320 Final Exam

sign

something the health professional can see/measure,

The nurse is educating the client about variant angina. Which statement by the client indicates that the teaching has been effective?

"Variant angina occurs at the same time each day."

S/S of TB

-usu asymptomatic -fever w/ night sweats -anorexia/weight loss -malaise, fatigue -cough, hemoptysis -dyspnea, pleuritic chest pain w/ inspiration -calcification -positive sputum culture

A patient who has severe chest pain for the last 4 hours is admitted with a diagnosis of a possible MI. Which of the ordered laboratory tests should the nurse monitor to help determine whether the patient has had an MI? 1) Troponin level 2) C-reactive protein CK-MB <next most important 3) HDL cholesterol 4) Homocysteine

1) Troponin level >3.0, CK-MB >6 is next

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1. Ambulates 10 feet (3 meters) farther each day 2.Verbalizes the benefits of increasing activity 3.Chooses a healthy diet that meets caloric needs 4.Sleeps without awakening throughout the night

1. Ambulates 10 feet (3 meters) farther each day

Musculoskeletal injury

1. Assess before you treat using the 6 P's, get x-ray, ask about pain, what the person was doing? *Fractures must be ruled out first* 2. PRICE: P: Protection: immobilize, R: rest, I: ice 10-15 mins 3-4 xs per day for 3-4 days post injury, C: compression wrap to decrease swelling, E: elevate above heart to reduce fluid in extremity

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1. Emotional stress 2.Atrial fibrillation 3.Nutritional anemia 4.Peptic ulcer disease 5.Recent upper respiratory infection

1. Emotional stress 2.Atrial fibrillation 3.Nutritional anemia 5.Recent upper respiratory infection

tool for assessing involvement following neuromuscular/neurological/

1. Pain 2. Pallor 3. Pulselessness 4. polkiothermia 5. paralysis 6. parenthesis 6 P's

tertiary interventions for perfusion

1. medications 2. smoking cessation 3. diet & exercise

The registered nurse (RN) is orienting a new RN assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction? 1."A cardiac output of 2 L/min is normal." 2."A cardiac output of 4 L/min is normal." 3."A cardiac output of 6 L/min is normal." 4."A cardiac output of 7 L/min is normal."

1."A cardiac output of 2 L/min is normal." The cardiac cycle consists of contraction and relaxation of the heart muscle. In adults, the cardiac output ranges from 4 to 7 L/min. Therefore, option 1 identifies a low cardiac output.

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? 1.Using a bedside commode 2.Sleeping in the supine position 3.Elevating the legs when in bed 4.Using seasonings to improve the taste of food

1.Using a bedside commode Rationale:Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. The supine position increases respiratory effort and decreases oxygenation. Elevating the client's legs increases venous return to the heartthus increasing cardiac workload. Seasonings may be high in sodium and promote further fluid retention.

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1.Weigh self on a daily basis. 2.Sleep with the head of the bed flat. 3.Take a double dose of the diuretic if peripheral edema is noted. 4.Withhold prescribed digoxin if slight respiratory distress occurs.

1.Weigh self on a daily basis. The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported to the health care provider (HCP). The client should sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the HCP.

The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? 1.Breath sounds 2.Peripheral edema 3.Hepatojugular reflux 4.Jugular vein distention

1.Breath sounds

Prothrombin Time (PT)

10-15 seconds

The client with impaired mobility is to be discharged within a week from the hospital. Which is the best example of a discharge goal for this patient? The patient will: 1. Give pain medications as scheduled 2. Be taught range-of-motion exercises 3. Transfer independently to a chair 4. Be kept clean and dry

3. Transfer independently to a chair

The nurse is preparing to ambulate a client on the third day after cardiac surgery. What should the nurse plan to do to enable the client to best tolerate the ambulation? 1.Remove telemetry equipment. 2.Provide the client with a walker. 3.Premedicate the client with an analgesic. 4.Encourage the client to cough and breathe deeply.

3.Premedicate the client with an analgesic. The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Providing the client with a walker and encouraging the client to cough and breathe deeply will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed

The nurse is assessing the client's condition after cardioversion. Which observation should be of highest priority to the nurse? 1.Heart rate 2.Skin color 3.Status of airway 4.Peripheral pulse strength

3.Status of airway Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority,

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? 1.Chloride level of 98 mEq/L (98 mmol/L) 2.Sodium level of 135 mEq/L (135 mmol/L) 3.Potassium level of 6.8 mEq/L 6.8 mmol/L) 4.Magnesium level of 1.6 mEq/L (0.8 mmol/L)

3.Potassium level of 6.8 mEq/L 6.8 mmol/L)

Semi-Fowler's Position

30-45 degree angle in bed

what is the priority intervention for a nurse to do when a pt arrives with a fracture?

immobilize them

Number one lab to check when MI is suspected

troponin >0.3 indicates MI

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? 1. Checking for a rash on the digits 2.Observing for softening of the nails or nail beds 3.Palpating for a rapid or irregular peripheral pulse 4.Palpating for diminished or absent peripheral pulses

4.Palpating for diminished or absent peripheral pulses

nursing assessments for atrial firillation

check heart rate (tachycardic), EKG - irregular rhythm (ventricles trying to keep up), no distinct p-wave, check blood pressure (high)

pts with PAD should walk until _______ and then _______ and ________

claudication/pain, rest, continue walking

skin assessments should be preformed every

8 hours (shift) w braden scale

Fowler's position

90 degree angle sitting

ventricular tachycardia

>100 BMP with overexaggerated QRS waves

CK-MB levels after MI

>6

Bi-ventricular pacing

A pacemaker is an electronic device used to increase the heart rate in severe bradycardia by electronically stimulating the myocardium. The basic pacing circuit consists of a battery-operated pulse generator and one or more conducting leads that pace the atrium and one or both ventricles. Pacemakers can be external (temporary) or surgically implanted (permanent).

Which patient has the highest risk for development of a blood clot? A woman who smokes and is taking estrogen-containing birth control pills A distance runner A man with a history of asthma A woman who is taking aspirin for menstrual cramps

A woman who smokes and is taking estrogen-containing birth control pills

Clients with immobility often have strong emotions. Which of the following emotions may a nurse see exhibited by a client with immobility? (Select all that apply.) A.Helplessness B. Hunger C. Anger D. Anxiety E. Increased Communication

A, C, D

Hypokalemia causes

depressed t wave

A left shift is ______

BAD!!! sign that immune system is failing Increased numbers of immature neutrophils in the blood

tool for assessing perfusion

CMS - color, motion, sensation

the two categories of perfusion 1. _______ and 2.______

Central and Tissue/Local Perfusion

A patient had a hip replacement 3 days ago. The patient states that the right leg is swollen below the knee and is warm to the touch. The patient has the diagnosis of deep vein thrombosis. Which intervention is appropriate for the patient?

Elevate the right lower leg when the patient is in the sitting position.

Creatinine Kinase (CK)

Enzyme present in large amounts in brain tissue and heart and skeletal muscle that is measured to aid in diagnosing heart attack

Airborne PPE removal

Gloves Gown Goggles Respirator AFTER leaving the pts room and closing the door.

Positive Chvostek's or Trousseaus sign is found in

hypocalcemia

ABI (ankle brachial index)

LE systolic number is the numerator, brachial systolic number is denominator LE Systolic/UE Systolic = ABI -The lower the number the more severe the PAD -0.91-1.3 = normal, 0.71-0.9 = mild, 0.41-0.7 = moderate, below 0.4 = severe

Sepsis Labs

Lactate >2.0!! , Blood Culture, CBC (WBC)

The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication?

No observable respiratory difficulty or shortness of breath over the last 24 hours

INR

Normal 1-2 seconds, Therapeutic (warfarin): 2-3 seconds

Nonpharmacologic interventions for fractures/muscles

PRICE (protect, rest, ice, compress, elevate), repo, heat,

Hyperkalemia causes

Peaked T waves

infarcation

hypoxia and lack of blood flow leading to necrosis

itchiness, brown pigmentation, edema that worsens when standing, thin-shiny-skin, recurrent ulcers (uneven edges/pink) on ankles and weeping dermatitis

S/S of venous insufficiency

patients experiencing atrial fibrillation will complain of

SOB, heart beating out of chest, dizziness, fatigue, weakness

seconday interventions for perfusion

Screenings for undetected disease BP checks/screening Cholesterol/lipd screening

A bands are

immature neutrophils

S/S of influenza

Severe headache, muscle ache, fever, chills, fatigue, weakness, anorexia

Faciotomy

Surgical incision to relieve compartment syndrome

Isoniazid (INH) Rifampin Ethambutol Pyrazinamide

TB treatment

antidiuretic hormone (ADH)

influences the absorption of water by kidney tubules

If MI is suspected, nurse should check what labs in priority order

Troponin >0.3 - stays elevated the longest (7-10 days)- best indicator of muscle damage CK-MB >6.0 - stays elevated for 24-48 hours - second best indicator of muscle damage Myoglobin: >85 - indicates compensatory increase O2 levels to try and reach the inschemic/infarcted muscles

symptom

a "subjective" experience reported by the patient ex. pain

PPE (personal protective equipment)

a barrier between a person and pathogens; includes gloves, gowns, masks, goggles, and face shields

coarction is ____

a narrowing of the aorta that causes stronger pulses in the upper extremities and weaker pulses in the lower extremities

Positive TB test means

a person has been exposed. not that they have it.

Which physiological or metabolic change indicates that the patient is at risk for metabolic syndrome? Hypotension Abdominal obesity Decreased triglyceride levels Decreased blood sugar levels

abdominal obesity

pts with venous insufficiency should elevate their feet ________ heart level for ____ - ____ minutes every few hours

above heart level, 10-20 minutes

are nurse should first always....

assess

S4 is heard when?

before S1 in late diastole/ pre-stystole

Immobility can lead to

blood clots (thrombus/embolism), pneumonia, infection (tissue integrity), perfusion issues,

this normally causes pulmonary embolisms

deep vein thrombosis (right heart clot)

reduce blood volume by preventing the reabsorption of sodium in the kidneys, which increases urine output.

diuretics Loops - furosemide, Thiazides -, K+ sparing - spironalactone

cardioversion (defibrillation)

electrical energy used to shock hear in a/v-fib back into normal sinus rhythm

two of the most common causes of secondary hypertension

estrogen (birth control) and kidney disease

the nurse should monitor for which reflex on a pt who recently had a stroke?

gag reflex/cough reflex, ability to swallow. soft/thickened while pt is sitting upright placing the food in unaffected side of mouth

Contact PPE

gloves and gown

Droplet PPE

gloves, gown, mask w/in 3 feet

Airborne PPE

gown, goggles, gloves and N95 mask for suspected TB

population at highest risk for fracture

infants/children: risky behavior, learning to walk, older adults: osteoporosis, comorbidities

a nurse should ALWAYS document their pt. _______

interventions

give O2g, give anticoagulant (reduce risk of clot formation), give dysrhythmia medication (digoxin), prepare client for cardioversion (defibrillation)

interventions for pt in a-fib

10 minutes without blood flow and oxygen in the brain leads to ______________

irreversible changes/damage

two types of strokes

ischemic and hemorrhagic

This type of stroke has decreased LOC in the first 24 hours that gets progressively worse as infarction and edema increases

ischemic thrombotic stroke

decrease the levels of lipids that contribute to atherosclerosis and result in blood vessel occlusion by reducing the synthesis of cholesterol.

lipid lowering agents - Lovostatin, statins, niacin b3, fish oil, etc...

CHADs scoring system: C: Congestive HF, H: HTN, A: age great than or equal to 75, D: DM, S: stroke Low CHADS score give __________ High CHADS score give ________

low (0-1) aspirin to thin blood High (2+) anticoagulants like heparin, lovenox, warfarin

the nurse should _______ the pts head of the bed to facilitate blood flow during a ischemic stroke

lower the bed to flat to try to facilitate blood flow

squatting during activity is a sign of ___________ in ________

perfusion in children

cyanotic lips/fingers/toes, frequent feeding breaks, poor weight gain, failure to thrive are symptoms of __________ in _______

poor perfusion in infants

Pain, swelling, redness, pain when bending foot hoomans sign

positive signs of DVT

how would a nurse assess a patients balance?

posture

primary intervention

preventive - before

Creatinine Kinase MB (CK-MB)

protein released when cardiac muscle has been damaged

the nurse should _______ the pts head of the bed to reduce _______ during a hemorrhagic stroke

raise to 30 degrees, to reduce ICP and facilitate venous drainage

a stroke on in the _____ side of the brain causes the person to be unaware and neglect the opposing side of the body

right - proprioception impaired, person is unaware of the left side of the body and neglects it

Blood pressure screenings should begin at age ______ and take place ______

right away, annually

stroke in the right side of the brain will affect the vision in the left side of both eyes. so the nurse should approach the pt from the _______ side

right side

transient ischemic attack

temporary interruption in the blood supply to the brain, short duration of confusion that resolves within 30-60 minutes

atrial fibrillation

the most common dysrhythmia, the p wave just quivers and never truly forms. atrial fibrosis and loss of muscle mass. Common with HTN, HF, CAD. As A-fib progresses cardiac output decreases by as much as 20-30%

First place that reflects the effects of hypertension

the retinas!!

this type of treatment is given IV within 3 hours of onset, the pt cannot have had surgery in the last 14 days, or an MI, trauma, or stroke in the last 3 months, cannot receive anticogulants/antiplatelets for 24 hours after this treatment, and blood pressure must be controlled during treatment therapy and for 24 hours after treatment

thrombolytic (TPA) therapy for ischemic stroke

disrupt blood clots that are impairing perfusion by lysing fibrin

thrombolytics - TNP - Ateplase, TPA

two types of ischemic stroke

thrombotic and embolic

necrosis

tissue death

Nursing Assistant, CNA, Nursing Technician

unlicensed assistive personal (UAPS)

The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1.Reposition the client. 2.Notify the health care provider (HCP). 3.Change the chest tube drainage system. 4.No action is necessary because this is a normal, expected finding.

2.Notify the health care provider (HCP). Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the HCP. The remaining options are incorrect.

The nurse employed in a cardiac unit determines that which client is the least likely to have an implanted cardioverter-defibrillator (ICD) inserted? 1.A client with syncopal episodes related to ventricular tachycardia 2.A client with ventricular dysrhythmias despite medication therapy 3.A client with an episode of cardiac arrest related to myocardial infarction 4.A client with 3 episodes of cardiac arrest unrelated to myocardial infarction

3.A client with an episode of cardiac arrest related to myocardial infarction

Which nursing intervention is most effective for clients with immobility to prevent occlusion of blood vessels in areas where bony prominences rest on a mattress? 1. Encouraging the client to breathe deeply 10 times per hour 2. Performing range-of-motion exercises twice a day 3. Placing a clean pad under the sacrum 4. Repositioning the client every 2 hours

4. Repositioning the client every 2 hours

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1.Elevated for 3 hours, then flat for 1 hour 2.Flat for 3 hours, then elevated for 1 hour 3.Flat for 12 hours, then elevated for 12 hours 4.Elevated on pillows continuously for 24 to 48 hours

4.Elevated on pillows continuously for 24 to 48 hours A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? 1.Tea 2.Cola 3.Coffee 4.Raspberry juice

4.Raspberry juice caffeine causes vasoconstriction and vasodialation is necessary to assist with proper blood perfusion

Which client is at highest risk for impaired mobility? A. A 26 year old after surgery. B. A 64 year old with osteoporosis. C. A 2 year old with a broken leg. D. An overweight 80 year old that walks daily.

B. A 64 y/o w/ osteoporosis two risk factors (age & disease) walking increases bone strength, broken leg will heal quickly, 26 y/o is young enough

homonymous hemianopsia

Blindness of half of the visual field on the same side of both eyes. Must turn their head to complete their whole visual field.

CK-MB

Creatine Kinase-Muscle Breakdown 2-6

Aldosterone

Hormone that stimulates the kidney to retain sodium ions and water

The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? ischemia pnemumoia MI PUD

Myocardial infarction Fatigue is an atypical symptom of myocardial infarction in women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal discomfort.

CABG (Coronary Artery Bypass Graft)

Open heart surgery involving arterial bypass using a transplanted vein by passing the occluded coronary artery

A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test?

Status of acid-base balance in arterial blood

what is a priority with stroke

assessing and maintaining a patent airway (paralysis)

ADOPIE

assessment, diagnosis, outcome identification, planning, implementation, evaluation

Cardiac output, cardiac function, blood pressure, blood volume are all things that effect ______ _______

central perfusion

white coat syndrome

elevated blood pressure in a clinical setting (may be related to anxiety) take several BPs waiting inbetween each one until it regulates

this type of stroke has is sudden and abrupt

embolitic - ischemic stroke

education for pts with PAD

exercise, do not smoke/avoid caffeine/avoid cold temps(vasoconstriction), control HTN, include protein in diet (wound healing)

ischemia

lack of blood flow

During an MI time is _______

muscle!

pressure ulcers are considered

never events (avoidable)

anoxia

no oxygen

aPTT (activated partial thromboplastin time)

normal: 40 seconds, therapeutic (Heparin): >60 seconds

assess pain, ask PQRST, check pulses/CMS/6P's and BP are all assessments to be done when a pt has __________

peripherial arterial disease

Maslow's Hierarchy of Needs

physiological before psychological, saftey

maintaining the head of the bed at 30 degrees prevents

shearing injury

intermittent claudication, pain, rest pain unrelieved by rest, night pain, dependent rubor, pallor with elevation, thin-shiny-dry-scaly-discolored-blue-grey-skin, missing or odd hair pattern, skin breakdown (ulcer), ulcers between toes, parenthesis

signs and symptoms of PAD

impaired proprioception, disoriented to time and place, personality changes like poor impulse control, poor judgement

signs of right sided stroke with left sided/weakness/paralysis/facial/droop

ventricular fibrillation

the rapid, irregular, and useless contractions of the ventricles. AV node firing 300-600 BPM

stroke pts should be NPO until ________

they can swallow

What is the most significant modifiable risk factor for the development of impaired gas exchange?

tobacco use

decrease the diameter of blood vessels by stimulating the alpha-adrenergic or dopamine receptors to effect the normal mechanism of vasoconstriction.13

vasopressors

positive sputum test

what test determines active TB

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? "I need to be sure not to go barefoot around the house." 2."If I cut my toenails, I need to be sure that I cut them straight across." 3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4."I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

"I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? 1)Assess the client's respiratory status. 2) Draw blood to assess the client's serum electrolytes. 3) Administer intravenous furosemide (Lasix). 4)Ask the client about current medications

1)Assess the client's respiratory status. ABCs

Nursing Process

1. Assessment (subjective and objective data) 2. Diagnosis: analyze assessment data to determine diagnosis 3. Planning: develop plan of car and prescribes interventions to attain expected outcome 4. Implementation: implements interventions 5. Evaluation: evaluates success or clients attainment of outcomes

LPN can do anything EXCEPT:

1. Assessments 2. First time teaching (can reinforce) 3. IV therapy allowed after specialized training 4. IV push medications 5. hang medications for Central line 6. Central line flushes 7. Never PCA (pt controled analgesic) pumps d/t RN has to do assessment 8. Blood products

UAP delegation tasks

1. CANNOT do STERILE specimen collection (wound vs. stool) 2. CANNOT Fingerstick Glucose when patient is on insulin drip 3. CAN assist with Bathing 4. CAN take Vital Signs AFTER initial assessment by RN 5. CAN feed AFTER RN does initial assessment for swallowing following procedures, surgery, and on admission

Model of clinical judgement

1. Noticing: is looking for patterns that are consistent with previous experiences and uses that information to guide care. 2. Interpreting: the process of assembling information to make sense of it. 3. Responding: is the implementation of actions and interventions, based on patient needs 4. reflecting: is the process of thinking and learning from experiences

The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions? 1."I must take the medication exactly as prescribed." 2."Once I start the medication, I will no longer be contagious." 3."I will not get any colds or infections while taking this medication." 4."This medication has minimal side effects and I can return to normal activities."

1."I must take the medication exactly as prescribed." Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate a change in activities, especially when driving or operating machinery if dizziness occurs.

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education? 1."It is important that I limit protein intake." 2."I need to maintain a regular exercise program." 3."I understand that I need to avoid adding salt to foods." 4."It is important that I begin reducing and then maintaining weight.

1."It is important that I limit protein intake." Obesity and sodium intake are modifiable risk factors for hypertension. These are of the utmost importance because they can be changed or modified by the individual through a regular exercise program and careful monitoring of sodium intake. Protein intake has no relationship to hypertension.

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1."Pulse rate will increase." 2."Blood pressure will decrease." 3."Edema will be present in the legs." 4."Crackles in the lungs will be present."

1."Pulse rate will increase." BP will drop but HR will increase before that

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? 1."This is a normal finding." 2."This is indicative of atrial flutter." 3."This is indicative of atrial fibrillation." 4."This is indicative of impending reinfarction."

1."This is a normal finding." PR interval is 0.12-0.20

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations

1.A client with an ileostomy (is a stoma)

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem? 1.Administer prescribed antibiotics. 2.Have the client breathe into a paper bag. 3.Administer antipyretics as needed (on prn basis). 4.Request a prescription for a partial rebreather oxygen mask.

1.Administer prescribed antibiotics. The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client in rebreathing exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's (HCP's) prescriptions? Select all that apply. 1.Elevation of the right leg 2.Administration of acetaminophen 3.Application of moist heat to the right leg 4.Monitoring for signs of pulmonary embolism 5.Ambulation in around the nursing unit every hour

1.Elevation of the right leg 2.Administration of acetaminophen 3.Application of moist heat to the right leg 4.Monitoring for signs of pulmonary embolism Standard management of the client with deep vein thrombosis includes possible bed rest for 5 to 7 days or as prescribed; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Although the health care provider may allow ambulation, hourly ambulation around the nursing unit is not encouraged because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism.

The health care provider (HCP) prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Encourage coughing with deep breathing. 2.Place in high Fowler's position for eating. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. 5.Place sequential compression boots on the client. 6.Encourage the intake of dark green, leafy vegetables.

1.Encourage coughing with deep breathing. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. The client with DVT may require bed rest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bed rest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with high Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1.Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

1.Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution. Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.

The nurse is caring for a client who had a right-sided stroke and has homonymous hemianopsia. What nursing action would be most appropriate in the early phase of treatment to assist the client with this visual problem? 1.Place objects on the right side. 2.Approach the client from the left side. 3.Place objects on the left side 4.Patch the affected eye.

1.Place objects on the right side.<- a right sided stroke will cause a loss of vision on the opposite side (left in this case)

The nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do first? 1.Review intake and output records for the last 2 days. 2.Prescribe daily weights starting on the following morning. 3.Change the time of diuretic administration from morning to evening. 4.Request a sodium restriction of 1 g/day from the health care provider (HCP).

1.Review intake and output records for the last 2 days. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Therefore, the nurse should review intake and output records for the last 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy? 1.Tarry stools 2.Nausea and vomiting 3.Orange-colored urine 4.Decreased urine output

1.Tarry stools

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids

1.The client who is taking diuretics The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1.Twitching 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes

1.Twitching The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1.Weight loss and poor skin turgor 2.Lung congestion and increased heart rate 3.Decreased hematocrit and increased urine output 4.Increased respirations and increased blood pressure

1.Weight loss and poor skin turgor A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

A patient with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the patient's breath sounds? 1)Stridor 2)Crackles 3)Rhonchi 4)Wheezes

2)Crackles <- Pulmonary Edema or left sided HF has possibly occurred causing fluid accumulation in the lungs

The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels. Which statement by one of the new RNs indicates that teaching has been effective? 1."Calcium has no effect on the risk for stroke." 2."Low calcium levels can lead to cardiac arrest." 3."Low calcium levels cause high blood pressure." 4."Calcium has no effect on urinary stone formation."

2."Low calcium levels can lead to cardiac arrest." The normal calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization and move back during repolarization. Depolarization is responsible for cardiac contraction. Options 1 and 3 are unrelated to calcium levels. Elevated calcium levels can lead to urinary stone formation. The nurse would take action and contact the health care provider when a calcium level is abnormal.

The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? 1."Ventricular fibrillation appears as irregular beats within a rhythm." 2."Ventricular fibrillation does not have P waves or QRS complexes." 3."Ventricular fibrillation is a regular pattern of wide QRS complexes." 4."Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves."

2."Ventricular fibrillation does not have P waves or QRS complexes." Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Premature ventricular contractions (PVCs) appear as irregular beats within a rhythm. Ventricular tachycardia is a regular pattern of wide QRS complexes. Sinus tachycardia has a recognizable P wave, QRS complex, and T wave. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.

An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range? 1.56% (0.56) 2.48% (0.48) 3.37% (0.38) 4.34% (0.34)

2.48% (0.48) normal Hct for a male is 45-54% 56% - too high 37% too low 34% too low

The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed? 1.Older adults tend to report pain less often than do younger adults. 2.Clients in this age group are less sensitive to pain and have a greater pain tolerance. 3.Mental images of pain are a less effective means to assess pain in this group than visual representations. 4.Pain in the cognitively impaired older adult may require more frequent assessments than in clients who are not impaired.

2.Clients in this age group are less sensitive to pain and have a greater pain tolerance.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1.Keep the legs aligned with the heart. 2.Elevate the legs higher than the heart. 3.Clean the skin with alcohol every hour. 4.Position the client onto the side during every shift.

2.Elevate the legs higher than the heart. In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of Addison's disease 4.Uric acid level of 9.4 mg/dL (559 mmol/L)

2.Requires nasogastric suction gastric juices are rich in potassium The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1.Metabolic acidosis, compensated 2.Respiratory alkalosis, compensated 3.Metabolic alkalosis, uncompensated 4.Respiratory acidosis, uncompensated

2.Respiratory alkalosis, compensated The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

After instruction on the application of antiembolism stockings, the nurse determines that the client requires further teaching if which of these actions is performed? 1.The client puts on the stockings before getting out of bed. 2.The client bunches up the stockings for easier application. 3.The client ensures that stockings are pulled up all the way. 4.The client ensures that the rough seams of the stockings are on the outside.

2.The client bunches up the stockings for easier application. When applying antiembolism stockings, the client should not bunch up the stockings. Instead, the client should place the hand inside the stocking and pull the heel out. The foot of the stocking should then be placed over the client's foot and the rest of the stocking pulled up the leg. This will help to prevent wrinkling and twisting of the stocking. The remaining options demonstrate correct application of the stockings.

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value comes back elevated? 1.Myoglobin 2.Troponinn 3.C-reactive protein 4.Creatine kinase (CK)

2.Troponinn

what should be done right after a stroke?

24 hour bed rest in right lateral position, then repositioning on affected side for 20 minutes, prone for 30 minutes 3xs a day, and getting mobile after 24 hours has passed

Which information given by the patient admitted with chronic stable angina will help the nurse confirm this diagnosis? 1) The patient rates the pain at a level of 3 of 5 (0-10 scale). 2) The patient states that the pain "wakes me up at night." 3) The patient indicates that the pain is resolved after taking one SL nitroglycerin tablet. 4) The patient states that the frequency has increased over the last few weeks.

3) The patient indicates that the pain is resolved after taking one SL nitroglycerin tablet.

A patient arrives in the emergency department with an ischemic stroke and is a candidate for tissue plasminogen activator (tPA) administration. Which is the priority nursing assessment? 1) Current medications 2) Complete physical and history. 3) Time of onset of current stroke. 4) Upcoming surgical procedures

3) Time of onset of current stroke. <-tPA can only be given within 3 hours of onset of the stroke 1) Current medications <- can't be on anticoagulants/antiplatelets for 24 hours after 2) Complete physical and history. 4) Upcoming surgical procedures <-cant have had surgery in past 14 days

A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? 1."I need to cut down on cigarette smoking." 2."I am so relieved that my heart is repaired." 3."I need to adhere to my dietary restrictions." 4."I am so relieved that I can eat anything I want to now."

3."I need to adhere to my dietary restrictions." After angioplasty, the client needs to be instructed on the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.

The nurse in the health care provider's office is reviewing the results of a client's phenytoin level determination performed that morning. The nurse identifies that a therapeutic medication level has been achieved if which result is noted? 1.3 mcg/mL (11.9 mmol/L) 2.8 mcg/mL (31.74 mmol/L) 3.15 mcg/mL (59.52 mmol/L) 4.24 mcg/mL (95.23 mmol/L)

3.15 mcg/mL (59.52 mmol/L) The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL (40 to 79 mmol/L) in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above this range indicates that the client is entering the toxic range and is at risk for toxic effects of the medication. In this case, the dose should be adjusted downward.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss and dry skin 2.Flat neck and hand veins and decreased urinary output 3.An increase in blood pressure and increased respirations 4.Weakness and decreased central venous pressure (CVP)

3.An increase in blood pressure and increased respirations A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? 1.Ad lib activities as tolerated 2.Strict bed rest for 24 hours after transfer 3.Bathroom privileges and self-care activities 4.Unsupervised hallway ambulation for distances up to 200 feet (60 meters)

3.Bathroom privileges and self-care activities

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine

3.Hyperactive bowel sounds The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1.Urinary output 2.Wound drainage 3.Integumentary output 4.The gastrointestinal tract

3.Integumentary output

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? 1.Heart failure 2.Atrial fibrillation 3.Myocardial infarction 4.Ventricular tachycardia

3.Myocardial infarction

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1.Use nail polish to protect the nail beds from injury. 2.Wear gloves for all activities involving the use of both hands. 3.Stop smoking because it causes cutaneous blood vessel spasm. 4.Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

3.Stop smoking because it causes cutaneous blood vessel spasm. raynauds is caused by arterial spasm brought on by vasospasm that constricts subcutaneous vessels

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST segment 5.Widened QRS complexes

3.Tall peaked T waves <----know this for 1st sem 5.Widened QRS complexes The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial in 1.The client is not experiencing dyspnea. 2.The client is not experiencing nausea or vomiting. 3.The pain has not been relieved by rest and nitroglycerin tablets. 4.The client says the pain began while she was trying to open a stuck dresser drawer.farction (MI) on the basis of what assessment finding?

3.The pain has not been relieved by rest and nitroglycerin tablets.

The nurse is creating a plan of care for a client who is receiving amphotericin B intravenously.A main component of the plan of care is monitoring for adverse effects related to the administration of this medication. Which should the nurse include in a list of manifestations to watch for? 1.Fatigue 2.Confusion 3.Visual difficulties 4.Increased urinary output

3.Visual difficulties Amphotericin B is an antifungal. Vision and hearing alterations, seizures, hepatic failure, paresthesias (tingling, numbness, or pain in the hands and feet), and coagulation defects also occur. Other adverse effects include nephrotoxicity, which occurs commonly and is evidenced by decreased urine output. Cardiovascular toxicity (as evidenced by hypotension and ventricular fibrillation) and anaphylactic reaction occur rarely

The nurse is auscultating a 56-year-old adult client's apical heart rate before giving digoxin and notes that the heart rate is 48 beats/minute. Which action should the nurse take? 1.Withhold the digoxin, and re-evaluate the heart rate in 4 hours. 2.Administer half of the prescribed dose to avoid a further decrease in heart rate. 3.Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity. 4.Administer the digoxin; the heart rate would be considered normal because of the client's age.

3.Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity.

A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? 1."It will really hurt when the catheter is first put in." 2."I will receive general anesthesia for the procedure." 3."I will have to go to the operating room for this procedure." 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."

4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours." It is common for the client to feel fatigued after the cardiac catheterization procedure. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. Other preprocedure teaching points include the fact that the procedure is done in a darkened cardiac catheterization room. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.

A client who had coronary artery bypass surgery states to the home health nurse, "I get so frustrated. I can't even do my gardening." The nurse then assesses the client for activity level since the surgery. Which client statement indicates a need for further teaching? 1."I pace my activities throughout the day." 2."I plan regular rest periods during the day." 3."I avoid outdoor physical activity during the heat of the day." 4."I try to walk immediately after lunch, after I've finished my morning housecleaning."

4."I try to walk immediately after lunch, after I've finished my morning housecleaning." Exercise is an integral part of the rehabilitation program. It is necessary for optimal physiological functioning and psychological well-being. Postoperative physical rehabilitation must be progressive, with planned periods of rest. Exercise tolerance is judged by the client's response, such as heart rate and endurance. Planning regular rest periods, pacing activities, and avoiding outdoor activities during the heat of the day are appropriate client activities. The correct option lacks planned periods of rest, and the client has grouped too many activities in a brief period of time, which will decrease endurance. Also, exercise after meals can decrease the client's tolerance because of shunting of blood to the gastrointestinal tract for digestion.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1.A postoperative client preparing for discharge with a new medication 2.A client requiring daily dressing changes of a recent surgical incision 3.A client scheduled for a chest x-ray after insertion of a nasogastric tube 4.A client with asthma who requested a breathing treatment during the previous shift

4.A client with asthma who requested a breathing treatment during the previous shift

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1.Correct the acidosis. 2.Administer 5% dextrose intravenously. 3.Apply a monitor for an electrocardiogram. 4.Administer short-duration insulin intravenously.

4.Administer short-duration insulin intravenously. Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action.

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency? 1.Headache 2.Dysphagia 3.Constipation 4.Electrocardiographic changes

4.Electrocardiographic changes Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave.

A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1.Limiting oral and intravenous fluids 2.Measuring the client's pulse each shift 3.Providing the client with short, frequent walks 4.Eliminating sources of caffeine from meal trays

4.Eliminating sources of caffeine from meal trays Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Measuring the pulse each shift will not decrease the heart rate. In addition, the pulse should be taken more frequently than each shift.

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? 1.It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. 2.It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. 3.It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4.It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

4.It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. An insulin pump provides a small continuous dose of short-duration (rapid- or short-acting ONLY) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas

The nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse should address with the client which most important measure to ensure client safety? 1.Assessing pain 2.Administering vasodilators 3.Avoiding over-the-counter (OTC) medications 4.Moving slowly from a sitting to a standing position

4.Moving slowly from a sitting to a standing position Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy. Although important, pain assessment and avoiding OTC medications are not directly related to the issue of safety.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1.The client with colitis 2.The client with Cushing's syndrome 3.The client who has been overusing laxatives 4.The client who has sustained a traumatic burn

4.The client who has sustained a traumatic burn The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1.The client taking diuretics and has tenting of the skin 2.The client with an ileostomy from a recent abdominal surgery 3.The client who requires intermittent gastrointestinal suctioning 4.The client with kidney disease and a 12-year history of diabetes mellitus

4.The client with kidney disease and a 12-year history of diabetes mellitus A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? A patient with asthma and severe shortness of breath A patient undergoing a bronchoscopy for a biopsy A patient with a pleural effusion requiring fluid removal A patient experiencing a problem with a pneumothorax

A patient experiencing a problem with a pneumothorax

A patient is in skeletal traction. Which nursing intervention ensures proper care of this patient? A. Inspect the skin at least every 8 hours B. Remove the traction weights only for bathing C. Ensure that pins are not loose, and tighten as needed D. Ensure that weights are attached to the bed frame or placed on the floor

A. Inspect the skin at least every 8 hours The patient's skin should be inspected every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights are not allowed to be placed on the floor; weights should hang freely at all times. Pin sites should be checked for signs and symptoms of infection and for security in their position to the fixation and the patient's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Weights must never be removed without a request from the health care provider.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action?

Check the client's status and lead placement.

The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client?

Cover the legs lightly when sitting in a chair. this provides warmth and vasodilation

Do not massage a pt if you suspect _____

DVT (or if they have a stage 1 ulcer for that matter)

A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner?

Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.

DASH diet

Dietary Approaches to Stop Hypertension, a dietary pattern designed to reduce blood pressure that emphasizes potassium-rich vegetables and fruits and low-fat dairy products; includes whole grains, poultry, fish and nuts and limits sodium, red meat, and added sugars.

Potassium should NEVER be given _______

IV push (bolus) - syringe pushed - it should always be diluted and given via IV pump

A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift?

Lethargy and constipation from hypercalcemia Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.

A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? 1. Perfusion assists the body by preventing clots and increasing stamina. 2. Perfusion assists the cell by delivering oxygen and removing waste products. 3. Perfusion assists the heart by increasing the cardiac output. 4. Perfusion assists the brain by increasing mental alertness.

Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.

What measure should the caregiver of a patient with diabetes take to treat moderate hypoglycemia? Provide half a cup of fruit juice. Offer 4 cubes, or teaspoons, of sugar. Subcutaneously inject 1 mg of glucagon. Provide 15 g of carbohydrate and cheese

Provide 15 g of carbohydrate and cheese When treating moderate hypoglycemia, the patient must be given 15 to 30 g of rapidly absorbed carbohydrate, followed by low-fat milk or cheese after 10 to 15 minutes. The patient with mild hypoglycemia usually has a blood glucose level of less than 60 mg/dL. It may be treated by offering the patient half a cup of fruit juice, or 4 cubes or teaspoons of sugar. In severe hypoglycemia, blood glucose is usually less than 20 mg/dL. The patient may be unconscious or unable to swallow; the patient should be administered 1 mg of glucagon as a subcutaneous or intramuscular injection.

Which vital sign is most important for the nurse to monitor in a patient receiving general anesthesia in the postanesthesia care unit? Pulse Blood pressure Respiratory rate Body temperature

RR A patient receiving general anesthesia must be regularly monitored for respiratory rate because the medication may lead to respiratory depression. Pulse, blood pressure, and body temperature are evaluated and recorded in the patient's medical record but are not the most important vital sign to monitor.

The nurse is caring for a patient diagnosed with a 55% blockage of the coronary arteries. What should the nurse monitor the patient for? bradycardia SOB p wave elevation weight loss

SOB Shortness of breath is important to monitor for in a patient with a 55% blockage of the coronary arteries because it can be a sign of decreased blood flow resulting from the blockage. Weight loss is not a sign of decreased blood flow, but weight gain would be. Bradycardia would not likely result from blockage. P wave elevation is not indicative of anything.

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/minute. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse report this rhythm? 1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm

Sinus dysrhythmia

Virchow's triad

Stasis, hypercoagulability, endothelial damage

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer?

Strict bed rest for 24 hours after transfer

Cardiac Output is _________

Stroke volume (Ml/per ventricular contraction) X Heart Rate (ventricular contraction/minute) CO (amount of blood pumped per minute (F=4.9L/min, M=5.25L/min @rest))

hypertensive crisis

Sudden elevation of BP - potentially fatal 200+/150+ Hypertension with Angina, Pulmonary Edema, Pregnancy or signs of cerebral edema (such as usually severe headache blurred vision/visual disturbances, nausea and vomiting, altered mental status, focal neurological sign or deficits, paresthesias, dizziness, vertigo or tinnitus

The nurse knows that which assessment finding is characteristic of a deep vein thrombosis in the leg? 1.Bilateral edema of the leg associated with an albumin level of 2 g/dL 2. Unilateral swelling with redness over the swollen area 3. Brisk reflexes in the lower extremities 4. Brownish discoloration of the skin over the lower extremities

Unilateral swelling with redness over the swollen area

percutaneous transluminal coronary angioplasty

a procedure in which a small balloon on the end of a catheter is used to open a partially blocked coronary artery by flattening the plaque deposit and stretching the lumen (AKA angioplasty) FROM DOOR TO BALLOON MUST BE DONE WITHIN 90 MINUTES OF MI DIAGNOSIS

ablation or surgery-maze procedures are used for ____ and do _____

a-fib, v-fib,create burn/ incision scar in myocardium causing the dysrhythmia because scar tissue cannot conduct electrical impulses

S3 is heard when?

after S2 , A third heart sound (S3) can be heard when the ventricles are resistant to filling during the early rapid filling phase. S3 is heard when the AV valves open and atrial blood first pours into the ventricles. could be caused by ventricular vibration or stenosis

ABC

airway, breathing, circulation

repo a pt every 2 hours is an example of _____

an intervention

Cholesterol screening should be done ______ starting at age ____-____ with risk or _____ without risks

annually, 20-35 w/ risk, 45+ w/o risk

prevent blood clotting at several locations in the clotting cascade to suppress the production of fibrin. They are most effective in preventing venous thrombosis.

anticoagulants - heparin (APTT), Lovenox (low mol. wt. heparin), warfarin (INR)

correct erratic electrical impulses to create regular cardiac rhythms. These agents act by blocking electrolytes that affect electrical conduction in the heart, such as sodium, potassium, and calcium, or by blocking beta-adrenergic receptors.13

antidysrhythmics - digoxin, amacarone

agents prevent platelets from aggregating to form clots. They are most effective in preventing arterial thrombosis.

antiplatelets - plavix, aspirin

stroke pts are at an increased risk for what when they begin eating?

aspiration (they may not even know it until it has entered the lungs)

1. ABCs 2. Pain assessment 3. Vitals: HR/BP/RR/ Auscultate (S3?) 4. ECG/ECG 12 lead - continuous monitoring 5. MONA: O2(g), Nitro, [IV access], Morphine (pain), Aspirin (blood thinner) 5b. notify rapid response team 5c. reassess pain/vitals after 5 min, give another nitro, 5 min, reassess, give one more nitro, notify physician! (up to 3xs - pain needs to be 0)

assessments and interventions for MI

this type of stroke accounts for 50% of strokes associated with _____________

atherosclerosis (carotid artery occlusion)

why is it very important to determine what kind of stroke a pt is having

because there are different treatments for different strokes. Thrombolytics will be given within 3 hours of onset to pts with ischemic strokes but that would make the bleeding worse is the pt. were having a hemorrhagic stroke

when a pt is injured a nurse should check the pulse ______ the injury

below

the ______ and the ______ require the most amount of perfusion (blood) out of all the organs in the body

brain and intestines

S2 is caused by

closure of semilunar valves

S1 is caused by

closure of the atrioventricular valves

sudden pain in an area that recently had trauma that is not relieved by analgesics and is more extreme than injury

compartment syndrome

when an injury occurs and a pts pain is excessive and unrelieved by analgesics it could be ________ _________

compartment syndrome

what should the nurse do if they expect compartment syndrome

elevate the area and call PCP

pts with PAD should ______ feet at rest but not above ________ level

elevate, heart blood flow is blocked, feet should be dangled/dependent to encourage gravity blood flow to the occluded area

Repositioning of patients is usually done: a. every 4 hours b. every 2 hours c. every 8 hours d. every hour

every 2 hours

this type of stroke is SUDDEN and causes a SEVERE HA

hemorrhagic stroke (ICP causes severe HA)

primary hypertension (essential hypertension)

high BP attributed to no single cause; risks include smoking, obesity, increased salt intake, hypercholesterolemia, and hereditary factors, >60 y/o, Af. Am., sedentary lifestyle, low intake of K,Ca, Mg, excessive/continuous stress

secondary hypertension

high blood pressure caused by the effects of another disease. DM, CKD,

constipation, lethargy are indications of this electrolyte imbalance

hypercalemia

when is the only time when pt goals and desires can be put aside?

in an emergency

diuretic

inhibits aldosterone sodium/water re-absorption, wasting of K+, and and causes urine excretion (watch out for hyperkalemia)

hypoxia

lack of oxygen

the nurse will need to be careful to give simple instructions if their pt had a stroke in the _____ side of the brain

left - comprehension and speech are affected

stroke on the left side of the brain will affect the right visual field of both eyes. so the nurse should approach the patient from the ____ side

left side

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient?

low flow O2g via nasal canula. COPD pts have adapted to high levels of CO2 and their breathing is often stimulated by Low O2 instead. if you give them too much O2 it will cause respiratory depression

Segs are

mature neutrophils (right shift- good)

objective

measurable data collected by nurse

3 parts of nursing diagnosis

problem, etiology, signs and symptoms ____ r/t etiology as e/b __S/Ss at risk for r/t ____etiology

age, HTN, previous ischemia stroke, obestity, smoking, CAD, HF, DM, valve dysfunction, TIA, Caucasian, excessive alcohol consumption (CNS depressant)

risk factors for atrial fibrillation

secondary intervention

screening and early detection - early

- Temperature of more than 100.4° F (38° C) or less than 96.8° F - Heart rate of more than 90 beats per minute - Respiratory rate of more than 20 breaths per minute or a PaCO2 level of less than 32 mm Hg - Abnormal white blood cell count (>12,000/mm3 or <4000/mm3 or >10% segs or >10% bands)

sepsis

problems with intellect, language speech, understanding, forming words dysarthia (slow speech), math skills

signs of a left sided stroke with right side weakness/facial droop/paralysis

smart goals for patients must be

specific, measurable, achievable, realistic, and timely always starts with "the pt will..."

What is wound dehiscence?

splitting open of wounds evisceration is complete separation with protruding organs. the nurse should apply wet dressing and call PCP.

patency of vascular system, hydro-static pressure, and capillary permeability are all things that effect

tissue/local perfusion

tertiary intervention

treatment

the nurse should do what to assist a patient with homonymous hemianopsia while they are eating?

turn the plate so the other half enters their field of vision

A 5-year-old boy with early flu symptoms is at school working with some math blocks. He sneezes into his hand and then continues working with his blocks. An unvaccinated teacher's helper cleans up the blocks when the child leaves them on the table. After touching the blocks, she rubs her nose with her hand. Which represents the most likely mode of transmission?

unwashed blocks

the nurse should be aware of what things when transferring a stroke patient

using a gait belt, placing the wheelchair on their strong (unaffected) side, watch out for their feet/ankles dragging on the affected side

The trendelenburg test checks for ____

varicose veins. upon standing veins fill up from the proximal end instead of distal, denoting valve dysfunction

increase the diameter of blood vessels in a variety of ways that block normal mechanisms. For example, vasodilators can block the following: alpha-adrenergic receptors; calcium influx into vascular smooth muscle; formation of angiotensin II, which normally increases aldosterone concentration to retain sodium as well as vasoconstriction; or receptors that receive angiotensin II. Myocardial contractility is reduced for the purpose of lowering cardiac output by blocking calcium influx into the myocardium and blocking the beta-adrenergic receptors in the heart. (13) Vasodilators are used to treat hypertension as well as angina.

vasodialators BB, CCB, ACE In., ARBs, Nitrates

subjective

what the patient tells you

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question?

where is the pain located?

Primary interventions for perfusion

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