Perfusion- PrepU

Which of the following observations helps the nurse in determining adequate oxygenation?

Pink nail beds

Which nursing intervention is essential in caring for a client with compartment syndrome?

Removing all external sources of pressure, such as clothing and jewelry

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?

Right sided heart failure

A client complains of not being able to experience satisfactory sexual intercourse. The nurse knows that erectile dysfunction is now recognized as a marker for:

cardiovascular disease

A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus?

Cardiac and respiratory status

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?

"I sleep on three pillows each night."

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following?

Decreased cardiac output

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?

Diminished or absent pulses

The nurse is instructing a health class of high school seniors on the function of the kidney. The nurse is correct to highlight which information? Select all that apply.

Excretes waste products Controls blood pressure Regulate calcium and the synthesis of vitamin D Activates growth hormone Regulates red blood cell production

The heart is a four-chambered pump. What is the function of the right ventricle?

pumps blood to lungs

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

Which lipid level would the nurse interpret as being high?

LDL cholesterol of 190 mg/dL

Incomplete closure of the mitral valve results in backflow of blood from the:

Left ventricle to left atrium

Proper function of the cardiovascular system relies on blood following the correct pathway through the heart. Valves within the heart separate the organ's chambers and prevent blood from flowing in the wrong direction. What valve separates the left atrium and left ventricle?

Mitral

Nitroglycerin is the drug of choice in treating angina. What does nitroglycerin release into the vascular smooth muscle of the target tissues?

Nitric oxide

A client presents to the clinic with symptoms of elevated blood pressure, dizziness, red face, pain in fingers and toes, headache, and difficulty concentrating. A blood smear reveals an increased number of erythrocytes. Based on these findings, the nurse anticipates which diagnosis?

Polycythemia vera

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?

The SA Node

Mr. Faulkner is a 69-year-old man who has enjoyed generally good health for his entire adult life. As a result, he has been surprised to receive a new diagnosis of hypertension after a series of visits to his primary care provider. The nurse who is working with Mr. Faulkner should recognize which of the following aspects of aging and hypertension?

The incidence and prevalence of hypertension increase with age.

The cardiac cycle describes the pumping action of the heart. Which statement is correct about systole?

Ventricles contract and blood is ejected from the heart.

The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

a blood pressure of 176/88 mm Hg.

A client has been prescribed a thiazide diuretic, hydrochlorothiazide (HCTZ), for the initial treatment of hypertension. What effect does the nurse know this drug will have on the body to consequently decrease blood pressure?

decreased vascular volume

The diagnosis of heart failure is usually confirmed by which of the following?

echocardiogram

A client has had an echocardiogram to measure ejection fracton. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55%

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?

7

A client with a history of acute coronary syndrome asks why she needs to take aspirin 81 mg every day. The most appropriate response by the nurse would be:

ASA will prevent blood clotting

A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take?

Administer the prescribed enoxaparin (Lovenox).

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling blood pressure

The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client?

Continue this as long as she enjoys it.

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanelle that corresponds with the newborn's heart rate. How would the nurse interpret this?

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.

A 75-year-old client with a history of heart valve replacement arrives at the outpatient clinic with multiple red pinpoint lesions. The nurse identifies the lesions as:

Petechiae

What is a nursing priority in the plan of care for a client with peripheral vascular problems?

Promote arterial and venous circulation.

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?

The radial pulse is difficult to obtain.

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?

To decrease workload of the heart

Which serum biomarker is highly specific for myocardial tissue?

Troponin

A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?

acute pulmonary edema.

The nurse caring for a client admitted with a deep vein thrombosis is reviewing the client's prepackaged medications delivered by the pharmacy. The nurse suspects a pharmacy omission when medication from which classification is missing?

anticoagulant

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?

blood gases

The nurse is assessing a middle-aged adult age 48 years in the clinic. The nurse recalls the changes that occur in middle age as they complete the physical and cognitive examination. Changes that occur include what?

cardiac output decreases

The nurse is planning care for a client with a urinary tract obstruction. The nurse includes assessment for which possible complication?

increased blood pressure

An 81-year-old male client who has a diagnosis of orthostatic hypotension is experiencing an episode of particularly low blood pressure. The man's body has responded by increasing levels of angiotensin II in the bloodstream, a hormone which decreases glomerular filtration rate in the kidneys and contributes to an increase in blood pressure. Which phenomena best describes what has occurred?

negative feedback; his regulation and attempt to normalize blood pressure is an example of a negative feedback mechanism, in which physiologic processes result in the maintenance of homeostasis.

What position should the nurse use for the client with venous insufficiency to enhance blood supply?

supine with lower extremities elevated

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following?

tachycardia

A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure?

To prevent supine hypotension syndrome

It is appropriate for the nurse to recommend smoking cessation for clients with hypertension because nicotine

increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.

In the emergency department, a client arrives following a car accident. His pulse is 122; BP 88/60; respiration is 18 bpm. Urine output is 4 mL over the first hour on arrival. When in shock, this lower urine output is primarily due to:

innervation of the sympathetic nervous system, causing constriction of the afferent arteriole.