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The nurse is teaching a health awareness class. Which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? 1 Pregnancy 2 Inactivity 3 Aerobic exercise 4 Tight clothing
2 Inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.
The nurse explains to a pregnant client with a class II heart failure that in pregnancy the cardiac system is most compromised during which time? 1 First trimester 2 Third trimester 3 First 2 days after the birth 4 Transitional phase of labor
3 First 2 days after the birth The first 2 days after the birth is the most critical period because of the rapid shift of extravascular fluid as it returns to the bloodstream; this mobilization of fluid can compromise the mother's heart and lead to cardiac decompensation. During the first trimester the increased amount of circulating blood volume is minimal and occurs gradually; therefore, it does not place an unusual burden on the heart. The risk for cardiac decompensation increases as pregnancy progresses; however, the increase in blood volume occurs gradually, and the mother is monitored closely. There is an increased risk for stress on the heart during labor; however, close monitoring and the use of agents to provide rest and pain relief have decreased these risks.
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? 1 Obtain chest x-ray film immediately. 2 Notify the primary health care provider. 3 Place client in a high-Fowler position. 4 Assess the client's oxygen saturation level.
3 Place client in a high-Fowler position. Placing the client in a high-Fowler position promotes lung expansion and gas exchange; it also decreases venous return and cardiac workload. Notifying the primary health care provider is necessary, but positioning should be done first because it will have an immediate effect. An x-ray film can be obtained, but after breathing is supported. Assessing the client's oxygen saturation level is important, but the priority is for the nurse to take action to improve the client's respiratory status.
A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? 1 Bradycardia 2 Flushed face 3 Unilateral chest pain 4 Decreased blood pressure
3 Unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or by pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence blood pressure.
When a client with a possible past history of myocardial infarction has an electrocardiogram (ECG) prescribed and asks the nurse the purpose of the ECG, which response by the nurse is accurate? 1 "This test will look for heart valve problems." 2 "This test will show how well your heart is pumping." 3 "The ECG will tell us how much exercise your heart can tolerate." 4 "The ECG will show if there has been damage to the heart muscle."
4 "The ECG will show if there has been damage to the heart muscle." ECG changes such as Q waves can indicate whether the client has had a previous myocardial infarction. An echocardiogram would be prescribed to assess for problems with the heart valves. An echocardiogram or coronary angiogram would be ordered to determine how effectively the heart is pumping (ejection fraction). An exercise or pharmacological stress test would be used to check for signs of ischemia with exercise or high cardiac workload.
A client with a myocardial infarction receives intravenous nitroglycerin to relieve pain. The nurse will assess for which medication side effect? 1 Nausea 2 Delirium 3 Bradycardia 4 Hypotension
4 Hypotension The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure and resulting in decreased cardiac workload. Nausea is not a common side effect of intravenous nitroglycerin. Nitroglycerin does not cause delirium. Reflex tachycardia may occur with the decrease in blood pressure.
When caring for a client hospitalized with deep vein thrombosis, which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis? 1 Daily aspirin use 2 Frequent ambulation 3 Warm soaks to legs 4 Avoidance of cold
2 Frequent ambulation Frequent ambulation decreases venous stasis and helps prevent recurrent venous thrombosis. Clients who are hospitalized with deep vein thrombosis will be discharged on an anticoagulant such as warfarin; aspirin use is insufficient to prevent recurrent venous thrombosis. Warm soaks to the legs may help with the pain associated with thrombophlebitis, but they will not prevent recurrence. Avoidance of cold might be suggested for clients with peripheral arterial disease, but it is not needed for clients with venous disease or thrombophlebitis.
A postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an activated partial thromboplastin time (aPTT) of 98 seconds. Which action would the nurse take in response to this situation? 1 Increase the IV rate of heparin. 2 Interrupt the infusion and notify the primary health care provider of the aPTT result. 3 Document the result on the medical record and recheck the aPTT in 4 hours. 4 Call the primary health care provider to obtain a prescription for a low-molecular-weight heparin
2 Interrupt the infusion and notify the primary health care provider of the aPTT result. The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25-36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is 1½ to 2 times the normal range. The primary health care provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.
A client who has been diagnosed with a myocardial infarction receives digoxin, fluoxetine, morphine, and docusate sodium. Which medication would the nurse identify as a risk factor for straining due to constipation? 1 Digoxin 2 Morphine 3 Docusate 4 Fluoxetine
2 Morphine Morphine is an opioid. Opioids decrease peristalsis, which may precipitate constipation; straining at stool should be avoided to prevent the Valsalva maneuver, which increases demands on the heart. Digoxin is unrelated to intestinal peristalsis and the potential for constipation. Docusate sodium is a stool softener, which would relieve, not cause, constipation. A side effect of fluoxetine is diarrhea, not constipation.
Which task can be safely delegated by the registered nurse (RN) to unlicensed assistive personnel (UAP) for a client with thrombocytopenia? 1 Shaving the client 2 Positioning the client 3 Performing oral hygiene 4 Giving intravenous platelet infusions
2 Positioning the client Clients with thrombocytopenia are at risk of bleeding with slight bruising. Tasks that do not risk bruising the client may be delegated to the UAP. The RN would shave the client and perform oral hygiene. Intravenous infusions would not be administered by UAP to any client.
Digoxin is prescribed for a client with heart failure. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply. One, some, or all responses may be correct. 1 Nausea 2 Yellow vision 3 Irregular pulse 4 Increased urine output 5 Heart rate of 64 beats/minute
1 Nausea 2 Yellow vision 3 Irregular pulse Signs and symptoms of digoxin toxicity include bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). In addition, electrocardiogram (ECG) findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of improved cardiac output; a pulse rate of 64 beats/minute is an acceptable rate when a client is receiving digoxin.
The nurse taught a client with heart failure who is scheduled for discharge about how medications, diet, and exercise improve activity tolerance. During a follow-up visit, the nurse finds that the client has learned how to adapt his or her exercise prescription to increase activity tolerance. Which theory did the nurse follow to achieve this positive outcome? 1 Roy's theory 2 King's theory 3 Leininger's theory 4 Henderson's theory
1 Roy's theory According to Roy's theory, the goal of nursing is to help a client with a disorder adapt to changes in physiological needs by identifying the demands that are causing him or her problems. King's theory illustrates that nursing is a dynamic interpersonal process among the nurse, client, and health care system. Leininger's theory is about transcultural care theory, which explains that caring is the central and unifying domain for nursing knowledge and practice. Henderson's theory illustrates that nurses working interdependently with other health care workers can best assist the client.
When caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI), which laboratory result will the nurse expect? 1 Decreased white blood cell count 2 Elevated serum troponins I and T 3 Decreased creatine kinase-MB (CK-MB) 4 Decreased B-type natriuretic peptide (BNP)
2 Elevated serum troponins I and T Elevations of troponin I and T levels are indicative and specific for cardiac muscle damage as would occur with STEMI. White blood cell count would increase in the first days after myocardial infarction because of the inflammatory response associated with myocardial cell death. CK-MB is found in cardiac muscle and levels increase with myocardial cell death. BNP levels are not directly reflective of myocardial infarction, but might increase if the client develops heart failure as a complication of myocardial infarction.
Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? 1 Thermography 2 Plethysmography 3 Duplex venous Doppler 4 Somatosensory evoked potential
3 Duplex venous Doppler Duplex venous Doppler records an ultrasound of the veins, including blood flow abnormalities of the lower extremities, aiding detection of deep vein thrombosis. Thermography, which measures the heat radiating from the skin surface, is used to determine client response to anti-inflammatory medication therapy and inflamed joints. Plethysmography is used to record variations in volume and pressure of blood passing through tissues; the test is nonspecific. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neurons and primary muscle disease
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the medication, the client complains of feeling dizzy. Which action will the nurse take? 1 Determine if this is an allergic reaction. 2 Elevate the client's head and keep the extremities warm. 3 Place the client in the supine position and take the vital signs. 4 Tell the client that this is not a typical sensation after receiving morphine sulfate.
3 Place the client in the supine position and take the vital signs. Dizziness is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, cardiac output, and blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.
The nurse is discussing discharge instructions with a client who had a myocardial infarction. The client asks, "When will it be safe to have sex again?" Which response by the nurse is best? 1 "Usually it takes several weeks for the heart to heal enough for sexual activity." 2 "The health care provider will discuss sexual activity with you before you leave the hospital." 3 "Many clients are not really interested in sexual activity for several weeks after having a heart attack." 4 "One indication that your heart has healed enough for sexual activity is being able to climb two flights of stairs."
4 "One indication that your heart has healed enough for sexual activity is being able to climb two flights of stairs." The response that the heart has healed enough for sexual activity when the client is able to climb two flights of stairs addresses the client's request for information. The energy required for sexual intercourse is equivalent to that of climbing two flights of stairs. It is true that the heart has usually recovered within 2 to 6 weeks after myocardial infarction, but there are multiple factors that affect an individual client's recovery. Although the health care provider should discuss sexual activity with the client, the nurse also is responsible for addressing the need for information rather than avoiding answering the client's question. Although some clients may not be interested in sexual activity for weeks after having a myocardial infarction, this client is clearly expressing interest. View Topics
Which action would the nurse perform immediately for a client with dysrhythmias according to priority? 1 Monitor oxygen saturation. 2 Establish intravenous access. 3 Administer oxygen via a nonrebreather mask. 4 Ensure airway-breathing-circulation (ABC).
4 Ensure airway-breathing-circulation (ABC). The client with any life-threatening complication such as dysrhythmias should be assessed for ABCs immediately because the client may be experiencing airway obstruction. Oxygen saturation should be monitored during ongoing assessments and after providing the client with initial treatment. Intravenous access should be established after performing initial assessments such as vital signs. After assessing ABCs in a client with dysrhythmias, the client should be provided with oxygen via nasal cannula or nonrebreather mask to maintain oxygen levels.
Which feeding education would the nurse provide the parent of a 2-month-old infant with the diagnosis of heart failure? 1 Use double-strength formula. 2 Avoid using a preemie nipple. 3 Refrain from feeding until crying from hunger begins. 4 Feed slowly while allowing time for adequate periods of rest
4 Feed slowly while allowing time for adequate periods of rest Because of limited exercise tolerance and fatigue, infants with heart failure become too tired to feed; allowing rest and feeding slowly limit the fatigue associated with feeding. Although the infant may be given a formula with a higher caloric value (30 kcal/oz [30 kcal/30 mL] rather than 20 kcal/oz [20 kcal/30 mL]), double-strength formula is too high of an osmotic load for the infant. A soft nipple used for preterm infants or a regular nipple with an enlarged opening is preferred to conserve the energy required for sucking. Crying consumes energy and is exhausting. The infant should be fed when exhibiting signs of hunger, such as sucking on a fist
A client, admitted to the cardiac care unit with a myocardial infarction, complains of chest pain. Which intervention will be most effective in relieving the client's pain? 1 Nitroglycerin sublingually 2 Oxygen per nasal cannula 3 Lidocaine hydrochloride 50-mg intravenous (IV) bolus 4 Morphine sulfate 2 mg IV
4 Morphine sulfate 2 mg IV Morphine is an opioid analgesic that acts on the central nervous system by a sympathetic mechanism. Morphine decreases systemic vascular resistance, which decreases left ventricular afterload, thus decreasing myocardial oxygen consumption. Nitroglycerin sublingually relieves anginal pain, not myocardial infarction pain. Oxygen administration elevates arterial oxygen tension, potentially improving tissue oxygenation; however, oxygen administration will not relieve the pain. Lidocaine is an antidysrhythmic, not an analgesic.
A client with myocardial infarction is brought to the emergency department, and the primary health care provider recommends the placement of a stent. The client is incompetent to understand the situation. Which model would the nurse manager think would be beneficial in this situation? 1 Decision model 2 Autonomy model 3 Social justice model 4 Patient-benefit model
4 Patient-benefit model The patient-benefit model uses substituted judgment such as determining what the client would want for him- or herself if capable of making these issues known, and thereby facilitates decision-making for incompetent clients. The decision model is used for nurses; it depends on specific circumstances to know if the situation is routine and predictable or complex and uncertain. The autonomy model facilitates decision-making for competent clients. The social justice model considers broad social issues and is accountable to the overall institution
When the clinic nurse is teaching a group of clients with heart failure (HF) about dietary interventions to prevent fluid overload, which topic will be included? 1 Fluid intake restrictions 2 Low-calorie diet for weight loss 3 Avoidance of high-fat, high-cholesterol foods 4 Use of fresh or frozen vegetables instead of canned ones
4 Use of fresh or frozen vegetables instead of canned ones The key principle to teach HF clients is the importance of decreasing sodium in their diet and which foods contain sodium. If sodium is decreased, water retention will decrease also. Fresh or frozen vegetables have less sodium than canned ones. Most heart failure clients do not need to restrict fluid intake. A low-calorie diet is needed for overweight clients but does not improve volume status. Avoidance of high-fat and high-cholesterol foods is important to prevent coronary artery disease but will not prevent fluid overload.
A client's cardiac monitor indicates multiple multifocal premature ventricular complexes (PVCs). Which medication is indicated for treatment of ventricular dysrhythmias? 1 Amiodarone 2 Epinephrine 3 Methyldopa 4 Hydrochlorothiazide
1 Amiodarone Amiodarone has an antiarrhythmic action that stabilizes cell membranes of the heart, reducing cardiac excitability; it is used for acute ventricular dysrhythmias. Methyldopa is used to treat hypertension, not PVCs. Epinephrine increases the contractibility of the heart; the effect is opposite of that which is needed. Hydrochlorothiazide is a diuretic used for hypertension, not for correcting multiple PVCs.
When a client is admitted with thrombocytopenia, which nursing actions would be included in the plan of care? Select all that apply. One, some, or all responses may be correct. 1 Avoid intramuscular injections. 2 Institute neutropenic precautions. 3 Monitor the white blood cell (WBC) count. 4 Administer prescribed anticoagulants. 5 Examine the skin for ecchymotic areas.
1 Avoid intramuscular injections. 5 Examine the skin for ecchymotic areas. Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased WBCs, not platelets. Platelet count, rather than WBC count, will be monitored. Anticoagulants are contraindicated because of the increased bleeding risk.
When caring for a client with a diagnosis of right ventricular heart failure, the nurse expects which assessment findings? Select all that apply. One, some, or all responses may be correct. 1 Dependent edema 2 Swollen hands and fingers 3 Collapsed neck veins 4 Right upper quadrant discomfort 5 Oliguria
1 Dependent edema 2 Swollen hands and fingers 4 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. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.
After the nurse teaches a group of women about coronary artery disease (CAD) and myocardial infarction (MI), which statement by the women indicates that the teaching has been effective? 1 Unusual fatigue is a common symptom of CAD in women. 2 Women usually have a more rapid recovery than men after MI. 3 Cardiac surgery is generally more successful in women than men. 4 High-density lipoprotein (HDL) levels increase after menopause.
1 Unusual fatigue is a common symptom of CAD in women. Studies indicate that women who have myocardial infarctions often experience unusual prodromal fatigue; also, during the prodromal period, women more commonly experience upper abdominal fullness instigated by exertion or emotional stress. Women report more disability than men after a cardiac event. Women have higher mortality and more complications than men after coronary artery bypass graft surgery. Low-density lipoprotein levels increase after menopause, increasing CAD risk.
A client with hypertensive heart disease who had an acute episode of heart failure is to be discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate when metoprolol is administered with digoxin? 1 Headaches 2 Bradycardia 3 Hypertension 4 Junctional tachycardia
2 Bradycardia Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate. Metoprolol reduces, not produces, headaches. These medications may cause hypotension, not hypertension. These medications may depress nodal conduction; therefore junctional tachycardia would be less likely to occur.
A client who had a myocardial infarction has runs of ventricular tachycardia. Which medication will the nurse prepare to administer? 1 Digoxin 2 Furosemide 3 Amiodarone 4 Norepinephrine
3 Amiodarone Amiodarone decreases the irritability of the ventricles by prolonging the duration of the action potential and refractory period. It is used in the treatment of ventricular dysrhythmias such as ventricular tachycardia. Digoxin slows and strengthens ventricular contractions; it will not rapidly correct ectopic beats. Furosemide, a diuretic, does not affect ectopic foci. Norepinephrine is a sympathomimetic and is not the medication of choice for ventricular irritability.
Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1 Serum sodium of 139 mEq/L (139 mmol/L) 2 Serum chloride of 100 mEq/L (100 mmol/L) 3 Serum calcium of 10.2 mg/dL (2.55 mmol/L) 4 Serum potassium of 7.2 mEq/L (7.2 mmol/L)
4 Serum potassium of 7.2 mEq/L (7.2 mmol/L) Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L). A concentration of 7.2 mEq/L (7.2 mmol/L) indicates hyperkalemia. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135-145 mmol/L). The normal chloride concentration ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum calcium level ranges between 9 and 10.5 mg/dL (2.25-2.625 mmol/L).
An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value would the nurse report to the health care provider? 1 Sodium of 140 mEq/L (140 mmol/L) 2 Ionized calcium of 2.35 mEq/L (1.2 mmol/L) 3 Chloride of 102 mEq/L (102 mmol/L) 4 Potassium of 3.0 mEq/L (3.0 mmol/L)
4 Potassium of 3.0 mEq/L (3.0 mmol/L) Because furosemide is a potassium-losing diuretic, the potassium should be frequently checked. Normal potassium concentration in infants is 3.5 to 5.0 mEq/L (3.5-5.0 mmol/L). A potassium concentration of 3.0 mEq/L (3.0 mmol/L) should be reported to the health care provider. The normal range for sodium is 139 to 146 mEq/L (139-146 mmol/L), ionized calcium is normally 2.24 to 2.46 mEq/L (1.12-1.23 mmol/L), and chloride is normally 98 to 106 mEq/L (98-106 mmol/L). The sodium, calcium, and chloride readings are normal.
A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, which medication will the nurse be prepared to administer? 1 Vitamin K 2 Oprelvekin 3 Warfarin sodium 4 Protamine sulfate
4 Protamine sulfate Protamine sulfate binds with heparin sodium to form a physiologically inert complex; it corrects clotting deficits. Vitamin K counteracts the effects of medications like warfarin sodium. Oprelvekin is a thrombopoietic growth factor that stimulates the production of platelets. It would not be appropriate for emergency management. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin.