ICU- Evolve/cardiac

Which clinical indicator should the nurse expect to identify when assessing a client with varicose veins? 1 Positive Homans sign 2 Pallor of the affected extremity 3 Continuous edema of the lower legs 4 Sensation of heaviness in calf muscles

(4) Sensation of heaviness in calf muscles Because of dilation in the veins and a concomitant decrease in blood flow, the client may experience heaviness or muscle cramps in the legs. Edema, if present, can be relieved by elevating the legs. Homans sign is calf pain when the ankle is dorsiflexed; usually it is related to thrombophlebitis. Pallor indicates decreased tissue perfusion that may be caused by a partial arterial occlusion. Edema usually decreases when the extremity is elevated.

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding? 1 Oliguria 2 Bradypnea 3 Pulse deficit 4 High potassium levels

1 Oliguria decreased blood volume leads to a decreased blood pressure and glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, resulting in decreased urine output. The respirations become rapid and shallow to compensate for decreased cellular oxygenation. The peripheral pulse rate may be rapid and thready, but it is the same rate as the apical rate. Hypokalemia, not hyperkalemia, occurs; as sodium is retained, potassium is excreted. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.

A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? 1 An irreversible phenomenon 2 A failure of the circulatory pump 3 Usually a fleeting reaction to tissue injury 4 Generally caused by decreased blood volume

2 A failure of the circulatory pump In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia will lead to hypovolemic shock; cardiogenic refers to the heart capabilities.

When assessing for hemorrhage on a client who has a total hip replacement, what is the most important nursing action to implement? 1 Measure the girth of the thigh. 2 Examine the bedding under the client. 3 Check the vital signs every 4 hours. 4 Observe for ecchymosis at the operative site.

2 Examine the bedding under the client. Because of the recumbent position, drainage may flow by gravity under the client and not be noticed unless the bedding is examined. Measuring the girth of the thigh is inaccurate when there is a dressing in place. In the immediate postoperative period, vital signs should be taken more frequently than every 4 hours; in addition, observation of the site is a more reliable indicator of hemorrhage. Dressings impede an accurate assessment of the site for ecchymosis. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

A nurse is assessing a client who has had a carotid endarterectomy. Which response does the nurse consider evidence of a complication of the surgery? 1 Decreased appetite 2 Impaired swallowing 3 Change in bowel habits 4 Slight edema of the neck

2 Impaired swallowing Impaired swallowing may occur as a result of cranial nerve damage during surgery. Slight edema of the neck is expected from the trauma of surgery; it is not a complication. Decreased appetite, change in bowel habits, and slight edema of the neck are not complications of a carotid endarterectomy.

A primary healthcare provider prescribes verapamil to be administered intravenously to an older adult client with hypertension. Which nursing intervention is specific to the intravenous administration of verapamil? 1 Monitor the electrocardiogram for a prolonged PR interval on initial administration. ÔŒŒŒ 3 Instill the dose in 50 mL of normal saline and administer it over 15 minutes. 4 Assess the client's respiratory rate and rhythm before administering the drug.

2 Keep the client in the recumbent position for 1 hour after administration. Hypotension is a common side effect of intravenously administered verapamil. Keeping the client in the recumbent position for 1 hour after administration provides for the safety of the client. A prolonged PR interval may occur during extended therapy, not on initial administration of verapamil. Verapamil should be administered undiluted when given intravenously. It is administered over 2 minutes for adults and over 3 minutes for older adults. The client's heart rate and blood pressure should be assessed before administration to provide a baseline for comparison. Verapamil will decrease the blood pressure and dysrhythmias.

On admission, the laboratory results of a client with leukemia indicate elevated blood urea nitrogen (BUN) and uric acid levels. What would the nurse determine that these laboratory results may be related to? 1 Lymphadenopathy 2 Thrombocytopenia 3 Hypermetabolic status 4 Hepatic encephalopathy

3 Hypermetabolic status The hypermetabolic state associated with leukemia causes more urea and uric acid (end products of metabolism) to be produced and to accumulate in the blood. Enlarged lymph nodes will not increase blood urea and uric acid. Thrombocytopenia causes a decrease in platelets, which causes bleeding. Hepatic encephalopathy is associated with liver disease, not leukemia. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.