NUR 256 Prep U Week 2
The nurse is reviewing a client's prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth?
History of postpartum hemorrhage (PPH) Clients who have a history of PPH are at higher risk for a PPH in subsequent pregnancies. This is a significant factor for the nurse to know in planning and being prepared for the birth of the baby because this is the client's fourth labor and birth. Urinary tract infections may occur during pregnancy as the enlarging uterus puts pressure on the ureters, resulting in urinary stasis. However, there is not a significant impact on labor and birth. Following amniocentesis, the client may experience cramping and feelings of increased pressure. The associated complications with amniocentesis are proximal (infection, fetal injury, bleeding) but do not pose a long-term consequence in relation to the labor process.
When developing the plan of care for a multigravid client with class III heart disease, the nurse should expect to assess the client frequently for which problem?
Tachycardia Assessing for signs and symptoms associated with cardiac decompensation is the priority. Class III heart disease during pregnancy has a 25% to 50% mortality. These clients are markedly compromised, with marked limitation of physical activity. They frequently experience fatigue, palpitations, dyspnea, or anginal pain. A pulse rate greater than 100 bpm or a respiratory rate greater than 25 breaths/min may indicate cardiac decompensation that could result in cardiac arrest. Additional symptoms include dyspnea, peripheral edema, orthopnea, tachypnea, rales, and hemoptysis.
The nurse is evaluating the therapeutic goal of a client with history of cardiac dysrhythmias and newly completed radiofrequency catheter ablation. Which client-centered goal is most appropriate?
The client will have a regular heart rhythm from destruction of errant tissue of the heart. The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue in hopes of allowing impulse conduction to travel over appropriate pathways. The goal does not include dilation of blood vessels or reperfusion of heart tissue. There is no stimulation of the heart.
A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate?
ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel Diagnostic testing is one source of information leading to a medical diagnosis. It is correct to anticipate cardiac and gastrointestinal studies due to the client's signs and symptoms. An ECG evaluates the report of chest pain, laboratory tests determine anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase, and LD levels are appropriate for a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.
The nurse is assessing a client with chronic bronchitis. For which finding should the nurse suspect that the client is developing right-sided heart failure?
Bilateral edema of the feet and ankles A client with chronic bronchitis, a form of chronic obstructive pulmonary disease (COPD), may experience symptoms that are similar to those of left-sided heart failure, such as dyspnea on exertion. However, without other risk factors, the client with COPD is at risk for right-sided, not left-sided, heart failure. Bilateral edema of the feet and ankles would not occur with chronic bronchitis but is evidence of right-sided heart failure due to the resistance to venous return to the right side of the heart. Bilateral crackles that clear with coughing would occur with chronic bronchitis. Note that pulmonary edema is not expected with right-sided heart failure. Nail clubbing develops in chronic bronchitis because of chronic oxygen deprivation and is not evidence of heart failure.
A middle-age client is hospitalized for a cholecystectomy and has an acute onset of chest pain. In which order should the nurse perform these actions? Place in order from first to last. All options must be used.
Check vital signs. Administer sublingual nitroglycerin. Obtain a 12-lead electrocardiogram (ECG). Draw serum CK-MB and troponin levels. With the onset of acute chest pain, the nurse first assesses vital signs to determine the client's hemodynamic stability and guide further interventions. Prior to administration of nitroglycerin, blood pressure is assessed because of the increased risk for hypotension. NTG is a vasodilator that reduces myocardial oxygen requirements, improves coronary artery perfusion, and can be administered if systolic blood pressure is above 90 mm Hg to relieve chest pain. The nurse can then obtain a 12-lead ECG to identify ischemia or injury to the heart; it may show changes during symptoms and in response to treatment. Cardiac markers are drawn last to assist in establishing the diagnosis of myocardial infarction because ST elevation by ECG may not be evident.
The nurse is reviewing the serum electrolyte levels of a client with heart failure who has been taking digoxin for 6 months. The nurse should report which finding from the lab report to the health care provider?
Hypokalemia The nurse is reviewing the serum electrolyte levels of a client with heart failure who has been taking digoxin for 6 months. The nurse should report which finding from the lab report to the health care provider?
The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant?
Keep feedings small, but frequent. Because children with heart defects fatigue so quickly, frequent small meals are suggested to ensure that the child receives adequate nutrition. Rough play would be considered too physically demanding on the child. Most children do not need oxygen at home.
The nurse is assessing an individual with peripheral artery disease. Which finding indicates complete arterial obstruction in the lower left leg?
coldness of the left foot and ankle Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction.
The health care provider (HCP) has prescribed metoprolol for a client with stage 2 hypertension who has been initially treated with furosemide and ramipril. The nurse should evaluate the client for which expected therapeutic effect of the metoprolol?
decrease in heart rate The effect of a beta-blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client may have an initial increase in fatigue when starting the beta-blocker. The mechanism of action does not improve blood sugar or urine output.
A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances?
early defibrillation in cases of ventricular fibrillation AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and the Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and the use of the AED as a tool to increase sudden cardiac arrest survival rates.
The nurse is monitoring a client postoperatively after a permanent pacemaker insertion. Which finding would be most concerning to the nurse?
heart rate of 48 beats/minute The client experiencing bradycardia would be the most serious report postoperatively because it likely indicates pacemaker malfunction. The blood pressure, while elevated, is not at a dangerous level at this time and only needs to be monitored. The urine output is normal over 1 hour and would be monitored and gauged against the client's intake. The client would be expected to have soreness in the left chest and should be given pain medication as needed.
The nurse understands that the client is experiencing acute hypertension crisis and immediate treatment includes IV anti-hypertensives
The client is experiencing a hypertensive crisis. In a hypertensive crisis, the blood pressure elevates suddenly, to more than 180/110 mm Hg. The client's blood pressure at 1400 is 188/114 mm Hg. Signs and symptoms of a hypertensive crisis include shortness of breath, headache, and anxiety. The client has all of these signs and symptoms at 1400. Secondary hypertension is usually gradual and results from an identifiable cause such as kidney disease. The blood pressure is not usually as high as 180/110 mm Hg. Stage 1 hypertension is defined as systolic blood pressure of 130-139 mm Hg and a diastolic blood pressure of 80-89 mm Hg. Essential hypertension is defined as primary hypertension and is usually chronic with no known cause. This client has the risk factors of smoking and cardiovascular disease. Also, essential hypertension is diagnosed over weeks of readings at the same time with same activity level. IV antihypertensives are the treatment of choice with hypertensive crisis because they work quickly in lowering the client's life-threatening blood pressure. IV antihypertensives along with IV diuretics are effective treatments. Oral medications work too slowly in these situations. Oral antihypertensives work too slowly and hypertensive crisis is life threatening and requires immediate lowering of the client's blood pressure. Similarly, oral diuretics would not be appropriate. Sublingual nitrates are not the treatment for a hypertensive crisis. Sublingual nitroglycerin is used for chest pain relief; in addition, a side effect of this medication can be hypotension. This is not the category of drugs of choice or route.
The nurse administers lisinopril to a client. What assessment findings does the nurse document as evidence of a positive therapeutic response?
blood pressure 118/74 mmHg Lisinopril is an angiotensin-converting-enzyme (ACE) inhibitor that lowers the blood pressure through inhibition of the renin angiotensin system. A therapeutic effect is shown as the medication vasodilates to bring down the blood pressure. The apical heart rate and total cholesterol levels are not affected by lisinopril. Potassium can become elevated due to the blocking of aldosterone with ACE inhibitors, but this is a side effect and not a therapeutic effect.
