EXAMS 4 & 6
A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged, resulting in a pulmonary embolism. Which type of shock is this client at risk of experiencing?
Obstructive shock Explanation: Obstructive shock results from mechanical obstruction of the flow of blood through the central circulation, such as the blockage that characterizes a pulmonary embolism.
Vasodilators used to treat heart failure include nitrates and ACE inhibitors.
True Explanation: Drug therapies used to treat heart failure include vasodilators, such as angiotensin-converting enzyme (ACE) inhibitors and nitrates, which decrease cardiac workload, relax vascular smooth muscle to decrease afterload, and allow pooling in the veins, thereby decreasing preload of the heart and helping to improve function.
A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?
Twin-to-twin transfusion syndrome (TTTS) Explanation: When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.
The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?
"Children who have this diagnosis may have had strep throat." Explanation: Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.
An asymptomatic client questions the nurse about mitral regurgitation and inquires about continuing exercises. Which is the most appropriate response by the nurse?
"Continue exercising until mild symptoms develop." Explanation: Exercise is not limited until mild symptoms develop. It is not important for an asymptomatic client to avoid exercise or to take ample rest after exercise.
A client awaiting a heart transplant is experiencing decompensation of the left ventricle that will not respond to medications. The health care provider (HCP) suggests placing the client on a ventricular assist device (VAD). The client asks what this equipment will do. Which response most accurately describes the purpose of a VAD?
"Decreases the workload of the myocardium while maintaining cardiac output and systemic arterial pressure." Explanation: Although the response is technical in nature, it is the most accurate. The nurse will use the most accurate terms and then follows up with an explanation of these terms based on the client's level of understanding of the terminology. Decompensated, refractory heart failure reflects deterioration in cardiac function that is unresponsive to medical or surgical interventions. Ventricular assist devices (VADs) are mechanical pumps used to support ventricular function. VADs are used to decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure. This decreases the workload on the ventricle and allows it to rest and recover. The rest of the distractors relate to the monitoring in an ICU of cardiac functioning. Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. With the balloon inflated, the catheter monitors pulmonary capillary pressures (i.e., pulmonary capillary wedge pressure or pulmonary artery occlusion pressure), which reflect pressures from the left ventricle. The pulmonary capillary pressures provide a means of assessing the pumping ability of the left ventricle. One type of pulmonary artery catheter is equipped with a thermistor probe to obtain thermodilution measurements of cardiac output.
A client at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse?
"I can understand your need to find an answer to what caused this. Let's talk about this further." Explanation: Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.
The nurse is providing education to a client who has been prescribed digoxin for symptomatic heart failure. What teaching point would the nurse convey to this client?
"Make sure to take your pulse for a minute before taking your digoxin." Explanation: Clients should measure their heart rate for a full minute before taking a dose of digoxin. The drug can be taken with food, and potassium intake should be increased, not decreased. The client's daily dose of digoxin should never be increased in response to short-term changes in symptoms.
The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption (abruptio placentae) are discussed. Which comment validates accurate learning by the parents?
"Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." Explanation: Placental abruption (abruptio placentae) occurs when there is a spontaneous separation of the placenta from the uterine wall. It can occur anywhere on the placenta and will cause painful, dark red vaginal bleeding. If the abruption is small, the ob/gyn will try to deliver the fetus vaginally. But if severe bleeding occurs or there is fetal distress, a cesarean birth will be performed. Women older than 35 are also at higher risk for developing placental abruption.
A client with heart failure asks, "Why am I taking a 'water pill' when it's my heart that is having a problem?" While educating the client about the Frank-Starling mechanism, which explanation is most appropriate to share?
"Since your heart is not pumping efficiently, the kidneys are getting less blood flow; therefore, the kidneys are holding on to sodium and water." Explanation: In heart failure with a reduced ejection fraction, a decrease in cardiac output and renal blood flow leads to increased sodium and water retention by the kidney with a resultant increase in vascular volume and venous return to the heart and an increase in ventricular end-diastolic volume. Drinking water may increase volume but is not the physiologic reason for retention of fluid. Diuretics do decrease weight as a result of diuresis, but weight loss is not the purpose for giving diuretics. The lungs are not the primary cause of heart failure.
A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?
"We can stop the penicillin when her symptoms disappear." Explanation: For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.
The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents asks the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the nurse?
"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." Explanation: For children with congenital defects with increased pulmonary blood flow, oxygen supplementation is not helpful. Oxygen acts as a pulmonary vasodilator. If pulmonary dilation occurs, pulmonary blood flow is even greater, causing tachypnea, increasing lung fluid retention, and eventually causing a much greater problem with oxygenation; therefore, preventing the development of pulmonary disease via early surgical correction is essential. Although oxygen must be ordered by the physician and it isn't the best treatment, the nurse stating, "While it seems that oxygen would help, it actually makes the condition worse. Treating the cause of the disease will help" best answers the question while also showing empathy.
A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first?
100% oxygen via a nonrebreather mask Explanation: The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied via a nonrebreather mask. The other orders should be completed after the client's airway is secure.
A nurse caring for a patient with atrial fibrillation who is started on digitalis is required to monitor plasma digitalis levels in the patient's blood. Which plasma level of digitalis indicates that the nurse should report to the practitioner?
2.2 ng/ml Explanation: A plasma digitalis level of more than 2 ng/ml would require the nurse to report to the practitioner; therefore plasma digitalis levels of 2.2 ng/ml indicate digitalis toxicity. In such circumstances, the nurses should immediately report to the practitioner. The therapeutic levels of plasma digitalis are 0.5 to 2 ng/ml.
A client experiences nausea and visual disturbances when taking digoxin (Lanoxin). The nurse would anticipate the client's digitalis level to be:
2.7 nanograms/mL Explanation: Therapeutic drug levels of digoxin are between 0.8 and 2 nanograms/ mL. Plasma digoxin levels greater than 2 nanograms/mL are considered toxic and the client may experience signs and symptoms of toxicity.
In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which level indicates inadequate renal perfusion?
20 mL/hour Explanation: In hypovolemia, renal vasculature is constricted in a compensatory attempt to circulate blood to more vital organs. Urinary output at 20 mL/hour or below indicates that renal perfusion is too inadequate.
The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is:
20 mL/hour Explanation: Urine output decreases very quickly in hypovolemic shock. Compensatory mechanisms decrease renal blood flow as a means of diverting blood flow to the heart and brain. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion.
Which client is most likely to be experiencing vasodilation?
A 51-year-old man with a history of hypertension who is taking a medication that blocks the effect of the renin-angiotensin-aldosterone system Explanation: Angiotensin is a potent vasoconstrictor, and medications that block this induce vasodilation. Epinephrine is also a vasoconstrictor. Histamine is a vasodilator, so antihistamine medications are likely to induce vasoconstriction. Serotonin is a vasoconstrictor, so medications that block its reuptake and increase free levels are apt to promote vasoconstriction.
The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.)
A heart rate >100 bpm Crackles Lethargy and mental confusion Explanation: In compensatory shock, the heart rate is >100 bpm, the patient experiences lethargy and mental confusion, respirations are >20 breaths/min (not <15), and respiratory alkalosis is present (not respiratory acidosis). Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Respirations are rapid and shallow. Crackles are heard over the lung fields.
The nurse observes that a patient has 2+ pitting edema in the lower extremities. What does the nurse know that the presence of pitting edema indicates regarding fluid retention?
A weight gain of 10 lbs Explanation: Pitting edema, in which indentations in the skin remain after even slight compression with the fingertips (Fig. 29-2), is generally obvious after retention of at least 4.5 kg (10 lb) of fluid (4.5 L)
A pregnant client is admitted to a health care unit with disseminated intravascular coagulation (DIC). Which prescription is the nurse most likely to receive regarding the therapy for such a client?
Administer cryoprecipitate and platelets. Explanation: In a pregnant client with DIC, the nurse may be told to administer cryoprecipitate and platelets. Whole blood does not contain clotting factors. Therefore, a ratio of 4 units of blood to 1 unit of fresh frozen plasma, and not 1 unit of blood to 4 units of frozen plasma, should be considered. The nurse should aim at maintaining the client's hematocrit above 30% and not just 20%. The nurse should expect one unit of blood to increase the hematocrit by 1.5 g/dl (15 g/L) not 3g/dl (30 g/L).
A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The clients reports that these symptoms came on suddenly. The nurse knows that these are symptoms of what condition?
Acute pulmonary edema Explanation: Clients with acute pulmonary edema exhibit sudden dyspnea, wheezing, orthopnea, restlessness, cough (often productive of pink, frothy sputum), cyanosis, tachycardia, and severe apprehension. These symptoms do not indicate progressive heart failure, pulmonary hypertension, or cardiogenic shock.
A nurse is caring for a pregnant client with eclamptic seizure. Which is a characteristic of eclampsia?
Coma occurs after seizure. Explanation: The nurse should know that coma usually follows an eclamptic seizure. Muscle rigidity occurs after facial twitching. Respirations do not become rapid during the seizure; they cease. Coma usually follows the seizure activity, with respiration resuming.
A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant?
Administer oxygen. Explanation: If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding. Infants are not usually put on fluid restriction.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
Amniocentesis Explanation: Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?
Assess the client's vital signs. Explanation: A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.
The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult?
Atherosclerosis Explanation: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process. The other choices may occur at any age.
A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection?
Avoid drawing a blood specimen from the right femoral vein before the procedure Explanation: Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine.
A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Explanation: Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply.
Burns Dehydration Explanation: The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.
The nurse reads an athletic client's electrocardiogram. What finding will be consistent with a sinus bradycardia?
Heart rate of 42 beats per minute (bpm). Explanation: The heart rate of 42 bpm is slow but normal when it occurs in athletes with a sinus bradycardia. The PR interval is prolonged at 0.24 seconds, indicating a heart block. The QR interval is prolonged and indicates ventricular delay. The ratio of P to QR should be 1:1 in sinus bradycardia.
Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his lips are dusty blue. Vital signs reveal heart rate 112, respiratory rate 36, and pulse oximeter reading of 81%. He starts coughing up frothy, pink sputum. The priority intervention is:
Call for emergency assistance utilizing hospital protocol. Explanation: Mr. V. is experiencing acute pulmonary edema. This is a life-threatening condition. The person is seen sitting and gasping for air. The pulse is rapid, skin moist, lips/nail beds cyanotic. Dyspnea and air hunger are accompanied by productive cough with frothy and often blood-tinged sputum (pink). The client needs the emergency responder team (including ICU nurses, physicians, respiratory therapy, etc) to intervene. Applying O2 by mask will not increase his oxygen level fast enough and he is probably mouth breathing (gasping for air). Suction equipment may be needed, but getting a physician to give orders for diuretics and inotropic medications is the priority. Of course, respiratory therapy will arrive with the emergency assistance team.
Which dosage forms are used for digoxin (Lanoxin) maintenance therapy? (Select all that apply.)
Capsule Injection Tablet Explanation: Capsules and tablets are used for maintenance therapy, injections are used for rapid digitalization, and digoxin patches and ointment do not exist.
The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause?
Chromosomal abnormality Explanation: The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done and the mother should feel no fault. The nurse needs to encourage the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother.
The ICU nurse is required to closely monitor four clients diagnosed with shock. During the shift assessment, the nurse documents the following values for the clients. Which client is most stable?
Client C: Heart rate 115 beats per minute, systolic BP 129 mm Hg, urine output 60 mL/hour Explanation: The stability of the client's condition is evidenced by a heart rate between 60 and 120 beats per minute, systolic BP between 90 and 139 mm Hg, urine output greater than 35 to 50 mL/hour, and capillary refill time between 2 and 3 seconds. Therefore, options A, B, and D are incorrect.
The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which of the following findings confirms a positive outcome? Select all that apply.
Client denies pain Right extremity pink Right extremity comparable in size to left No bleeding or bruising noted Explanation: Evaluation of the expected outcome of thrombolytic therapy includes restoring blood flow to the extremity. Findings include no pain from impaired circulation, a pink extremity of comparable size, and no bleeding from complications of the thrombolytic medication. A thready pulse would indicate impaired circulation, and a positive Homan's sign would indicate a continuing thrombus.
The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:
Cold, clammy skin and tachycardia. Explanation: In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.
A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse
Consults with the physician about substituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Explanation: Pantoprazole tablets are not to be broken, crushed, or chewed. Lansoprazole is substituted for this medication. The nurse consults with the physician about substituting another proton pump inhibitor for pantoprazole. Enteral feedings are initiated at a slow rate to ensure adequate digestion. The nasogastric tube is measured from earlobe to xiphoid process and 6 inches are added to the length of the tube to be inserted. Placement of a PEG tube is not necessary at this time. The client is unstable. The tube is meant for long-term, not short-term, placement.
A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client?
Control the shivering. Explanation: Hyperthermia may develop related to altered temperature regulation secondary to sepsis. Because the act of shivering increases body heat through the contraction of skeletal and pilomotor muscles in the skin, it is important to get the shivering under control. Use of a warming blanket would not be an appropriate intervention because this client is septic and hyperthermic. Conduction and radiation transfer heat, which would increase the client's body temperature. Keeping the client dry and covered would not help this situation because measures that prevent evaporation and heat loss from radiation interfere with the loss of body heat. Supine positioning with elevated legs is appropriate for clients with ineffective peripheral tissue perfusion.
The nurse is discussing risk factors for developing CAD with a patient in the clinic. Which results would indicate that the patient is not at significant risk for the development of CAD?
High-density lipoprotein (HDL), 80 mg/dL Explanation: A fasting lipid profile should demonstrate the following values (Alberti et al., 2009): LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients); total cholesterol less than 200 mg/dL; HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females; and triglycerides less than 150 mg/dL.
A client is being treated for heart failure. What assessment finding would the nurse interpret as most indicative of improved health status?
Decreased pitting edema Explanation: A decrease in pitting edema is an indication of diminished fluid volume, which is indicative of an improved blood supply to the body tissues. Increased skin turgor may represent an increase in fluid volume. A heart rate of 52 is too slow to provide good contractility. Improved sensorium indicates adequate perfusion but is not the most indicative of improved heart failure status.
After teaching a class of students about heart failure and drug therapy, the instructor determines that the teaching has been successful when the students identify which drug as most often used as treatment?
Digoxin Explanation: Digoxin is the drug most often used to treat heart failure. Human B-type natriuretic peptide, nitrate, or furosemide also may be used, but these drugs are not the ones most commonly used.
The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock?
Distributive Explanation: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.
A client has been living with an internal, fixed-rate pacemaker. When checking the client's readings on a cardiac monitor the nurse notices an absence of spikes. What should the nurse do?
Double-check the monitoring equipment. Explanation: One of the reasons for lack of pacemaker spikes is faulty monitoring equipment.
A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply.
Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. Explanation: During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist.
The nurse is teaching a female patient about newly prescribed digoxin. The patient tells the nurse that she occasionally uses herbal therapies. The nurse should caution the patient against using therapies that involve which herbs?
Ginseng Explanation: Patients taking digoxin should avoid licorice, ginseng, or hawthorn because concomitant use of those products can increase drug effects or cause toxicity. In general, patients taking any medication should discuss all herbal remedies with a health care provider to assess for potential interactions.
A 65-year-old client presents to the health care provider's office with reports of shortness of breath on exertion, edema in the ankles, and waking up in the middle of the night unable to breathe. The nurse suspects that the symptoms are indicative of which condition?
Heart failure Explanation: Cardinal manifestations of HF are dyspnea and fatigue, which can lead to exercise intolerance and fluid retention resulting in pulmonary congestion and peripheral edema.
The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with ordinary physical activity. Under what classification does the nurse understand this patient would be categorized?
II Explanation: Classification II of heart failure is indicated by the patient being comfortable at rest, but experiencing fatigue, palpitation, or dyspnea during ordinary physical activity.
The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?
Immediate defibrillation Explanation: Defibrillation is used during pulseless ventricular tachycardia and ventricular fibrillation.
Which would be considered a therapeutic effect of digoxin?
Increased force of contraction Explanation: Digoxin increases the force of myocardial contraction, increases cardiac output and renal perfusion, and slows the heart rate.
An 86-year-old client is disappointed to learn that he or she has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which age-related change predisposes older adults to the development of heart failure?
Increased vascular stiffness Explanation: Increased vascular stiffness in older adults causes a progressive increase in systolic blood pressure with advancing age, which in turn contributes to the development of left ventricular hypertrophy and altered diastolic filling. A loss of action potential does not typically accompany aging, and contractility tends to decrease as a result of cardiac stiffness. Orthostatic hypotension is neither a normal age-related change nor a cause of heart failure.
What medication order would the nurse question for a patient being treated for pericarditis?
Indomethacin Explanation: Analgesic medications and NSAIDs such as aspirin or ibuprofen may be prescribed for pain relief during the acute phase of pericarditis. These agents also hasten reabsorption of fluid in patients with rheumatic pericarditis. Indomethacin is contraindicated because it may decrease coronary blood flow. Colchicine or corticosteroids (e.g., prednisone) may be prescribed if the pericarditis is severe or if the patient does not respond to NSAIDs. Colchicine also may be used instead of NSAIDs during the acute phase.
A pregnant woman has been admitted to the hospital due to preeclampsia with severe features. Which measure will be important for the nurse to include in the care plan?
Institute and maintain seizure precautions. Explanation: The woman with preeclampsia with severe features should be maintained on complete bed rest in a dark and quiet room to avoid stimulation. The client is at risk for seizures; therefore, institution and maintenance of seizure precautions should be in place.
Milrinone is a miscellaneous inotropic drug used in the short-term management of heart failure. What is the only way this drug is approved to be administered?
Intravenously Explanation: Milrinone (Primacor) is only to be given intravenously. The other routes are not used.
Anaphylactic shock is the most severe form of systemic allergic reaction. Immunologically medicated substances are released into the blood, causing vasodilation and an increase in capillary permeability. What physiologic response often follows the vascular response in anaphylaxis?
Laryngeal edema Explanation: Anaphylaxis is a clinical syndrome that represents the most severe form of systemic allergic reaction. Anaphylactic shock results from an immunologically mediated reaction in which vasodilator substances such as histamine are released into the blood. The vascular response in anaphylaxis is often accompanied by life-threatening laryngeal edema and bronchospasm, circulatory collapse, contraction of gastrointestinal and uterine smooth muscle, and urticaria (hives) or angioedema.
The heart is a four-chambered pump. Which chamber of the heart pumps blood into the systemic circulation?
Left ventricle Explanation: The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs. The left ventricle pumps blood into the systemic circulation.
The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?
Lie very still at intermittent times during the test. Explanation: The nurse should instruct the client, who is to undergo a MUGA scan, to lie very still at intermittent times during the 45-minute test. The client need not drink plenty of fluids, avoid activities before/after the test, or avoid dairy products during the test.
The client's digoxin level is 0.125. How does the nurse interpret this level?
Low Explanation: The therapeutic serum digoxin level is 0.8 to 2.0 ng/mL. Higher serum levels are associated with an increased risk of adverse effects and toxicity without clear evidence of improved efficacy.
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?
Monitor the client's vital signs and bleeding. Explanation: A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending spontaneous abortion (miscarriage). Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.
ECG monitoring has been found to be more sensitive than a client's report of symptoms when identifying transient ongoing myocardial ischemia. Why is this?
Most ECG-detected ischemic events are clinically silent. Explanation: Persons with acute coronary syndrome are at risk for developing extension of an infarcted area, ongoing myocardial ischemia, and life-threatening dysrhythmias. Research has revealed that 80% to 90% of ECG-detected ischemic events are clinically silent. Thus, ECG monitoring is more sensitive than a client's report of symptoms for identifying transient ongoing myocardial ischemia.
When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?
Myocardial depression Explanation: The body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin.
A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?
Myocardial ischemia Explanation: Myocardial dysfunction and HF can be caused by a number of conditions, including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of clients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, myocardial cell death, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left-sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.
In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart?
Nitroprusside Explanation: A disadvantage of nitroprusside is that it causes hypotension. Dopamine and epinephrine improve contractility, increase stroke volume, and increase cardiac output. Methoxamine increases blood pressure by vasoconstriction.
The nurse is to administer digoxin to a client with heart failure. The nurse auscultates an apical pulse rate of 52. What action should the nurse take?
Notify the health care provider Explanation: Before administering each dose of digoxin, take the apical pulse rate for 60 seconds. If the apical rate is below 60 beats per minute, withhold the drug and notify the provider. Blood pressure is not affected by digoxin. Without prescriptive authority, the nurse cannot change medication dosages.
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?
Palpate the fundus and check fetal heart rate. Explanation: The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.
Clinical characteristics of neurogenic shock are noted by which type of stimulation?
Parasympathetic Explanation: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The client experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation.
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?
Peeling hands and feet; fever Explanation: Kawasaki disease is an acute systemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region. The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue. The other symptoms are not necessarily characteristic of Kawasaki disease. The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.
On a holiday trip home, the nurse's mother states that the nurse's father was diagnosed with right-sided heart failure. Which manifestation exhibited by the father does the nurse know might have preceded this diagnosis?
Peripheral edema, weight gain Explanation: In right-sided heart failure, blood backs up into the venous side of the circulatory system causing increased hydrostatic pressure in capillaries and leakage of plasma, which forms peripheral edema and becomes apparent as weight gain. The other manifestations listed are not characteristic of right-sided failure.
A nurse is required to monitor a client for right ventricular dysfunction. Which would the nurse most commonly assess?
Pitting edema Explanation: One of the most common symptoms associated with right ventricular dysfunction is pitting edema. The other symptoms of right ventricular dysfunction are nocturia, anorexia, weight gain, and weakness. Dyspnea, orthopnea, and hacking cough are the symptoms associated with left ventricular dysfunction, and not right ventricular dysfunction.
An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?
Place the infant in the knee-chest position. Explanation: Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta Explanation: Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.
A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta?
Pulses weaker in lower extremities compared to upper extremities Explanation: With coarctation of the aorta there is a narrowing causing the blood flow to be impeded. This produces increased pressure in the areas proximal to the narrowing and a decrease in pressures distal to the narrowing. Thus, the infant would have decreased systemic circulation. The upper half of the body would have an increased B/P and be well perfused with strong pulses. The lower half of the body would have decreased B/P with poorer perfusion and weaker pulses. Coarctation is not a cyanotic defect. The cyanosis would be associated with tetralogy of Fallot.
The heart is a four-chambered pump. What is the function of the right ventricle?
Pumps blood to the lungs Explanation: The right ventricle pumps blood to the lungs. The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The left ventricle pumps blood into the systemic circulation.
In arteriosclerosis, commonly referred to as hardening of the arteries, the rigid arterial vessels fail to stretch. This has the potential for what?
Sending a reduced volume of oxygenated blood to the major organs of the body Explanation: As the left ventricle contracts, sending oxygenated blood from the heart, the rigid arterial vessels fail to stretch. The potential result is a reduced volume of oxygenated blood delivered to organs such as the myocardium, brain, kidneys, and extremities. Arteriosclerosis does not decrease the flow of unoxygenated blood throughout the body; it does not slow or increase the flow of blood throughout the body.
The nurse should anticipate administering intravenous antibiotic therapy as a priority to a client experiencing which type of shock?
Septic shock Explanation: Septic shock is a subtype of distributive shock. The treatment of sepsis and septic shock focuses on control of the causative agent and support of the circulation and the failing organ systems. The administration of antibiotics that are specific for the infectious agent is essential. Swift and aggressive fluid administration is needed to compensate for third spacing, though which type of fluid is optimal remains controversial. Equally, aggressive use of vasopressor agents, such as norepinephrine or epinephrine, is needed to counteract the vasodilation caused by inflammatory mediators.
What is the primary cause of heart failure in infants and children?
Structural heart defects Explanation: Structural (congenital) heart defects are the most common cause of heart failure in children.
The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response?
The autonomic nervous system controls the heart rate. Explanation: The autonomic nervous system primarily controls the heart rate. When the sympathetic branch is stimulated, heart rate increases. When the parasympathetic branch is stimulated, heart rate decreases. Stroke volume is the amount of blood pumped out of the ventricle with each contraction and depends on three factors: preload, afterload, and contractility.
A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?
The child will need the blood pressure checked two more times. Explanation: The child will need the blood pressure checked two more times. It is routine to check the blood pressure on three separate occasions to get the most accurate analysis of the blood pressure. The child usually does not need surgery or need to go to the emergency room. This is not a normal result in a blood pressure finding.
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?
The client demonstrates ability to tolerate more activity without chest pain. Explanation: The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
The client says his rings have become tight and are difficult to remove. Explanation: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply.
The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55-year-old client with spina bifida The client who reports an allergy to peanuts that causes throat swelling Explanation: Risk factors for anaphylactic shock include transfusion reaction, latex allergy, and severe allergy to foods or medications. The client in the first 15 minutes of receiving blood is at risk for an anaphylactic reaction. This is why the nurse should remain in the room for the first 15 minutes of infusion. The client with spina bifida is at risk for a latex allergy, which, in turn, increases the risk for an anaphylactic reaction if latex gloves are used. The client with a peanut allergy is at risk for an anaphylactic reaction if food is prepared or accidentally contaminated with a nut-based oil. The other clients are not at an increased risk for anaphylactic shock.
What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)?
The level of physical activity each allows Explanation: Both Class I and Class II levels of heart failure are considered Mild under the New York Heart Association (NYHA) guidelines. The difference is that in Class II, the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea, whereas in Class I, the client is comfortable both at rest and during ordinary physical activity. A marked limitation of physical activity would be a sign of Moderate heart failure, and inability to carry out any physical activity is a sign of Severe heart failure.
The nurse is administering furosemide to a client with heart failure. What best describes the therapeutic action of the medication?
The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. Explanation: Loop diuretics such as furosemide blocks sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. Furosemide also dilate renal vessels. Although loop diuretics block potassium reabsorption, this isn't a therapeutic action. Thiazide diuretics, not loop diuretics, promote sodium secretion into the distal tubule.
A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?
This is caused by an opening that usually closes by 1 week of age. Explanation: A PDA is caused by an opening called the ductus arteriosus. A PDA usually closes by 1 week of age. If it does not close, the defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.
Which type of pacing involves the placement of large patch electrodes on the anterior and posterior chest wall that can be connected by a cable to an external pulse generator?
Transcutaneous Explanation: The type of pacing described is transcutaneous because it is the only form that is accessible externally.
When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?
Treat the oxygenation needs of the heart muscle Explanation: As with all forms of shock, the underlying cause of cardiogenic shock must be corrected. It is necessary first to treat the oxygenation needs of the heart muscle to ensure its continued ability to pump blood to other organs.
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
Ventricular assist device (VAD) Explanation: VADs may be used for one of three purposes:(1) a bridge to recovery, (2) a bridge to transplant, or (2) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days
A client was admitted to the hospital with a diagnosis of aortic regurgitation. On assessment, what positive indicators for the disease process will the nurse note? Select all that apply.
Visible neck vein pulsations The pulse has a rapid upstroke, then collapses The presence of a diastolic murmur Explanation: Pulse pressure widens and systolic blood pressure in the lower extremities is higher than in the upper extremities as a result of progressive left ventricular failure.
A nurse assessing a client on digoxin suspects toxicity. Which visual disturbances would the nurse expect to assess?
Yellow or green vision Explanation: The visual disturbance the nurse should assess for is yellow or green vision with a white halo. Visual disturbances occur in digoxin toxicity. Blurring of vision and borders around dark objects are the other visual disturbances. Double vision, difficulty of near vision, and complete loss of vision do not occur in digitalis toxicity.
Following a coronary artery bypass graft, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiogram (ECG) strip for interpretation. In looking at the strip, what change in the QRS complex would most support the nurse's suspicion?
amplitude decrease Explanation: An amplitude decrease would support the nurse's suspicion because fluid surrounding the heart, such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing and widening complexes as well as an amplitude increase aren't expected findings on the ECG of an individual with cardiac tamponade.
A client was admitted to the hospital unit with an elevated leukocyte count and a fever accompanied by warm, flushed skin. These symptoms suggest that the client has:
an overwhelming bacterial infection. Explanation: Unlike other forms of shock, clients with septic shock have an elevated leukocyte count and initially manifest fever accompanied by warm, flushed skin and a rapid, bounding pulse. Therefore, the client with an overwhelming bacterial infection is most likely to exhibit these symptoms. Blood loss may precipitate hypovolemic shock. Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive.
A client tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the client is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the client to
avoid caffeinated beverages. Explanation: If premature atrial complexes (PACs) are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the client to avoid caffeinated beverages.
A patient with class-IV CHF has a medication regimen consisting of metoprolol (Lopressor), enalapril (Vasotec), and furosemide (Lasix). In addition to regularly assessing the patient's heart rate, the nurse should prioritize assessment of the patient's
blood pressure. Explanation: Fluid balance, cognition, and exercise tolerance are all affected by CHF and should be regularly assessed as part of thorough nursing care. However, the combination of an ACE inhibitor, a beta blocker, and a diuretic constitutes a significant risk for hypotension and indicates a need for frequent blood pressure monitoring.
A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect?
ensures passage of all the products of conception Explanation: Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an abortion to ensure passage of all the products of conception. Rho(D) immune globulin is used to suppress the immune response and prevent isoimmunization.
A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect?
gestational trophoblastic disease Explanation: This client has risk factors of a "molar" pregnancy: nausea and vomiting at an early gestational week and dark brown vaginal discharge. The early nausea/vomiting can be due to a high hCG level, which is a sign of gestational trophoblastic disease. There is only one sign/symptom of hyperemesis gravidarum. Placenta previa is marked by bright red bleeding and tends to happen later in gestation. There are no data to support any psychosis at this stage.
A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply.
heart fails as effective pump blood volume decreases peripheral vascular dilation Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate (Wedro, 2014).
The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be:
improving quality of life by relieving symptoms. Explanation: A primary treatment goal for a client with CHF is to improve the quality of life through symptom management. CHF will not be cured, and maintaining a higher oxygen level will assist with dyspnea associated with CHF. A stent is not an option for treatment of CHF.
A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply.
kidney failure disseminated intravascular coagulation acute respiratory distress syndrome Explanation: When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.
What would be the physiologic basis for a placenta previa?
low placental implantation Explanation: The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.
A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure?
low urine output Explanation: Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP), or the average pressure at which blood moves through the vasculature. When a MAP falls below 65 mm Hg, a client with progressive shock will have decreased kidney function and low urine output. Clients with low MAP will have tachycardia, slow respirations, and bloody diarrhea.
A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?
mask Explanation: Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen is one of the first tools used to fight pulmonary edema. A mask, rather than nasal cannula, is needed to deliver the maximum percentages of oxygen. Intubation is reserved for when respiratory failure occurs. Mechanical ventilation is applied once respiratory failure occurs.
Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy?
methotrexate Explanation: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.
A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?
orthopnea Explanation: Decreased left ventricular function would be characterized by orthopnea, dyspnea, anorexia, bibasilar rales not cleared with coughing, and resting tachycardia.
A newborn is diagnosed with tetralogy of Fallot. When explaining this condition to the mother, which defect would the nurse's description include?
overriding of the aorta Explanation: One of the components in the tetralogy of Fallot is the overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with four components. The defects in the tetralogy of Fallot include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy. Atrial septal defect, stenosis of the aorta, and left ventricular hypertrophy are not components of tetralogy of Fallot.
During a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 mm Hg with mild facial edema. The nurse recognizes that the client has which condition?
preeclampsia without severe features Explanation: A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to have preeclampsia without severe features when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart and mild facial or extremity edema. A woman has progressed to preeclampsia with severe features when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a tonic-clonic seizure or coma has occurred.
A woman at 35 weeks' gestation with severe polyhydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client?
preterm rupture of membranes followed by preterm birth Explanation: Even with precautions, in most instances of polyhydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.
A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?
prevent maternal D antibody formation. Explanation: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
A woman has presented to the emergency department with symptoms that suggest an ectopic pregnancy. Which finding would lead the nurse to suspect that the fallopian tube has ruptured?
referred shoulder pain Explanation: Referred pain to the shoulder area indicates bleeding into the abdomen caused by phrenic nerve irritation when a tubal pregnancy ruptures. Vaginal spotting, nausea, and breast tenderness are typical findings of early pregnancy and an unruptured ectopic pregnancy.
A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?
respiratory rate Explanation: A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.
The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding?
softening of the nail beds Explanation: Softening of nail beds is the first sign of clubbing due to chronic hypoxia. Rounding of the fingernails is followed by shininess and thickness of nail ends.
A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time?
spontaneous abortion (miscarriage) Explanation: The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for spontaneous abortion (miscarriage). Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.
A client was chopping firewood and experienced a heaviness in the chest and dyspnea. The client arrives in the emergency department four hours after the heaviness and the health care provider diagnoses an anterior myocardial infarction (MI). What orders will the nurse anticipate?
sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry Explanation: The nurse should anticipate an order for sublingual nitroglycerin, tPA, and telemetry, as the client's chest pain began 4 hours before diagnosis. The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. Stress testing shouldn't be performed during an MI. The client doesn't exhibit symptoms that indicate the use of lidocaine.