420: Test 1 Part C
The nurse is assessing a client with irreversible shock. The nurse should document the progression of which expected finding? 1. increased alertness 2. circulatory collapse 3. hypertension 4. diuresis
2. circulatory collapse Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? 1. blood pressure 110/62 mm Hg, atrial fibrillation with heart rate 82, bilateral basilar crackles 2. confusion, urine output 15 mL over the last 2 hours, orthopnea 3. SpO2 92% on 2 L nasal cannula, respirations 20 breaths/min, 1+ edema of lower extremities 4. weight gain of 1 kg in 3 days, blood pressure 130/80 mm Hg, mild dyspnea with exercise
2. confusion, urine output 15 mL over the last 2 hours, orthopnea A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.
When assessing a client for early sepsis, which assessment finding would most concern the nurse? 1. pale, yellow urine 2. mean arterial pressure less than 70 mmHg 3. two-second capillary refill 4. purulent drainage from surgical site
2. mean arterial pressure less than 70 mmHg Symptoms of early sepsis include fever with restlessness and confusion. As sepsis advances, the nurse will find a decrease in blood pressure including a mean arterial pressure (MAP) less than 70 mmHg accompanied by tachypnea and tachycardia; decreased urine output; and hyperglycemia with the absence of diabetes. Later sepsis includes the presence of shock: hypotension despite adequate fluid resuscitation along with the presence of abnormal tissue perfusion. Purulent drainage from the surgical site should be reported and a culture obtained, but would not be the greatest concern. Pale yellow urine is not a negative finding in sepsis.
A nurse assesses a 40-year-old female client with Raynaud's phenomenon involving her right hand. The nurse records the information in the progress notes, as shown. From these findings, what should the nurse first instruct the client how to manage? 1. acute pain. 2. numbness. 3. lack of circulation. 4. potential for skin breakdown.
2. numbness. The client has numbness in the fingertips, and the nurse should first help the client regain sensory perception and discuss strategies for prevention of injury. The client does not have acute pain. The client does have adequate circulation and is not at risk for skin breakdown at this time.
A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because: 1. the client is experiencing heart failure. 2. the client is going into cardiogenic shock. 3. the client shows signs of aneurysm rupture. 4. the client is in the early stage of right-sided heart failure.
2. the client is going into cardiogenic shock. This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.
A client had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client about residual limb care. Which statement by the client indicates that the client understands how to implement the plan of care? 1. "I should inspect the incision carefully when I change the dressing every other day." 2. "I should wash the incision, dry it, and apply moisturizing lotion daily." 3. "I should rewrap the stump as often as needed." 4. "I should elevate the stump on pillows to decrease swelling."
3. "I should rewrap the stump as often as needed." The purpose of wrapping the residual limb is to shape the residual limb to accept a prosthesis and bear weight. The compression bandaging should be worn at all times for many weeks after surgery and should be reapplied as needed to keep it free of wrinkles and snug. The dressing should be changed daily to allow for inspection of the stump incision. No lotions should be applied to the stump unless specifically prescribed by the health care provider (HCP) . The stump should not be elevated on pillows because this will contribute to the formation of flexion contractures. Contractures will prevent the client from wearing a prosthesis and ambulating.
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? 1. brachial artery 2. radial artery 3. aorta 4. right ventricular wall
3. Aorta Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall.
A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus? 1. Measure blood pressure in the right arm, then in the left arm as the client slows the pace of their inhalations and exhalations. 2. Measure blood pressure in either arm with the client holding their breath, then with the client breathing normally. 3. Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. 4. Measure the blood pressure in the right arm as the client inhales slowly, then measure the blood pressure in the left arm as the client exhales slowly.
3. Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. To determine pulsus paradoxus, the nurse should measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Cardiac Tamponade or any condition that alters intrathoracic pressure or causes right ventricular distention, the nurse will notice a fall in systolic blood presuure of >10mm Hg during the inspiratory phase. Unless the client has these conditions, the two measurements are usually less than 10 points apart.
Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the lab tests (see chart). What should the nurse do first? 1. Administer the medications. 2. Call the health care provider (HCP). 3. Withhold the captopril. 4. Question the metoprolol dose.
3. Withhold the captopril. The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.
The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? 1. a Sa02 reading of 92% 2. a white blood cell count of 19,000/mm3 3. a urinary output of 50 mL in the past 3 hours 4. vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60
3. a urinary output of 50 mL in the past 3 hours Sepsis can cause the release of myoglobin from the cells which will directly block the renal tubules causing decreased urinary output. If it is not treated with hydration and antibiotics, the client could develop renal failure. A high white blood cell count is expected with sepsis. Temperature can be elevated or below normal, in clients with sepsis. The elevated pulse and respirations are normal in the presence of infection and should be monitored. The saturated oxygen level is within normal limits as is the blood pressure.
A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will require long-term administration of: 1. aspirin or acetaminophen. 2. pentoxifylline or acetaminophen. 3. aspirin or clopidogrel. 4. penicillin V or erythromycin.
3. aspirin or clopidogrel. After PTCA, the client begins long-term aspirin or clopidogrel therapy to prevent thromboembolism. Physicians order heparin for anticoagulation during this procedure; some physicians discharge clients with a prescription for long-term warfarin or low-molecular-weight heparin therapy. Pentoxifylline, a vasodilator used to treat chronic arterial occlusion, isn't required after PTCA because the procedure itself opens the vessel. The physician may order short-term acetaminophen therapy to manage fever or discomfort, but prolonged therapy isn't warranted. The client may need an antibiotic, such as penicillin or erythromycin, for a brief period to prevent infection associated with an invasive procedure; long-term therapy isn't necessary.
The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which condition? 1. a hypoglycemic reaction 2. cardiogenic shock associated with heart block 3. development of congestive heart failure 4. acute renal failure
3. development of congestive heart failure Crackles probably signify pulmonary edema, which occurs when there is left-sided congestive heart failure. The client is very dyspneic, and the heart appears to be compensating (increased rate because of respiratory congestion). Initiation of measures to help strengthen the heartbeat is a very important priority. Signs and symptoms do not indicate hypoglycemic reaction or renal failure. Heart block would be indicated by bradycardia.
The nurse is assessing a client admitted to the hospital for surgery to repair an abdominal aortic aneurysm. Prior to surgery, the nurse should assess the client for which factor that puts the client at risk for rupture? 1. anemia 2. dehydration 3. high blood pressure 4. hyperglycemia
3. high blood pressure In the preoperative phase, the goal is to prevent rupture. The client is placed in a semi-Fowler's position and in a quiet environment. The systolic blood pressure is maintained at the lowest level the client can tolerate. Anemia, dehydration, and hyperglycemia do not put the client at risk for rupture.
A client is in hypovolemic shock. In which position should the nurse place the client? 1. supine 2. semi-Fowler's 3. supine with the legs elevated 15 degrees 4. Trendelenburg's
3. supine with the legs elevated 15 degrees A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation. Neither semi-Fowler's position nor the supine position by itself promotes venous return. Semi-Fowler's position would not facilitate venous return. Trendelenburg's position inhibits respiratory expansion and possibly causes increased intracranial pressure.
Following a coronary artery bypass graft (CABG), a client reports chest "fullness," anxiety, and dizziness. Vital signs are pulse 108, respirations 24, and blood pressure 94/62mmHg on inhalation, and 108/70mmHg on expiration. The nurse prints a lead II electrocardiogram (ECG) strip for interpretation and identifies an amplitude decrease in the QRS complex. What intervention would have the highest priority? 1. Place the client in Trendelelberg position. 2. Administer morphine sulfate 2mg intravenous push (I.V.P.). 3. Increase oxygen delivery to 3L by nasal cannula. 4, Prepare the client for emergency pericardiocentesis.
4, Prepare the client for emergency pericardiocentesis. An amplitude decrease in the client with these symptoms would suggest cardiac tamponade. Following a CABG, there is a risk for fluid surrounding the heart, which would suppress the amplitude of the QRS complexes on an ECG. The nurse's highest priority would be to prepare the client for a pericardiocentesis, which will aspirate pericardial fluid in which the client should feel immediate relief. Placing the client in Trendelenberg position would worsen the condition by increasing intrathoracic pressure. This is an emergency, and administration of morphine will ease the client's pain and anxiety, but is not the highest priority. Administration of oxygen of 3 liters by nasal cannula will not address the immediate problem of increased pressure in the pericardial sac. An increase in oxygen will not help the heart pump better because it is being squeezed by the fluid in the pericardial sac.
An older adult is admitted to the hospital with sudden onset of severe pain in the back, flank, and abdomen. The client reports feeling weak; the blood pressure is 68/31 mm Hg. There has been no urine output. Bilateral leg pulses are weak, although bruit and pulsation are noted at the umbilicus. What should the nurse do first? 1. Obtain consent for emergency surgery. 2. Assess leg pulses with a Doppler test. 3. Palpate the abdomen for presence of a mass. 4, Start an IV infusion.
4, Start an IV infusion. The symptoms noted are classic symptoms of leaking abdominal aneurysm and shock; the client needs immediate fluid volume replacement. Assessing the pulses with a Doppler will be of no additional diagnostic value. Palpating the abdomen on a client with a suspected abdominal aneurysm is contraindicated and could lead to rupture. After emergency fluid resuscitation, consent for surgery is needed.
A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm? 1. The blood pressure and pulse are within normal limits, but the client's skin color is pale and slightly diaphoretic. 2. The client reports feeling nauseated. 3. The client has been taking an antihypertensive for the past 3 years but forgot to take it today. 4. The client reports increasing severe back pain.
4. The client reports increasing severe back pain. Increased severe back pain and increased irritation to nerves are indicative of a potential rupture of an aneurysm. The client would be hypertensive and present with tachycardia, so the other choices are not correct. Nausea, although possible, or a missed dose of medication, do not indicate potential rupture.
A client presents to the ED in shock. During what phase of shock does the nurse know that metabolic acidosis is going to most likely occur? 1. compensation 2. irreversible 3. early 4. decompensation
4. decompensation The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.
What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? 1. cardiac pacemaker 2. hypothermia-hyperthermia machine 3. defibrillator 4. intra-aortic balloon pump
4. intra-aortic balloon pump Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.
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. What should the nurse tell the family? 1. "Because of the cardiogenic shock, there is a decrease in the blood flow through the kidneys." 2. "an obstruction of urine flow from the kidneys." 3. "a blood clot that formed in the kidneys." 4. "structural damage to the kidney."
1. "Because of the cardiogenic shock, there is a decrease in the blood flow through the kidneys." There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.
A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline, 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? 1. "Practice meticulous foot care." 2. "Consider cutting down on your smoking." 3. "Reduce your level of exercise." 4. "See the physician if complications occur."
1. "Practice meticulous foot care." Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe their feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.
A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? 1. "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" 2. "a decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" 3. "generally caused by decreased blood volume" 4. "severe hypersensitivity reaction resulting in massive systemic vasodilation."
1. "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" Shock may have different causes (e.g., hypovolemia, cardiogenic, septic), but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Movement of plasma into the interstitial spaces could reflect dependent edema and sepsis. Decreased blood volume is an example of hypovolemia. A hypersensitivity reaction is an example of anaphylactic shock or distributive shock.
A middle-aged man collapses in the emergency department waiting room. What should the nurse do first? 1. Ask the client to state his name. 2. Perform the chin-tilt to open the victim's airway. 3. Feel for any air movement from the victim's nose or mouth. 4. Watch the victim's chest for respirations.
1. Ask the client to state his name. Calling the victim's name and gently shaking the victim is used to establish unresponsiveness. The head-tilt, chin-lift maneuver is used to open the victim's airway. Feeling for any air movement from the victim's nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victim's chest for respirations to see if the victim is breathing.
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? 1. Call the rapid response team. 2. Administer a sedative. 3. Try to elicit a positive Homan's sign. 4. Increase the flow rate of intravenous fluids.
1. Call the rapid response team. Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client's change in mental status, tachypnea, and tachycardia indicate a possible pulmonary embolism. The nurse should promptly call the rapid response team. Administering a sedative without further evaluation of the client's condition is not appropriate. There is no need to elicit a positive Homans' sign; the client is already diagnosed with deep vein thrombosis. Increasing the IV flow rate may be an appropriate action but not without first notifying the HCP.
Which performance improvement strategy helps prevent adverse reactions to blood products? 1. confirming client identification with two qualified health professionals 2. obtaining baseline vital signs 3. instructing the client about the signs and symptoms of a blood reaction 4. priming the blood administration tubing with normal saline solution
1. confirming client identification with two qualified health professionals The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions.
Before surgery to repair an aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for: 1. loss of consciousness. 2. anxiety. 3. headache. 4. disorientation.
1. loss of consciousness. If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain. Anxiety is not a sign of aortic valvular insufficiency. The end result of decreased cerebral blood flow is loss of consciousness, not headache or disorientation.
Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? 1. septic shock 2. chronic obstructive pulmonary disease 3. asthma 4. heart failure
1. septic shock The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.
A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? 1. shock 2. stroke 3. seizures 4. hyperglycemia
1. shock Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.
A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding? 1. tachycardia 2. bradycardia 3. decreased PaCO2 4. narrowed pulse pressure
1. tachycardia The nurse should assess the client who is bleeding for tachycardia because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying red blood cells. The degree of cardiopulmonary distress and anemia will be related to the amount of hemorrhage that occurred and the period of time over which it occurred. Bradycardia is a late symptom of hemorrhage; it occurs after the client is no longer able to compromise and is debilitating further into shock. If bradycardia is left untreated, the client will die from cardiovascular collapse. Decreased PaCO2 is a late symptom of hemorrhage, after transport of oxygen to the tissue has been affected. A narrowed pulse pressure is not an early sign of hemorrhage.
A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client? 1. Anaphylaxis 2. Acute respiratory distress syndrome (ARDS) 3. Chronic obstructive pulmonary disease (COPD) 4. Mitral valve prolapse
2. Acute respiratory distress syndrome (ARDS) ARDS is a complication associated with sepsis. ARDS causes respiratory failure and may lead to death, even after the client has recovered from sepsis. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial air flow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.
A client presents with a heart rate of 30 beats/min. The nurse notes a pacemaker in the client's right upper chest wall. What is the nurse's priority action? 1. Administer atropine. 2. Assess the blood pressure. 3. Review the medical record to determine when the pacemaker was placed. 4. Assess capillary refill.
2. Assess the blood pressure. Atropine, which blocks vagal stimulation, may be administered for symptomatic bradycardia. The nurse should determine if the client has complications of poor cardiac output and tissue perfusion such as hypotension, dizziness, or change in mental status. In an emergency, reviewing the medical record is done after assessment and any needed intervention. Although peripheral capillary refill may decrease during episodes of bradycardia, the blood pressure and mental status will give more information of systemic perfusion.
A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take? 1. Administer pain medication concurrently. 2. Monitor blood pressure continuously. 3. Evaluate arterial blood gases at least every 2 hours. 4. Monitor for signs of infection.
2. Monitor blood pressure continuously. The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine