Cardiac Adaptive Qs

A client reports foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. Which client statement indicates to the nurse that further teaching is needed?

"I will elevate my foot."

The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement?

"Red blood cells appear normal in size and color; however, there is a decreased amount produced."

A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best?

"The cause is incompetent valves of superficial veins."

Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor?

"The monitor will record any abnormal heart rhythms while I go about my usual activities."

Toursades de pointes interventions

- CPR - 1mg Epinephrine - CPR - H & Ts? - @@@ Magnesium IV push @@@@

A-fib crisis interventions

- Cardioversion - Metoprolol (5mg) - Vagal maneuevers if QRS is narrow

Normal HCO3 range

22-26 mEq/L

Following Advanced Cardiac Life Support (ACLS) guidelines, monophasic defibrillation with a _____J shock was carried out next.

360

The nurse is caring for a client after the client's open heart surgery (coronary artery bypass grafting [CABG]). Serosanguineous fluid drains from the client's chest tube. The nurse expects what volume of drainage from the tube during the first 24 hours after the surgery?

400 to 500 mL During the first 24 hours after CABG surgery, 500 mL of fluid will accumulate in the intrapleural space because of trauma and the inflammatory response; gradually, this amount will decrease.

A client is seen in the clinic with sickle cell crisis. Which hemoglobin range will the nurse expect to find?

6-8 g/100 mL (60-80 mmol/L) In sickle cell crisis, hemoglobin values are low, usually in the 6-8 g/100 mL (60-80 mmol/L) range showing many sickle-shaped cells, and the client also will have a low oxygen level.

When a Schilling test is prescribed for a client suspected of having cobalamin deficiency because of pernicious anemia, what should the nurse plan to do?

A 24-hour to 48-hour urine specimen assesses parietal cell function. After radioactive cobalamin is administered, its excretion is measured; if cobalamin cannot be absorbed, as in pernicious anemia, very little is excreted in the urine.

A nurse is working in the intensive care unit. Which client will the nurse be prepared to assist with cardioversion?

A client with supraventricular tachycardia Cardioversion involves administration of precordial shock, which is synchronized with the R wave to interrupt the heart rate. It is used for atrial fibrillation, supraventricular tachycardia, and ventricular tachycardia with a pulse when pharmaceutical preparations fail.

Which of the following statements about cardiopulmonary bypass are true?

A. Venous blood is drained into the cardiopulmonary bypass machine C. Blood is oxygenated, filtered, and temperature-regulated as it circulates through the cardiopulmonary bypass machine D. Oxygenated blood is returned to the body E. A dry, easily-visualized operative area is obtained while a patient remains on cardiopulmonary bypass

Postoperative hypothermia could have detrimental effects on Mr. Peterson. Negative consequences associated with perioperative hypothermia include:

A. increased risk for infection B. increased blood pressure C. increased serum catecholamine levels D. impaired clotting

A nurse is completing the admission assessment of a client with peripheral arterial disease (PAD). Which assessments will the nurse expect to observe? Select all that apply.

Absence of hair on the toes Reports of pain associated with exercising The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when arterial flow is impaired

A nurse is preparing medications. Which client's health problem motivates the nurse to question a prescription for a beta blocker?

Acute heart failure Beta blockers reduce cardiac output and must be started slowly, so they are contraindicated for clients with acute heart failure.

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client?

Ambulate early and frequently

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first?

Assess the client's heart and lung sounds

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care?

Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. Which postoperative intervention on the day after surgery is appropriate for the nurse to implement?

Assist the client with ambulation

To determine the status of a client's carotid pulse, where should the nurse palpate?

At the anterior neck, lateral to the trachea

What is the priority nursing action when caring for a client with disseminated intravascular coagulation?

Avoid giving intramuscular injections

The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding?

Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta." RA > RV > Lungs > LA > LV > Aorta

Troponin I and A general info

Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI) were also drawn and are being followed. Cardiac troponins are proteins that exist in myocardial cells. With myocardial injury, they are released into the serum. Cardiac troponins (especially cTnI) are more specific for cardiac injury that CK-MB. On average, cTnI and cTnT levels rise within several hours after myocardial injury, and remain elevated 10-14 days.

The nurse observes a client collapse while walking down the hallway and establishes unresponsiveness. What should the nurse do first?

Check for a carotid pulse

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear?

Crackles Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration

A client has left ventricular heart failure. For which clinical indicators should the nurse assess the client? Select all that apply.

Crackles Dyspnea on exertion

A client with dehydration suddenly becomes diaphoretic, clammy, and pale. The client's blood pressure falls to 50/30 mm Hg. In which position will the nurse place the client?

Feet elevated with head at 20-degree angle Feet elevated while keeping head flat or elevated to no more than a 30-degree angle is the best position for hypovolemic shock.

To assess for a pericardial friction rub, you would help a patient assume which position?

Fowler's and leaning forward

A client with multiple myeloma is scheduled to have a chest x-ray examination and a bone scan. For this client, what is the primary responsibility of the nurses and other members of the healthcare team?

Handle the client with supportive movements Because of bone erosion, pathologic fractures are a common complication of multiple myeloma.

A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client?

Hematoma formation

A blood transfusion of packed cells has been prescribed for a client. The transfusion started 5 minutes ago, and the client is complaining of chest pain, nausea, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 99.2° F (37.3° C), and the client seems less alert. What should the nurse suspect?

Hemolytic reaction Chest pain, nausea, difficulty breathing, and chills are early signs of hemolytic reaction, which occurs with incompatible blood.

A client receiving hemodialysis has an external shunt for circulatory access. With which life-threatening complication associated with external cannulas should the nurse be most concerned?

Hemorrhage

After administering Tenormin (atenolol), you carefully monitor Mr. Swan for which of the following reasons?

His heart rate may decrease His blood pressure may decrease

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client?

Increase oxygen concentration to heart cells

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common?

Increased cardiac workload With anemia, the heart works harder to compensate for the reduced oxygen-carrying ability of the blood. With polycythemia, the heart works harder to propel more viscous blood through the circulatory system.

A client is found unconscious and unresponsive. What should the nurse do first?

Initiate a code (check for CAROTID pulse after)

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first?

Instruct the client to remain in bed

When auscultating for a pericardial friction rub, the chest piece of the stethoscope is placed at which location?

Left sternal border A pericardial friction rub is best heard at the left sternal border, at the third intercostal space. This location is also called Erb's point.

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure?

Left ventricular functioning

Which drug should be available to treat Jane Doe's premature ventricular contractions (PVCs)?

Lidocaine Lidocaine is an antiarrhythmic drug used in the treatment of ventricular ectopy. A bolus IV injection is indicated to obtain therapeutic levels quickly

normal hematocrit levels

Male: 45%-52% Female: 37-48%

Normal Hgb levels

Men: 14-18 Women: 12-16

A nurse is auscultating a client's heart sounds and hears S 1. Which valves is the nurse assessing?

Mitral and tricuspid

A nurse is auscultating a client's heart; closure of what structures produces the first heart sound (S1)?

Mitral and tricuspid valves

After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves?

Removing the dilated superficial veins

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? Select all that apply.

Seizures Confusion

Sinus Tach interventions

Treat the underlying cause - Oxygen - Fluid bolus PACS = common, can occurs during electrolyte imbalances, excess caffeine, stress.

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure?

Unusual fatigue Dependent edema Nocturnal dyspnea Weight gain Urinary output decrease Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia; women more commonly report unusual fatigue than men. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure.

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply.

Unusual fatigue Dependent edema Nocturnal dyspnea

An older adult with peripheral vascular disease has stopped smoking, and the client's children want to make the home environment safe. What should the home healthcare nurse emphasize when providing instructions?

Use measures that can prevent thermal injuries The ability to perceive extremes in temperature is limited in the presence of peripheral vascular disease. Prevention of thermal injury through avoidance of hot and cold (e.g., hot water, heating pads, ice packs) is advised.

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?

Verify the pulse by using a Doppler

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe?

blood product replacement

You discuss with Jane the factors that determine cardiac output. These include:

contractility, preload, afterload, heart rate

Pronestyl (procainamide)

may be tried for treatment of a stable, wide-complex tachycardia of unknown origin.

A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. Which is the priority nursing intervention for this client?

Provide pain medication

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment?

Pulsating abdominal mass

With acute pericarditis, changes may also be noted on the patient's ECG. Which of the following ECG changes is most helpful in identifying acute pericarditis?

ST-segment elevation in all leads except AVR

When Rosie is assessing her client with chest pain, she is evaluating whether or not the client is suffering from angina or MI. Which symptom would be indicative of an MI?

Substernal chest pressure relieved only by opioids

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication?

Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin.

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand?

The dilated saphenous veins are removed

A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60 mm Hg. What should the nurse assess in the client as an early sign of decreased arterial pressure?

Weak radial pulses Hypovolemia occurs with decreased cardiac output; the resulting decreased arterial pressure is reflected in weak,

A client with coronary artery disease is scheduled for a cardiac catheterization. What should the client be able to describe if the nurse's preoperative teaching is considered effective?

What will be experienced during the procedure

Cardiogenic shock results from

a decrease in cardiac output.

Early septic shock is characterized by

a high cardiac output (CO) (greater than 8 liters per minute), high cardiac index (CI), and low pulmonary artery pressure (PAP) and pulmonary artery occlusion pressure (PAOP/PCWP)

The patient experiencing an MI may also present with other symptoms such as

confusion, breathlessness, hypotension, diaphoresis, weakness, nausea, syncope, or dysrhythmias

Coronary artery bypass graft (CABG) surgery

the most common type of cardiac surgery performed, improves myocardial perfusion by bypassing narrowed or obstructed coronary vessels. During surgery, a graft from the internal mammary artery (IMA) and/or a saphenous vein or radial artery, is attached to the aorta and anastomosed to the diseased coronary artery (distal to the point of occlusion). Tissue perfusion is reestablished by this procedure. Patients should experience symptomatic relief of chest pain, as well as an improved prognosis if that was a goal.

A positive Homans sign occurs with

thrombophlebitis

Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching?

"A pillow under the knees can result in clot formation because it slows blood flow."

After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse?

"You will be able to run progressively longer distances before tiring."

V fib (pulseless) interventions

- CPR - Shock - Epinephrine 1mg (while still giving CPR) - Reshock, analyze? - Amiodarone 300mg - If airway placed, braeths not needed (machine at 10), continue CPR while letting machine give breaths - NARCAN? (0.2mg) If morphine overdose and respiratory depression ensues (RR <10).

Two defibrillation attempts with Jane Doe have been unsuccessful. Jane Doe's cardiac monitor exhibits ventricular fibrillation (VF). Which of the following actions are indicated now?

-Administration of epinephrine -Continued cardiopulmonary resuscitation (CPR)

Mr. Swan is also taught which of the following regarding his use of Tenormin (atenolol)?

-He should delay taking a dose if his pulse is less than 60 beats per minute -He should monitor his weight and report any increase in weight -He may experience erectile dysfunction as a side effect -He should avoid stopping the drug abruptly since rebound chest pain might occur

Mr. Swan is also taught about nitroglycerin and its common side effects. In particular, he is taught about:

-Headache -Dizziness -Flushing

A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply

1.Dependent edema 2.Distended abdomen 3.Polyuria at night

INR desired therapeutic level

2-3.5

The nurse is completing an assessment on a couple seeking genetic counseling for sickle cell anemia. Both prospective parents carry sickle cell traits. The nurse recognizes that the couple has what chance of having a child who develops the disease?

25% Sickle cell is an autosomal recessive genetic disorder. If both individuals have sickle cell traits, there is a 25% chance they will produce a child with the disease

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status?

A low hemoglobin level causes reduced oxygen-carrying capacity.

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic?

Activated partial thromboplastin time (APTT) is double the control value Activated partial thromboplastin time should be 1.5 to 2.5 for the control of heparin therapy. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT increases to a range of 150 to 200 when heparin reaches therapeutic levels.

A client has serially decreasing blood pressures after surgery. Which mechanisms involved in the regulation of blood pressure should the nurse consider? Select all that apply.

Activation of regulators that control renal angiotensin II Increase of left ventricular stroke volume to maintain blood volume Enervation of the sympathetic nervous system to constrict arterioles

During auscultation of the heart, where does the nurse expect the first heart sound (S 1) to be the loudest?

Apex of the heart

A client who is suspected of having leukemia has a bone marrow aspiration. What should the nurse do Immediately after the procedure?

Apply brief pressure to the site.

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of?

Cardiac irritability

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of?

Cardiac irritability is the cardinal reason for PVCs

A client had a pneumonectomy. For which postoperative complication specific to this type of surgery should the nurse assess this client?

Cardiac overload Cardiac overload can be caused by the loss of the large vascular lung or a mediastinal shift.

Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI)

Cardiac troponins are proteins that exist in myocardial cells. With myocardial injury, they are released into the serum.Cardiac troponins (especially cTnI) are more specific for cardiac injury that CK-MB. On average, cTnI and cTnT levels rise within several hours after myocardial injury, and remain elevated 10-14 days.

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis?

Cold, clammy skin The action of the sympathetic nervous system causes vasoconstriction, and as cellular and peripheral hypoperfusion progresses, the skin becomes cold, clammy, cyanotic, or mottled. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs

Why is Coronary artery bypass graft (CABG) surgery is not a cure for coronary artery disease?

Coronary artery disease, characterized by insufficient blood supply to the myocardium, is generally caused by coronary atherosclerosis. This disorder of lipid metabolism causes the accumulation of fat-containing substances along the intima of coronary arteries. These substances narrow or obstruct vessels, impairing blood flow to the areas perfused by the involved vessels. Atherosclerosis can possibly be prevented, but not cured.

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply.

Crackles Coughing Orthopnea Frothy blood tinged sputum

CL general info

Creatine kinase (CK) is an enzyme normally present in the heart, skeletal muscle, brain, and gastrointestinal tract. When tissue injury occurs to these areas, serum CK elevates. Each of the CK isoenzymes, CK-MB, CK-MM, and CK-BB is specific for different sites of tissue damage. CK-MM and CK-BB are specific for damage to skeletal muscle and brain tissue, respectively. CK-MB is sensitive for myocardial necrosis. On average, CK-MB rises 3-6 hours after myocardial tissue injury, peaks at 12-24 hours, and returns to normal in 3-4 days.

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority?

Decrease the workload on the heart and promote maximum coronary artery filling

A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse?

Decreased force of contraction

When caring for a client who has hyponatremia, the nurse would monitor for which symptom?

Decreased specific gravity

The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis? Select all that apply.

Dyspnea Diaphoresis Tachycardia

The nurse is assessing a client with the diagnosis of left ventricular failure. Which assessment finding does the nurse expect to identify?

Dyspnea on exertion

A primary healthcare provider decides to omit a treatment that was part of a course of chemotherapy for a client because the client demonstrates myelosuppression. What information would be appropriate for the nurse to give to the client regarding myelosuppression?

Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. Myelosuppression involves a decreased number of red blood cells (anemia), resulting in a reduced oxygen-carrying capacity of the blood and fatigue

Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply.

Edema Ascites

Which information indicates an increased risk for coronary artery disease (CAD)?

Family history or hyperlipidemia frequent consumption of high fat diet smoking

A client demonstrates signs and symptoms of a transfusion reaction. The nurse immediately stops the infusion; what should the nurse's next action be?

Hang a bag of normal saline with new tubing

How should the nurse prepare for the inspection of the precordium?

Help the client to a supine position on the bed with his chest exposed

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?

How long the client was anoxic Irreversible brain damage will occur if a client is anoxic for more than four minutes

A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority?

Immediate defibrillation

Describe 1st degree HB

In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session?

Increased blood viscosity

A nurse is performing external cardiac compression. Which action should the nurse take?

Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it.

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.

Irregular heart rate Muscular weakness Decreased bowel sounds

A thallium scan is prescribed for a client with a history of chest pain. Which information should the nurse include when explaining the purpose of the test to the client?

It assesses myocardial ischemia and perfusion. @@important@@@

For which expected response should the nurse monitor a client after a cardiac catheterization?

Marked increase in the volume of urine output

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop?

Metabolic acidosis

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what?

Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop?

Metabolic acidosis Hyperkalimia PCO2 increase Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis.

A client who recently had a myocardial infarction is admitted to the cardiac care unit. How can the nurse best determine the effectiveness of the client's ventricular contractions?

Monitoring urinary output hourly A decreased urinary output reflects a decreased cardiac output (kidney perfusion); immediate action is indicated if urinary output decreases.

What clinical finding should the nurse expect when assessing a client who had a splenectomy?

Pain on inspiration

The spouse of a patient who had emergency coronary artery bypass surgery asks why there is a dressing on the patient's left leg. How should the nurse explain the dressing?

"A vein in the leg was used to bypass the coronary artery."

Mr. Leon asks you why he is getting amiodarone, since he did not take this drug before surgery. What is the best response to his question?

"Following open heart surgery, it is very common to have an abnormal heart rhythm. This drug is given to help keep your heart rhythm normal."

A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse?

"It manages an abnormally slow heart rate." Vagal stimulation during surgery may cause a severe bradycardia; in anticipation, pacemaker wires are inserted into the right atrium to be used to initiate impulses if the natural rate decreases below the preset rate of the pacemaker; this will ensure that the heart beats at the rate set for the pacemaker. This pacemaker initiates an impulse if the heart rate drops below a certain rate; the concept underlying this pacemaker is to speed up the heart, not to slow it down.

A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best response by the nurse?

"Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

HDL level that equals increased risk for women?

An HDL of less than 50mg/dL for women indicated increased risk

Which cardiac isoenzyme is the most sensitive indicator for myocardial damage?

Creatine kinase-MB fraction (CK-MK).

A client is experiencing tachycardia. Which adverse hemodynamic effects will the nurse consider when planning care for this client? Select all that apply.

Decreased ventricular filling time Decreased cardiac output Tachycardia is a fast heart rate; the fast heart rhythm may cause a decrease in cardiac output because of the decreased filling time for the ventricles

A client who is to have sclerotherapy asks the nurse, "How did I get varicose veins?" Which etiology should the nurse take into consideration when formulating a response?

Defective valves within the veins

What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)?

Deflate the balloon as soon as the PCWP is measured

The primary healthcare provider prescribes two units of packed red blood cells for a client who is bleeding. Before blood administration, what is the nurse's priority?

Determining proper typing and crossmatching of blood

A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period?

Dysrhythmias, especially atrial fibrillation

Creatine kinase (CK)

Enzyme normally present in the heart, skeletal muscle, brain, and gastrointestinal tract. When tissue injury occurs to these areas, serum CK elevates. Each of the CK isoenzymes, CK-MB, CK-MM, and CK-BB is specific for different sites of tissue damage. CK-MM and CK-BB are specific for damage to skeletal muscle and brain tissue, respectively.CK-MB is sensitive for myocardial necrosis. On average, CK-MB rises 3-6 hours after myocardial tissue injury, peaks at 12-24 hours, and returns to normal in 3-4 days.

A client develops iron-deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased?

Ferritin level Ferritin, a form of stored iron, is reduced with iron-deficiency anemia

After receiving 75 mL of packed red blood cells, the client complains of chills and low back pain. The nurse suspects a hemolytic transfusion reaction and stops the infusion. The blood bag and a urine specimen are sent to the laboratory. What will the urine specimen be tested for?

Free hemoglobin

A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse notifies the surgeon. What is the rationale for the nurse's action?

Graft is leaking. Hypertension increases pressure on the suture lines, which can affect the integrity of the graft or the graft causing leaking or rupture

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply

Hypotension Pulsus paradoxus Muffled heart sounds Jugular vein distention

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses?

Hypovolemic shock

What is the term for shock associated with a ruptured abdominal aneurysm?

Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel.

The nurse is caring for a client who is receiving therapy for vitamin B 12 deficiency. Which finding indicates that the therapy is having the desired effect?

Improved hemoglobin and hematocrit levels

A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home?

Increased edema in the leg that provided the donor graft

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change?

Increased intravascular volume As fluid is administered intravenously or retained by the kidneys, the intravascular fluid volume increases, resulting in increased preload and afterload, increasing pulmonary artery wedge pressure & increased afterload

The client is admitted with paroxysmal supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and the client is asymptomatic except for a "fluttering feeling" in the chest. Which treatments should the nurse be prepared to administer? Select all that apply.

Intravenous adenosine Intravenous beta blockers Intravenous amiodarone Intravenous calcium channel blockers If the client is symptomatic or hemodynamically unstable, **synchronized cardioversion** is considered

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer?

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse

After preparing the client the nurse visually inspects the precordium by first observing for an apical impulse. The nurse is unable to observe for an apical impulse. The nurse next assesses for a left ventricular heave.

Left midclavicular line 5th intercostal space

A client is diagnosed with hypertension that is related to atherosclerosis

Lipid plaque formation occurs within the arterial vessels

Hypovolemic shock is characterized

Low cardiac output (CO), cardiac index (CI), pulmonary artery pressure (PAP), and pulmonary artery occlusion pressure (PAOP/PCWP) characterize hypovolemic shock.

A client has a tentative diagnosis of Hodgkin disease. How does the nurse expect the diagnosis to be confirmed?

Lymph node biopsy The diagnosis depends on the identification of characteristic histologic features of an excised lymph node.

The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively?

Maintaining a reduced blood pressure

Which group of clients should the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas?

Older adults

A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit? Select all that apply.

Oliguria Hypotension Tenting tissue turgor

key features of left-sided heart failure

Oliguria, pallor, and cool extremities

An 80-year-old client with a history of coronary artery disease is admitted to the hospital for observation after a fall. During the night the client has an episode of paroxysmal nocturnal dyspnea. In what position should the nurse place the client to best decrease preload?

Orthopneic (Tripod)

Mr. Peterson's hemoglobin (Hgb) and hematocrit (Hct) are low. You anticipate an order for which of the following?

Packed red cells are indicated for correction of red cell deficit. Circulating fluid volume will also be increased with the administration of packed red cells.

A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical?

Pain when exercising and thickening of the toenails Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails.

A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply.

Pallor Tachycardia Hypotension Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension occurs in response to hemorrhage as the person experiences hypovolemia.

Which of the following measures help prevent venous stasis and deep vein thrombosis (DVT)?

Passive leg exercises Active leg exercises Ambulation Support stockings

A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action should the nurse take to prepare for the arrival of the client?

Prepare equipment for chest tube insertion. The priority is to reinflate the lungs and stabilize the client's respiratory status.

A client is admitted to the critical care unit after receiving multiple injuries in a motorcycle accident. Twelve hours later the client reports increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed, and the client is scheduled for an emergency splenectomy. What should the nurse include when providing preoperative teaching?

Presence of abdominal drains for several days

A nurse is caring for a client with varicose veins. Which clinical manifestations should the nurse expect with this diagnosis? Select all that apply.

Presence of ankle edema Increased muscle fatigue Report of leg fullness and pruritus Presence of ankle edema, increased muscle fatigue, and a report of leg fullness and pruritus are signs of varicose veins caused by venous dilation resulting from incompetent valves that are expected to prevent backflow. Varicose veins do not affect arterial circulation (diminished pulses).

A primary healthcare provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive?

Pseudoephedrine Pseudoephedrine has a pressor effect that may counteract antihypertensive medications, causing an increase in blood pressure.

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, what is the most accurate measurement of the client's left ventricular pressure?

Pulmonary capillary wedge pressure Pulmonary capillary wedge pressure is an indirect measure of left ventricular end-diastolic pressure, an indication of ventricular contractility.

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan about prevention of thrombophlebitis?

Put on elastic stockings before arising

A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include?

Put the stockings on before rising in the morning.

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what?

Tissue necrosis

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization?

To visualize the disease process in the coronary arteries

A client is receiving warfarin. The nurse explains the need for careful regulation of dietary intake of vitamin K. What is the rationale for the nurse's teaching?

Vitamin K promotes prothrombin formation by the liver. Vitamin K promotes the liver's synthesis of prothrombin, an important blood clotting factor, and will reverse the effects of warfarin.

A client comes to the emergency department with pressure in the chest and shortness of breath. The client is admitted for observation after receiving a tentative diagnosis of a myocardial infarction. Which assessment finding should the nurse monitor for in this client that supports this diagnosis?

Vomiting Nausea and vomiting are clinical manifestations that are associated with a myocardial infarction. The heart rate will increase.

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.

Vomiting Muscle weakness Irregular heart rate Diarrhea Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle, and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The mother shares that she is 4 weeks pregnant and questions as to whether this pregnancy will result in a child with hemophilia. What is the best response by the nurse?

With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child

For a patient presenting with chest pain in an Emergency Department (ED) setting, determining whether the patient is a candidate for reperfusion is a priority, why?

With reperfusion, coronary artery patency can be restored, and infarct size can be limited. Reperfusion can be accomplished with primary percutaneous coronary intervention (PCI), and/or with fibrinolytic drugs. When a patient is a candidate for reperfusion, primary percutaneous coronary intervention (PCI) is preferred for reperfusion, because it is likely to result in more effective reperfusion. However, PCI is preferred only when it can be done quickly (within a few hours of an acute MI) and accomplished by a team with a high success rate.PCI usually involves percutaneous transluminal coronary (balloon) angioplasty (PTCA), laser angioplasty, and/or the implantation of intracoronary stents @@@@IMPORTANT@@@@@

You start Mr. Whiting's Intropin (dopamine) IV drip. In evaluating the effectiveness of the Intropin (dopamine) IV drip, you observe for:

an increase in heart rate;an increase in urine output

The administration of sodium bicarbonate should be based on

arterial blood gas (ABG) results that indicate the presence of severe acidosis. CPR, defibrillation, and antiarrrhythmic drugs are the initial therapies for treatment of cardiac arrest.

Unstable angina (UA) is defined by

at least one of the following: severe, new onset (less than six weeks) chest pain, chest pain at rest that lasts more than ten minutes, or crescendo-pattern (worsening in severity or frequency) chest pain. It may be associated with nonspecific changes on electrocardiogram (ECG).

Signs and symptoms of myocardial infarction (MI) are highly variable. The patient experiencing an MI may present with

chest pain, confusion, breathlessness, hypotension, diaphoresis, weakness, nausea, syncope, and/or dysrhythmias

Educating Mr. Swan about prescribed drugs is important. As you administer Tenormin (atenolol) to Mr. Swan you teach him that this drug is given to

decrease the oxygen needs of his heart Tenormin (atenolol), a beta-blocker, inhibits the effect of the sympathetic nervous system on the heart. Heart rate, blood pressure, and heart contractility are reduced. Cardiac workload and oxygen consumption are decreased. Myocardial perfusion and subsequently oxygen supply are increased. Beta-blockers improve the myocardial oxygen supply-demand relationship, and reduce the likelihood of recurrent ischemia and infarction

Intropin (dopamine) is indicated for

hemodynamically-significant hypotension (without hypovolemia). It can be used for hypotension associated with bradycardia while pacing is being set up (client in 3rd degree HB)

Levophed (norepinephrine) is indicated for

hemodynamically-significant hypotension and cardiogenic shock

Before having sclerotherapy for varicose veins, a client asks the nurse why a solution is injected into the vein. How should the nurse respond?

"The solution causes the vein to scar and collapse. The vein is reabsorbed into local tissue and eventually fades."

A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram (ECG). Which explanation should the nurse include when teaching the client about this procedure?

"This is a noninvasive test to check your heart's response to physical activity.

A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond?

"This surgery significantly decreases symptoms in most clients." The majority of those who have this surgery have marked relief from their symptoms because the flow of blood to myocardial cells is increased.

A client comes to the clinic reporting weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. Which question is most appropriate for the nurse to ask initially?

"When did it first become evident to you that you had a fever?" The length of time a low-grade fever is present, together with a history of night sweats and other physical findings, is valuable information in assisting the nurse with care planning and helping the primary healthcare provider determine a diagnosis.

What sound is significant and heard in patients with myocardial infarction (MI), heart failure, hyperthyroidism, pulmonary hypertension, and aortic and pulmonary stenosis?

A fourth heart sound (atrial S4) is caused by an increased diastolic pressure or overloading of the ventricles. It is considered normal in children and some well-conditioned athletes. However, it is not heard in patients with pericarditis.

A client with angina pectoris is scheduled for a stress echocardiogram. What should the nurse tell the client that an echocardiogram is?

A noninvasive approach to assess cardiovascular status A stress echocardiogram is noninvasive and uses echoes from pulsed high-frequency sound waves to locate and study the movements and dimensions of cardiac structures; it assesses myocardial disease, valve function, congenital heart defects, blood flow abnormalities, and systemic and pulmonic hypertension. A stress echocardiogram assesses structural defects as well as blood flow abnormalities. A stress echocardiogram is valuable in diagnosing and indicating treatment for a variety of conditions involving the heart's structure and function. A stress echocardiogram is not an invasive examination.

After MI, if a patient complained of chest pain characteristic of pericarditis, you would auscultate his chest for which of the following?

A pericardial friction rub A pericardial friction rub is commonly heard in pericarditis, due to inflammation of the parietal and visceral layers of the pericardium. It is a high-pitched sound, heard better with a diaphragm chest piece, and often described as coarse or scratchy. Other signs and symptoms of pericarditis include joint pain, fever, night sweats, and weakness.

A child in sickle cell crisis is admitted to the pediatric unit. Which actions will the nurse take? Select all that apply

Administer hydroxyurea Apply oxygen via nasal cannula Offer age-appropriate activities Administer intravenous (IV) hydration

After verbalizing "all clear" and visually verifying that no one is in contact with Jane Doe or attached devices, monophasic defibrillation using a 360 J shock is administered. CPR is resumed. VF continues. Which drug do you have available for use now?

Amiordone According to ACLS guidelines, the antiarrhythmic drug amiodarone is a drug of choice to follow unsuccessful defibrillation at this time. When ventricular fibrillation (VF) does not respond to epinephrine and defibrillation, amiodarone is the next drug of choice. Amiodarone 300 mg, administered IV in 20-30 mL D5W, is followed by defibrillation. If VF continues, amiodarone 150 mg can be administered after 3-5 minutes. Lidocaine is also an acceptable antiarrhythmic, but is less preferred

A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing?

Anaphylactic shock Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish.

A client with varicose veins is scheduled for surgery. Which clinical finding does the nurse expect to identify when assessing the lower extremities of this client?

Ankle edema

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? Select all that apply.

Anorexia Leg cramps The gastrointestinal manifestations associated with hypokalemia are caused by decreased neuromuscular irritability of the gastrointestinal tract; this results in anorexia, nausea, vomiting, and decreased Peristalsis [1] [2]. Because of potassium's role in the sodium-potassium pump, hypokalemia results in altered neuromuscular functioning, which precipitates leg cramps.

The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse will look for potential causes. Which causes will the nurse look for in this client? Select all that apply.

Anxiety Caffeine Exercise Anemia The dysrhythmia itself is not treated, but the cause is identified and treated appropriately. Causes of sinus tachycardia include hypovolemia, heart failure, anemia, exercise, use of stimulants, fever, sympathetic response to fear or pain.

You know how useful the intraaortic balloon pump (IABP) can be in assisting a failing heart. You also know that it cannot be used with all patients. For which of the following conditions is the IABP contraindicated?

Aortic valve insufficiency The intraaortic balloon pump (IABP) is contraindicated with aortic valve insufficiency. Proper functioning of the IABP depends on normal aortic valve opening and closing. If the aortic valve does not close properly, balloon inflation would fill the left ventricle from the aorta. Abdominal aortic aneurysm The intraaortic balloon pump (IABP) would be contraindicated if the patient had an existing abdominal aortic aneurysm. Use of IABP could lead to rupture of the aneurysm. The intraaortic balloon pump (IABP) would also be contraindicated in the presence of an active aortic dissection. Use of IABP could worsen the dissection, which could be fatal.

A client is admitted to the hospital with a large leg ulcer, and a femoral angiogram is performed. What should the nurse do after this procedure?

Apply pressure to the catheter insertion site Pressure promotes coagulation and prevents the complication of bleeding. Bending the operative leg may cause decreased perfusion to the leg or bleeding at the catheter insertion site

Chest pain assessment and MI considerations based on age/gender

Assessment for chest pain is especially important. Chest pain often occurs with MI, but the pain associated with MI can be highly variable.With MI, chest pain may be located over the precordium or may be substernal -- it may radiate to one or both arms, the neck, the jaw, or other areas. It may be described in many ways, including squeezing, heavy pressure, aching, or a burning discomfort. The onset of pain is usually sudden, and its duration is generally more than 30 minutes. Pain is often severe. Women and diabetics often have an atypical presentation, reporting pain in the neck or throat, and/or fatigue and dizziness. Pain may not be present at all with MI, especially in elderly and diabetic persons.

Which condition may cause the gradual occlusion of the internal or common carotid arteries, manifested by transient ischemic attacks?

Atherosclerosis of the vascular system

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus?

Atrial fibrillation Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli.

Given Jane Doe's current ECG rhythm of bradycardia, which of the following is the drug treatment of choice?

Atropine Jane Doe is in sinus bradycardia and she is hypotensive. Atropine is the drug of choice for treatment of symptomatic bradycardia. It enhances both sinus node and atrioventricular (AV) node conduction. Atropine must be used cautiously when there is acute coronary ischemia or myocardial infarction because it increases myocardial oxygen consumption

A client being treated for uncontrolled hypertension and chest pain calls out to the nurse and reports a nosebleed. Upon entry to the client's room, the nurse immediately applies pressure. Which action should the nurse take next?

Auscultate the client's blood pressure.

A client being treated for uncontrolled hypertension and chest pain calls out to the nurse and reports a nosebleed. Upon entry to the client's room, the nurse immediately applies pressure. Which action should the nurse take next?

Auscultate the clients blood pressure

A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.

Avoid IM injections Examine the skin for ecchymotic areas

A client is diagnosed with pancytopenia caused by chemotherapy. What should a nurse teach the client about this complication?

Avoid traumatic injury and exposure to infection

A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects which diagnostic finding specific for multiple myeloma?

Bence Jones protein in the urine Bence Jones protein (globulin) results from tumor cell metabolites. It is present in clients with multiple myeloma.

To evaluate Mr. Swan's response to nitroglycerin, which of the following assessments are indicated?

Blood pressure Chest discomfort

What is the most definitive test to confirm a diagnosis of multiple myeloma?

Bone marrow biopsy

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

Bradycardia Hypotension Bladder dysfunction

After multiple bee stings, a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what processes?

Bronchial constriction and decreased peripheral resistance

Mr. Whiting's condition has significantly deteriorated. Hemodynamic pressure readings suggest which complication associated with an MI?

Cardiogenic shock hemodynamic pressures reflect cardiogenic shock, which usually occurs when the heart has lost 40% of its pumping ability. His anterior wall MI has led to this serious complication, in which cardiac output (CO) and cardiac index (CI) are low, and pulmonary artery pressure (PAP), right atrial pressure (RAP), and pulmonary artery occlusion pressure (PAOP/PCWP) are elevated. A reduced cardiac output has caused reduced tissue perfusion and oxygenation. Underperfusion of the kidneys has resulted in a decreasing urine output. Inadequate oxygenation of the brain has caused Mr. Whiting to become confused. Mr. Whiting's skin is pale, cold, and clammy because of reduced peripheral tissue perfusion, as compensation occurs and blood is shunted to more vital organs.

Early recognition and treatment of cardiogenic shock is critical. In patients at risk for cardiogenic shock, which of the following signs often appears early as the heart fails?

Change in level of consciousness A decrease in cardiac output results in poor perfusion and oxygenation. A change in level of consciousness, due to hypoxia from inadequate perfusion of the brain, is often an early sign of cardiogenic shock. Ongoing assessment of level of consciousness is indicated in all patients after acute MI. Confusion and irritability may be early signs of a failing heart and cardiogenic shock.

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history?

Childhood strep throat Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart.

A nurse is caring for a client with the diagnosis of right ventricular failure. Which condition unrelated to cardiac disease is the major cause of right ventricular failure?

Chronic obstructive pulmonary disease (COPD)

A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care?

Client has increased plasma hydrostatic pressure.

A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit?

Clients who have atrial fibrillation have a pulse deficit caused by reduction of preload. An accelerated heart rate is known as tachycardia

After undergoing a cardiac catheterization, the client complains of tingling sensations in the affected leg. What should the nurse do to determine the cause of the tingling?

Compare femoral, popliteal, and pedal pulses in both legs Tingling indicates decreased arterial circulation to the extremity; it may be caused by an embolus distal to the arterial insertion site. Checking all pulses will help locate an embolus. Tingling sensations of an extremity are not related to bleeding, but rather to lack of circulation

Constriction of the peripheral vessels increases the force of flow.

Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels

A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take?

Continue to monitor the client Premature atrial contractions usually are benign if they occur at a rate of fewer than 10 per minute. Their presence indicates atrial irritability, and the client should be monitored closely.

left-sided heart failure characterized by

Crackles in the lung, indicating the presence of fluid, characterize left-sided heart failure. In left-sided heart failure, there is back up of blood entering the left side of the heart from the lungs. shortness of breath, bilateral basilar crackles, and abnormal chest x-ray are a result of failure of the left ventricle to function properly, secondary to infarction. The presence of a third heart sound (S3, an extra heard sound, heard in early diastole) is also consistent with left ventricular failure. These signs and symptoms characterize pulmonary edema, which develops as a result of backup of fluid in the lungs as the left side of the heart fails as a pump (acute left ventricular failure).

You are aware that Nipride (nitroprusside), if administered over a period of days, can cause:

Cyanide poisoning Nipride (nitroprusside) is transformed to cyanide and then metabolized by the liver to thiocyanate, which is cleared by the kidney. Excessive, prolonged use of Nipride (nitroprusside) can cause cyanide or thiocyanate toxicity. To prevent this from occurring, serum levels of each are monitored. Patients should be assessed for signs of thiocyanate toxicity, including abdominal pain and mental changes (psychosis, confusion, weakness, tinnitus, hyperreflexia, seizures, headache, dilated pupils, dizziness). Signs of cyanide toxicity include tachycardia, acidosis, and a decline in cardiac output.

Nitroglycerin titrated IV, and a stat dose of morphine sulfate IV push, provide temporary pain relief. Morphine, a narcotic analgesic, is commonly used to alleviate chest pain. When used with a patient having chest pain, other therapeutic actions of morphine include:

Decrease in anxiety Reduction of preload (This is a scam question, as "respiratory depression" is an effect but not a therapeutic effect)

A lidocaine IV drip is started. You observe Mr. Whiting for safe and effective lidocaine administration. Which of the following reflects an expected therapeutic effect of lidocaine?

Decrease in premature ventricular contractions (PVCs) Lidocaine is an antidysrhythmic specifically given for treatment of ventricular dysrhythmias. Premature ventricular contractions (PVCs) should decrease with the administration of a lidocaine IV drip. PVCs are common in the first few hours after MI and are usually transient. However, when PVCs occur coupled, in bursts of three of more, are multiform in shape, or more than six occur per minute, treatment with lidocaine is usually initiated. When lidocaine is used post-MI, serum levels are closely followed, since lidocaine clearance is reduced after MI. Lidocaine is not used prophylactically after MI.

Which symptoms indicate to the nurse that the client has an inadequate fluid volume? Select all that apply.

Decreased urine Hypotension Dry mucous membranes Poor skin turgor

What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)?

Deflate the balloon as soon as the PCWP is measured.

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

Dependent edema Swollen hands and fingers Right upper quadrant discomfort With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.

Dependent rubor Ulcers on the toes Delayed capillary refill

When assessing the client with peripheral arterial disease (PAD) , the nurse anticipates the presence of which clinical manifestations? Select all that apply.

Dependent rubor Ulcers on the toes Delayed capillary refill Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill longer than three seconds.

Which of the following is routinely used during intraaortic balloon pump (IABP) therapy to avoid complications?

Dextran Low-molecular-weight Dextran (Dextran 40), a volume expander with hemodilution properties, is used concurrently with intraaortic balloon pump (IABP) therapy to prevent thrombus formation along the IABP catheter, and to promote sufficient venous flow in the affected lower extremity

A nurse assesses a client for increasing intracranial pressure by monitoring the pulse pressure. What is the pulse pressure?

Difference between systolic and diastolic readings

For which client should the nurse conclude that a prescription for digoxin is appropriate?

Digoxin is used to treat atrial fibrillation

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure?

Dilation of blood vessels

A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply.

Distended abdomen Dependent edema Urinating at night Distended neck veins Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by a distended abdomen, dependent edema, and urinating at night. Distended, not collapsed, neck veins occur in right-sided heart failure. Cool extremities are key features of LEFT-sided heart failure

A nurse expects that a client with right-sided heart failure will exhibit which of these signs or symptoms?

Distended neck veins Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure

A client who had injection sclerotherapy for varicose veins is advised to wear compression (support) stockings. What is most important for the nurse to explain to the client about compression stockings?

Don the stockings before getting out of bed in the morning. To prevent distention of the veins, stockings should be applied before the legs are placed in a dependent position. Stockings should be used preventively before the discomfort associated with venous pressure and edema occurs.

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client

Edema of the left leg Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return.

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client?

Edema of the left leg Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return.

A client who had abdominal surgery 24 hours ago reports pain in the left calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do first?

Elevate both legs The clinical findings indicate a possible thrombophlebitis. The legs should be elevated and the healthcare provider notified immediately. A thrombus may progress to a pulmonary embolus. The legs should be kept elevated until the client is evaluated by the healthcare provider.

A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?

Elevate the legs

An electrocardiogram is prescribed for a client complaining of chest pain. The nurse recognizes which as an early finding of an infarcted area of the heart?

Elevated ST segments

A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for?

Elevated U and flattened T waves

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?

Emboli associated with atrial fibrillation Emboli, occurring from atrial fibrillation, cause complete occlusion of vessels; usually middle cerebral arteries are involved. The infarct may cause hemiplegia, aphasia, or spatial perceptual deficits.

A client with a history of thrombophlebitis and varicosities is to have a herniorrhaphy for an incarcerated hernia. What primary nursing action should be implemented postoperatively considering the client's medical history?

Encourage the client to turn often and to exercise the legs regularly. Because of the client's history and the site of the surgery, thrombi are likely to develop; activity is a preventive measure.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what symptoms of bleeding they should be looking for in the future. What symptoms should the nurse list? Select all that apply.

Epistaxis Hematuria Hemarthrosis Easy bruising Dark-colored tarry stools

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what symptoms of bleeding they should be looking for in the future. What symptoms should the nurse list?

Epistaxis, Hematuria, Hemarthrosis, Easy bruising, Dark colored tarry stools

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply.

Extreme fatigue Coughing at night Difficulty breathing Fatigue is caused by a lack of adequate oxygenation of body cells caused by a decreased cardiac output. As the cardiac output decreases, pulmonary congestion increases, resulting in pulmonary edema; coughing, especially when lying down, and blood-tinged sputum occur

A client is seen in the clinic with sickle cell anemia. The primary healthcare provider has prescribed an iron supplement to treat the client's anemia. What is the nurse's primary concern in regard to giving the supplement?

Giving iron with this condition is contraindicated Giving iron is contraindicated as sickled cells do not incorporate the iron, so it will build up in the body, causing pain rather than being absorbed

You prepare to take pressure readings from Mr. Whiting's pulmonary artery catheter. Considering Mr. Whiting's symptoms, which patient/bed position is best for him?

Head of bed at 45 degrees with the transducer referenced to the right atrium Pulmonary artery pressure readings need not be taken in any particular position. As long as the transducer is referenced to Mr. Whiting's right atrium, he can assume any comfortable position. Considering his respiratory distress, the sitting position with the head of bed at 45 degrees or higher is the best position. If desired, patient position can be noted when readings are recorded.

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply.

Headache Crackles on lung auscultation

The nurse in the intensive care unit is monitoring a client who had an aortic valve replacement. What can a slow pulse rate during the early postoperative period after open heart surgery indicate?

Heart block During open heart surgery the conductive system of the heart can be damaged because of trauma. Shock results in a weak, rapid pulse. Hypoxia causes tachycardia. Heart failure causes a rapid pulse rate.

A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the primary healthcare provider probably will insert a pacemaker?

Heart block Heart block is the primary indication for a pacemaker because there is an interference with the electrical conduction of impulses from the atria to the ventricles of the heart

A nurse is caring for a client who had a splenectomy. Which complication in the immediate postoperative period is priority for the nurse to assess for in this client?

Hemorrhage Because the spleen is highly vascular, hemorrhage may occur, and abdominal distention results.

A client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period?

Hoarseness and airway obstruction may result from laryngeal nerve damage.

High cholesterol level

Hypercholesterolemia is a major risk factor for coronary artery disease (CAD). At a health fair recently, Mr. Swan was told his cholesterol level was 250 mg/dL, which is high. A total cholesterol level below 200 mg/dL is desirable. A total cholesterol panel includes total cholesterol, triglycerides, HDL (high-density lipoprotein) or "good" cholesterol, and LDL (low-density lipoprotein) or "bad" cholesterol. A triglycerides level below 150 mg/dL is desirable. An HDL level greater than 40 mg/dL is desirable. A desirable LDL level depends on individual cardiac risk factors

On admission, the laboratory results of a client with leukemia indicate elevated blood urea nitrogen (BUN) and uric acid levels. What would the nurse determine that these laboratory results may be related to?

Hypermetabolic status

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes?

Hypokalemia

A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse?

Identifying the concerns and helping the client explore feelings

A nurse is assessing a client who has had a carotid endarterectomy. Which response does the nurse consider evidence of a complication of the surgery?

Impaired swallowing

To ensure that Mr. Leon understands his planned surgery, you ask him what he knows about coronary artery bypass graft (CABG) surgery. What statement by the client confirms that he understands the reason for his surgery?

Improves circulation to the heart muscle Coronary artery bypass graft (CABG) surgery involves the placement of a graft(s) that will improve blood flow to the myocardium. Since Mr. Leon's arteries are occluded, revascularization is necessary to insure sufficient blood flow and oxygenation to the myocardium.CABG surgery, the most common type of cardiac surgery performed, improves myocardial perfusion by bypassing narrowed or obstructed coronary vessels.

A client is admitted with a higher than expected red blood cell (RBC) count. What physiologic alteration does the nurse expect will result from this clinical finding?

Increased blood viscosity Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases.

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition?

Increased pressure within the circulatory system Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure, fluid moves into the tissues, causing edema, and into the abdominal cavity, causing ascites; ascites leads to an increased abdominal girth.

The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level?

Increased total iron-binding capacity (TIBC)

A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses?

Inflammation in the myocardium causes a rise in the systemic body temperature

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply

Irregular heart rate Muscular weakness Decreased bowel sounds Because of potassium's role in the sodium-potassium pump, hypokalemia may cause nerve and muscle weakness, which may precipitate irregular heartbeats and dysrhythmias. Muscle weakness is associated with hypokalemia. Decreased bowel sounds and paralytic ileus result from decreased bowel motility associated with hypokalemia. On an ECG tracing, the T wave is depressed or flattened with hypokalemia. Deep tendon reflexes are depressed

A client experiences crushing chest pain and is brought to the emergency department. When assessing the electrocardiogram (ECG) tracing, the nurse concludes that the client is experiencing premature ventricular complexes (PVCs). Which abnormalities of the ECG support this conclusion?

Irregular rhythm, absence of a P wave, and wide and distorted QRS

A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session?

It is relieved by rest.

Mr. Whiting's nitroglycerin IV drip continues to infuse. Which of the following are TRUE about the administration of a nitroglycerin IV drip to Mr. Whiting?

It should reduce Mr. Whiting's chest pain It should improve blood flow to Mr. Whiting's myocardium It should reduce myocardial oxygen demands It must be administered in a glass container (to avoid the drug binding with plastic iv bags)

A primary healthcare provider prescribes verapamil to be administered intravenously to an older adult client with hypertension. Which nursing intervention is specific to the intravenous administration of verapamil?

Keep the client in the recumbent position for 1 hour after administration. Hypotension is a common side effect of intravenously administered verapamil. Keeping the client in the recumbent position for 1 hour after administration provides for the safety of the client

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication?

Kidney failure Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures

Before a femoral arteriogram is started, what should the nurse teach the client regarding the procedure?

Local anesthesia will be used to decrease pain at the site

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, what should the nurse include?

Maintaining the supine position for a minimum of 4 hours The supine position prevents hip flexion, limiting injury and promoting healing of the catheter insertion site; if the head of the bed is elevated, it should not exceed 20 degrees.

After administration of epinephrine, continued cardiopulmonary resuscitation (CPR), and rhythm check that reveals continued ventricular fibrillation (VF), what action is indicated?

Monophasic defibrillation with 360 J

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations on the client's body should the nurse assess? Select all that apply.

Nail beds Conjunctivae Palms of hands

A nurse is obtaining a health history on a client admitted to the hospital with heart failure. Which assessment finding will the nurse expect the client to report?

Needing to use three pillows at night to sleep

What is the rationale for the concurrent use of Intropin (dopamine) and Nipride (nitroprusside)?

Nipride (nitroprusside) balances the vasoconstricting effect of Intropin (dopamine) Intropin (dopamine) and Nipride (nitroprusside) are useful when used together. Intropin (dopamine) is a sympathomimetic vasopressor. At low (less than 3 mcg/kg/minute) and moderate (3-10 mcg/kg/minute) doses, it increases renal perfusion and urine output. This is important in preventing kidney shutdown. At moderate doses, Intropin (dopamine) also improves myocardial perfusion and contraction (positive inotropic effect), cardiac output, and BP. At higher doses, Intropin (dopamine) is primarily a vasoconstrictor that results in an increase in BP, but also an increase in afterload and workload of the heart. Nipride (nitroprusside), a vasodilator, decreases afterload and balances the vasoconstrictive effects of Intropin (dopamine). This helps to improve cardiac output without increasing the oxygen demands of the heart.

A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply.

Obesity Hypertension Diabetes MELLITUS The risk is higher for African-Americans

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?

Oliguria

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?

Oliguria Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume

A client comes to the outpatient clinic with a large leg ulcer. Which clinical finding will help the nurse determine that the ulcer is arterial?

Pain at the ulcer site Arterial ulcers are painful because of their depth and interruption of blood supply.

While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply.

Pain in the calf Redness in the affected area Localized warmth in the lower extremity Pain is related to the edema associated with the inflammatory response. Redness is related to vasodilation and the inflammatory response. Thrombophlebitis is inflammation of a vein that occurs with the formation of a clot. Warmth is related to vasodilation. Intermittent

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.

Pallor Agitation Tachycardia Narrow pulse pressure

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? Select all that apply.

Pallor Stupor Paresthesia in affected body parts Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Peripheral vasoconstriction and the effect of cold on the peripheral nervous system result in paresthesias in the affected body parts.

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit?

Palpitations Tachycardia Nervousness Palpitations are of neurogenic origin associated with hypoglycemia; the sympathetic nervous system is stimulated by the decline in blood glucose. Tachycardia occurs with low serum glucose levels because of sympathetic nervous system activity. Nervousness, anxiety, and shakiness occur as a result of sympathetic nervous system stimulation associated with hypoglycemia.

The nurse notices sudden bursts of fast rhythm that end abruptly. The heart rate is 220 beats per minute during these bursts, but the P waves are very difficult to see. The QRS interval is normal. The nurse notifies the primary healthcare provider. Which rhythm did the nurse share with the primary healthcare provider?

Paroxysmal supraventricular tachycardia (PSVT)

IV nitroglycerin (Tridil) is prescribed for a post MI patient. What is a primary goal of this medication?

Perfuse cardiac tissue by dilating coronary arteries

The nurse is providing information about blood pressure to an unlicensed health care worker and recalls that the factor that has the greatest influence on diastolic blood pressure is what?

Peripheral vascular resistance

A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse knows to watch for what distinguishing sign that is unique to a fat embolus?

Petechiae

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema?

Place the client in the orthopneic position. The orthopneic, or tripod position, allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs.

A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. How should the nurse position the client's feet and legs?

Place them dependent to the torso

A client is brought into the emergency department with reports of chest pain. Which conditions does the nurse assess for in this client? Select all that apply.

Pleurisy Pneumonia Costochondritis Myocardial infarction Pleurisy, pneumonia, costochondritis, and myocardial infarction are differential diagnoses that may present with the clinical manifestation of chest pain

The nurse is assessing the pulse of a client with an on-demand pacemaker. What should the nurse identify when a client's on-demand pacemaker is functioning effectively?

Pulse rate at least at the preset rate On-demand pacing initiates impulses when the client's pulse rate begins to fall below the preset rate

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade?

Pulsus paradoxus Muffled heart sounds Jugular vein distention HYPOtension Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first?

Raise the client to high-Fowler position Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.

Rapid pulse Decreased urinary output The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased,

Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first?

Record the temperature reading and continue to monitor it. Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2° F (37.9° C) is an expected response to myocardial necrosis, not a respiratory infection.

A client is brought to emergency services after a motor vehicle accident. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. Based on this information, the nurse assesses the client for which early response to decreased arterial pressure?

Reduced peripheral pulses Hypovolemia results in a decreased cardiac output and a decreased arterial pressure, which are reflected by a feeble, weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. Confusion and lethargy are late signs of shock. The pulse pressure narrows with decreased cardiac pressure associated with hypovolemic shock.

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client?

Reduced peripheral pulses Hypovolemia results in decreased cardiac output and decreased arterial pressure, which are reflected by a weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. The pulse pressure narrows with decreased cardiac output associated with hypovolemic shock. Lethargy with confusion is a late sign of shock.

An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action?

Remove the clothing Clothing retains body heat; clothing must be removed before other cooling methods are employed to reduce body temperature.

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness?

Rheumatic fever Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the heart's valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of streptococcal infections have limited the occurrence of rheumatic heart disease

Atrial pressure measurement info

Right atrial pressure (RAP) is measured through a proximal port. Pulmonary artery pressure (PAP) and pulmonary artery occlusion pressure (PAOP/PCWP) are measured through a distal port. The catheter is temporarily "wedged" in a small branch of the pulmonary artery for PAOP/PCWP readings.

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?

S/S of HF

Which ECG change is indicative of myocardial injury?

ST segment elevation

The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS; then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the primary healthcare provider. Which rhythm does the nurse share with the provider?

Second degree AV block Mobitz I (Wenckebach) Also called Mobitz I or Wenckebach heart block, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex

The nurse notes that the client's ECG rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. How should the nurse interpret this strip?

Second degree AV block Mobitz II Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout, with the exception of the dropped beat(s)

Describe 2nd degree HB type 2

Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s).

Which clinical indicator should the nurse expect to identify when assessing a client with varicose veins?

Sensation of heaviness in calf muscles

A client has an open reduction and internal fixation of a fractured hip. To prevent the most common complication after this type of surgery, what does the nurse expect the client's postoperative plan of care to include?

Sequential compression stockings Compressed air inflates the padded plastic stockings systematically from ankle to calf to thigh and then deflates; this promotes venous return and prevents venous stasis and thromboembolism.

Serum cardiac biomarkers

Serum cardiac biomarkers include serum CK-MB assay and cardiac troponins (troponin I, cTnI and troponin T, cTnT). Serum cardiac biomarkers are often ordered after coronary artery bypass graft (CABG) surgery to identify if there has been any myocardial injury, which would be a serious complication

The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply.

Shock Abdominal distention Pulmonary complications Because of its great blood supply and general fragility, the spleen may hemorrhage, causing shock and abdominal distention. Pulmonary complications may occur because the spleen is close to the diaphragm, resulting in defensive shallow breathing and the effects of anesthesia. The immediate postoperative period is too soon for the client to exhibit signs of infection.

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling light-headed. The client is pale and has a rapid pulse. What does the nurse conclude that the client's symptoms indicate?

Shock The clinical findings are early signs of shock. Shock ensues rapidly after a ruptured aortic aneurysm because of profound hemorrhage. The nurse can observe hyperventilation by watching the client's breathing patterns; rapid respirations are expected with hyperventilation

After two hours, Mr. Whiting's cardiovascular status has not improved. Primacor (milrinone) is ordered. Which of the following is expected as the drug's primary therapeutic effect?

Significant increase in cardiac output Primacor (milrinone) is primarily given to improve cardiac output. Primacor (milrinone) is a phosphodiesterase inhibitor that has positive inotropic and vasodilating effects. Its inotropic effect increases the force of myocardial contraction. Its vasodilating effect reduces peripheral resistance (afterload) and myocardial oxygen consumption. Cardiac output is expected to increase. Primacor (milrinone) is sometimes used as first line treatment to improve cardiac output instead of Intropin (dopamine) in combination with Nipride (nitroprusside).

The client's heart monitor shows a regular rhythm made up of wide and bizarre-looking QRS complexes and no P waves. The rate is 40 beats per minute. How should the nurse interpret these findings?

Sinoatrial (SA) and atrioventricular (AV) nodes fail to initiate an impulse. Idioventricular rhythm is a rhythm that is generated by the ventricular ectopic pacemaker. This rhythm emerges only when the SA and AV nodes fail to initiate an impulse. Because this last pacemaker is located in the ventricles, the QRS complex appears wide and bizarre with a slow rate. No P waves are present. Purkinje fibers can be a ventricular type of pacemaker and can be stimulated.

The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. How should the nurse interpret this rhythm?

Sinus rhythm with first degree AV block In first degree block, P and QRS waves are consistent in shape. A P wave precedes every QRS complex, which is followed by a T wave. PR interval is prolonged and is greater than 0.20 seconds

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding?

Sinus rhythm with premature atrial contractions (PACs)

A client presents to the emergency department with severe epistaxis. Which client position is most beneficial?

Sitting with head tilted slightly forward The sitting position will reduce bleeding and allow for assessment of the quantity of bleeding; leaning forward will prevent blood from entering the stomach and possible aspiration.

A client has second degree atrioventricular (AV) block. Which information will the nurse consider when planning care? Select all that apply.

Some P waves are conducted to the ventricles. Treatment consists of atropine or a pacemaker. Second degree heart block refers to AV conduction that is intermittently blocked. Therefore, some P waves are conducted, and some are not. The client may require administration of atropine as well as transcutaneous or transvenous pacing for emergent treatment.

Indocin (indomethacin)

Sometimes nonsteroidal antiinflammatory medications, such as Indocin (indomethacin), are prescribed for relief of pericardial pain.

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in phytonadione (VIT K) and that should be avoided. What should the nurse include on the list? Select all that apply.

Spinach Broccoli

When a client has a myocardial infarction, one of the major manifestations is a decrease in the conductive energy provided to the heart. When assessing this client, the nurse is aware that the existing action potential is in direct relationship to what?

Strength of contraction A direct relationship exists between the strength of cardiac contractions and the electrical conductions through the myocardium. The heart rate is related to factors such as sinoatrial (SA) node function, partial pressures of oxygen and carbon dioxide, and emotions. The refractory period is when the heart is at rest, not when it is contracting. Pulmonary pressure does not influence action potential; it becomes elevated in the presence of left ventricular failure.

A nurse is caring for a client with a myocardial infarction. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart?

Strength of contractions

What must the nurse do to determine a client's pulse pressure?

Subtract the diastolic from the systolic reading. Top - Bot

A client with severe varicose veins has surgery that involves ligation, dissection, and removal of incompetent vessels. In which position should the nurse place the client after surgery?

Supine with the legs elevated at a 15-degree angle

A client has contrast medium injected into the brachial artery so that a cerebral angiogram can be performed. What nursing assessment is most essential immediately after the procedure?

Symmetry of the radial pulses Trauma to the artery can interfere with circulation to the accessed extremity; this is most easily assessed by checking the pulses bilaterally.

Which clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

Syncope With complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope.

You will observe Mr. Whiting's intraaortic balloon deflating just before __________.

Systole

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.

Tachycardia Restlessness Decreased urinary output The heart rate increases and the respiratory rate increases in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/hr because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan?

Techniques to reduce stress

A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis? Select all that apply

Tender area in the posterior lower leg Warmth along the course of the involved vessel Thrombophlebitis, not uncommon after abdominal surgery, is inflammation of a vein; it is associated with the formation of a clot (thrombus) in a vein in the leg. Findings associated with thrombophlebitis include pain, redness, swelling, and heat. Warmth along the course of the involved vessel is related to the inflammatory process accompanying the thrombus. Although swelling accompanies thrombophlebitis, it is not a pitting edema. Thrombophlebitis usually is located in the area of the calf, not over a bony prominence. Itching is not a symptom of phlebitis.

A thallium scan is scheduled for a client who had a myocardial infarction. What should the nurse explain to the client regarding the reason the scan has been prescribed?

That it establishes the viability of myocardial muscle A thallium scan is a radionuclear study that establishes the viability of myocardial tissue; necrotic or scar tissue does not extract the thallium isotope.

ECG wave events/description

The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, visualization of atrial repolarization is obscured by the QRS complex. The T wave represents ventricular repolarization.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

The RR intervals are relatively consistent. One P wave precedes each QRS complex. QRS <0.12 PR 0.12-2

The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. What teaching will be included?

The client will be given a general anesthetic and therefore will be asleep during the procedure. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. With the femoral approach, bed rest is maintained for several hours.

Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon?

The client's intraarterial pressure may compromise the graft's viability

A client in the emergency department is diagnosed with atrial fibrillation. Initially the primary healthcare provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm?

The vagus nerve is stimulated Inhaling and forcing the diaphragm and chest muscles against a closed glottis increase intrathoracic pressure, which affects the vagus nerve and slows the heart.

A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client's question?

There is leakage of red blood cells (RBCs) through the vascular wall

The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip?

Third degree AV block (complete heart block)

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock?

Thirst, cool skin, and orthostatic hypotension

A client with peripheral arterial insufficiency tells the nurse that walking sometimes results in severe pain in the calf muscles. Which information should the nurse share with the client?

This is called intermittent claudication

A nurse is working with a cardiologist for a client needing temporary pacing. Which methods are examples that the cardiologist with the assistance of the nurse might use? Select all that apply.

Transcutaneous pacing Transvenous pacing Epicardial pacing

A nurse is caring for a client with chronic occlusive arterial disease. Which precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions?

Trauma from mechanical, chemical, or thermal sources

The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply.

Unexplained profuse diaphoresis Indigestion not relieved by antacids Acute chest pain after rigorous exercise Non remitting chest pain after three sublingual nitroglycerin tablets

With infusion of Primacor (milrinone), you observe for which of the following adverse effects?

Ventricular dysrhythmias Primacor (milrinone) can cause ventricular rhythm abnormalities, including premature ventricular contractions (PVCs) and ventricular tachycardia. Patients receiving Primacor (milrinone) need to be monitored closely.

Vitamin K, B-1, C, E

Vitamin E has antioxidant properties. Vitamin K assists in synthesizing blood clotting factors. Vitamin B 1 is necessary for protein and fat metabolism and for functioning of the nervous system. Vitamin C is used for formation of collagen, which is important for maintaining capillary strength, promoting wound healing, and resisting infection.

Describe what happens with In first degree AV block on the ECG

a P wave precedes every QRS complex, which is followed by a T wave indicating complete conduction. P waves are visible, but the PR interval is prolonged.

After insertion, you will observe Mr. Whiting's intraaortic balloon inflating during __________.

diastole The intraaortic balloon pump (IABP) is designed to decrease afterload and increase coronary artery perfusion. Inflation of the balloon during diastole, the relaxation phase of the heartbeat during which the coronary arteries fill with blood, will force blood backward. This diastolic augmentation will enhance coronary flow and myocardial oxygenation

Cardiomyopathy

disease of the heart muscle, the myocardium involves idiopathic hypertrophy (enlargement) of the left ventricle

You prepare Mr. Whiting for percutaneous insertion of the intraaortic balloon pump (IABP) catheter. The procedure will be done at his bedside. Mr. Whiting's skin is cleansed and hair is clipped in preparation of catheter insertion at the:

femoral artery The intraaortic balloon pump (IABP) catheter will be inserted in the femoral artery. The balloon (at the distal end of the catheter) will then be advanced and positioned in the descending thoracic aorta below the left subclavian artery, and above the renal arteries.

Raynaud phenomenon

intermittent episodes of constricted arteries and arterioles in response to extreme cold or emotional stress, causing pallor, paresthesias, and pain

Acid-base imbalance is not unexpected after cardiac arrest. Typical arterial blood gas results after cardiac arrest would be:

pH 7.18 PaCO2 40, HCO3 17 With cardiac arrest, there is poor tissue perfusion and hypoxemia which can result in a lactic acidosis, a form of metabolic acidosis. These arterial blood gas values reflect acidosis (low pH), of metabolic origin (low bicarbonate, HCO3) -- metabolic acidosis. PaCO2 (carbon dioxide) is normal.

Confirmed inferior wall MI is associated with risk for right ventricular failure. Patients at risk should be assessed for:

peripheral edema jugular venous distention shortness of breath hypotension

Mr. Whiting's BP normalizes at 100 mm Hg systolic. You prepare the Nipride (nitroprusside) IV drip, which must be:

protected from light Nipride (nitroprusside) solution must be protected from light. The solution will deteriorate if exposed to light. A dark bag is used as a cover.

Which nursing action should be included in the plan of care for a client who has a permanent fixed (asynchronous) pacemaker inserted?

take own pulse daily & log it

One hallmark of third degree heart block is that

the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

Antidysrhythmic medications are used initially; cardioversion is used only if

the client does not respond to medication. (Ex: Parox A-fib)

Stridor

tracheal constriction or obstruction

Normal PCO2 range

35-45 mmHg

Normal ACT (activated clotting time)

70-120 seconds

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results?

A 65-year-old with pulmonary fibrosis The low pH and elevated Pco 2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider

A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client?

A loss of atrial kick Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The ineffectual contraction of the atria results in loss of "atrial kick." If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated.

CABG post op BP and med intervention

An elevated blood pressure is not uncommon after coronary artery bypass graft (CABG) surgery. It is a result of hypothermia, cardiopulmonary bypass, and the patient emerging from anesthesia standing orders for Nipride (nitroprusside) will be implemented to lower Mr. Peterson's systolic pressure to a more desirable range

How can the nurse best describe heart failure to a client?

An inability of the heart to pump blood in proportion to metabolic needs As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?

Arteriolar constriction occurs The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction

Reduced cardiac output and hypovolemia commonly occur after cardiac surgery. Which of the following can contribute to these problems?

B. Bleeding C. Preoperative fluid restriction D. Postsurgical third-spacing of fluids

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check for a pulse Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first?

Check the client's pedal pulses These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings?

Cloudy urine may be indicative of infection

The nurse should explain which adverse effect that can occur when a daily dose of transdermal nitroglycerin in started?

Dizziness

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?

Endocarditis Streptococcal infection can be spread through the circulation to the heart; endocarditis results and affects the valves of the heart

Acute coronary syndrome (ACS)

involves either acute myocardial infarction (MI) or unstable angina (UA) that may result in MI.Angina is a signal that the myocardium is being deprived of oxygen. It is usually a consequence of severe ischemia secondary to increasing obstruction from plaque rupture and evolving thrombus (clot) formation in an atherosclerotic coronary vessel

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?

Feeling of heaviness in both legs Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas

You realize that Mr. Whiting's history was critical to know and review when fibrinolytic reperfusion was considered. Any contraindications were important to determine, examples include:

Fibrinolytic reperfusion is done cautiously in patients who had recent trauma, surgery, or internal bleeding of any kind (such as stroke), those with severe hypertension or currently taking anticoagulants, those with any history of familial bleeding disorders, and those with active peptic ulcer disease. Patients with chest pain but without ST-segment elevation on ECG are NOT candidates for fibrinolytic reperfusion.These patients may be hospitalized and evaluated, and may be treated with aspirin, heparin, and nitroglycerin. These patients may also be treated with a platelet GP IIb/IIIa receptor antagonist. By inhibiting platelet aggregation, these agents, if administered early, may reduce the size of an infarct, and decrease risk of a subsequent coronary event. Percutaneous coronary intervention (PCI) may also be implemented, as needed @@@IMPORTANT@@@

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client?

Headache Lung crackles Cerebral edema caused by hypervolemia may cause a headache. Crackles on lung auscultation indicate the presence of fluid in the alveoli (pulmonary edema). Increased fluid volume in the intravascular compartment (overhydration) will cause the pulse to feel full and bounding. The blood pressure will increase, with hypervolemia. Dizziness when standing up occurs when pooling of blood in the peripheral vessels causes orthostatic (postural) hypotension.

With Mr. Whiting, reperfusion is being done using fibrinolytic therapy. When a patient is evaluated for fibrinolytic reperfusion, it is important to determine any contraindications. Which of the following would contraindicate fibrinolytic reperfusion therapy?

Ischemic stroke two months prior: Fibrinolytic therapy increases risk for bleeding. Fibrinolytic agents promote the conversion of plasminogen to plasmin, which breaks down thrombi. A recent ischemic stroke (less than three months prior) would be an absolute contraindication for fibrinolytic reperfusion. Recent arterial events in the brain predispose a person to intracranial bleeds with the administration of fibrinolytics. Damaged blood vessel walls at a recent stroke site tend to hemorrhage easily. Recommendations are to wait at least three months post-stroke before considering fibrinolytics. Transurethral resection of the prostate (TURP) ten days prior: Fibrinolytic therapy increases risk for bleeding. Fibrinolytic agents promote the conversion of plasminogen to plasmin, which breaks down thrombi. Recent surgery (less than three weeks prior) would be an absolute contraindication for fibrinolytic reperfusion. Using fibrinolytic therapy in a patient who had surgery or another invasive procedure would predispose the person to bleeding and possibly hemorrhage. Recently-formed clots/fibrin deposits could easily breakdown and bleed. Highly-vascular areas such as the bladder would be especially prone to bleeding

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest?

It decreases the potential for further dislodgment of emboli.

A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion?

It should be kept extended while on bed rest.

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis?

Metabolic Alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

NSTEMI

Non-ST-segment elevation MI (NSTEMI) is initially characterized by chest pain and/or other symptoms of an acute coronary event, and ECG changes that may or may not include slight ST-segment elevation, or ST-segment depression, and/or T-wave inversion. NSTEMI is confirmed when serum cardiac biomarkers elevate (creatine kinase MB and troponins).Usually, with NSTEMI, myocardial damage does not include the entire depth of the myocardial muscle wall.

A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension?

Occipital headache in the morning Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged.

A nurse is determining whether or not a client's atrial rhythm is regular when reviewing the ECG rhythm strip. Which consistency of spacing will the nurse use to determine regularity?

P waves The P wave represents atrial contraction. Regularity is assessed by using electronic or physical calipers, or a piece of paper and pencil. To determine atrial regularity, identify the P wave and place one caliper point on the peak of the P wave. Locate the next P wave and place the second caliper point on its peak. The second point

Ortho BP range to be significant

Postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure)

The nurse encourages a client with Raynaud disease to stop smoking. Which primary goal is the nurse trying to achieve?

Prevent peripheral vasoconstriction

A recent activated clotting time (ACT) is 380 seconds. Which medication is likely to be ordered stat?

Protamine sulfate Protamine sufate is needed to reverse the effects of heparin. Anticoagulation with heparin is necessary during cardiopulmonary bypass and open-heart surgery. For cardiopulmonary bypass and open-heart surgery, the activated clotting time (ACT) is maintained at 400-480 seconds with heparin. This anticoagulation can cause postoperative bleeding if not adequately reversed after surgery.

A client's blood pressure increases dramatically six hours after a femoral-popliteal bypass graft. Which priority concern motivates the nurse to inform the primary healthcare provider?

Rapidly increasing blood pressure may rupture the graft The client is hypertensive, and the intraarterial pressure is increased; this increased pressure may cause the arterial suture line to rupture. Hypertension may cause the graft to occlude, but this is unlikely; however, because blood pressure is increased, the client is at risk for bleeding. Hypervolemia is an assumption; other causes, such as arterial constriction, can precipitate hypertension. Although extremely high blood pressure may cause a brain attack, the priority at this time is protecting the graft.

STEMI

ST-segment elevation MI (STEMI), acute myocardial infarction (MI), usually presents with significant chest pain and/or other symptoms of an acute coronary event, and ST-segment elevation on the presenting ECG. STEMI is confirmed when serum cardiac biomarkers elevate (creatine kinase MB and cardiac troponins) and/or there is evidence of Q waves on ECG. Q waves indicate myocardial cell death is present. Q waves can persist on an ECG for months to years after an MI.With STEMI, myocardial damage is significant. The entire depth of the myocardial muscle wall has been affected.

Buerger's disease

Small/medium-artery vasculitis treatment approaches exist for Buerger's disease, but are less effective than quitting smoking. Options include: Medications to dilate blood vessels, improve blood flow or dissolve blood clots

A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations?

Systemic responses of the body to a localized inflammatory process With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate

For a patient presenting with chest pain in an Emergency Department (ED) setting, determining whether the patient is a candidate for reperfusion is a priority. Which of the following is MOST important in identifying candidates for reperfusion?

Taking a 12-lead ECG In a patient presenting with clinical signs of acute MI, candidacy for reperfusion is primarily determined by 12-lead ECG. An ECG that demonstrates persistent significant ST-segment elevation (greater than 2 mm above the baseline in two contiguous precorial leads and 1 mm in two limb leads) is diagnostic for myocardial injury that would benefit from reperfusion of the injured area. Whether primary percutaneous coronary intervention (PCI) is used or reperfusion is accomplished with fibrinolysis, the earlier treatment is initiated, the better the chance of successful reperfusion.

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care?

The body initially attempts to compensate by maintaining peripheral vasoconstriction

Mr. Swan asks you if angina is the same as a heart attack. You correctly teach Mr. Swan and his wife that:

The chest pain of angina is temporary and can be relieved with nitroglycerin and/or rest. The chest pain of MI is long-lasting and not easily relieved There is no myocardial damage with angina. There is permanent myocardial damage with an MI Episodes of angina are usually associated with activity or stress. An MI often occurs without a precipitating event

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

The decreased tissue perfusion caused lactic acid production Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production.

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

The first step is to feel for a pulse after unresponsiveness is established. In this case, it has been established the client has no pulse (cardiopulmonary arrest); therefore chest compressions are initiated FIRST

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition?

The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. While it can affect hematocrit, it is really a result of the abnormal hemoglobin

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?

The stockings should be applied before getting out of bed

The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding?

Unifocal A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical in shape and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal) and every third beat (trigeminal). Two consecutive PVCs are called a couplet.

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client?

Whole blood products The client has experienced acute blood loss from the long bone and pelvic fractures and is tachycardic and hypotensive. Therefore the most appropriate parenteral fluid is whole blood

MI symptomatic onset description

With MI, the onset of pain is usually sudden, and its duration is generally more than 30 minutes. Pain is often severe.The chest pain associated with an MI usually is not relieved with rest, position change, or nitroglycerin

A myocardial infarction (MI) is usually due to

a clot that partially or totally obstructs the flow of blood in a coronary vessel. It is a consequence of severe prolonged myocardial ischemia, and injury that initially causes myocardial cell dysfunction, and eventually myocardial cell death

Reye's syndrome (RS)

a potentially fatal condition that has been linked to giving aspirin to children suffering from viral infections

Jane assists you in preparing Nipride (nitroprusside). You ask Jane what she knows about the drug. She correctly responds that it is:

a vasodilating agent that directly relaxes arteriolar smooth muscle and reduces peripheral resistance