2021 HESI - CV System

Which clinical manifestations will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L (6.4 mmol/L)? Select all that apply. One, some, or all responses may be correct. 1-Anorexia 2-Constipation 3-Muscle weakness 4-Irregular heart rhythm 5-Hyperactive bowel tones

-3,4,5 -Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. Dysrhythmias such as bradycardia and prolongation of the PR interval and QRS duration occur with hypokalemia. The most serious complications of hyperkalemia are fatal cardiac rhythms such as complete heart block, asystole, and ventricular fibrillation. Hyperactive bowel sounds and diarrhea are symptoms of hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.

A client with an abdominal aortic aneurysm is suddenly pale and reports feeling light-headed and having abdominal pain. Which action would the nurse take first? A-Assess the respiratory rate for hyperventilation. B-Check the blood pressure for hypotension. C-Administer the prescribed morphine for pain. D-Inspect the abdomen for distension and firmness.

-B -The history of abdominal aortic aneurysm, with new symptoms of pallor, lightheadedness, and abdominal pain, suggests bleeding or dissection of the aneurysm. The nurse would first check blood pressure and report hypotension immediately to the health care provider, anticipating the need to give intravenous fluids and prepare the client for emergency surgery. The other actions are also appropriate after the nurse has obtained the blood pressure. Hyperventilation may cause lightheadedness. Treatment of pain is appropriate if the blood pressure is stable, but morphine would further lower blood pressure if the client is hypotensive. Inspection of the abdomen would help confirm a diagnosis of bleeding or dissection but would not be first action.

After the nurse educator finishes teaching a group of new staff nurses about postoperative care of the vascular bypass client, which statement by the new nurse indicates that more education is needed? A-"A cool, pale extremity can indicate vascular reocclusion." B-"Hourly assessment of the extremity is needed for the first 24 hours." C-"A client report of throbbing pain typically indicates vascular reocclusion." D-"Ongoing pain even after use of the patient-controlled analgesia (PCA) pump indicates possible occlusion."

-C - Throbbing pain occurs with the pulsations of arterial blood flow and is common after arterial bypass as blood flow is restored to the extremity. Occlusive pain is often severe, continuous, and aching or burning. A cool, pale extremity without a pulse indicates occlusion. Perfusion of the affected extremity is monitored in the first 24 hours after surgery. The PCA pump may not be effective against occlusive pain, which is caused by ischemia of tissues.

Which diet choice by a client who has been prescribed a 2-g sodium diet indicates that diet teaching has been effective? A-Macaroni and cheese B-Sausage and scrambled eggs C-Hamburger with bun, lettuce, and tomato D-Canned chicken noodle soup with fruit plate

-C -A hamburger with bun, lettuce, and tomato would be low in sodium. Cheese is high in sodium. Sausage is high in sodium. Canned soups are typically high in sodium.

When the international normalized ratio (INR) for a client receiving warfarin for venous thrombosis is 4.6, which action will the nurse take? A-Administer the scheduled dose of warfarin. B-Offer the client foods that are high in vitamin K. C-Notify the health care provider of the laboratory results. D-Warn the client about risk for spontaneous hemorrhage.

-C -The therapeutic level for INR when treating a venous thrombosis is 2 to 3, so the nurse would notify the health care provider and anticipate a decrease in warfarin dosage. Administration of a scheduled warfarin dose would further increase the INR. Although vitamin K can decrease warfarin effectiveness, dietary vitamin K is not used to reverse high INR levels. Although higher INR levels may lead to spontaneous bleeding, an INR of 4.6 would not cause hemorrhage.