Med Surge Exam 3
The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. What is the best response?
"Cardiac catheterization is usually done to assess how blocked or open a client's coronary arteries are." Cardiac catheterization is usually used to assess coronary artery patency to determine if revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after stress. An ECG shows the electrical activity of the heart.
The nurse is calculating a cardiac client's pulse pressure. If the client's blood pressure is 122/76 mm Hg, what is the client's pulse pressure?
46 mm Hg Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46 mm Hg.
The nurse is caring for a client who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?
A heart rate of 54 bpm Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm. An increase in preload will lead to an increase in stroke volume. A pulse oximetry reading of 94% does not indicate hypoxemia, as hypoxia can decrease contractility. Transitioning from standing to sitting would more likely increase rather than decrease cardiac output.
A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply.
Air embolism Pneumothorax Infection Complications from use of hemodynamic monitoring systems are uncommon, but can include pneumothorax, infection, and air embolism. Complications of hemodynamic monitoring systems do not include atelectasis or bronchospasm.
The nurse working on a cardiac care unit is caring for a client whose stroke volume has increased. The nurse is aware that afterload influences a client's stroke volume. The nurse recognizes that afterload is increased when there is what?
Arterial vasoconstriction Arterial vasoconstriction increases the systemic vascular resistance, which increases the afterload. Venous vasoconstriction decreases preload thereby decreasing stroke volume. Venous vasodilation increases preload.
A client's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend?
Bananas Bananas are high in potassium. Apples, fish, and rice are not high in potassium.
The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe?
Cardiopulmonary bypass Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.
The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration?
Extravasation of the medication Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.
The physician has prescribed a peripheral IV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
Consider potential effects on the client's mobility when selecting a site. Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the client to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.
A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause?
Coronary arteriosclerosis In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.
The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem?
Diminished deep tendon reflexes To gauge a client's magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.
A client has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the client for this test, what action should the nurse perform?
Establish peripheral IV access. An IV is necessary if contrast is to be used to enhance the images of the CT. The client does not need to fast or limit activity. Incentive spirometry is not relevant to this diagnostic test.
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
Extreme anxiety Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health?
Fluid volume status A specific gravity will detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.
Which could be a potential cause of respiratory acidosis?
Hypoventilation Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in PaO2.
The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)?
Increased serum sodium Increased serum sodium causes increased osmotic pressure, increased thirst, and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?
Increases arterial pH Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.
The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.
The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?
Lipids and fibrous tissue As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.
The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD may result in what?
Myocardial ischemia Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Clients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital.
The student nurse is preparing a teaching plan for a client being discharged status post MI. What should the nurse include in the teaching plan? Select all that apply.
Need for dietary modifications Need for careful monitoring for cardiac symptoms Need for carefully regulated exercise Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased.
A client has questioned the nurse's administration of IV normal saline, asking, "Wouldn't sterile water would be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously?
Never, because it rapidly enters red blood cells, causing them to rupture. IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.
The health care provider has placed a central venous pressure (CVP) monitoring line in an acutely ill client so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate?
Possible hypovolemia Hypovolemia may cause a decreased CVP. MI, valve regurgitation and heart failure are less likely causes of decreased CVP.
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. The laboratory values are as follows sodium is 147 mEq/L (mmol/L) potassium is 3.0 mEq/L (mmol/L) chloride is 112 mEq/L (mmol/L) Magnesium is 2.3 mg/dL (0.95mmol/L) What laboratory value is consistent with the client's symptoms?
Potassium 3.0 mEq/L (mmol/L) Potassium is the major intracellular electrolyte. Hypokalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias. The sodium, chloride and magnesium levels are within normal limits.
The critical care nurse is caring for a client who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the client's left ventricular function?
Pulmonary artery pressure monitoring (PAPM) Pulmonary artery pressure monitoring is used to assess left ventricular function. CVP is used to assess right ventricular function; systemic arterial pressure monitoring is used for continual assessment of BP. ABGs are used to assess for acidic and alkalotic levels in the blood.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?
Pulse An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.
A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect?
Reducing the heart's workload by decreasing heart rate and myocardial contraction Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are given to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?
Respiratory alkalosis The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.
The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?
T wave inversion T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.
A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by kidney disease. Renal compensation for imbalances is relatively slow (a matter of hours or days).
A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, "A client with kidney disease partially loses the ability to regulate changes in pH." What is the cause of this partial inability?
The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.
A resident of a long-term care facility has reported chest pain to the nurse. What aspect of the resident's pain would be most suggestive of angina as the cause?
The pain occurs immediately following physical exertion. Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of chest pain are more closely associated with noncardiac etiologies.
The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding?
This is an accurate indicator of myocardial injury. Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.
The nurse is caring for a client who is scheduled for cardiac surgery. What should the nurse include in preoperative care?
With the client, clarify the surgical procedure that will be performed. Preoperatively, it is necessary to evaluate the client's understanding of the surgical procedure, informed consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to admission. The physician would write orders to alter the client's medication regimen, if necessary; this will vary from client to client. Fears should be addressed directly and empathically.
The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:
diet therapy and smoking cessation. Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostics findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.
Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's:
electrocardiogram (ECG). Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Urine output is an indicator of pump effectiveness; CK and troponin levels monitor myocardial damage. Blood pressure and heart rate measurements are too nonspecific to help determine the effectiveness of parenteral lidocaine.
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance?
hypokalemia Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.
A client's electrocardiogram reveals an irregular rhythm of 75 bpm with a normal QRS and P wave. The nurse who is caring for the client should anticipate:
no immediate treatment. This client's ECG suggests sinus dysrhythmia. Sinus dysrhythmia does not cause any significant hemodynamic effect and therefore is not typically treated.
Central venous pressure is measured in which heart chamber?
right atrium The pressure in the right atrium is used to assess right ventricular function and venous blood return to the heart. The left atrium receives oxygenated blood from the pulmonary circulation. The left ventricle receives oxygenated blood from the left atrium. The right ventricle is not the central collecting chamber of venous circulation.
The nurse is relating the deficits in a client's synchronization of the atrial and ventricular events to his diagnosis. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization? Select all that apply.
Automaticity Conductivity Excitability Three physiologic characteristics of two types of specialized electrical cells, the nodal cells and the Purkinje cells, provide this synchronization: automaticity, or the ability to initiate an electrical impulse; excitability, or the ability to respond to an electrical impulse; and conductivity, the ability to transmit an electrical impulse from one cell to another. Loop connectivity is a distracter for this question. Independence of the cells has nothing to do with the synchronization described in the scenario.
A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances?
Ensure the client has sufficient potassium intake. Diuretics cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake and increased fluid intake does not reduce the client's risk for electrolyte disturbances.
The nurse is providing care for a client with chronic obstructive pulmonary disease (COPD). When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?
Diffusion Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the ECF compartment, where the sodium concentration is high, to the ICF, where its concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is impermeable to the dissolved substances; fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. Active transport implies that energy must be expended for the movement to occur against a concentration gradient. Movement of water and solutes occurring from an area of high hydrostatic pressure to an area of low hydrostatic pressure is filtration.
One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal?
Help distinguish reduced renal blood flow from decreased renal function If a client is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a client with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.
When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
Hydrostatic pressure resulting from the pumping action of the heart An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.
The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate?
Hypocalcemia You can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek sign.
The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance?
Hypocalcemia The client is experiencing an elevated serum phosphorus concentration. Hyperphosphatemia is defined as a serum phosphorus that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus concentration tends to cause a low serum calcium concentration.
The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance?
Hypovolemia Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.
Which condition might occur with respiratory acidosis?
Increased intracranial pressure If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.
While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should the nurse document this complication related to IV therapy?
Infiltration Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.
The physician has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a client. The results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis?
Inflammation High-sensitivity CRP is a protein produced by the liver in response to systemic inflammation. Inflammation is thought to play a role in the development and progression of atherosclerosis.
A nurse is preparing a client for scheduled transesophageal echocardiography. What action should the nurse perform?
Inform the client that she will remain on bed rest following the procedure. During the recovery period, the client must maintain bed rest with the head of the bed elevated to 45 degrees. The client must be NPO 6 hours pre-procedure. The client is sedated to make her comfortable, but will not be heavily sedated, and opioids are not necessary. Also, the client will have a peripheral IV line initiated pre-procedure.
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?
Jugular vein distention Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
With which condition should the nurse expect that a decrease in serum osmolality will occur?
Kidney failure Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.
During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI?
Left midclavicular line of the chest at the fifth intercostal space The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
Light-headedness or paresthesia The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?
Provide oral care every 2-3 hours. Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.
The nurse is caring for a client who has had a biventricular pacemaker implanted. When planning the client's care, the nurse should recognize what goal of this intervention?
Resynchronization Biventricular (both ventricles) pacing, also called resynchronization therapy, may be used to treat advanced heart failure that does not respond to medication. This type of pacing therapy is not called defibrillation, angioplasty, or ablation therapy.
A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure?
The test is noninvasive, and nothing will be inserted into the client's body. Before transthoracic echocardiography, the nurse informs the client about the test, explaining that it is painless. The test does not evaluate electrophysiology and bed rest is unnecessary after the procedure.
The critical care nurse is caring for a client with a pulmonary artery pressure monitoring system. In addition to assessing left ventricular function, what is an additional function of a pulmonary artery pressure monitoring system?
To assess the client's response to fluid and drug administration Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating the client's response to medical interventions, such as fluid administration and vasoactive medications. Pulmonary artery monitoring is preferred over central venous pressure monitoring for the client with heart failure. Arterial catheters are useful when arterial blood gas measurements and blood samples need to be obtained frequently. Neither intervention is used to clear pulmonary emboli.
