NU473 Week 4: Evolve Elsevier EAQ Cellular Regulation
A client receiving a blood transfusion reports itching and difficulty breathing. The heart rate has increased, and the blood pressure is falling. Which type of shock would the nurse suspect the client is experiencing? o Septic shock o Cardiogenic shock o Neurogenic shock o Anaphylactic shock
o Anaphylactic shock · Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.
Which finding is most important to communicate to the health care provider for a client who had femoropopliteal bypass graft surgery 6 hours earlier? o Blood pressure of 198/106 mm Hg o Pulsating pain at the incision site o Apical heart rate 103 beats per minute o Inspiratory crackles at both lung bases
o Blood pressure of 198/106 mm Hg · The increased blood pressure can cause leaking or rupture of the graft incision. The health care provider would be notified rapidly so that actions to lower the blood pressure can be taken. The client's pain needs to be addressed, but postoperative pulsating type pain at an arterial surgical site is not unusual. The heart rate is elevated slightly above normal, which is common with stress and pain. Inspiratory crackles at the lung bases indicate that the client has not been taking deep breaths. The nurse would have the client cough and deep breathe, but it is not urgently necessary to discuss this finding with the health care provider.
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? o Maintain muscle strength o Reduce leg discomfort o Prevent clot formation o Improve wound healing
o Prevent clot formation · Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Active ROM exercises will not improve wound healing.
A 30-year-old client who is diagnosed with hyperlipidemia and hypertension asks the nurse to explain why treatment is important, stating "I feel fine, so I don't really see the need to make any changes." Which response would the nurse make? o "Both high blood pressure and high cholesterol contribute to development of heart disease." o "Lifestyle adaptations alone will be adequate as long as you continue to be asymptomatic." o "Usually someone with these diagnoses will have symptoms of heart disease already." o "You should discuss your questions about medical problems with the health care provider."
o "Both high blood pressure and high cholesterol contribute to development of heart disease." · Because cardiac risk factors are cumulative in their effect on the development of coronary artery disease, treatment of both risk factors is advised before development of symptoms. Although lifestyle adaptations are an initial action in management of hypertension and hyperlipidemia, treatment with medications is also frequently required. The majority of young adults with hypertension and hyperlipidemia are asymptomatic. Although the health care provider will certainly answer questions, the nurse is also responsible for teaching clients about how to manage cardiac risk factors.
When a client is diagnosed with Hodgkin disease, which lymph nodes would the nurse expect to be affected first? o Cervical o Axillary o Inguinal o Mediastinal
o Cervical · Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows the disease progresses.
The nurse new to the telemetry floor asks the charge nurse what can be done to decrease the frequent alarms of a client's telemetry monitor. Which is the best response by the charge nurse? o "Turn off the alarm and take frequent vital signs." o "Change the alarm parameters to decrease alerts." o "Follow our clinical alarm policy and check the client." o "Contact the health care provider to discontinue telemetry."
o "Follow our clinical alarm policy and check the client." · Alarm fatigue is a serious safety issue that should be addressed through internal policy and procedure. Telemetry alarms always should be turned on; taking frequent vital signs is not a substitute for continuous heart rate and rhythm monitoring. Changes to alarm parameters are done only after assessment of the client, and according to institutional policies. Although the health care provider might be contacted if the nurse felt that telemetry monitoring was no longer needed, asking that telemetry be discontinued because of frequent alarms is not safe for a client who needs cardiac monitoring.
When the primary health care provider prescribes "bathroom privileges only" for a client with an exacerbation of heart failure, the client becomes irritable and asks why bed rest is needed. Which response by the nurse is best? o "Why do you want to be out of bed?" o "Bed rest plays a role in most therapy." o "Rest reduces the amount of work your heart has to do right now." o "Maybe the primary health care provider will increase your activity tomorrow."
o "Rest reduces the amount of work your heart has to do right now." · A client's knowledge about the treatment program enhances compliance and reduces stress. With heart failure hospitalization, a decrease in activity level ("bathroom privileges only") is often temporarily needed until the heart failure exacerbation resolves. The response, "Why do you want to be out of bed?" does not answer the client's question and might produce frustration. The response, "Bed rest plays a role in most therapy," does answer the client's question, but does not explain specifically why. Because the nurse does not have the scope of practice to change the provider's activity prescription, the response, "Maybe the primary health care provider will increase your activity tomorrow," is inappropriate.
Which finding in a client who has just returned to the nursing unit after having right upper lobectomy requires the most rapid action by the nurse? o 100 mL of blood in the chest tube drainage chamber o Complaint of 9/10 (0 to 10 scale) right side chest pain o Deviation of the client's trachea to the left side o Decreased breath sounds on the client's right side
o Deviation of the client's trachea to the left side · Deviation of the trachea indicates increased intrathoracic pressure on the right, causing compression of the heart, aorta, and superior and inferior vena cava and leading to decreased cardiac output. The nurse would immediately check the client's chest tube for possible obstruction caused by clots or compression of the chest tube. While the nurse will continue to monitor for bleeding, loss of 100 mL of blood during and immediately after thoracic surgery is not unusual. Severe postoperative pain is common with chest surgery and the nurse would rapidly treat the pain, but pain is not life threatening. Decreased breath sounds in the immediate postoperative period indicate that the lung has not yet reexpanded and are not unusual.
When a client receiving hemodialysis has an external shunt for circulatory access, the nurse would be most concerned about which possible complication? o Infection o Hemorrhage o Skin breakdown o Impaired circulation
o Hemorrhage · Exsanguination (hemorrhage) can occur in a matter of minutes if cannulas are dislodged. Infection, skin breakdown, and impaired circulation are not life-threatening situations; preventing hemorrhage takes priority.
Which information would the nurse include when explaining the purpose of a thallium scan to the client who has a history of chest pain? o It monitors action of the heart valves. o It assesses myocardial ischemia and perfusion. o It visualizes ventricular systole and diastole. o It identifies the adequacy of the conduction system.
o It assesses myocardial ischemia and perfusion. · Thallium imaging is used to assess myocardial ischemia or necrotic muscle tissue related to angina or myocardial infarction. Necrotic or scar tissue does not extract the thallium isotope, leading to cold spots. Action of the heart valves is available from an echocardiogram or, if indicated, from a cardiac catheterization with an angiography. Visualization of the ventricular systole and diastole is determined by cardiac angiography. Identifying the adequate cardiac conduction is determined by an electrocardiogram.
When assessing a client who has aortic stenosis and is scheduled for aortic valve replacement, which finding by the nurse is most important to communicate to the health care provider? o Loud systolic murmur o Multiple dental caries o Heartburn when lying down o Paroxysmal nocturnal dyspnea
o Multiple dental caries · Multiple dental caries increase the risk for endocarditis in clients with valvular disease and caries should be treated before surgery. A loud systolic murmur is typical for aortic stenosis. Heartburn will be treated with medications such as histamine blockers or protein pump inhibitors, but is not a reason to postpone surgery. Paroxysmal nocturnal dyspnea is a common symptom of severe aortic stenosis.
When the nurse is caring for a diabetic client with a bacterial infection of the foot, which assessment finding indicates a need to activate the rapid response team? o Hypertonic bowel sounds in all 4 quadrants o Blood glucose level 145 mg/dL (8.1 mmol/L) o Client report of level 9 pain of the foot (0 to 10 scale) o Systolic blood pressure persistently 85 to 90 mm Hg
o Systolic blood pressure persistently 85 to 90 mm Hg · A systolic blood pressure less than 90 in a client who is at risk for sepsis (such as this client with a bacterial infection and diabetes) indicates possible sepsis and systemic inflammatory response syndrome (SIRS). The nurse would immediately activate the rapid response team and anticipate collaborative actions such as further diagnostic testing, massive fluid infusion, and administration of vasoconstrictive medications. Hypotonic bowel sounds may indicate sepsis or SIRS. Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or SIRS in a nondiabetic client, but would not be unusual in a client with diabetes. Level 9 out of 10 pain would require administration of analgesics, but is not as concerning as hypotension and does not require activation of the rapid response team.
