. Albumin Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? A. Assess fetal heart rate. B. Assess maternal blood pressure. C. Assess for constipation. D. Assess for dry mouth.

A. Assess fetal heart rate. After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier with symptoms including assessing heart rate and variability. After birth, there may be a decrease in alertness. Maternal factors of a decreased blood pressure, constipation and dry month are of a lower

During a home visit, the nurse assesses a client who is taking hydrochlorothiazide and lisinopril for the treatment of hypertension. Which finding would indicate the nurse should inform the health care provider of a possible need to change medication therapy? A. Client has a persistent cough. B. Client is experiencing nocturia. C. Potassium level is 4.1 mEq/L. D. Blood pressure is 132/80 mm Hg.

A. Client has a persistent cough A persistent cough is a side effect of the ACE inhibitor that may warrant a change to another antihypertensive medication.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? A. Contact the primary care provider and prepare for an escharotomy. B. Elevate the leg on pillows and reassess the leg in 1 hour. C. Apply an elastic stocking to the extremity and administer SQ heparin per order. D. Document the findings and instruct the client to report numbness of the extremity.

A. Contact the primary care provider and prepare for an escharotomy. The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply. A. Hematoma B. Embolization C. Dissection of the vessel D. Bleeding E. Stent migration

A. Hematoma B. Embolization C. Dissection of the vessel D. Bleeding E. Stent migration Complications from PTA include hematoma, embolization, dissection of the vessel, bleeding, intimal damage (dissection), and stent migration.

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) A. Pulmonary crackles B. Jugular vein distention C. Dyspnea D. Ascites E. Cough

A. Pulmonary crackles C. Dyspnea E. Cough The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? A. Teach the client how to apply an elastic sleeve B. Offer cold applications to promote comfort and to enhance circulation C. Inform the physician if the client's temperature remains low D. Avoid elevating the area

A. Teach the client how to apply an elastic sleeve In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing? A. Vitamin C B. Vitamin E C. Calcium D. Vitamin D

A. Vitamin C Vitamins A and C and the B vitamins are important for healthy skin and wound healing. Vitamins D and calcium are important for bone healing. Adequate protein intake is necessary for improving skin integrity. Vitamin E isn't necessary for wound healing.

After the nurse has administered droperidol, care is taken to move the client slowly based on the knowledge of droperidol's effect on the: A. cardiovascular system. B. central nervous system. C. respiratory system. D. psychoneurologic system.

A. cardiovascular system. Because droperidol causes tachycardia and orthostatic hypotension, the client should be moved slowly after receiving this medication. Droperidol produces a tranquilizing effect and does affect the central nervous, respiratory, or psychoneurologic system, but the primary reason for moving the client slowly is the potential cardiovascular effects of hypotension.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to: A. divide daily food intake into five or six meals. B. take a vitamin and mineral supplement. C. eat three well-balanced meals per day. D. exercise 1 hour before each meal.

A. divide daily food intake into five or six meals. To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue.

The analgesic of choice for a hospitalized patient with an MI is morphine sulfate. An important nursing responsibility, prior to administering morphine, is to do which of the following? A. Check the radial pulse for arrhythmias. B. Count the respiratory rate for bradypnea. C. Measure urinary output for dehydration. D. Measure the blood pressure for hypertension.

B. Count the respiratory rate for bradypnea. The nurse should always check the respiratory rate prior to administering morphine sulfate. The drug should be withheld, and the health care provider notified, if the respiratory rate is below 16 breaths/minute.

A physician has scheduled a client with mitral stenosis for mitral valve replacement. Which condition may arise as a complication of mitral stenosis? A. Left ventricular hypertrophy B. Pulmonary hypertension C. Left-sided heart failure D. Myocardial ischemia

B. Pulmonary hypertension Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, oedema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include mural thrombi, pulmonary hemorrhage, and embolism to vital organs. Myocardial ischemia may occur in a client with coronary artery disease. Left ventricular hypertrophy is a potential complication of aortic stenosis.

Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure? A. Abstinence from smoking B. Push fluids C. Restrict dietary sodium D. Avoid excess alcohol

B. Push fluids Lifestyle recommendations include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise.

Which is a classic sign of cardiogenic shock? A. High blood pressure B. Tissue hypoperfusion C. Increased urinary output D. Hyperactive bowel sounds

B. Tissue hypoperfusion Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). Low blood pressure is a classic sign of cardiogenic shock. Hypoactive bowel sounds are classic signs of cardiogenic shock. Decreased urinary output is a classic sign of cardiogenic shock.

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine A. causes diuresis. B. causes vasospasm. C. slows the heart rate. D. depresses the cough reflex.

B. causes vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Nicotine has stimulant effects. Nicotine does not suppress cough; rather, smoking irritates the bronchial tree, causing coughing. Nicotine does not cause diuresis.

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured? A. cardiac ultrasound B. echocardiogram C. cardiac catheterization D. electrocardiogram

B. echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? A. lying on side, arms grasped on abdomen B. head elevated, grasping knees, breathing out C. squatting while holding her breath D. lying supine with legs in lithotomy stirrups

B. head elevated, grasping knees, breathing out An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.

The stimulation of beta1 adrenergic receptors in the heart by epinephrine would cause what result? A. decreased heart muscle contractions B. increased heart rate C. vasoconstriction of the coronary arteries D. decreased oxygen demand by the myocardium

B. increased heart rate The predominant effect in response to activation of beta1 receptors in the heart is cardiac stimulation. Beta1 activation results in increased force of myocardial contraction, or a positive inotropic effect and increased speed of electrical conduction in the heart.

The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which signs? A. harsh systolic murmurs with a palpable thrill B. loud cardiac murmurs through systole and diastole C. profound cyanosis over most of the body D. decreased cardiac output with faint peripheral pulses

B. loud cardiac murmurs through systole and diastole With a patent ductus arteriosus, a cardiac defect marked by a failure of the patent ductus arteriosus to close completely at birth, blood from the aorta flows into the pulmonary arteries to be reoxygenated in the lungs and returned to the left atrium and ventricle. The effect of this altered circulation includes increased workload on the left side of the heart and increased pulmonary vascular congestion. Term infants are commonly asymptomatic, but a loud, machinery-like murmur may be heard throughout systole and diastole. This murmur may be accompanied by a suprasternal thrill, and the heart may be enlarged. Decreased cardiac output with faint peripheral pulses, poor peripheral perfusion, feeding difficulties, and severe congestive heart failure are symptoms associated with severe aortic stenosis. With this defect, the aortic valve is thickened and rigid, leading to decreased cardiac output and reduced myocardial blood flow. Profound cyanosis over most of the body, fatigue on exertion, feeding difficulties, and chronic hypoxemia are associated with tetralogy of Fallot. With this defect, malalignment of the ventricular system results in nonrestricted ventral septal defects, pulmonic stenosis, overriding of the aorta, and hypertrophy of the left ventricle. The heart appears boot shaped. A harsh systolic murmur with a palpable thrill is associated with truncus arteriosus. It is marked by incomplete division of the great vessel. This is caused by a ventral septal defect. Bounding pulses and a widening pulse pressure may also be present.

Which of the following is an inaccurate statement regarding an autograft? A. The autograft is an alternative for children and women of child-bearing age. B. They are obtained by excising the patient's own pulmonic valves and a portion of the pulmonary artery. C. Anticoagulation is necessary. D. Aortic valve grafts have remained viable for more than 20 years.

C. Anticoagulation is necessary. Anticoagulation is unnecessary because the valve is the patient's own tissue and is not thrombogenic. Autografts are obtained by excising the patient's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. The autograft is an alternative for children and women of child-bearing age. Aortic valve autografts have remained viable for more than 20 years.

Four hours after a cast has been applied for a fractured ulna, the nurse assesses that the client's fingers are pale and cool and capillary refill is delayed for 4 seconds. How should the nurse interpret these findings? A. Nerve impairment is developing in the fingers. B. Venous stasis is occurring in the fingers. C. Arterial blood supply to the fingers is decreased. D. The finding is normal for this recovery period.

C. Arterial blood supply to the fingers is decreased. The pallor and cool temperature of the fingers and the decreased return time for capillary refill indicate decreased arterial blood supply to the fingers. These findings are not normal for any time in the recovery process. Nerve impairment includes numbness, tingling, and impaired movement of the fingers. Signs of venous stasis include edema and reddening of the fingers, not pallor and cool temperature.

While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child's left thigh is swollen. What should the nurse do next? A. Notify the health care provider (HCP) immediately. B. Obtain the child's vital signs. C. Assess the neurologic status of the toes. D. Determine the circulatory status of the upper thigh.

C. Assess the neurologic status of the toes. Because the nurse suspects a possible fracture based on the child's presentation, assessing the neurologic and circulatory status of the toes, the tissues distal to the fracture, is important. Soft tissue contusions, which accompany femur fractures, can result in severe hemorrhage into the tissue and subsequent circulatory and neurologic impairment. Once this information has been obtained, vital signs can be assessed, and the nurse can notify the health care provider (HCP) and report the findings. In fractures, circulation impairment will occur distal to the injury.

A client has developed global ischemia of the brain. The nurse determines this is: A. Inadequate perfusion of the right side of the brain B. inadequate perfusion of the nondominant side of the brain C. Inadequate to meet the metabolic needs of the entire brain C. Inadequate perfusion to the dominant side of the brain

C. Inadequate to meet the metabolic needs of the entire brain Global ischemia occurs when blood flow is inadequate to meet the metabolic needs of the entire brain. The result is a spectrum of neurologic disorders reflecting diffuse brain dysfunction.

A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction? A. Cyanosis B. Gangrene C. Pallor D. Clubbing of the fingers

C. Pallor Pallor is the initial symptom in Raynaud's followed by cyanosis and aching pain. Gangrene can occur with persistent attacks and interference of blood flow. Clubbing of the fingers is a symptom associated with chronic oxygen deprivation to the distal phalanges.

A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant? A. The patient reports chest pain after eating a large meal. B. The patient's has an enlarged liver and oedematous abdomen. C. The patient reports shortness of breath when walking. D. The patient has jugular vein distention and 3+ pedal edema.

C. The patient reports shortness of breath when walking. Dyspnea on exertion is typically the earliest manifestation of mitral valve stenosis. Late signs of right-sided heart failure are jugular vein distention, edema, and enlarged liver. Chest pain rarely occurs with mitral valve stenosis.

A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP? A. To control bleeding in the bladder. B. To prevent bladder distention. C. To keep the catheter free from clot obstruction. D. To instill antibiotics into the bladder.

C. To keep the catheter free from clot obstruction. Continuous irrigation, usually consisting of sterile normal saline, is used after TURP to keep blood clots from obstructing the catheter and impeding urine flow. Antibiotics may be instilled in the bladder with the use of an irrigating solution, but this is not the primary reason for using continuous irrigation in TURP. The irrigating solution may secondarily help prevent bladder distention because it keeps the catheter from becoming obstructed.

There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? A. shock B. pulmonary embolism C. avascular necrosis D. fat embolism

C. avascular necrosis Avascular necrosis is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head.

The laboratory notifies the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 95 seconds. After verifying the values, the nurse calls the health care provider (HCP). What prescription for the client should the nurse recommend the HCP consider? A. warfarin B. packed red blood cells C. protamine sulfate D. vitamin K

C. protamine sulfate The aPTT is at a critical value, and the client should receive protamine sulfate as the antidote for heparin. Vitamin K is the antidote for warfarin. Packed red blood cells are administered to increase the hematocrit.

After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which complication related to this pelvic surgery? A. peritonitis B. ascites C. thrombophlebitis D. inguinal hernia

C. thrombophlebitis After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? A. A client receiving oxygen therapy via Venturi mask B. A client on a ventilator with PEEP C. A client sitting in a chair after prolonged bed rest D. A client experiencing hypothermia

D. A client experiencing hypothermia Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action? A. Assess the client's jugular venous pressure B. Call an emergency code C. Perform a Mini Mental Status Examination (MMSE) D. Assess the client's blood pressure

D. Assess the client's blood pressure Combining phenelzine with beer can precipitate a hypertensive crisis. There is no immediate indication that an emergency code is needed. The client's jugular venous pressure is less likely to be affected and is not a priority for assessment. Performing the MMSE is not a short-term priority

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? A. Tetany B. Pulmonary embolus C. Fluid volume excess D. Cardiac dysrhythmias

D. Cardiac dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

An 18-month-old with a congenital heart defect is to receive digoxin twice a day. Which instructions should the nurse give the parents? A. Digoxin is absorbed better if taken with meals. B. Signs of toxicity include increased pulse and visual disturbances. C. If the child vomits within 15 minutes of administration, the dosage should be repeated. D. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.

D. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm. Digoxin's effect is to slow the rate of the electrical conduction through the heart and increase the strength of the heart's contraction. Signs of toxicity include anorexia and decreased heart rate not visual changes or increases in heart rate. Digoxin should be taken 1 hour before meals or 2 hours after meals in order to obtain better absorption of the drug. If the child vomits within 15 minutes of administration, the dose should not be repeated because it is not known how much of the medication has been absorbed.

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmias. Which of the following assessment considerations is essential when caring for this age-group? A. Dyspnea B. Cardiac output C. Activity level D. Digoxin level

D. Digoxin level The action of Digoxin slows and strengthens the heart rate. Assessment of the pulse rate is essential prior to administration in all clients. Due to decreased perfusion common in geriatric clients, toxicity may occur more often. The nurse must monitor Digoxin levels in the body. Monitoring symptoms reflecting cardiac output, activity level, and dyspnea are also important assessment considerations for all clients.

For patients diagnosed with aortic stenosis, digoxin would be ordered for which of the following clinical manifestations? A. Angina B. Edema C. Dyspnea D. Left ventricular dysfunction

D. Left ventricular dysfunction Digoxin may be used to treat left ventricular dysfunction, and diuretics may be used for dyspnea. Nitrates may be prescribed for the treatment of angina, but must be used with caution due to the risk of orthostatic hypotension and syncope.

The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide? A. BNP of 100 B. Sodium level of 135 C. Hemoglobin of 12 D. Potassium level of 3.1

D. Potassium level of 3.1 Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP does not demonstrate a severe heart failure. Sodium level of 135 is within normal range, as is the hemoglobin level.

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong? A. She should stand when taking her pulse to increase blood flow. B. She needs to take her pulse after her medication so that her pulse is stronger. C. She needs to press harder until she feels a pulse. D. She should place her three fingers just below the wrist on the outside of the arm with the palm up.

D. She should place her three fingers just below the wrist on the outside of the arm with the palm up. A client is taught to take his or her own pulse before certain medications or after exercise, depending on the individual client's needs. When teaching a client to take his or her own pulse, the nurse should teach the client to sit down and place an arm on a hard service with the palm upward. Using three fingers, the client should feel just below the wrist on the outer side of the arm for the pulse. The client should be taught not to press too hard or the pulse can be obliterated.

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: A. high cardiac output. B. heart failure. C. diminished stroke volume. D. adequate tissue perfusion.

D. adequate tissue perfusion. Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to: A. feel fetal movements. B. hear the fetal heartbeat with a stethoscope. C. palpate the fetal outline. D. detect fetal heart sounds with a Doppler.

D. detect fetal heart sounds with a Doppler. Fetal heart sounds are audible with a Doppler at 10 to 12 weeks of gestation but cannot be heard through a stethoscope until 18 to 20 weeks of gestation. Fetal movements can be felt by a woman as early as 16 weeks of pregnancy and felt by the examiner around 20 weeks' gestation. The fetal outline is also palpable around 20 weeks of gestation.

Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following? A. "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." B. "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." C. "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." D. "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers."

A. "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers.

Two days after being placed in a cast for a fractured femur, the client suddenly has chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for: A. compartment syndrome. B. osteomyelitis. C. fat embolism syndrome. D. venous thrombosis.

C. fat embolism syndrome. Clients with fractures of the long bones such as the femur are particularly susceptible to fat embolism syndrome (FES). Signs and symptoms include chest pain, dyspnea, tachycardia, and cyanosis. Changes in mental status are caused by hypoxemia and can be the first symptoms noted in FES. The client can also be restless and febrile and can develop petechiae. Osteomyelitis is infection of the bone; signs and symptoms of osteomyelitis do not include respiratory symptoms. Compartment syndrome causes signs of localized neurovascular impairment, not systemic symptoms. Venous thrombosis occurs in the lower extremities and is caused by venous stasis.

A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? A. "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." B. "You are experiencing pain due to inadequate removal of carbon dioxide from the tissues in the legs." C. "The pain is related to atherosclerosis that is the same problem causing your angina." D. "You are experiencing leg pain because of venous congestion."

A. "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." When there is a history of atherosclerosis affecting the heart and resulting in intermittent claudication, there is arterial insufficiency. This results in inadequate provision of oxygenated blood to the muscles when there is an increase in muscle demand. This results in the pain of intermittent claudication. The other choices refer to problems with venous congestion rather than arterial perfusion. That the pain is related to atherosclerosis does not explain the specific reason for the pain.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? A. Local capillary pressure must be lower than external pressure. B. The heart must be able to pump adequately. C. Arteries and veins must be patent and functioning well. D. The volume of circulating blood must be sufficient.

A. Local capillary pressure must be lower than external pressure. Local capillary pressure must be higher than external pressure for adequate skin perfusion

What clinical manifestations does the nurse recognize would be associated with a diagnosis of hyperthyroidism? Select all that apply. A. Muscular fatigability B. An elevated systolic blood pressure C. Weight loss. D. Intolerance to cold E. A pulse rate slower than 90 bpm

A. Muscular fatigability B. An elevated systolic blood pressure C. Weight loss. Manifestations of hyperthyroidism include an increased appetite and dietary intake, weight loss, fatigability and weakness (difficulty in climbing stairs and rising from a chair), amenorrhea, and changes in bowel function. Atrial fibrillation occurs in 15% of in older adult patients with new-onset hyperthyroidism (Porth & Matfin, 2009). Cardiac effects may include sinus tachycardia or dysrhythmias, increased pulse pressure, and palpitations. These patients are often emotionally hyperexcitable, irritable, and apprehensive; they cannot sit quietly; they suffer from palpitations; and their pulse is abnormally rapid at rest as well as on exertion. They tolerate heat poorly and perspire unusually freely.

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? A. PC: Decreased cardiac output related to cardiac tissue damage B. PC: Fear related to new diagnosis of myocardial infarction C. PC: Disturbed body image related to decreased activity tolerance D. PC: Activity intolerance related to decreased oxygenation capacity

A. PC: Decreased cardiac output related to cardiac tissue damage All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life threatening issues. Decreased cardiac output is life threatening so it must be the priority concern.

When measuring blood pressure in each arm of a healthy adult, the nurse recognizes that the pressures A. differ no more than 5 mm Hg between arms. B. must be equal in both arms. C. may vary 10 mm Hg or more between arms. D. may vary, with the higher pressure found in the left arm.

A. differ no more than 5 mm Hg between arms. Normally, in the absence of disease of the vasculature, arm pressures differ by no more than 5 mm Hg. The pressures in each arm do not have to be equal to be considered normal. Pressures that vary more than 10 mm Hg between arms are an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

What does decreased pulse pressure reflect? A. reduced stroke volume B. reduced distensibility of the arteries C. elevated stroke volume D. tachycardia

A. reduced stroke volume Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?' A. It is designed for extremely active patients. B. An LVAD only supports a failing left ventricle. C. It is specifically designed for long-term use. D. It never needs batteries.

B. An LVAD only supports a failing left ventricle. A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

A nursing instructor is preparing a class on pressure ulcers. Which of the following would the instructor most likely include as a possible risk factor? Select all that apply. A. Increased tissue perfusion B. Anemia C. Immobility D. Enhanced sensory perception E. Increased moisture

B. Anemia C. Immobility E. Increased moisture Risk factors associated with pressure ulcer development include immobility, decreased sensory perception, anemia, decreased tissue perfusion, and increased moisture.

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? A. Carotid endarterectomy B. Anticoagulant therapy C. Monthly prothrombin levels D. Cholesterol-lowering drugs

B. Anticoagulant therapy Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if indicated to manage atherosclerosis. Prothrombin and international normalized ratio (INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque.

A nurse working in the clinic is seeing a client who has just been prescribed a new medication for hypertension. The client asks why hypertension is sometimes called the "silent killer." The nurse's correct response is which of the following? A. "Hypertension often kills early in the disease process." B. "Hypertension is difficult to diagnose." C. "Hypertension often causes no symptoms." D. "Hypertension often causes no pain."

C. "Hypertension often causes no symptoms." Hypertension is sometimes called the "silent killer" because people with it are often symptom free. Physical examination may reveal no abnormalities other than elevated blood pressure. People with hypertension may remain asymptomatic for many years. The usual consequences of prolonged, uncontrolled hypertension are myocardial infarction, heart failure, renal failure, strokes, and impaired vision. Pain is not usually an issue, but that is not why hypertension is called the "silent killer." Hypertension is easily diagnosed by taking a series of blood pressure readings.

A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? A. Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients B. Fatigue related to decreased hemoglobin and hematocrit C. Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit D. Risk for falls related to complaints of dizziness

C. Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema.

Which of the following assessment results is considered a major risk factor for PAD? A. LDL of 100 mg/dL B. Triglyceride level of 150 mg/dL C. Cholesterol of 200 mg/dL D. BP of 160/110 mm Hg

D. BP of 160/110 mm Hg Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.

Following a total joint replacement, which complication has the greatest likelihood of occurring? A. displacement of the new joint B. wound evisceration C. polyuria D. deep vein thrombosis (DVT)

D. deep vein thrombosis (DVT) DVT is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a deep vein thrombosis or pulmonary embolism are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the health care provider (HCP) for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Displacement of the new joint is unlikely. Wound evisceration is more likely to occur after abdominal surgeries.