PrepU-Perfusion

A client is receiving cilostazol for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports:

"I am able to walk further without leg pain."

A 12-year-old boy taken to the emergency department after a soccer injury cries out, "Look, my leg is bigger now!" How will the nurse respond to the boy?

"Swelling is a normal response from your body to prepare for healing."

A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?

2 to 5 days after surgery

Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently?

Alterations in cardiovascular function affect the fetus.

The nurse caring for a client admitted with a deep vein thrombosis is reviewing the client's prepackaged medications delivered by the pharmacy. The nurse suspects a pharmacy omission when medication from which of the following classifications is missing?

Anticoagulant

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?

Arterial blood supply to the fingers is decreased.

One hour after receiving blood pressure medication, the client complains of feeling lightheaded and dizzy. What is the nurse's best first action?

Assess the client's blood pressure

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage, and finds it to be cooler and paler than the left lower leg. What should the nurse do next?

Assess the distal pulses

Which nursing action should the PACU nurse take to prevent postoperative complications in patients?

Assist the patient to do leg exercises to increase venous return.

An obese patient has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the patient's peripheral pulses. How should the nurse proceed with this assessment?

Auscultate the patient's apical pulse

A nurse assesses a patient for blood pressure. Which of the following techniques would be used for this assessment?

Auscultation

The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient 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. The nurse's best response based on the clinical findings is which of the following?

Contact the primary care provider and prepare for an escharotomy.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is which of the following?

Contrast phlebography

A nurse who has diagnosed a patient as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

Distended neck veins

A client with newly diagnosed hypertension asks what she can do to decrease the risk for related cardiovascular problems. Which of the following risk factors is modifiable by the client?

Dyslipidemia

The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?

Echocardiogram

Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color?

Hemangioma

A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document?

Hypotension

A new client has been admitted with right-sided heart failure. The nurse knows to look for which of the following assessment findings when assessing this client?

Jugular venous distention

A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client?

Keep the legs elevated when sitting or lying down.

What is the most important goal of nursing care for a client who is in shock?

Manage inadequate tissue perfusion.

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called which of the following?

Megaloblasts

A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take?

Monitor blood pressure continuously.

During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.

The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?

Observe stools for blood.

Clinical characteristics of neurogenic shock are noted by which type of stimulation?

Parasympathetic

The nurse recognizes that the treatment for a non-ST elevation myocardial infarction (NSTEMI) differs from that of a patient with a STEMI, in that a STEMI is more frequently treated with which of the following?

Percutaneous coronary intervention (PCI)

When the client complains of increased fatigue following radiotherapy, the nurse knows this is most likely to be related to which factor?

Radiation can result in myelosuppression

The nurse is caring for a patient with muscular dystrophy who is confined to bed. The patient develops a pressure ulcer on his sacrum. The nurse documents the pressure ulcer as which of the following?

Secondary condition

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone?

Stage IV

A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation?

Tachycardia

The nurse is assessing an adult who has a pulse rate of 180 beats/minute. Which condition would the nurse document?

Tachycardia

A pulse deficit is the difference between

The apical pulse and the radial pulse rate

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are difficult to remove.

A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect?

The number of premature ventricular contractions is decreasing.

A nurse is teaching the Dietary Approaches To Stop Hypertension (DASH) diet to a group of clients who are newly diagnosed with hypertension. The nurse will include all the following points except:

Three to four regular dairy foods per day

Telangiectasia is the term that refers to

Vascular lesions caused by dilated blood vessels

When administering blood, the nurse must check the name on the label of the blood with the name on the client's:

Wristband in the presence of another nurse.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

a contrast phlebography

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in:

cardiac arrhythmias.

Following a total joint replacement, which complication has the greatest likelihood of occurring?

deep vein thrombosis (DVT)

A client has a left tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the fracture despite the morphine injection administered 30 minutes previously. Which area should be the nurse's next assessment?

distal pulse

While assessing the penis of a child who has had surgery for repair of a hypospadias, the nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon?

dusky blue at the tip

One of the most common causes of mitral valve regurgitation in people living in developed countries is

ischemia of the left ventricle.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position?

left lateral

The nurse is assessing the neurovascular status of a client's right arm, which has just had a cast applied. The nurse should notify the health care provider when which symptom occurs?

nail bed capillary refill time of 10 seconds

(see full question) When performing cardiopulmonary resuscitation (CPR), which finding indicates that external chest compressions are effective?

palpable pulse

A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:

reposition the client, apply oxygen, and increase IV fluids.

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to:

revascularize the blocked coronary artery.

The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which change on the client's chart to the health care provider (HCP)?

urine output

The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery?

vitamin K

A child, age 4, fell and broke his arm and had a cast applied. Which of these statements by the child indicates an immediate risk for compartment syndrome?

"I can't wiggle my fingers."

A client reports to the primary health care facility with complaints of chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack. What should be the nurse's reply?

"The physician wants to monitor you and control your pain."

Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States?

All options are correct. Explanation: Healthcare professionals have revised guidelines for identifying hypertension because hypertension places people at risk for heart disease, heart failure, stroke, and kidney disease

Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States?

All options are correct. Explanation: Healthcare professionals have revised guidelines for identifying hypertension because hypertension places people at risk for heart disease, heart failure, stroke, and kidney disease.

A nurse documents a patient's hemoglobin as 8 g/dL. What nutritional condition does this biochemical data signify?

Anemia

Which of the following is a key diagnostic indicator of heart failure?

BNP

The nurse is administering the morning mediations to a patient on the cardiac telemetry unit. Atenolol has been prescribed for this patient. Prior to administration, the nurse would tell the patient that the medication is which type of antihypertensive?

Beta blocker

Which nursing assessment finding would be indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier?

Capillary refill of left fingers greater than 3 seconds

Which complication of cardiac surgery occurs when there is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles?

Cardiac tamponade

You are caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?

Examine the legs for color, capillary refill time, and tissue integrity.

A nurse is caring for a client with a cast on his left arm after sustaining a fracture. Which assessment finding is most significant for this client?

Fingers on the left hand are swollen and cool

A harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle is termed which of the following?

Friction rub

Which type of jaundice is the result of increased destruction of red blood cells?

Hemolytic

The nurse understands that patient education related to antihypertensive medication should include all of the following instructions except which of the following?

If a dosage of medication is missed, double up on the next one to catch up.

A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regime?

Improve venous return

A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which of the following is the best way for the nurse to assess blood pressure?

In the supine, sitting, and standing positions

A nursing class is practicing the measurement of blood pressure. The finding in one otherwise healthy man, 36 years old, is 130/88. This man requires follow-up for prehypertension. Which of the following lifestyle factors would the nurse discuss with the client?

Physical activity, dietary sodium, and the DASH diet

The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. The correct response would be which of the following?

Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers

A 26-year-old client is returning for diagnostic follow-up. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minutes. What type of dysrhythmia would you expect the cardiologist to diagnose?

Sinus tachycardia

A client with newly diagnosed hypertension on BP medication has been taking her own BP at home for two weeks. When she calls and reports her BP readings to the nurse, the nurse notes an elevated BP in the morning. The client states that she wakes up, has her daily cup of coffee and takes her BP before eating as she was instructed. What should the nurse recommend to this client?

Take her BP before drinking her morning cup of coffee.

A nurse is caring for a client with a kidney disorder. What role might the kidneys have in causing the client to have fluctuations in blood pressure?

The kidneys release renin, a hormone that initiates the production of angiotensin and aldosterone to increase blood pressure and blood volume.

A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, which rationale best explains why a pregnant client would lie on her left side when resting or sleeping in the later stages of pregnancy?

To prevent compression of the vena cava

An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began taking it after she arose from her nap and found that her BP would drop from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client?

You may have orthostatic hypotension and should be seen by your health care provider as soon as you can.

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was:

a decrease in the blood flow through the kidneys

A child who had a cast applied to his arm earlier this morning tells the nurse that his fingers are numb. The nurse should

assess the circulation to the fingers

(see full question) A child who had a cast applied to his arm earlier this morning tells the nurse that his fingers are numb. The nurse should:

assess the circulation to the fingers.

The neonate in the nurse's care has a pneumothorax. The nurse knows the signs of early decompensation and to observe carefully for changes in which assessments? Select all that apply.

blood pressure color heart rate

A client is admitted to the Emergency Department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should:

call the health care provider (HCP) to report the loss of the radial pulse.

A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should:

check the client's pedal pulses frequently.

It is appropriate for the nurse to recommend smoking cessation for patients with hypertension because nicotine

increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.

Which of the following postoperative exercises promotes venous return, and decreases complications related to venous stasis?

leg exercises

A woman who gave birth to a healthy baby 6 hours is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. The nurse should:

notify the health care provider (HCP).

The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses the following: respirations are 30 per minute and are rapid and shallow; presence of faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was administered 3 hours ago. The nurse should first:

notify the health care provider (HCP).

A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should:

position the left leg at or below the body's horizontal plane.

A nurse is giving instructions to a client who's going home with a cast on his leg. Which teaching point is most critical?

Reporting signs of impaired circulation

After taking vital signs, the nurse writes down findings as T = 98.6, P = 66, R = 18, BP = 124/82. Which of these numbers represents the systolic blood pressure?

124

Which ethnic background would the nurse screen for hypertension at an early age?

African American population

The patient diagnosed with thrombocytopenia is at risk for which of the following adverse effects:

Bleeding

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?

Elevating the stump for the first 24 hours

Which of the following is a characteristic of right-sided heart failure?

JVD

A patient has been diagnosed with congestive heart failure. Which of the following is a cause of crackles heard in the bases of the lungs?

Pulmonary congestion

Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure?

Push fluids

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock?

Restlessness and confusion

A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which agent should the nurse expect the health care provider (HCP) to prescribe?

fresh-frozen platelets

A blood pressure of 140/90 mm Hg is considered to be

hypertension.