PassPoint

A client returns from a left heart catheterization. The right groin was used for catheter access. To evaluate distal blood flow, the nurse should palpate the pulse on this client at which location?

dorsal surface of the right foot

What increases the risk of CAD?

- Total cholesterol higher than 200 mg/dL (11.1 mmol/L) - LDL higher than 100 mg/dL (5.5 mmol/L) - HDL lower than 40 mg/dL (2.2 mmol/L) in males - HDL lower than 50 mg/dL (2.8 mmol/L) in females - males 45 years and older - females 55 years and older - smoking - obesity

How do you apply Nitro ointment?

wear gloves The client should not rub or massage the ointment into the skin. The ointment should be allowed to absorb slowly.

A client with chest pain doesn't respond to nitroglycerin. When the client is admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The health care provider also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

6 hours

An older adult client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client?

Right-Sided Paralysis

The nurse observes a sudden dampening of the arterial waveform. What is the priority action by the nurse?

Assess clients BP

The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client reports anxiety because of receiving less monitoring than in the CCU. How can the nurse allay the client's fears?

Assign the same nurse to the client when possible.

Why is renal failure the most common complication after AAA removal?

Renal failure commonly occurs if clamping time is prolonged, cutting off the blood supply to the kidneys. Hemorrhage and shock are the most common complications before abdominal aortic aneurysm resection, and they occur if the aneurysm leaks or ruptures. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.

A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client?

Stop Smoking

One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. What should the nurse instruct the client to do to achieve this goal?

Stop Smoking

Dorsal Cavity

The dorsal cavity consists of the cranial (skull) and vertebral canal (spinal cavity).

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first?

The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Remember ABC's Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs an analgesic, but that does not take priority over a client with difficulty breathing.

A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states "I am so tired. Even my vision is blurry." What is the nurse's best action?

Decrease the lidocaine infusion rate. Side effects of lidocaine include lightheaded, euphoria, shaking, low blood pressure, drowsiness, confusion, weakness, blurry or double vision, and dizziness. Serious reactions such as seizures, bradycardia, and heart block are possible if lidocaine reaches toxic levels.

After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine, 5 mcg/kg/minute I.V. Which classification describes dobutamine?

Direct-acting beta-active agent

Early Sign of Hypocalcemia

Neuromuscular irritability is usually the first indication that a client has developed a low serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuromuscular irritability. Depressed reflexes, decreased memory, and ventricular dysrhythmias are indications of hypercalcemia.

A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem?

myocarditis Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection. The T lymphocytes respond to the viral infection by secreting cytokines to kill the virus, but they also kill the virus-infected myocardium.

Ventral Cavity

thoracic cavity and abdominopelvic cavity

A nurse should be prepared to manage complications following abdominal aortic aneurysm resection. Which complication is most common?

Renal Failure

The client has had hypertension for 20 years. The nurse should assess the client for?

Renal insufficiency and failure.

Compartment Syndrome

increased pressure in an enclosed space that can compromise muscle, vascular, and nerve function, can be caused by a cast that is too tight and is manifested by the inability to feel light touch, pain, paresthesia, coolness, and pallor distal to the cast. To reduce swelling and pressure under the cast and to promote venous return, the nurse should elevate the client's left leg. If the cast is too tight, pressure can build up in the fascial compartment, causing neurovascular damage. The nurse should anticipate that the provider will cut or bivalve the cast to relieve pressure. The nurse monitors the level of pain to determine the effectiveness of treatment to reduce pressure under the cast. Nurse monitors for paresthesias, which can occur as pressure increases within the confined space of the leg cast. Paresthesia is manifested as numbness, burning, or tingling in the extremity. Fat embolism syndrome can occur in the client with a long bone fracture, such as the tibia, due to a fat embolism from the fractured bone. Manifestations include hypotension, tachycardia, hypoxemia, hypoxemia, dyspnea, petechiae, and a change in the level of consciousness.

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding?

Pulse Deficit

Client being seen today for follow-up of a blood pressure reading of 158/92 mm Hg at a community health fair. Client denies experiencing dizziness, fatigue, chest pain, shortness of breath, nose bleeds, blood in the urine, or blurry vision. No report of back or abdominal pain. Breath sounds clear. S1 and S2 heart sounds heard on auscultation; no S3, murmurs, or rubs noted. Radial and dorsalis pedis pulses strong, no edema in feet noted. No bruits heard over abdomen or carotid arteries. Vital signs: temperature, 98.2°F (36.8°C); heart rate, 76 beats/min; respiratory rate, 18 breaths/min; blood pressure, 156/94 mm Hg in right arm, 155/92 mm Hg in left arm. Weight 208 lb. (94.4 kg), height 69 in. (175.3 cm); body mass index (BMI), 30.7.

Stage 2 hypertension is defined as a systolic blood pressure at or above 140 mm Hg or a diastolic blood pressure at or above 90 mm Hg. Monitor the client's blood pressure to determine if captopril and lifestyle modifications are effective in reducing BP. Hypertension can affect the cardiovascular, neurological, & renal systems, monitor for signs and symptoms of heart disease, stroke, retinopathy of the eyes, and changes in renal function tests. Because hypertension causes damage to organs of the body, such as the heart, kidneys, brain, & eyes (end-organ damage) monitor for evidence of disease progression. Normal BP is defined as a systolic BP less than 120 mm Hg and a diastolic BP less than 80 mm Hg. Stage 1 hypertension is defined as a systolic BP 130 to 139 mm Hg or a diastolic BP 80 to 90 mm Hg. The client should be encouraged to follow a DASH diet, which promotes consumption of low-fat dairy products. DASH diet also promotes low-sodium, low total fat, low saturated fat foods. Teach the client to engage in at least 30 minutes per day of aerobic exercise, most days of the week.

Osteomyelitis

bone infection, is manifested by fever, chills, and redness, warmth, and pain at the site of infection. Renal calculi (urinary tract stones) can occur from decalcification following prolonged bedrest secondary to a fracture. It is manifested by fever, chills, flank pain, nausea, and vomiting. If the client had an infection, such as osteomyelitis, the nurse would anticipate an order to administer IV antibiotics. Troponin levels increase with ischemia and necrosis of cardiac muscle, not skeletal muscle. The serum creatinine kinase level would be elevated with skeletal muscle ischemia. Anticoagulants would be contraindicated until it is known if the client requires surgery, such as a fasciotomy, to relieve compartment pressure in the lower leg. The nurse would monitor oxygen saturation if the client was hypoxemic and having alterations in oxygenation, such as a pulmonary embolism. If the client has an infection, such as osteomyelitis, the nurse would monitor body temperature to determine the effectiveness of antibiotic treatment. If the client had renal calculi, the nurse would monitor for a decrease in urinary output or the passing of stones.