Cardiovascular System, Blood, and Lymphatic System
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is: 1. Discontinue the IV site and contact the primary health care provider 2. Elevate the head of the bed and obtain vital signs 3. Contact the primary health care provider to obtain a prescription for a sedative 4. Assess for allergies and change the IV to an intermittent infusion device
2. Elevate the head of the bed and obtain vital signs The client's ability to speak indicates that the client is breathing. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Checking the vital signs after this is the first step in assessing the cause of the distress. Discontinuing the IV access line may cause unnecessary discomfort if it must be restarted; there are too few data to call the health care provider at this time. There is not enough information to support calling the health care provider and obtaining a prescription for a sedative; further assessment is required. There is no information to support assessing for allergies and changing the IV to an intermittent infusion device; assessment for allergies should be done on admission.
What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1. Arterial spasm 2. Heart muscle ischemia 3. Blocking of the coronary veins 4. Irritation of nerve endings in the cardiac plexus
2. Heart muscle ischemia Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.
A nurse is caring for a client who had emergency surgery for a ruptured appendix. What action should the nurse take when the client manifests signs and symptoms of shock? 1. Prepare for a blood transfusion 2. Elevate the head of the bed 30 degrees 3. Administer 2 L oxygen via nasal cannula 4. Notify the health care provider immediately
4 - Notify health care provider immediately Peritonitis and shock are potentially life-threatening complications that may occur after abdominal surgery; prompt, rigorous treatment is necessary. Fluids, not blood, will be needed to expand and maintain the circulating blood volume. The head of the bed should be flat to increase tissue perfusion and oxygenation to vital organs. Two liters of oxygen is inadequate; a higher flow rate is necessary.
A health care provider prescribes enoxaprarin (Lovenox) 30 mg subcutaneously daily. To ensure client safety, which measure would the nurse take when administering this medication? 1. Remove air pocket from prepackaged syringe before administration. 2. Rub site after administration. 3. Push over 2 minutes. 4. Administer in the abdomen.
4. Administer in the abdomen. Enoxaprarin specifically targets blood clots throughout the body and carries a lower risk of hemorrhage than that associated with the drugs heparin and warfarin. Enoxaprarin is administered once a day through a subcutaneous injection site around the naval. Enoxaprarin should be injected into the fatty tissue only, which is why the abdomen is the recommended injection site. Avoid administering in a muscle. Manufacturer recommendations indicate the air pocket from prepackaged syringes not be removed before administration. Rubbing the site is contraindicated as it can cause bruising. There are no recommendations to push medication over 2 minutes.
A nurse is caring for a client with heart failure. The health care provider prescribes a 2 gram sodium diet. What should the nurse include when explaining how a low salt diet helps achieve a therapeutic outcome? 1. Allows excess tissue fluid to be excreted 2. Helps to control food intake and thus weight 3. Aids the weakened heart muscle to contract and improves cardiac output 4. Helps reduce potassium accumulation that occurs when sodium intake is high
1 - Allows excess tissue fluid to be excreted A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet, exercise (if permitted), and prevention of fluid retention. The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.
What is the most important information the nurse can give a client who was just diagnosed with hypertension? 1. "Long-term follow-up care is necessary." 2. "Monitor yourself for signs of hypertension." 3. "Perform occasional blood pressure measurements." 4. "Adjust your antihypertensive dose based on daily blood pressure results."
1. "Long-term follow-up care is necessary." Hypertension can affect other body tissues, such as the kidneys and eyes; follow-up care and adherence to the therapeutic regimen (e.g., medications, diet, and exercise) are imperative. Hypertension often is asymptomatic, not symptomatic. The client should maintain routine (e.g., daily, weekly) records of blood pressure results as advised. The medication regimen should be followed exactly as prescribed; doses are adjusted by the health care provider.
A client has a femoral-popliteal bypass graft. When a nurse assesses the vital signs, the client's blood pressure is 200/110 mm Hg. Why should the nurse notify the health care provider immediately? 1. Graft may rupture. 2. Client is anaphylactic. 3. Client is hypervolemic. 4. Graft may be occluded.
1. Graft may rupture. Hypertension increases pressure on the suture lines of the graft. Signs of shock, including a drop in blood pressure, are associated with a severe allergic reaction. An increased blood pressure does not necessarily mean that the client is hypervolemic. An occluded graft is indicated by absent pedal pulses.
A client is seen in the clinic with sickle cell anemia. The hemoglobin range that is expected to be seen in this client in sickle cell crisis would be: 1. 3--4g/100 mL 2. 6--8g/100 mL 3. 12--14g/100 mL 4. 16--18g/100 mL
2 - 6--8g/100 mL In sickle cell crisis, hemoglobin values are usually in the 6--8g/100 mL range showing many sickle shaped cells, and the client also will have a low oxygen level. A level of 3--4g/100 mL would not carry enough oxygen as hemoglobin carries oxygen. A range of 12--14g/100 mL is not indicative of anemia. 16--18g/100 mL may be indicative of dehydration rather than anemia.
A nurse is caring for a client eight hours after surgery. The client's portable wound drainage device is half full of drainage. After emptying the drainage collection chamber, the nurse creates negative pressure in the system by: 1. Attaching the device to a wall suction unit 2. Milking the tubing toward the suction device 3. Compressing the device while closing the air plug 4. Keeping the device in a position lower than the site of insertion
3 - Compressing the device while closing the air plug Compressing the device expels air in the unit, and closing the plug while it is compressed reestablishes the closed system and creates negative pressure. A portable suction device usually is not attached to a mechanical suction machine. Milking the tubing promotes patency but will not create negative pressure. Although a portable wound drainage container is kept below the level of the insertion site, which facilitates drainage by gravity, this will not create negative pressure in the system.
A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering the laboratory result, the nurse should monitor the client's electrocardiogram (ECG) for: 1. Tall, peaked P waves 2. Increased P-R intervals 3. Elevated U and flattened T waves 4. Multiple trigeminy and bigeminy runs
3. Elevated U and flattened T waves Elevated U and flattened T waves reflect low serum potassium levels. U waves are not expected; they signify repolarization of the terminal Purkinje fibers and are seen with hypokalemia. T waves represent ventricular repolarization; T waves flatten with hypokalemia and peak with hyperkalemia. Changes in P waves reflect atrial depolarization and contraction activity; P waves flatten with hyperkalemia, not hypokalemia. Increased P-R intervals are related to a delay in conduction from the sinoatrial (SA) node to the ventricles, and are not altered with hypokalemia. Trigeminy and bigeminy reflect ventricular irritability, not the serum potassium level.
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, the nurse should be prepared to administer: 1. Vitamin K 2.Panheparin 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 drugs like warfarin sodium (Coumadin). Panheparin is an alternate name for heparin sodium. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin.
A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client two days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of: 1. Tissue necrosis 2. Venous thrombosis 3. Pulmonary infarction 4. Respiratory infection
1. Tissue necrosis The body's inflammatory response to myocardial necrosis causes an elevation of temperature as well as leukocytosis within 24 to 48 hours after the event. Venous thrombosis is not an expected finding after a myocardial infarction. Pulmonary infarction is not an expected finding after a myocardial infarction. Respiratory infection is not common after myocardial infarction.
A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? 1. History of hypertensive disease 2. Emboli associated with atrial fibrillation 3. Developmental defect of the arterial wall 4. Inappropriate paroxysmal neural discharge
2 - Emboli associated with atrial fibrillation Emboli, occurring from atrial fibrillation, cause complete occlusion of vessels; usually middle cerebral arteries are involved. The infarct may cause hemiplegia, aphasia, or spatial perceptual deficits. Hypertension may cause spasm of the arteries, but it does not cause anatomical occlusion. A developmental defect of the arterial wall is associated with a saccular aneurysm. A seizure is caused by an inappropriate paroxysmal discharge, not a complete occlusion of the branches of the middle cerebral artery.
After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? 1.Elevate the legs and tell the client to drink more fluids. 2. Instruct the client to remain in bed and notify the health care provider. 3. Rub the client's legs to stimulate circulation and cover the client with a blanket. 4. Tell the client about the dangers of prolonged bed rest and encourage ambulation.
2 - Instruct the client to remain in bed and notify the health care provider. Localized sensory changes may indicate nerve damage, impaired circulation, or thrombophlebitis. Activity should be limited. Symptoms may indicate a serious problem, and the health care provider must be notified. While fluids may be helpful to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral intake. Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if present. Bed rest is indicated to prevent the possibility of further damage or creation of an embolus.
A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. The nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when: 1. Sublingual tingling is experienced. 2. The tablets are more than three months old. 3. The pain is unrelieved, but facial flushing is increased. 4. Onset of relief is delayed, but the duration of relief is unchanged.
2. The tablets are more than three months old. Nitroglycerin tablets are affected by light, heat, and moisture. Loss of potency can occur after three months, reducing the drug's effectiveness in relieving pain. A new supply should be obtained routinely. Experiencing sublingual tingling indicates the tablets have retained their potency. Unrelieved pain with an increase of facial flushing and delayed relief with the duration of relief remaining the same do not necessarily indicate loss of potency.
The first step in dysrhythmia analysis is to determine heart rate. To do this the nurse: 1. Counts QRS complexes only because they indicate ventricular contraction. 2. Counts P waves only because the sinoatrial (SA) node is the pacemaker of the heart. 3. Counts both P waves and QRS complexes because they can be different. 4. Records the rate on the monitor screen because it is always accurate.
3 - Counts both P waves and QRS complexes because they can be different. Under normal conditions, the atria and the ventricles depolarize in a regular sequence. However, each can depolarize at a different rate. P waves are used to calculate the atrial rate, and QRS waves or "R" waves are used to calculate the ventricular rate. Cardiac monitors continuously display heart rates. However, the calculated rates should always be verified.
A client who had a myocardial infarction receives a prescription for a beta-blocker and a nitroglycerin patch. The nurse determines that the purpose of the nitroglycerin patch is to decrease the: 1. Pulse rate, thereby strengthening cardiac contractility 2. Cardiac output, thereby reducing the cardiac workload 3. Preload of the heart, thereby reducing the cardiac workload 4. Coronary artery lumens, thereby reducing peripheral resistance
3 - Preload of the heart, thereby reducing the cardiac workload Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect; it dilates coronary arteries, reduces myocardial ischemia, strengthens contractility, and increases efficiency of cardiac output. Decreasing the pulse rate does not strengthen cardiac contractility. Cardiac output is increased, not decreased. Peripheral resistance is affected not by dilating the coronary arteries but by dilating the peripheral arteries.
What is the normal pathway followed during the cardiac cycle? 1. Atrioventricular (AV) node, bundle of His, sinoatrial (SA) node, Purkinje fibers, bundle branches 2. SA node, Purkinje fibers, AV node, bundle branches, bundle of His 3. SA node, AV node, bundle of His, bundle branches, Purkinje fibers 4. Bundle of His, SA node, AV node, bundle branches, Purkinje fibers
3 - SA node, AV node, bundle of His, bundle branches, Purkinje Fibers The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinus or SA node. The impulse quickly reaches the AV node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The electrical impulse then is conducted rapidly through the bundle of His to the ventricles via the left and right bundle branches. The bundle branches divide into smaller and smaller branches, finally terminating in tiny fibers called Purkinje fibers that reach the myocardial muscle cells or myocytes.
A client who had a coronary artery bypass graft six months ago is being discharged after a recent hospitalization for an exacerbation of emphysema. What should the nurse teach the client? 1. Take one aspirin every other day. 2. Drink a cup of warm tea before going to bed at night. 3. Wear a scarf or mask over the mouth in cold weather. 4. Take the prescribed bronchodilators on an empty stomach.
3 - Wear a scarf or mask over the mouth in cold weather. Wearing a scarf or mask over the mouth in cold weather helps to warm the air, thereby preventing bronchospasm. Taking one aspirin every other day requires a health care provider's prescription and is used to prevent clotting; it does not influence the respiratory tract. Drinking a cup of warm tea before going to bed at night is not recommended unless it is decaffeinated; tea contains caffeine, a stimulant, which may interfere with sleep. Bronchodilators cause gastrointestinal irritation and should not be taken on an empty stomach.
What instructions about the use of nitroglycerin should the nurse provide to a client with angina? 1. "Identify when pain occurs, and place two tablets under the tongue." 2. "Place one tablet under the tongue, and swallow another when pain is intense." 3. "Before physical activity place one tablet under the tongue, and repeat the dose in five minutes if pain occurs." 4. "Place one tablet under the tongue when pain occurs, and use an additional tablet after the attack to prevent recurrence."
3 - before physical activity place one tablet under the tongue, and repeat the dose in five minutes if pain occurs." Anginal pain, which can be anticipated during certain activities, may be prevented by dilating the coronary arteries immediately before engaging in the activity. One tablet is generally administered at a time; doubling the dosage may produce severe hypotension and headache. The sublingual form of nitroglycerin is absorbed directly through the mucous membranes and should not be swallowed. When the pain is relieved, rest generally will prevent its recurrence by reducing oxygen consumption of the myocardium.
Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings? 1. Support hose should reach the middle of the knee. 2. The stockings should be applied before getting out of bed. 3. The stockings should be applied at the first sign of discomfort. 4. Elastic bandages may be substituted because they are more economical.
3. The stockings should be applied at the first sign of discomfort. To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. The stockings apply uniform pressure; elastic bandages may slip, creating uneven pressure and constriction. Edema also may result.
A client's blood pressure increases dramatically six hours after a femoral-popliteal bypass graft. Which concern motivates the nurse to inform the health care provider? 1. Hypertension may cause the graft to occlude. 2. Hypervolemia may be the cause of the hypertension. 3. Extremely high blood pressure may cause a brain attack (cerebrovascular accident). 4. Rapidly increasing blood pressure may rupture the graft.
4. Rapidly increasing blood pressure may rupture the graft. The client is hypertensive, and the intraarterial pressure is increased; this increased pressure may cause the arterial suture line to rupture. Hypertension may cause the graft to occlude but is unlikely; however, because blood pressure is increased, the client is at risk for bleeding. Hypervolemia is an assumption; other causes, such as arterial constriction, can precipitate hypertension. Although extremely high blood pressure may cause a brain attack, the priority at this time is protecting the graft.
A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? 1. Fever and chest pain 2. Positive Homans' sign 3. Loss of sensation in the operative leg 4. Tachycardia and petechiae over the chest
4. Tachycardia and petechiae Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans' sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurological dysfunction; it is not an indication of a fat embolism.