Exam #3 Content - ATI/LEWIS

Which of the following is the most common risk factor for a pulmonary embolism? A. Immobility B. Fractured long bone C. Obesity D. DVT

Answer D (mine) but all of these are risk factors! Also HF, smoking, oral contraceptive use, clotting disorders, pregnancy, Afib, central venous catheters, surgery, malignancy

When caring for a patient with a diagnosed pulmonary embolism, the nurse should keep the head of the bed in which of the following positions? A. High-Fowlers B. Semi-Fowlers C. Trendelenburg D. Flat

B. Semi fowlers (mine) HOB to 30-45 degrees or Semi fowlers

Treatment modalities for the management of cariogenic shock includes (select all that apply): A. Dobutamine to increase myocardial contractility B. Vasopressors to increase SVR C. Circulatory assist devices such as an intraaortic balloon pump D. Corticosteroids to stabilize the cell wall in the infarcted myocardium E. Trendelenburg positioning to facilitate venous return and increase preload

Answer: A, C

A nurse is caring for a client who is hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

Answer: 0.9% sodium chloride Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride (A crystalloid) is physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products. B and C are hypertonic solutions. These solutions will diffuse into the cells of the tissue and have no effect on circulating volume. A is a hypotonic solution which can cause lysis of RBCs because it has fewer solutes than the cell, causing osmotic pressure to pul the fluid into the few cells remaining.

When caring for a patient who has a suspected pulmonary embolism (PE), the client experiences an allergic reaction to the IV contrast media used in the spiral CT scan. Which of the following tests should the nurse expect the provider to order to help confirm the diagnosis of a PE? A. Ventilation/perfusion (V/Q) scan B. Coronary angiography C. Electroencephalogram D. Abdominal CT

Answer: A (mine) This is used if the patient cannot have IV contrast media. The ventilation scanning is when the patient inhales radioactive gas, and the physicians look for the distribution of the gas in the lungs. In perfusion scanning, they inject radioisotope, and look for perfusion in the pulmonary vasculature. Other tests include a pulmonary angiography (maybe not in someone allergic to IV contrast) which is the most sensitive but invasive. There is also the chest x-ray and an ECG, but both are just informative and not diagnostic.

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min, and SpO2 955. Which of the following actions should the nurse take? A. Administer antihypertensive medication for blood pressure B. Monitor to ensure the client's urinary output is 20 mL/hour C. Withhold pain medication to prepare the client for surgery D. Take the client's vital signs every 2 hours

Answer: A Administer antihypertensive medication for blood pressure The nurse should administer antihypertensive medication for elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall. Oliguria can indicate a rupture of the aneurysm. The nurse should administer pain medication because pain occurs due to the pressure from the aneurysm on the lumbar nerves. Pain can also cause hypertension. The nurse should take the client's VS at least every 15 minutes to monitor for a sudden drop in BP, which can indicate rupture of the aneurysm.

The healthcare provider is caring for a patient who has a diagnosis of cardiogenic shock secondary to left ventricular dysfunction. The goals of pharmacotherapy for this patient include which of these outcomes? Select all that apply. A. Decreased preload B. Increased afterload C. Increased peripheral resistance D. Increased contractility E. Decreased cardiac output

Answer: A and D (Khan academy) The goals of pharmacotherapy are to enhance the effectiveness of the pump and improve tissue perfusion without increasing cardiac workload. Inotropic agents are used to increase contractility. Diuretics are used to decrease preload. After the patient has been stabilized, vasodilating agents may be used to further reduce both preload and afterload.

A patient is being treated in the intensive care unit for septic shock related to a gram-negative bacterial infection. Which of these are expected findings for this patient? Select all that apply. A. Peripheral edema B. Increased PAWP C. A MAP of 65 D. Increased WBCs with left shift E. Partial pressure of oxygen: 80%

Answer: A and D (khan) The bacteria stimulate a systemic immune and inflammatory response. Many mature functioning neutrophils and other immune cells will be needed to fight the infection. Inflammation causes the capillary beds to be leaky, so the patient will be edematous as fluid shifts to interstitial space.

A nurse is planning postoperative care for a client following a surgical placement of an endocasvular stent graft to repair an aneurysm. Which of the following interventions should the nurse include in the plan of care? A. Assess pedal pulses B. Monitor for an increase in pain below the graft site C. Maintain the client in high-Fowler's position D. Monitor the femoral site for bleeding E. Report hourly urine output of 60 mL

Answer: A, B, D Assess the pulses distal to the graft site to detect possible occlusion of the graft. Monitor for an increase in pain below the graft site. This can be an indication of graft occlusion or rupture. Check the femoral insertion site for bleeding and for a thrombus formation. The head to the bed should one maintained at less than 45 degrees to prevent flexion of the graft. Urine output of 60 mL/hour is an expected finding.

A nurse is reviewing manifestations of a thoracic aortic aneurysm with a newly hired nurse. Which of the following findings should the nurse include in the discussion? (Select all that apply.) A. Cough B. Shortness of breath C. Upper chest pain. D. Diaphoresis E. Altered swallowing

Answer: A, B, E Report of severe back pain is a manifestation of thoracic aortic aneurysm. Diaphoresis is a finding of dissecting aortic aneurysm.

When assessing a patient with a pulmonary embolism, the nurse should expect which of the following manifestations to be present: (Select all that apply) A. Dyspnea/SOB B. Change in LOC C. Bradycardia D. Hemoptysis E. Wheezing

Answer: A, B. D, E (mine) Will also have: tachypnea, chest pain, cough, crackles, tachycardia, syncope

A nurse is caring for a group of clients. Which of the following clients are at a risk for a pulmonary embolism? Select all that apply. A. A client who has a BMI of 30. B. A female client who is post menopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

Answer: A, C, & E A client who has a BMI of 30 is considered to be obese and is at increased risk for blood clots. A female who is post menopausal has decreased estrogen levels. Increased estrogen levels are a risk factor for developing a pulmonary embolism. The client who has a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. The client who is a marathon runner has increased blood flow and circulation of his body, which decreases the risk for developing a PE. The client who has turbulent blood flow in the heart, such as with atrial fibrillation, is also at increased risk for a blood clot.

A nurse is assessing a client who has a deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Hardening along the blood vessel B. Absence of a peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumference

Answer: A, C, E Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your bloodstream." D. "Treatment with heparin will dissolve the clot and keep other clots from forming."

Answer: A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." Fibrinolysis is a process that breaks down a clot over time in the body. This process is a treatment option for clots that are not immediately life-threatening. There is no physiological mechanism that stabilizes a clot, although a desired outcome is stabilization and eventual resolution. Mobile clots (emboli) are pathological and not an expected resolution of an existing clot. Heparin does not dissolve clots. It prevents enlargement of the existing clots and future clot formation. Thrombolytic therapy, not anticoagulation therapy, dissolves clots.

A nurse is caring for a client who has a prescription for an after load-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? A. Cardiogenic B. Obstructive C. Hypovolemic D. Distributive

Answer: A. Cardiogenic Identify that a prescription to reduce after load will allow the heart to pump more effectively, which is needed for the client who has cariogenic shock. In obstructive shock, the high after load is due to obstruction of blood flow. Afterload-reducing agents will not remove the obstruction. Fluid replacement and reduction of further fluid loss are the focus of management of hypovolemic shock. Afterload reducing medication is not administered to a client who has distributive shock because the client already has decreased preload.

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

Answer: A. Hip arthroplasty 2 weeks ago The client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. An elevated sedimentation rate is not a contraindication to receiving heparin. An Incident of exercise-induced asthma 1 week ago is not a contraindication to receiving heparin. An Elevated platelet count is not a contraindication to receiving heparin.

A patient with a history of alcoholism is admitted to the ICU with hemorrhage from esophageal varicose. Admission VS are BP 84/58 mm Hg, HR 105, and RR 32. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding which indication of organ failure first: A. Pulmonary edema B. Cardiac dysrhythmias C. Absent bowel sounds D. Decreasing blood pressure

Answer: A. Pulmonary Edema The respiratory system is often the first system to show signs of dysfunction in systemic inflammatory response syndrome. lIncreases in capillary permeability facilitate movement of fluid from the pulmonary vasculature into the pulmonary interstitial spaces. The fluid then moves to the alveoli, causing alveolar edema and pulmonary edema.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify which of the following is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

Answer: A. Stabbing chest pain A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom. Calf tenderness is a manifestation of a blood clot in the leg, which can lead to a PE.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

Answer: A. Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs. Tracheal deviation is an indication of pnenumothorax. Tachycardia is a clinical manifestation of pulmonary embolism.

The nurse understands that the CVP is measured in which part of the heart: A. The right atrium B. The right ventricle C. The left atrium D. The left ventricle

Answer: A. the right atrium (my question)

A 78 year old man with a history of diabetes has confusion and temperature of 104 F. There is a wound on his right heel with purulent drainage. After an infusion of 3 L of NSS, his assessment findings are BP 84/50 mmHg, HR 110, RR 42 and shallow, CO 8 L/min, and PAWP 4 mmHg. This patient's symptoms are most likely indicative of A. sepsis B. Septic shock C. Multiple organ dysfunction syndrome D. systemic inflammatory response syndrome

Answer: B

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that the aneurysm has ruptured? A. rapid onset of shortness of breath and hemoptysis B. Sudden severe low back pain and bruising along his flank C. Gradually increasing substernal chest pain and diaphoresis D. Sudden, patchy blue mottling on the feet and toes and rest pain

Answer: B

Which patient is at highest risk for venous thromboembolism? A. a 62 year old man with spider veins who is having arthroscopic knee surgery B. A 32 year old woman who smokes, takes oral contraceptives, and is planning a trip to Europe C. A 26 year old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during labor D. An active 72 year old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia

Answer: B

A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? A, Maintain adequate fluid volume with IV infusions B. Administer antibiotic therapy. C. Monitor hemodynamic status D. Administer vasopressor medication.

Answer: B The greatest risk to the client is injury from elimination endotoxins and mediators from bacteria. The priority intervention is to administer antibiotics, which will reduce vasodilation. Maintain the client's fluid volume by administration of IV fluids. However, another action is the priority. Monitor hemodynamic status to monitor the blood pressure inside the veins, arteries and heart. However, another action is the priority. Administer vasopressor medication to increase the contractility of the heart muscle and to cause vasoconstriction. However, another action is the priority.

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (Select all that apply.) A. Heart rate 60/min B. Seizure Activity C. Respiratory rate 42/min D. Increased urine output E. Weak, thready pulse

Answer: B, C, & E Seizure activity caused by progressive hypoxia can be present in a client who is in shock. Tachypnea is an expected finding in a client who is in shock due to the body's attempt to increase oxygen intake. A weak, thready pulse caused by low fluid volume, vasoconstriction, and hypotension is an expected finding in a client who is in shock. Tachycardia is an expected finding in a client who is in shock. Decreased urine output is an expected finding in shock.

The hemodynamic changes the nurse expects to find after successful initiation of intraortic balloon pump therapy in a patient with cariogenic shock include (select all that apply): A. decreased SV B. deceased SVR C. decreased PAWP D. increased diastolic BP E. decreased myocardial O2 consumption

Answer: B, C, D, E

A nurse is caring for a patient experiencing septic shock. Which of the following are appropriate nursing interventions? (Select all that apply) A. Assess neurological status Q shift B. Continuously monitor ECG C. Assess the patient's response to fluid resuscitation every 15 minutes D. Assess breath sounds every 1-2 hours E. Administer acetaminophen if the patient's temperature rises above 101.5

Answer: B, C, D, E (no rationale given)

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following should the nurse expect?(Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distention

Answer: B, C, E The formation of large amounts of micro emboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distention due to internal bleeding. Tachycardia and pallor are manifestations of hemorrhaging.

In a patient who is experiencing hypovolemic shock, the nurse should expect which of the following lab values to reflect their condition: (Select all that apply) A. Normal CO B. Decreased CO C. Increased SVR D. Decreased SVR E. Low CVP

Answer: B, C, E (my question)

A patient presents to the emergency department with and altered level of consciousness, hypotension and a weak, thready pulse. A bolus of normal saline is given but the BP remains unchanged. The patient has a bronze discoloration in the skin folds and mucous membranes, and a capillary glucose screening reveals hypoglycemia. Shock related to adrenal insufficiency is suspected. Which of these interventions should be implemented for this patient? Select all that apply. A. Administer epinephrine IM B. Administer a bolus of hydrocortisone IV C. Start an infusion of 5% dextrose in NSS D. Give an additional bolus of NSS E. Start an infusion of dopamine

Answer: B, C, and E (Kahn) A patient with adrenal insufficiency will lack both glucocorticoids and mineralocorticoids. The ability of the patient's vasculature to constrict is impaired due to the lack of endogenous cortisol. Dextrose in normal saline will correct the hypoglycemia and hyponatremia. This patient's hypotension is refractory to vasopressors without cortisol, so hydrocortisone will be given along with the dopamine.

Which clinical findings should the nurse expect in a person with acute lower extremity VTE? (Select all that apply) A. pallor and coolness of foot and calf B. mild to moderate calf pain and tenderness C. grossly decreased or absent pedal pulses D. unilateral edema and induration of the thigh E. Palpable cord along a superficial varicose vein

Answer: B, D

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? (Select all that apply) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

Answer: B, D, & E Expect the client to have tachypnea. Expected the client to have a pleural friction rub. Expect the client to have hypotension. Expect the client to have petechiae and tachycardia.

The client finds a poster on the wall titled "Virchow's Triad" and asks the nurse to tell them about it. The nurse correctly identifies the three originations for a thrombus or embolus formation: (Select all that apply). A. Ventilation/perfusion mismatch B. Hypercoaguable state C. Increased dead space D. Venous stasis E. Endothelial injury

Answer: B, D, E (mine)

A nurse caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day for my ulcer." C. "I had a blood clot in. my leg several years ago." D. "It hurts to take a deep breath."

Answer: B. "I take antacids several times a day for my ulcer." The greatest risk to the client is the possibility of bleeding from a peptic ulcer. the priory intervention is to notify the client's provider of the finding. Document the client's allergy to morhpine to manage the client's discomfort due to a blood clot. However, another action is the priority. Document the client's history of a blood clot to provide preventative measures. However, another action is the priority. Expect the client to report pain with breathing. However, another action is the priority.

A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at the greatest risk for a complication? A. A 3-year-old client who has a burned foot B. An 80-year-old client who has a fractured hip C. A 30-year-old client who has a cast applied for a fractured ankle D. A 42-year-old client who has an indwelling urinary catheter

Answer: B. An 80-year-old client who has a fractured hip The nurse should identify that an 80-year old client who has a fractured hip is at the greatest risk for a complication due to immobility and a lack of lower-extremity movement, which can lead to DVT. DVT is caused by venous stasis and blood clot formation in the vascular system and can lead to pulmonary embolic. The nurse should encourage the client to ambulate as soon as prescribed and implement ROM exercises while on bedrest to prevent DVT.

A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority? A. Decreased skin turgor B. Capillary refill 5 seconds C. Heart rate 150/min D. Dry mucous membranes

Answer: B. Capillary refill 5 seconds When using the urgent vs non urgent approach to client care, the nurse should identify that the priority finding is a capillary refill of 5 seconds. A capillary refill above 4 seconds is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic shock.

A nurse is caring for a client who is undergoing repair of an abdominal aortic aneurysm. After the surgery and immediate postoperative recovery, the nurse should expect which of the following team members to coordinate the client's ongoing and specific needs for care? A. Charge nurse B. Case manager C. Vascular surgeon D. home health care nurse

Answer: B. Case manager The case manager's role is to plan and coordinate resources and services to help meet the client's needs over the continuum of care.

A nurse is teaching a client who is premenopausal and has a prescription for a combination oral contraceptive. Which of the following findings should the nurse include as an adverse effect of oral contraceptives? A. Bone fractures B. Deep vein thrombosis C. Increased LDL cholesterol D. Increased risk of breast cancer

Answer: B. Deep vein thrombosis The nurse should include in the teaching that clients who are premenopausal and have a prescription for a combination oral contraceptive containing estrogen are at an increased risk for developing DVT, which is an adverse effect of this medication.

A nurse in the ED is assessing a client who was in a motor vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis

Answer: B. Fat embolism syndrome The nurse should identify the triad of neurological changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and a fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels. The nurse should suspect hypovolemic shock in a client who experiences hypotension following extreme fluid loss, as with uncontrolled bleeding, dehydration, or severe edema.

To establish hemodynamic monitoring for a patient, the nurse zeros the: A. cardiac output monitoring system to the level of the left ventricle B. Pressure monitoring system to the level of the catheter tip in the patient C. pressure monitoring system to the level of the atrium, or the phlebostatic axis D. pressure monitoring system to the level of the atrium, or the midclavicular line

Answer: C

What are the priority nursing interventions 8 hours after an abdominal aortic aneurysm repair? A. Assessing nutritional status and dietary preferences B. Initiating IV heparin and monitoring anticoagulation C. Administering IV fluids and watching kidney function D. Elevating the legs and applying compression stockings

Answer: C

What is the first priority of interprofessional care for a patient with a suspected acute aortic dissection? A. reduce anxiety B. Monitor chest pain C. Control blood pressure. D. Increase myocardial contractility

Answer: C

A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? A. Methyprednisolone B. Diphenhydramine C. Epinephrine D. Dobutamine

Answer: C When using the ABC framework, place the priority on administering epinephrine to the client. this is a rapid acting medication that promotes effective oxygenation and is used to treat anaphylactic shock. Administer methylprednisolone to treat the inflammatory response. However, another action is the priority. Administer diphenhydramine to treat urticaria. However, another action is the priority. Administer dobutamine or other medications to improve cardiac status if IV fluid replacement is not successful. However, another action is the priority.

Which of the following pressure readings would reflect a patient who is experiencing septic shock? A. Increased CO, increased SVR, increased CVP B. Decreased CO, normal SVR, normal CVP C. Increased CO, decreased SVR, decreased CVP D. Decreased CO, decreased SVR, increased CVP

Answer: C (mine)

A nurse is receiving report on a patient who was diagnosed with a pulmonary embolism. The nurse should monitor the patient for which of the following complications? A. Right atrial shunt B. Increased coagulability C. Pulmonary infarction D. Superior vena cava syndrome

Answer: C (mine) Would also expect pulmonary infarction and saddle embolus

A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? A. "I will wear a continuous movement machine on my knees for 24 hours a day." B. "I should avoid taking NSAID medications for pain after surgery." C. "I should wear elastic stockings on both of my legs." D. " I will begin exercising my legs the day after surgery."

Answer: C. " I should wear elastic stockings on both of my legs." The purpose of elastic stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery. Therefore, the nurse should identify this statement as an understanding of the teaching.

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. "I'll expect a little leg swelling since I wont be that active for a while." B. "I'll see the doctor every week to change my vena cava filter." C. "I'll call the doctor if I see any blood in my urine or stool." D. "I'll have to take the blood thinner for a few more days."

Answer: C. "I'll call the doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately. The client might have to limit activities for a while but should not report any leg swelling or tenderness as an indiction of clot formation. The vena cava filter remains in place either until the provider determines there is not a high risk for clot formation or permanently. Clients who had a pulmonary embolism typically require anticoagulant therapy for weeks to years after the acute event.

A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to brush your teeth gently." D. Avoid taking acetaminophen while receiving this medication."

Answer: C. "Use a soft toothbrush to brush your teeth gently." An adverse effect of heparin therapy is an increased risk of bleeding. Heparin is an anticoagulant used to treat DVT. During continuous administration, the client will need frequent monitoring of activated partial thrombbopalstin time (aPTT) to assess for the effectiveness of therapy. A DVT can be uncomfortable, and the client needs accurate information to improve comfort. She can use prescribed oral analgesics, warm moist heart, and elevation of the affected extremity to enhance comfort. The client should avoid aspirin while receiving heparin therapy. Common adverse effects of this medication include anemia, bleeding, rashes, and thrombocytopenia.

A nurse is caring for a group of clients on a med-surg unit.. Which of the following clients should the nurse attend to first? A. A client who is receiving metoclopramide and reports diarrhea B. A client who is receiving tamsulosin and reports feeling dizzy C. A client who is receiving cephalexin and reports dyspnea. D. A client is receiving erythromycin and reports epigastric pain.

Answer: C. A client who is receiving cephalexin and reports dyspnea. The greatest risk to this client is an injury from dyspnea due to an allergic reaction from the antibiotic. The client is at risk of anaphylactic shock with a compromised airway; therefore, the nurse should first discontinue cephalexin and notify the provider immediately. Emergency equipment should be placed in the client's room in case the client goes into anaphylactic shock.

When caring for a patient who is undergoing a spiral (helical) CT scan for diagnosis of a pulmonary embolism, the nurse should assess the patient for which of the following? A. Adequate cardiac output B. Normal liver function tests C. Adequate renal function D. Full orientation

Answer: C. Adequate renal function (mine) The others are important too but this procedure requires IV contrast which is hard on the kidneys. The nurse should also assess the patient for an allergy to IV contrast media or shellfish.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mmHg. Which of the following nursing actions is the priority? A. Notify the provider B. Administer heparin via IV infusion C. Administer oxygen therapy D. Obtain a CT scan

Answer: C. Administer oxygen therapy When using the ABCs, determine that the priority finding is related to the respiratory status. Meeting oxygenation needs by administering oxygen therapy is the priority action. Notify the provider about the condition to obtain guidance on treatment. However, another action is the priority. Administer IV heparin as a treatment to prevent growth of the existing clot and to prevent additional clots from forming. However, another action is the priority. Obtain a CT scan to detect the presence and location of the blood clot. However, another action is the priority.

A nurse in the ED is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical antimicrobials C. Administration IV fluid replacement D. Administer tetanus prophylaxis

Answer: C. Administration of IV fluid replacement The greatest risk to this child is an injury from hypovolemic shock, therefore, the first action the nurse should take after ensuring the child has a patent airway is to administer IV fluid replacement therapy.

When observing the labs of a client with a suspected pulmonary embolism, which of the following findings would help confirm the patient's diagnosis? A. Creatinine 0.9 B. Potassium 4.8 C. D-Dimer 965 D. Calcium: 9.1

Answer: C. D-dimer 965 (mine) Normal D-dimer is less than 500. ABGS, troponin, and BNP are informative, but NOT diagnostic.

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30 degree angle D. Place the client in a semi-Fowler's position

Answer: C. Elevate the client's legs to a 30 degree angle The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30 degree angle. This improves blood flow and reduces manifestations of hypotension. A client who is experiencing postpartum hypovolemic shock requires IV fluid replacement and potentially blood transfusion. The nurse should maintain running IV access and possibly increase the IV fluid rate. Oxygen supplementation is important for a client who is experiencing postpartum hypovolemic shock. Oxygen should be administered at 10 L/min via facemark to increase oxygenation and perfusion to the tissues.

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001

Answer: C. Hit 55% An elevated Hct indicates hypovolemia. Other indications of hypovolemia are weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated bun, increased urine specific gravity, and decreased urine output.

A nurse is admitting a client who has a suspected occlusion of a graft of the abdominal aorta. Which of the following manifestations should the nurse expect? A. Increase in urine output B. Bounding pedal pulse C. Increase in abdominal girth

Answer: C. Increase in abdominal girth

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased HR B. .Jugular vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

Answer: C. Report of sudden, severe back pain. An aortic aneurysm is a weak spot in the wall if the aorta (The primary artery that carries blood from the heart to the head and extremities) that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurism is extending downward and pressing on the lumbar sacral nerve roots. If the client develops a rupturing AAA, the nurse should expect indications of shock(e.g. decreased BP and increased HR). JVD and peripheral edema are manifestations of right-sided heart failure, not an extending AAA. Chest pain radiating to the left arm is a manifestation of MI, not AAA.

A nurse in the ED is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea

Answer: C. Tachycardia Due to the decreased circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output while increasing the respiratory rate. Cool, clammy skin is an indication of hypovolemic shock. Urine output of </= 30 mL/hour is an indication of hypovolemic shock. Tachypnea is an indication of hypovolemic shock.

A postpartum nurse is caring for a client who has developed hemorrhagic shock. Which of the following manifestations would the nurse expect? A. urinary output of 40 mL/hour B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hands with prompt capillary refill

Answer: C. Weak and irregular pulse. A weak, irregular and rapid pulse can indicate postwar hemorrhagic shock due to decreased oxygenation and perfusion to the heart. The client will need fluid replacement and medical attention. Decreased UO is a manifestation of hemorrhagic shock due to decreased renal perfusion. Rapid and shallow respirations are a sign of hemorrhagic shock due to the lungs lacking adequate oxygenation and perfusion. Cool and clammy skin is an indication of hemorrhagic shock due to poor circulation.

A nurse in the ED is admitting a client who has possible dissecting abdominal aortic aneurysm. Which of the following actions is the priority for the nurse to take? A. administer pain medication as prescribed B. provide a warm environment C. administer IV fluids as prescribed D. Initiate a 12-lead ECG

Answer: C. administer IV fluids as prescribed When using the ABC framework to client care, determine that priority is on administering IV fluids to the client. The client is at risk of inadequate circulatory volume due to profuse sweating related to the pain and feeling of fullness related to the aneurysm and to possible leaking or rupture of the aneurysm. The nurse should perform the other options, but they are not the first priority.

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: A. relative hypervolemia B. An absolute hypovolemia C. Neurogenic shock from low blood flow D. Neurogenic sock from massive vasodilation

Answer: D

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are: A. blood pressure, pulse, and respirations B. Breath sounds, blood pressure, and body temperature C. Pulse pressure, level of consciousness and pupillary response D. Level of consciousness, urinary output, and skin color and temperature

Answer: D

Which treatment should the nurse anticipate for an otherwise healthy person with an initial VTE? A. IV argatroban as an inpatient B. IV unfractionated heparin as an inpatient C. Subcutaneous unfractionated heparin as an inpatient D. Subcutaneous low molecular weight heparin as an outpatient

Answer: D

A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? A. A client who is having occasional PVCs on the ECG monitor. B. client who has been experiencing vomiting and diarrhea for several days C. A client who has a gram-negative bacterial infection D. A client who has a pulmonary arterial stenosis

Answer: D Obstructive shock results from decreased cardiac function by a non cardiac cause, such as with pulmonary arterial stenosis or hypertension, or thoracic tumor. Ventricular dysthymia is a risk factor for cariogenic shock. Dehydration from vomiting and diarrhea for several days is a risk factor for hypovolemic shock. Presence of a gram-negative bacterial infection is a risk factor for septic shock.

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting Edema in lower extremities D. Lower back discomfort

Answer: D Lower back discomfort An abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back Bain and abdominal pain indicate that the aneurysm is extending downward and pressing on the lumbar spinal nerve roots, causing pain. The nurse should assess for mid or lower abdominal pain to the left of the midline because of the enlarged artery mass. The nurse should auscultate for a bruit heard over the location of the mass. Pitting edema is a manifestation of heart failure. This is not an assessment expected with an AAA.

A nurse is teaching a client who has a new diagnosis of an aneurysm. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following statements should the nurse give? A. "This can occur when the wall of an artery becomes thin and flexible." B. "This can occur when there is turbulence in blood flow in the artery." C. "It is due to abdominal enlargement." D. "It is due to hypertension."

Answer: D. "It is due to hypertension." Explain to the client that aneurysm ruptures as a result of hypertension increasing pressure within the arterial walls. An aneurysm ruptures as a result of thickening in the intimacy of the artery and a lack of elasticity in the vessel wall, which is typically under pressure due to hypertension. A bruit is objective data that indicates the presence of an aneurysm, not the cause of the rupture. Abdominal distention can occur when an aneurysm ruptures, but it is not the cause of the rupture.

A patient admitted to the hospital from a long term care facility appears to be in the late stage of shock with systemic inflammatory response syndrome (SIRS). Which order implement by the nurse has the highest priority? A. Insert an indwelling urinary catheter B. Insert two large-bore IV catheters C. Administer 0.9% NSS at 100 mL/hour D. Administer 100% oxygen by non-rebreather mask

Answer: D. Administer 100% oxygen by non-rebreather mask A patient t in the irreversible stage of shock (late stage) will demonstrate profound hypotension and hypoxemia. If the condition progresses to systemic inflammatory response syndrome, the patient may experience profound hypoxemia. Oxygenation is a priority and should be initiated with a 100% oxygen delivery method such as a non-rebreather mask.

A nurse is caring for a client who is 12 hours postoperative following a total hip arthroplasty. Which of the following medications should the nurse anticipate administering to this client to prevent deep vein thrombosis (DVT)? A. Aspirin B. Warfarin C. Ticagrelor D. Enoxaprin

Answer: D. Enoxaparin The nurse should anticipate the administration of enoxaparin for the the client who is 12 hours post-op following surgery. Enoxaparin is low-molecular-weight (LMW) heparin that is used to prevent a DVT by inhibiting the effects of antithrombin and thrombin.

In a patient who is experiencing cardiogenic shock, the nurse may see the following lab values: (Select all that apply) A. Low cardiac output B. Normal cardiac output C. Increased SVR D. Normal SVR E. Increased CVP

Answers: A, C, E (will also have an elevated PAWP) (my question)