** Concept Complex I Exam 2 : Perfusion Part 2

Mr. Bob is currently in the cardiac unit receiving enoxaparin 1 mg/kg SQ daily for his atrial fibrillation. As the nurse, you are reviewing the lab results from this morning. Which lab concerns you most?* 1. Potassium 3.7 2. Platelets 90 3. WBC 4.2 4. INR 2.5

2

The nurse performs a focused cardiovascular assessment for a client with atrial fibrillation. Which location allows the nurse to assess the apical pulse? Fifth intercostal space, left midclavicular line Second intercostal space, right sternal border Second intercostal space, left sternal border Fifth intercostal space, right midclavicular line

5th intercostal space, left midclavicular line

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: A. Sinus tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation

B

Clinical Manifestations of PAD:

Burning, cramping and pain in the legs during exercise*** (intermittent claudication) -Numbness/burning pain primarily in feet when in bed. - Pain relieved by placing legs at rest in a dependent position-**Dangle Arteries to relieve pain - Bruit over femoral/aortic arteries - Decreased cap. Refill of toes (greater than 3 sec) -Loss of hair on lower calf, ankle, foot -Dry scaly mottled skin - Thick toenails -Cold and cyanotic extremity - Pallor of extremity with elevation -Dependent rubor (redness) of extremity -Muscle atrophy -Ulcers and possible gangrene of toes.

What is the treatment for asystole?

Cardiopulmonary Resuscitation, and intravenous administration of epinephrine given every three to five minutes as needed. When a reversible underlying cause is found, that cause should be treated directly to reverse asystole. start CPR epinephrine NO DEFIBRILLATION

A significant cause of venous thrombosis is: A. Altered blood coagulation B. Stasis of blood C. Vessel wall injury D. All of the above

D

Diagnostics for PVD:

D-dimer test- measures fibrin degradation products present in the blood produced from fibrinolysis. + test indicates thrombus formation has possibly occurred. Trendelenburg test for Varicose Veins- place pt in supine position with legs elevated. When pt sits up, the veins will fill from the proximal end if varicosities are present. Other Lab work: aPTT, PT, INR, H&H, platelet count Venous duplex ultrasonography Contrast venography

DVT Clinical Manifestations:

May be asymptomatic Calf or groin pain, tenderness, and sudden onset of edema of extremity Changes in circumference of calf/thigh over time; localized edema over the affected area. Warmth, edema and induration and hardness over involved blood vessel positive homen's sign - pain in calf upon foot dorsiflexion (unreliable w/ false positive)

Teaching/Health Promotion for PVD: Elevate veins to relieve pain

Venous insufficiency- elevate legs for at least 20 min, 4-5x/day. ****Elevate legs above the heart when in bed.******** Avoid crossing legs and restrictive clothing/stockings.** Wear elastic compression stockings. Apply after legs have been elevated & when swelling is at a minimum. STOP SMOKING Meticulous foot care is vital to prevent ulceration and infection.

The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD? A. High levels of low-density lipid (LDL) cholesterol B. High levels of high-density lipid (HDL) cholesterol C. Low concentration triglycerides D. Low levels of LDL cholesterol.

a

With peripheral arterial insufficiency, leg pain during rest can be reduced by: A. Elevating the limb above heart level. B. Lowering the limb so it is dependent. C. Massaging the limb after application of cold compresses. D. Placing the limb in a plane horizontal to the body.

b

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: A. Has a pale colored base. B. Is deep, with even edges. C. Has little granulation tissue. D. Has brown pigmentation around it.

d

DVT risk factors

***Associated with Virchow's triad Hypercoagulability Impaired blood flow Damage to blood vessels- endothelial injury Hip surgery, total knee replacement, open prostate surgery Heart failure A-fibrillation- risk of DVT is increased during the first 6 months following diagnosis of atrial fibrillation Acute MI Ischemic stroke Immobility Pregnancy Oral contraceptives Active cancer Ulcerative colitis Central venous and dialysis access catheters Factor V Leiden defect

Mr. Smith presents to the ER with a BP of 86/40 and states that he is feeling dizzy. Based on his EKG, which medication do you anticipate administering?* 1. Atropine 2. Aspirin 3. Amiodarone 4. Adenosine

1

Identify the image.* 1. Atrial fibrillation 2. Normal sinus rhythm 3. Sinus tachycardia 4. Atrial flutter

1 Rate: atrial, 300-600 bpm (too rapid to count); ventricular, 100-180 bpm in untreated patients Rhythm: irregularly irregular s/s: Hypotension dizziness shortness of breath fatigue angina ECG characteristics of atrial fibrillation include an irregular rhythm and the absence of identifiable P waves. The atrial rate is so rapid that it is not measurable. patient at risk for falls increases the risk of thromboemboli development and the incidence of stroke is high

When calculating the rate on an EKG strip, which is true?* 1. Count number of QRS and multiply by 15 2. We don't have to calculate rate on rhythms 3. Count number of small boxes between R-R interval and divide by 1500 4. Count number of p-waves and multiply by 1500

3

A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. A nurse assesses the client for: A. Hypotension and dizziness B. Nausea and vomiting C. Hypertension and headache D. Flat neck veins

A

A client has intermittent claudication at rest. The client reports that the weight of bed sheets is uncomfortable on the lower legs and asks the nurse about pain prevention. Which measures does the nurse recommend? A. "Cigarette smoking should be avoided." B. "Use compression stockings to improve blood flow." C. "Elevate the legs above the level of the heart." D. "Apply a cold compress when in pain."

A

A client with Raynaud syndrome is admitted to the hospital with cyanotic fingers and extreme digit pain. The nurse tells the client to avoid which action? A. Caffeinated beverages B. Exposure to extreme heat C. Alcohol D. Prolonged bed rest

A

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms? A. Inadequate tissue perfusion leading to nerve damage. B. Fluid overload leading to compression of nerve tissue. C. Sensation distortion due to psychiatric disturbance. D. Inflammation of the skin on the hands and feet.

A

A patient at the outpatient clinic describes leg pain that occurs while walking and is relieved with rest. The patient asks why this happens to him. The nurse knows that the pain is related to: A. Arterial insufficiency. B. Heart failure. C. Angina. D. Venous insufficiency.

A

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis? A. Family history of heart disease B. Overweight C. Smoking. D. Age.

A

The nurse is caring for a client with advanced heart failure who develops asystole. The nurse corrects the new graduate when the graduate offers to perform which intervention? a. Defibrillation b. Cardiopulmonary resuscitation (CPR) c. Administration of atropine d. Administration of oxygen

A

Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? A. Exertional dyspnea B. Confusion C. Elevated creatine phosphokinase concentration D. Chest pain

A

A nurse is presenting a program at the local fair about prevention of atherosclerosis. Which recommendation should the nurse include? SATA A. Follow a smoking cessation program B. Maintain an appropriate weight C. Eat a low fat diet D. Increase fluid intake E. Decrease intake of complex carbs

A, B, C

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select all that apply: A. It results when oxygen demand is greater than oxygen supply. B. It is characterized by pain that often occurs during rest. C. It is a result of tissue hypoxia. D. It is characterized by cramping and weakness. E. It always affects the upper extremities.

A, C, D

1. Sinus tachycardia 2. Atrial fibrillation 3. Normal sinus rhythm 4. Atrial flutter

4 Rate: atrial, 240-360 bpm; ventricular rate depends on degree of AV block and usually is less than 150 bpm Rhythm: atrial, regular; ventricular, usually regular s/s: palpitations or a fluttering sensation in the chest or throat decreased LOC hypotension decreased urinary output cool, clammy skin ECG characteristics include a "sawtooth" or "picket fence" appearance of P waves, which are labeled flutter (F) waves.

The nurse cares for a client who has been newly diagnosed with persistent atrial flutter. Which best practice interventions does the nurse anticipate if the client experiences hemodynamic instability? Select All That Apply Emergent cardioversion Administration of heparin IV atropine Radiofrequency catheter ablation IV diltiazem

Cardioversion Heparin Diltiazem

A patient is diagnosed with a DVT. Which of the following, if stated by a UAP (Unlicensed Assistive Personnel), requires intervention by the nurse? A. "The patient states that her leg is warm, swollen, and painful." B. "Sometimes I wish the patient would talk a little less. It's hard to get out of the room." C. "The patient and I were talking, and we both play softball!" D. "I am going to ambulate the patient to the bathroom and assist her with using the toilet."

D

After assessing a client, the nurse teaches the client about peripheral vascular disease (PVD). The nurse reviews what test used in diagnosing PVD? A. Cardiac stress test B. Echocardiogram C. Allen test D. Ankle brachial pressure index

D

Nurse Justin is taking care a client with deep vein thrombosis. Which position should be provided to the client? A. Bed rest with the affected extremity remain flat at all times. B. Bed rest with the unaffected extremity on top of the affected extremity. C. Bed rest with the affected extremity in a dependent position. D. Bed rest with the affected extremity elevated.

D

The nurse suspects that a client has deep venous thrombosis (DVT). Which test(s) would gather evidence in support of this diagnosis? Select All That Apply D-dimer Tinel sign Weber test Venous ultrasound Venography

D-Dimer Venous ultrasound Venography

Client with history of PAD, assessing the client's lower extremities and ankles. Which of the following findings should the nurse expect? Pitting edema Areas of reddish-brown pigmentation Dry pale skin with minimal body hair

DRY PALE SKIN WITH MIN. BODY HAIR

Teaching for PAD: Dangle arteries to relieve pain

Encourage exercise to build collateral circulation. Initiate gradually and increase slowly Instruct to walk until the point of pain, stop & rest then walk a little further. Promote vasodilation and avoid vasoconstriction Provide warm environment for client Wear insulated socks Never apply direct heat like a heating pad to the affected extremity because of sensitivity is decreased- can cause a burn Avoid exposure to cold Avoid stress, caffeine and nicotine Avoid crossing legs Refrain from wearing restrictive garments Elevate legs to reduce swelling, but not above heart; extreme elevation slows arterial blood flow to the feet.

DVT TEACHING/CARE:

Encourage to walk after initiation of anticoagulant therapy. Perform dorsiflexion /plantar flexion exercises of foot when in bed Elevate legs above level of heart while in bed (no pillow under knee)** Intermittent/Continuous warm moist compresses as prescribed **Don't Massage affected limb. Wear thigh-high compression or anti-embolism stockings. Use a recliner chair or footstool when patients are sitting Encourage frequent position changes (at least every 2 hours) while awake. Encourage active ROM (performed by the patient) exercises at least every 8 hours

Client taking Simvastatin po daily for high lipid level,which item should the RN remove from the client's breakfast tray? Grapefruit juice Hardboiled eggs Coffee Oatmeal

Grapefruit juice

The nurse encourages a client with peripheral artery disease (PAD) to enroll in a scheduled exercise program. What benefit does the client receive from an exercise program for PAD treatment? Improve collateral circulation Reduce body weight Promote venous return Increase high-density lipoproteins

Improve collateral circulation

A community clinic nurse assesses a client with a history of diabetes and peripheral arterial disease (PAD) who is complaining of right lower-extremity pain at 7 out of 10. Which findings does the nurse emergently report to the client's provider? Select All That Apply Client reports pain that is not relieved with rest Decreased sensation on the bottoms of both feet Bruising on bilateral knees Mottled skin on the right foot Toes on the right foot feel cold Hair loss on lower extremities Posterior tibial pulse is not palpable

Pain Not relieved Mottled skin Toes cold Pulse not palpable

Complications: major complications of DVT are recurrent DVT and PE

Pulmonary embolism - dislodged clot that traveled to pulmonary system SOB and chest pain; sudden onset dyspnea, decreased systemic oxygen, hemoptysis, impending doom, tachypnea, crackles, pleural fritction rub, s3 or s4 heart sounds, sweating, low grade fever, chest pain with inspiration Elevated head of bed, oxygen therapy and ABGs Chronic venous ulcers- valves in veins are destroyed - retrograde

The nurse provides discharge instructions to a 35-year-old female client with lower-extremity deep venous thrombosis (DVT). Which statement by the client indicates the need for additional teaching? "I am at higher risk for recurrent blood clots." "I do not need lab testing to monitor my apixaban levels." "I can take my dog for a short walk tonight." "I can safely continue my oral contraceptive medication."

Safely continue my oral contraceptive

Clinical Manifestations of Venous insufficiency:

Statis dermatitis- brown discoloration along ankles that extends up the calf relative to the level of insufficiency. Edema Statis ulcers- typically found around ankles. Clinical Manifestations of Varicose veins: -Distended, superficial veins that are visible just below the skin and are tortuous in nature. - Muscle cramping and aches, pain after sitting and pruritus. Intermittent claudication (a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity) is characteristic of PVD. The pain is often accompanied by weakness and is relieved by rest.

Treatment for sinus tachycardia:

Treated only if symptomatic or patient is at risk for myocardial damage Treatment of underlying cause (e.g., hypovolemia, fever, pain) Medications to slow down the rate: Beta blockers: Metoprolol Calcium channel blockers: (Verapamil or Diltiazem) Miscellaneous: pain medication, antipyretics etc.

Treatment for Sinus Bradycardia:

Treated only if symptomatic: Possible administration of IV Atropine or isoproterenol, and/or pacemaker therapy Sinus bradycardia may be asymptomatic; it is important to assess the patient before treating the rhythm.

Diagnostics for DVT:

Venous duplex ultrasonography- high frequency sound waves to provide a real-time pic of blood flow thru a vessel. Doppler flow studies- audible sound produced when venous circulation is normal; little to no sound when veins are thrombosed. Impedance plethysmography- determines the variations of blood passing thru veins, identifies abnormal venous flow in affected limb. Venogram- used if above tests are negative for DVT but one is still suspected. Uses contrast or magnetic resonance imaging for accurate diagnosis.

When the nurse plans interventions for a client with a superficial vein thrombosis who has been on anticoagulation therapy for 2 days, which interventions are included? Select All That Apply Apply a warm wet compress to the affected leg. Apply a compression stocking to the unaffected leg. Ambulate frequently and increase distance daily. Elevate the affected leg. Administer pain medication.

Warm wet compress compression to unaffected elevate pain med

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: A. Familial tendency toward peripheral vascular disease. B. Smoking history. C. Recent exposures to allergens. D. History of insect bites.

b

Pharmacologic Interventions for DVT:

Anticoagulants: - Warfarin- monitor PT & INR - 3-4 days for effects to develop, start while pt is on heparin - Taken at home - Heparin -monitor aPTT & platelet counts - Only taken in the hospital- changed to Warfarin before discharge - antidote is protamine sulfate - Enoxaparin - Given SQ; used for prevention and treatment of DVT - Injections can be given in the home setting - DON'T GIVE IF low platelet counts (<100,000), surgeries of the eye, brain, spinal cord Thrombolytics: Alteplase tissue plasminogen activator, Abciximab, Eptifibatide dissolve clots that have already developed; must be started 5 days after development to be effective

The nurse assesses a client admitted with palpitations and a palpable radial pulse of 122 beats/min. The nurse notes "saw-tooth" waves between each QRS complex on the cardiac monitor instead of normal P waves. Which cardiac rhythm is most likely the cause of the client's symptoms? Atrial flutter Ventricular fibrillation Atrial fibrillation Supraventricular tachycardia

Atrial flutter

A client comes to the outpatient clinic and tells the nurse that he has had leg pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? A. An acute obstruction in the vessels of the legs. B. Peripheral vascular problems in both legs. C. Diabetes D. Calcium deficiency

B

A nurse assesses a client with an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize has atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complexes B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 125/min with a wide QRS

B

In preparation for the discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: A. Walking several times each day as an exercise program. B. Keeping the heat up so that the environment is warm. C. Wearing a TED hose during the day. D. Using hydrotherapy for increasing oxygenation.

B

Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to: A. Report incidents of diarrhea B. Avoid foods high in vitamin K C. Use a straight razor when shaving D. Take aspirin for pain relief

B

The nurse cares for a client with venous insufficiency. What does the nurse teach the client about the condition? A. "Varicose veins are more common in men than in women." B. "Varicose veins are sometimes a result of a familial predisposition." C. "Sclerotherapy is the only cure for varicose veins." D. "Discomfort is directly related to the size of the varicosities."

B

The nurse is caring for a 27-year-old female client with venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A. Apply dressing using sterile technique B. Improve the client's nutrition status C. Initiate limb compression therapy D. Begin proteolytic debridement

B

Which technique is considered the gold standard for diagnosing DVT? A. Ultrasound imaging B. Venography C. MRI D. Doppler flow study

B

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions? A. Walk barefoot whenever possible. B. Use a heating pad to keep feet warm. C. Avoid crossing the legs. D. Use antibacterial ointment to treat skin lesions at risk of infection.

C

Teaching a client with venous insufficiency about self-care. Which statement should the nurse identify as an indication that the client understands the teaching? A. "I should avoid walking as much as possible." B. "I should sit down and read for several hours a day." C. "I will wear clean graduated compression stockings every day." D. "I will keep my legs level with my body when I sleep at night."

C

Varicose veins can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

C

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: A. The presence of occasional coupled beats. B. Long pauses in an otherwise regular rhythm. C. A continuous and totally unpredictable irregularity. D. Slow but strong and regular beats.

C

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: A. At least 12 hours B. The first 24 hours C. 2-3 days D. 1 week

C

Which of the following characteristics is typical of the pain associated with DVT? A. Dull ache B. No pain C. Sudden onset D. Tingling

C

You obtain an ECG on a patient and the rhythm is sinus bradycardia with a rate of 52 bpm. Your NEXT nursing action is to? A. Prepare to administer Atropine IV push B. Set-up for transcutaneous pacing C. Assess the patient D. Call a rapid response

C When discovering sinus bradycardia, the nurse should determine if the patient is having symptoms. Not all cases of this rhythm require medical treatment.

Assessing lower extremities and ankles of client with history of peripheral artery disease. Which finding is expected ? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. Sunburned appearance with desquamation

C- because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage.

The nurse cares for a client newly diagnosed with atrial fibrillation. Which ECG pattern does the nurse observe in this client? The ECG shows an irregularly irregular rhythm with no clear P waves. The ECG shows an irregular rhythm with no P waves or QRS complexes. The ECG shows a regular rhythm with no P waves and a wide, repetitive QRS complex. The ECG shows a regular rhythm with a P wave, QRS complex, and T wave.

irregularly irregular