Saunders Ch 56 & 57
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia
1. Atrial fibrillation (Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.)
A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1. 50 J 2. 120 J 3. 200 J 4. 360 J
4. 360 J ( The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.)
A hospitalized client with a diagnosis of abdominal aortic aneurysm suddenly complains of severe back pain and shortness of breath. What should the nurse do?
If the client with an abdominal aortic aneurysm suddenly complains of severe back pain and shortness of breath, the nurse should suspect rupture (a surgical emergency) and should immediately contact the health care provider (HCP). The nurse should also obtain information about the back pain, stay with the client while waiting for the arrival of the HCP, monitor vital signs and neurological status, and provide support to the client. Other signs of rupture include severe abdominal pain or fullness, soreness over the umbilicus, and sudden development of discoloration in the extremities.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position
1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously (Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.)
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm
1. Sinus tachycardia (Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.)
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds
2. Crackles (Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.)
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin
2. Metformin (Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.)
A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates that the medication has achieved the expected effect? 1. Cough becomes productive of frothy pink sputum. 2. Urine output increases from 10 mL/hour to greater than 50 mL hourly. 3. The serum potassium level changes from 3.8 to 3.1 mEq/L (3.8 to 3.1 mmol/L). 4. B-type natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL (200 to 262 ng/L).
2. Urine output increases from 10 mL/hour to greater than 50 mL hourly. (Bumetanide is a diuretic and expected outcomes include increased urine output, decreased crackles, and decreased weight. Options 1, 3, and 4 are incorrect.)
The nurse is planning to administer hydrochlorothiazide to a client. The nurse should monitor for which adverse effects related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Increased risk of osteoporosis 3. Hypokalemia, hyperglycemia, sulfa allergy 4. Hyperkalemia, hypoglycemia, penicillin allergy
3. Hypokalemia, hyperglycemia, sulfa allergy (Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.)
The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia
3. Ventricular fibrillation (Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.)
The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? 1. "I will avoid alcohol consumption." 2. "I will take my pills every day at the same time." 3. "I have already called my family to pick up a MedicAlert bracelet." 4. "I will take coated aspirin for my headaches because it will coat my stomach."
4. "I will take coated aspirin for my headaches because it will coat my stomach." (Aspirin-containing products need to be avoided when a client is taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.)
A client is prescribed nicotinic acid for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. "It is not necessary to avoid the use of alcohol." 2. "The medication should be taken with meals to decrease flushing." 3. "Clay-colored stools are a common side effect and should not be of concern." 4. "Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing."
4. "Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing." (Flushing is an adverse effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this effect. The medication should be taken with meals to decrease gastrointestinal upset; however, taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be reported to the health care provider (HCP) immediately.)
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I should notify my doctor if my feet or legs start to swell." 2. "My doctor told me to call his office if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."
4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." (Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the health care provider. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with his or her spouse.)
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? 1. Anxiety level of the client and family 2. Presence of a MedicAlert card for the client to carry 3. Knowledge of restrictions on postdischarge physical activity 4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver (The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.)
A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1. Administer digoxin. 2. Defibrillate the client. 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing.
4. Prepare for transcutaneous pacing. (Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.)
The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2. Nonarousable, sinus rhythm, BP 88/60 mm Hg 3. Arousable, marked bradycardia, BP 86/54 mm Hg 4. Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg
1. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg (After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.)
A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication? Time: 11:00 a.m. 11:15 a.m. 11:30 a.m. 11:45 a.m. Pulse: 92 beats/min 96 beats/min 104 beats/min 118 beats/min Respiratory rate: 24 breaths/min 26 breaths/min 28 breaths/min 32 breaths/min Blood pressure: 140/88 mm Hg 128/82 mm Hg 104/68 mm Hg 88/58 mm Hg 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm
1. Cardiogenic shock (Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine output; and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.)
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.
1. It can develop into ventricular fibrillation at any time. (Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.)
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.
1. The neurovascular status is normal because of increased blood flow through the leg. (An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.)
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1. Muffled heart sounds 2. A rise in blood pressure 3. Jugular venous distention 4. Client expressions of dyspnea
2. A rise in blood pressure (Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.)
The nurse is monitoring a client who is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply. 1. Tremors 2. Diarrhea 3. Irritability 4. Blurred vision 5. Nausea and vomiting
2. Diarrhea 4. Blurred vision 5. Nausea and vomiting (Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/mL.)
Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1. Vitamin K 2. Protamine sulfate 3. Potassium chloride 4. Aminocaproic acid
2. Protamine sulfate (The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.)
The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness
2. Status of airway (Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.)
The nurse is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? 1. The development of complaints of insomnia 2. The development of audible expiratory wheezes 3. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after 2 doses of the medication 4. A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/minute after 2 doses of the medication
2. The development of audible expiratory wheezes (Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. Beta blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.)
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure
2. Ventricular dysrhythmias (Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.)
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Sensation of palpitations 2. Causative factors, such as caffeine 3. Blood pressure and oxygen saturation 4. Precipitating factors, such as infection
3. Blood pressure and oxygen saturation (Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.)
The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4 °F (37.4 °C) orally 3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/minute
3. Blood pressure of 198/110 mm Hg (Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the HCP before initiating therapy.)
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Call the health care provider. 3. Check the client's status and lead placement. 4. Press the recorder button on the electrocardiogram console.
3. Check the client's status and lead placement. (Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.)
A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority? 1. Administer oxygen and protamine sulfate. 2. Cut the infusion rate in half and sit the client up in bed. 3. Stop the infusion and call for the Rapid Response Team (RRT). 4. Administer diphenhydramine and epinephrine and continue the infusion.
3. Stop the infusion and call for the Rapid Response Team (RRT). (The client is experiencing an anaphylactic reaction. Therefore, the priority action is to stop the infusion and notify the RRT. The health care provider should be contacted once the client has been stabilized. The client may be treated with epinephrine, antihistamines, and corticosteroids as prescribed, but the infusion should not be continued.)
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions
3. Ventricular tachycardia (Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular.)
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Notify the health care provider. 4. Continue to monitor for any rhythm change.
4. Continue to monitor for any rhythm change. (Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.)
The nurse notes that a client taking warfarin sodium has an international normalized ratio (INR) of 2.8. What should the nurse do?
The normal INR is 0.81 to 1.2 (0.81-1.2). The treatment goal of warfarin sodium is to raise the INR to an appropriate value. An INR of 2 to 3 is appropriate for most clients, although for some clients the target INR is 3 to 4.5, such as in the case of a mechanical heart valve. If the INR is below the recommended range, warfarin sodium should be increased. If the INR is above the recommended range, warfarin sodium should be reduced. If the INR is 2.8, the nurse should plan to administer the same dosage as prescribed.
A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? 1. Prothrombin time of 12.5 seconds 2. Activated partial thromboplastin time of 60 seconds 3. Activated partial thromboplastin time of 28 seconds 4. Activated partial thromboplastin time longer than 120 seconds
2. Activated partial thromboplastin time of 60 seconds (Common laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the normal value, the client's aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.)
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection
2. Acute kidney injury (The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine: male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.)
The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L) and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1. Check the urine specific gravity. 2. Call the health care provider (HCP). 3. Put the IV line on a pump so that the infusion rate is sure to stay stable. 4. Check to see if the client had a blood sample for a serum albumin level drawn.
2. Call the health care provider (HCP). (Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine: male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). Options 1 and 4 are not associated with the data in the question. The IV should have already been on a pump. Urine output lower than 30 mL/hour is reported to the HCP.)
A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results? 1. Collaborate with the health care provider (HCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. 2. Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. 3. Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. 4. Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin sodium.
2. Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. (When a client is receiving warfarin for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range, the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the HCP to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.)
The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms? 1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Hypertension and headache
3. Hypotension and dizziness (The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.)
A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available.
3. Monitor for signs of bleeding. (Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin may be administered after thrombolytic therapy, but the question is not asking about follow-up medications.)
The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (10 mmol/L). The client is taking cholestyramine and the nurse teaches the client about the medication. Which statement, by the client, indicates the need for further teaching? 1. "Constipation and bloating might be a problem." 2. "I'll continue to watch my diet and reduce my fats." 3. "Walking a mile each day will help the whole process." 4. "I'll continue my nicotinic acid from the health food store."
4. "I'll continue my nicotinic acid from the health food store." (Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin needs to be avoided. Constipation and bloating are the 2 most common adverse effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.)
A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and is complaining of anorexia. The health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range? 1. 0.3 ng/mL 2. 0.5 ng/mL 3. 0.8 ng/mL 4. 1.0 ng/mL
4. 1.0 ng/mL (The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/mL. If the client is experiencing symptoms such as anorexia and is experiencing hypokalemia as evidenced by a low potassium level, digoxin toxicity is a concern. Therefore, option 4 is correct because it is outside of the therapeutic level and an elevated level.)
A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? 1. Measure the heart rate on the rhythm strip. 2. Administer prescribed nitroglycerin tablets. 3. Obtain a 12-lead electrocardiogram immediately. 4. Auscultate the client's apical pulse and obtain a blood pressure.
4. Auscultate the client's apical pulse and obtain a blood pressure. (Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although measuring the heart rate on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure.)
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1. Ensure that the client has been intubated. 2. Set the defibrillator to the "synchronize" mode. 3. Administer an amiodarone bolus intravenously. 4. Confirm that the rhythm is actually ventricular fibrillation.
4. Confirm that the rhythm is actually ventricular fibrillation. (Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.)
Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.5 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity? 1. Serum calcium level 2. Serum potassium level 3. Serum creatinine level 4. Serum magnesium level
4. Serum magnesium level (An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. The calcium, creatinine, and potassium levels are all within normal limits. The normal range for magnesium is 1.3 to 2.1 mEq/L (0.65-1.05 mmol/L) and the results in the correct option are reflective of hypomagnesemia.)
