Perfusion

a nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?

Apex of the heart

A nurse is teaching a client who has vitamin K deficiency about the effects of vitamin K. Which of the following information should the nurse include in the teaching?

Vitamin K reverses warfarin toxicity

a nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

irregular pulsations PVCs are early ventricular depolarizations with a pause immediately afterwards. That pause in the usual heart rhythm results in an irregular force and rate on palpation of a peripheral pulse and an irregular beat on auscultation of the apical pulse. PVCs have a wide variety of causes. Clients typically perceive them as "palpitations" and can feel lightheaded if they occur frequently.

A nurse is obtaining vital signs from a 2 month infant. The infant's heart is 190 bpm and his temperature is 40C (104F). The father asks the nurse why the infant's heart is beating so fast. Which of the following is an appropriate response?

"The fever is causing an increase in your baby's heart rate"

A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to hold the medication?

Heart rate 46/min

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Atrial Fibrillation Atrial fibrillation causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

Atropine

The nurse is caring for a patient with hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.

A nurse is providing discharge instructions to a client following cardiac catheterization. Which of the following information should the nurse include?

you will notice a small hematoma at the incision site

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of transfusion?

Chills

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Blood pressure 92/50

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations?

Fatigue Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness.

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adrenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Increase in HR from 88 to 110 MY ANSWER Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole.

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD) Which of the following information should the nurse include?

The client should hold his cell phone on the side opposite of the ICD

A nurse is caring for a client who reports palpitations. An ECG confirms that the client is experiencing ventricular tachycardia. The nurse should anticipate the need for taking which of the following actions?

elective cardioversion

a nurse is monitoring a patient who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

the p wave falls before the QRS complex

a nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. which of the following client statements should the nurse recognize as an understanding of the teaching?

the pacemaker can be checked at home over the telephone

A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he does not understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?

"Cardiac rehabilitation cannot undo the damage done to your heart but it can help you get back to your previous level of activity safely"

A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply)

"I must stop smoking" "I need to monitor my weight" "I will limit my intake of fast food"

A nurse is preparing to administer potassium chloride elixir 40 mEq divided into 2 equal doses every 12 hour. Available is 6.7 mEq/5mL. How many mL should the nurse administer per dose?

15

A nurse is caring for a client who develops ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Defibrillation

a nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Blood pressure 115/68 The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings supports this conclusion?

Confusion Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

Different apical and radial pulses Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the atrium depolarizes too quickly and sends erratic impulses to the ventricles. The presence of a pulse deficit between the apical and radial pulses is an indication of atrial fibrillation. The nurse should assess further by obtaining an ECG or telemetry reading.

A nurse is teaching a client who has a family history of of hemophilia A about manifestations of the disorder. The nurse should include which of the following manifestations in the teaching?

Disabling joint pain A client who has hemophilia A can have disabling joint pain over time, especially of the knee and hip, because of hemorrhage into the joints.

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

Dysrhythmias Dysrhythmias can result from straining while defecating. Pressure can be exerted with the Valsalva maneuver, when the client contracts the abdominal muscles and holds their breath while bearing down. When the client exhales, there is a sudden release of intraabdominal pressure against the closed airway, which can result in cardiac dysrhythmias and elevated blood pressure.

A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

Frequent swallowing

A nurse is providing discharge instructions to the parents of a 10 year old child following cardiac catheterization. Which of the following instruction should the nurse include?

Give the child acetaminophen for discomfort

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Hemodynamic Status A pulmonary artery catheter is inserted into the pulmonary artery and monitors a client's hemodynamic status by measuring pulmonary artery pressures and cardiac output.

A nurse is preparing the administer verapmil by IV bolus to a client who is having cardiac dysrhythmias. For which of adverse effects should the nurse monitor when giving medications?

Hypotension Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhythmias. It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A major adverse effect of verapamil is hypotension; therefore, blood pressure and pulse must be monitored before and during parenteral administration.

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

Hypovolemia A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Increased Heart Rate The nurse should anticipate an increased heart rate as an early indication of shock because the body attempts to compensate for decreased circulatory volume.

A nurse is assessing a client who is receiving a continuous IV drip infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect?

Increased urine output

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should determine that which of the following findings indicates the medication is effective?

Increased urine output Dobutamine is administered to clients who have heart failure to improve their hemodynamic status. The nurse should identify an increase in client's urine output as an indication that the medication is effective.

A nurse is reviewing lab results of four children. Which of the following findings should the nurse report to the provider?

Iron 38 mcg/dL

A nurse is assessing a client with atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Irregular With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing tamponade. Which of the following assessments findings should the nurse identify as supporting the suspicion?

Muffled heart sounds Muffled heart sounds are a key indicator of cardiac tamponade because of the excess amount of fluid surrounding the heart.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Narrowing pulse pressure Pulse pressure is the difference between the systolic and diastolic blood pressures. In the initial stage of shock there is a slight increase in the diastolic blood pressure, which narrows the pulse pressure.

A nurse is reviewing lab results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?

PT 45 seconds The expected reference range for PT is 11 to 12.5 seconds. During therapy, the nurse should expect to see the values increase 1.5 to 2.5 times the baseline. Therefore, the nurse should withhold the warfarin and notify the provider.

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Pacemaker spikes before each QRS complex The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

Packed RBCS Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock.

A nurse is planning care for a client following a cardiac catheterization accessed through the femoral artery. Which of the following actions should the nurse plan to take.

Perform neurovascular checks with vital signs The nurse should assess color, temperature, and pulse in the affected extremity and monitor the client for neurovascular changes that can indicate a stroke, such as slurred speech and visual disturbances.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?

Report of low-back pain Low-back pain, fever, and chills are manifestations of a hemolytic transfusion reaction. The nurse should discontinue the transfusion and administer 0.9% sodium chloride through new IV tubing.

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

The client experiences weakness of one arm and leg

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

manifestations preceded by a severe headache

A nurse is caring for a female client who reports an increase in bruising. The nurse should expect which of the following lab results?

platelets 110,000

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?

to reduce the risk of stroke in patients with atrial fibrillation Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as dabigatran, help prevent thrombus formation.