Perfusion Questions

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2. A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

1 1. 2. 3. 4. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. The blood count is important, but the nurse should first assess patellar reflexes. The baseline weight is important, but the nurse should first assess patellar reflexes. The urinalysis should be obtained, but the nurse should first assess patellar reflexes.

4. The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2 proteinuria. 3. Decrease in plasma protein. 4. 3 patellar reflexes.

1 1. 2. 3. 4. Weight loss is a positive sign. This client is losing protein. The nurse would evaluate a 0-to-trace amount of protein as a positive sign. A decrease in serum protein is a sign of pathology. An increase in serum protein would be a positive sign. 3 reflexes are pathological. Normal re- flexes are 2.

7. A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's re- sponse is based on the fact that the changes may be caused by which of the following? 1. Altered glomerular filtration. 2. Cardiac failure. 3. Hepatic insufficiency. 4. Altered splenic circulation.

1 Altered glomerular filtration leads to protein loss and, subsequently, to fluid retention, which can lead to swelling in the face and hands. Monitoring women for the appearance of swollen hands and puffy face is related to the development of preeclampsia, not of cardiac failure. Monitoring women for the appearance of swollen hands and puffy face is related to the development of preeclampsia, not of hepatic insufficiency. Monitoring women for the appearance of swollen hands and puffy face is related to the development of preeclampsia, not of altered splenic circulation.

A primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse to say she has had a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client: a) "I think the health care provider should see you today. Can you come to the clinic this morning?" b) "I'll ask the health care provider to call in a prescription for nausea medications. What is your pharmacy's number?" c) "You need to lie down and rest. Have you tried placing a cool compress over your head?" d) "Take two acetaminophen tablets. They are not as likely to upset your stomach."

"I think the health care provider should see you today. Can you come to the clinic this morning?" Correct Explanation: A client with preeclampsia and a continuous headache for 2 days should be seen by a health care provider (HCP) immediately. Continuous headache, drowsiness, and mental confusion indicate poor cerebral perfusion and are symptoms of severe preeclampsia. Immediate care is recommended because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to take two acetaminophen tablets would be inappropriate and may lead to further complications if the client is not evaluated and treated. Although the application of cool compresses may ease the pain temporarily, this would delay treatment. Treatment for nausea may be indicated, but only after the primary care primary provider has seen the client and determined if the preeclampsia requires further treatment

62. A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).

1 The nurse must have calcium glu- conate in the client's room. Morphine sulfate should not be in the client's room. It is a controlled substance. Narcan does not have to be in the client's room. Demerol should not be in the client's room. It is a controlled substance.

A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation? A "When I finish the rehabilitation program I'll never have to worry about heart trouble again." B "I won't be able to jog again even with rehabilitation." C "Rehabilitation will help me function as well as I physically can." D "I'll get rest during these rehabilitation classes. All I have to do is sit and listen to the instructor."

"Rehabilitation will help me function as well as I physically can." Explanation: The client demonstrates understanding of cardiac rehabilitation when he states that it helps the client reach his activity potential. Coronary artery disease, which typically causes an acute MI, is a chronic condition that isn't cured. Many clients who suffer an acute MI can eventually return to such activities as jogging, depending on the extent of cardiac damage. Cardiac rehabilitation involves physical activity as well as classroom education.

Which statement by the client indicates an understanding of teaching regarding use of corticosteroids during preterm labor? a) "The corticosteroids may help my baby's lungs mature." b) "The goal of the corticosteroids is to stop contractions and help me get to my due date." c) "I will be taking corticosteroids until my baby's due date so that he will have the best chance of doing well." d) "If I take corticosteroids, my baby will not have to spend any time in the neonatal intensive care unit when he is born."

"The corticosteroids may help my baby's lungs mature." Correct Explanation: Corticosteroids given IM have been shown to increase fetal lung maturity by increasing surfactant and reduce the risk of respiratory distress syndrome in premature infants. It is not a guarantee that a premature newborn would not have problems at birth that would require time in the neonatal intensive care unit. The administration of the corticosteroids is normally completed within 24 to 48 hours

The client asks the nurse what his urine output has to do with his cardiac function. The best reply by the nurse is which of the following? A "High urine output indicates poor cardiac function." B "Too much urine output indicates a need for a blood transfusion." C "The urine output is an important indicator of cardiac function; poor urine output may indicate inadequate blood flow to the kidneys." D "Poor urine output indicates a need for a blood transfusion."

"The urine output is an important indicator of cardiac function; poor urine output may indicate inadequate blood flow to the kidneys." Explanation: Urine output is an important indicator of cardiac function. Reduced urine output may indicate inadequate renal perfusion.

5. A 32-week-gestation client was last seen in the prenatal client at 28 weeks' gesta- tion. Which of the following changes should the nurse bring to the attention of the certified nurse midwife? 1. Weight change from 128 pounds to 138 pounds. 2. Pulse rate change from 88 bpm to 92 bpm. 3. Blood pressure change from 120/80 to 118/78. 4. Respiratory rate change from 16 rpm to 20 rpm.

1 A weight gain of 10 pounds in a 4-week period is worrisome. The rec- ommended weight gain during the second and third trimesters is approx- imately 1 pound per week. The pulse rate normally increases slightly during pregnancy. A slight drop in BP is normal during pregnancy. The respiratory rate normally increases during pregnancy.

After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client makes which statement? A "I may develop hyperthyroidism because of my high blood pressure." B "I need close monitoring because I may have a small-for-gestational-age infant." C "It is possible that I will have excess amniotic fluid and may need a cesarean section." D "I may develop placenta accreta, so I need to keep my clinic appointments."

"I need close monitoring because I may have a small-for-gestational-age infant." Explanation: Women with chronic hypertension during pregnancy are at risk for complications such as preeclampsia (about 25%), abruptio placentae, and intrauterine growth retardation, resulting in a small-for-gestational-age infant. There is no association between chronic hypertension and hyperthyroidism. Pregnant women with chronic hypertension are not at an increased risk for hydramnios (polyhydramnios), an abnormally large amount of amniotic fluid. Clients with diabetes and multiple gestations are at risk for this condition. Placenta accreta, a rare placental abnormality, refers to a condition in which the placenta abnormally adheres to the uterine lining. It is not associated with chronic hypertension.

An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she makes which statement? a) "I need to consume more fluids and fiber each day." b) "I need to reduce my caloric intake to 1,200 calories a day." c) "I should eat more frequent meals if I get heartburn." d) "A regular diet is recommended during pregnancy."

"I need to reduce my caloric intake to 1,200 calories a day." Correct Explanation: Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant women report that eating more frequent, smaller meals decreases heartburn resulting from the reflux of acidic secretions into the lower esophagus. Pregnant women need adequate hydration (fluids) and fiber to prevent constipation

After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which client statement would indicate the need for additional teaching? a) "I should limit my salt intake at meals." b) "I should reduce my intake of protein in my diet." c) "I should avoid being near people who have a cold." d) "I may be given antibiotics during my pregnancy."

"I should reduce my intake of protein in my diet." Correct Explanation: The client needs a diet that is adequate in protein and calories to prevent anemia, which can place additional strain on the cardiac system, further compromising the client's cardiac status. The client should avoid contact with people who have infections because of the increased risk for developing endocarditis. The client may need antibiotics during the pregnancy to prevent endocarditis. Limiting sodium intake can help to prevent excessive expansion of blood volume and decrease cardiac workload

9. A client with 4 protein and 4 reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

1 Clients with severe preeclampsia are high risk for seizure. Clients with severe preeclampsia should be monitored for a drop in platelets. Clients with severe preeclampsia are not at risk for explosive diarrhea. Clients with severe preeclampsia are not at risk for fractured pelvis.

After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans? A 30-minute period three times a day. B 45-minute period after lunch each day. C 1-hour period each day. D 12-hour period each week.

1-hour period each day. Explanation: Numerous methods have been proposed to record the maternal perceptions of fetal movement or "kick counts." A commonly used method is the Cardiff count-to-10 method. The client begins counting fetal movements at a specified time (e.g., 8:00 a.m.) and notes the time when the 10th movement is felt. If the client does not feel at least 6 movements in a 1-hour period, she should notify the health care provider. The fetus typically moves an average of 1 to 2 times every 10 minutes or 10 to 12 times per hour. A 30- or 45-minute period is not enough time to evaluate fetal movement accurately. The client should monitor fetal movements more frequently than 1 time per week. One hour of monitoring each day is adequate.

A man has just arrived in the ER with a possible myocardial infarction (MI). The electrocardiogram (ECG) should be obtained within which time frame of arrival to the ER? A 10 minutes B 5 minutes C 15 minutes D 20 minutes

10 minutes Explanation: The ECG provides information that assists in diagnosing acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the emergency department. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored.

A nurse has come upon an unresponsive, pulseless victim. She has placed a 911 call and begins CPR. The nurse understands that if the patient has not been defibrillated within which time frame, the chance of survival is close to zero? A 15 minutes B 20 minutes C 10 minutes D 25 minutes

10 minutes Explanation: The survival rate decreases for every minute that defibrillation is delayed. If the patient has not been defibrillated within 10 minutes, the chance of survival is close to zero. The other options are too long of a time frame.

67. The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and head board. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2 Eclamptic clients should be monitored for proteinuria, not for the presence of ketones. The side rails of eclamptic clients' beds should be padded.

63. Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? 1. 3 pitting edema and pulmonary edema. 2. Epigastric pain and systemic jaundice. 3. 4 deep tendon reflexes and clonus. 4. Oliguria and elevated specific gravity.

2 A client with severe preeclampsia could exhibit symptoms of 3 pitting edema and pulmonary edema without the addi- tion of HELLP syndrome. Epigastric pain and jaundice are re- flective of hemolysis of red blood cells and of severe liver damage. These symptoms should make the nurse sus- pect HELLP syndrome. 4 reflexes with clonus are consistent with a diagnosis of severe preeclampsia and may be present without the addition of HELLP syndrome. Oliguria and elevated specific gravity are consistent with a diagnosis of severe preeclampsia and may be present without the addition of HELLP syndrome.

13. A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4 proteinuria, and a weight gain of 10 pounds over the last 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of 2 . 4. Nystagmus.

2 At 29-weeks' gestation, the normal fun- dal height should be 29 cm. With severe preeclampsia, the nurse may see poor growth—that is, a fundal height below 29 cm. The nurse would expect to see papilledema. The nurse would expect to see hyperreflexia—that is, patellar reflexes higher than 2 The nurse would not expect to see nys- tagmus.

6. A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appro- priate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Assess the woman's fundal height. 4. Ask the woman about stressors at work.

2 Discovering whether or not the client has allergies is important for the nurse to learn if medications are to be ordered, but that is not the most important infor- mation the nurse needs to learn. The nurse should assess the client's blood pressure. Fundal height assessment is important, but not the most important information the nurse needs to learn at this time. Discovering whether or not the client has stressors at work is important, but it is not the most important information the nurse needs to learn about.

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? A Palpable B Thready C 24 D Within normal limits

24 Explanation: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.

3. When counseling a preeclamptic client about her diet, what should the nurse en- courage the woman to do? 1. Restrict sodium intake. 2. Increase intake of fluids. 3. Eat a well-balanced diet. 4. Avoid simple sugars.

3 Sodium restriction is not recommended. 2. There is no need to increase fluid intake. 3. It is important for the client to eat a well-balanced diet. 4. Although not the most nutritious of foods, there is no need to restrict the in- take of simple sugars.

61. Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3 3. Low platelets are consistent with the diagnosis of HELLP syndrome.

65. A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 120 seconds. 4. Fetal heart rate 156 with early decelerations.

3 3. The duration of the contractions is prolonged. The baby will be deprived of oxygen.

14. A client with mild preeclampsia, who has been advised to be on bed rest at home, asks why it is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bed rest will help you to conserve energy for your labor." 2. "Bed rest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."

3 Bed rest, especially side-lying, helps to improve perfusion to the placenta.

At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of gestational hypertension. Based on this diagnosis, the nurse expects the assessment to reveal: a) 3+ edema in the lower extremities. b) temperature of 101.4° F (38.6° C). c) urine glucose of +2. d) inability to keep food down.

3+ edema in the lower extremities. Correct Explanation: Classic signs of gestational hypertension include edema (especially of the face) and elevated blood pressure. Fever is a sign of infection. Glycosuria, evidenced by a +2 urine glucose level indicates hyperglycemia. Vomiting may be associated with various disorders

8. A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.

4 4. The fetus should be assessed for in- trauterine growth restriction.

64. A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of 3. 2. Urinary output of 30 cc/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 gm/dL.

4 Hyperreflexia is seen with severe preeclampsia. The magnesium sulfate is being administered to depress the hyperreflexia. 30 mL/hr is an acceptable urinary output. A respiratory rate of 16 rpm is within normal limits. A serum magnesium level of 9 gm/dL is dangerously high. The health care practitioner should be notified.

A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. How does the nurse document the patellar reflexes? a) 4+ b) 1+ c) 3+ d) 2+

4+ Explanation: These findings would be documented as 4+. 1+ indicates a diminished response; 2+ indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are two movements.

12. A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.

4. Epigastric pain is associated with the liver involvement of HELLP syndrome

69. A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures.

4. The absence of seizures is an ex- pected outcome related to magnesium sulfate administration.

In order to be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)? A 30 minutes B 9 days C 60 minutes D 6 to 12 months

60 minutes Explanation: The 60-minute interval is known as "door-to-balloon time" for performance of PTCA on a diagnosed MI patient. The 30-minute interval is known as "door-to-needle time" for administration of thrombolytics post MI. The time frame of 9 days refers to the time for onset of vasculitis after administration of streptokinase for thrombolysis in an acute MI patient. The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same patient for acute MI.

Which of the following would be a pulse pressure indicative of shock? A 90/70 B 100/60 C 120/90 D 130/90

90/70 Explanation: A narrowing or decreased pulse pressure is an early indicator of shock, thus 90/70 indicates a narrowing pulse pressure.

Which of the following blood pressure (BP) readings would result in a pulse pressure indicative of shock? A 120/90 mm Hg B 100/60 mm Hg C 130/90 mm Hg D 90/70 mm Hg

90/70 mm Hg Explanation: Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. A BP reading of 90/70 mm Hg indicates a narrowing pulse pressure.

5. 24-36 hours after a myocardial infarction _____________ congregate at the site during the inflammation phase.* A. Neutrophils B. Eosinophils C. Platelets D. Macrophages

A patient is admitted with chest pain to the ER. The patient has been in the ER for 5 hours and is being admitted to your unit for overnight observation. From the options below, what is the most IMPORTANT information to know about this patient at this time?* A. Troponin result and when the next troponin level is due to be collected B. Diet status C. Last consumption of caffeine D. CK result and when the next CK level is due to be collected

At an obstetrics and gynecology physician's office, a nurse and a nursing student discuss the prioritization of returning client phone messages. Which of the following clients would be a priority to call? Select all that apply. A A client at 34 weeks reporting transient blurred vision and shoulder pain B A client at 32 weeks reporting a weight gain of 2 pounds (1 kg) over the last week C A client at 36 weeks reporting feeling anxious and short of breath D A client at 30 weeks reporting her morning sickness has suddenly returned e A client with spotting and cramping 1 day after a cerclage

A client at 34 weeks reporting transient blurred vision and shoulder pain A client at 36 weeks reporting feeling anxious and short of breath A client at 30 weeks reporting her morning sickness has suddenly returned Explanation: Symptoms of preeclampsia include hypertension, proteinuria, edema, headache, abdominal pain/shoulder pain, lower back pain, sudden weight gain, and changes in vision. Clients could also report increased anxiety and sense of impending doom. These clients should come to the office and be assessed for preeclampsia. The client with the 2-pound (1 kg) weight gain over the last week would be an expected finding. Feeling cramping and spotting the day after a cerclage would also be an expected finding. "Morning sickness" should resolve after the first trimester, and a sudden return later in the pregnancy could be a symptom of preeclampsia.

You are overseeing a 62-year-old who has started to exhibit dangerous PVCs in the cardiac postoperative unit. He's been given a bolus of lidocaine and is under continuous IV infusion, but serious side effects, including hypotension during administration, could occur. What should you be ready to do? A Adjust the IV infusion. B Administer additional lidocaine. C Prepare for defibrillation. D Call for the doctor and just wait.

Adjust the IV infusion. Explanation: Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient. Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient. Do not do anything else. Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient. Stay focused on the IV. Call for the physician and while waiting, adjust the IV infusion to the slowest possible rate until the physician can examine the patient.

A 48-year-old client with challenging menopausal symptoms is visiting the OB-GYN practice where you practice nursing. She has discussed treatment options with the physician and now has some questions that she would like to further discuss with you. The client includes in her questioning, "What are the potential risks of hormone replacement therapy?" Which of the following is the best answer? A All options are correct. B Breast cancer C Stroke (CVA) D Heart disease

All options are correct. Explanation: In using hormonal replacement therapy, the risks of breast cancer and the seriousness of future myocardial infarction and stroke may outweigh the potential benefit of alleviating symptoms associated with menopause. The Women's Health Initiative study revealed an increase in breast cancer in postmenopausal women taking HRT. The Women's Health Initiative study revealed an increase in blood clots and stroke in postmenopausal women taking HRT. The Women's Health Initiative study revealed an increase in heart disease in postmenopausal women taking HRT.

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD? A It's designed for extremely active patients. B It's specifically designed for long-term use. C An LVAD only supports a failing left ventricle. D It never needs batteries.

An LVAD only supports a failing left ventricle. Explanation: A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

Which of the following terms refers to chest pain brought on by physical or emotional stress and relieved by rest or medication? A Atherosclerosis B Angina pectoris C Atheroma D Ischemia

Angina pectoris Explanation: Angina pectoris is a symptom of myocardial ischemia. Atherosclerosis is an abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumens. Atheromas are fibrous caps composed of smooth muscle cells that form over lipid deposits within arterial vessels. Ischemia is insufficient tissue oxygenation and may occur in any part of the body.

Following a percutaneous coronary intervention (PCI), a patient is returned to the nursing unit with large peripheral vascular access sheaths in place. The nurse understands that which of the following methods to induce hemostasis after sheath is contraindicated? A Application of a sandbag to the area B Application of a vascular closure device C Direct manual pressure D Application of a mechanical compression device

Application of a sandbag to the area Explanation: Applying a sandbag to the sheath insertion site is ineffective in reducing the incidence of bleeding and is not an acceptable standard of care. Application of a vascular closure device (Angioseal, VasoSeal), direct manual pressure to the sheath introduction site, and application of a mechanical compression device (C-shaped clamp) are all appropriate methods used to induce hemostasis following peripheral sheath removal.

Which of the following methods to induce hemostasis after sheath removal post percutaneous transluminal coronary angioplasty (PTCA) is the least effective? A Application of a vascular closure device, such as Angioseal, VasoSeal, Duett, or Syvek patch B Direct manual pressure C Application of a pneumatic compression device (eg, Fem-Stop) D Application of a sandbag to the area

Application of a sandbag to the area Explanation: Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding. Application of a vascular closure device has been demonstrated to be very effective. Direct manual pressure to the sheath introduction site has been demonstrated to be effective and was the first method used to induce hemostasis post PTCA. Application of a pneumatic compression device post PTCA has been demonstrated to be effective.

A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She does not have transportation. How can the nurse help this client be compliant with her care? a) Do nothing. It's the client's responsibility to find a way to get to the clinic. b) Ask the clinic case manager to speak with the client. c) Ask the client to find a friend to help her. d) Set up cab service.

Ask the clinic case manager to speak with the client. Correct Explanation: The nurse should ask the case manager to speak with the client because the case manager is familiar with community resources that can assist with transportation. Resources and additional support will greatly increase the client's compliance. The nurse can't set up cab service if the client doesn't have the funds to pay for transportation. The client may be noncompliant if she has no assistance or if she has to rely on a friend to help

A client at 28 weeks' gestation presents to the emergency department with a "splitting headache." What actions are indicated by the nurse at this time? Select all that apply. A Reassure the client that headaches are a normal part of pregnancy. B Assess the client for vision changes or epigastric pain. Obtain a nonstress test. C Assess the client's reflexes and presence of clonus. D Determine if the client has a documented ultrasound for this pregnancy.

Assess the client for vision changes or epigastric pain. Obtain a nonstress test. Assess the client's reflexes and presence of clonus. Explanation: Headaches could be a sign of preeclampsia or eclamplsia in pregnancy. The client should be assessed for headache, vision changes, epigastric pain, hyperreflexes, and clonus. Her fetus should be assessed using a nonstress test. An ultrasound in this pregnancy does not give information to assess the presence of preeclampsia/eclampsia

A client at 35 weeks' gestation complains of severe abdominal pain and passing clots. The client's vital signs are blood pressure 150/100 mm Hg, heart rate 95 beats/minute, respiratory rate 25 breaths/minute, and fetal heart tones 160 beats/minute. The admitting nurse must determine the cause of the bleeding and respond appropriately to this emergency. Which action should the nurse do first? a) Perform an ultrasound to determine placental placement. b) Assess the location and consistency of the uterus. c) Examine the vagina to determine whether her client is in labor. d) Prepare for immediate vaginal birth.

Assess the location and consistency of the uterus. Correct Explanation: The nurse must determine whether placenta previa or abruptio placentae is the problem. (Fifty percent of all clients with hypertension will develop abruptio placenta.) In this case, the presenting symptoms are highly suggestive of an abruption, so the nurse must determine the level of the uterus and mark that level on the client's abdomen. She must also check the consistency of the uterus; a uterus that is filling with blood because the placenta has detached early is rigid. Bleeding from a placental previa is usually painless. A vaginal examination is contraindicated in the presence of bleeding. Most nurses haven't been taught how to perform an ultrasound. If the client has a placental abruption, birth will most likely be by cesarean birth

A client in the hospital informs the nurse he ?"feels like his heart is racing and can''t catch his breath." ?What does the nurse understand occurs as a result of a tachydysrhythmia? A It causes a loss of elasticity in the myocardium. B It reduces ventricular ejection volume. C It increases after load. D It increases preload.

A client at 32 weeks of gestation has mild preeclampsia. She is discharged home with instructions to remain in bed rest. She would also be instructed to call her health care provider if she experiences which of the following symptoms? Select all that apply. a) Increased urine output b) Severe nausea and vomiting c) Difficulty sleeping d) Headache e) Epigastric pain f) Blurred vision

Blurred vision • Headache • Epigastric pain • Severe nausea and vomiting Correct Explanation: The care of a client with mild preeclampsia can be managed at home with proper instructions. Headache, blurred vision, epigastric pain, and severe nausea and vomiting can indicate worsening preeclampsia. Decreased, not increased, urine output is a concern because preeclampsia is associated with decreased renal perfusion, leading to a reduction in the glomerular filtration rate and decreased urine output. Difficulty sleeping, a common concern during the third trimester, is only a concern if it is caused by any of the other symptoms

The nurse recognizes that there are many risk factors for the development of hypovolemic shock. Which of the following are considered "internal" risk factors? Select all that apply. A Vomiting B Burns C Diarrhea. D Dehydration E Trauma

Burns Dehydration Explanation: The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid losses) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe preeclampsia. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which action should the nurse do first? A Pad the side rails of the client's bed. B Turn the client to the right side. C Insert a padded tongue blade into the client's mouth. D Call for immediate assistance in the client's room.

Call for immediate assistance in the client's room. Explanation: The first action by the nurse should be to call for immediate assistance in the client's room because this is an emergency. Throughout the seizure, the nurse should note the time and length of the seizure and continue to monitor the status of both client and fetus. The side rails should have been padded at the time of the client's admission to the hospital as part of seizure precautions. The client should be turned to her left side to improve placental perfusion. Inserting a tongue blade is not recommended because it can further obstruct the airway or cause injury to the client's teeth.

A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe preeclampsia. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which action should the nurse do first? a) Call for immediate assistance in the client's room. b) Turn the client to the right side. c) Insert a padded tongue blade into the client's mouth. d) Pad the side rails of the client's bed.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which action should the nurse take first? A Insert an airway to improve oxygenation. B Note the time when the seizure begins and ends. C Call for immediate assistance. D Turn the client to her left side.

Call for immediate assistance. Explanation: Principles of emergency management begin with calling for assistance. If a client begins to have a seizure, the first action by the nurse is to remain with the client and call for immediate assistance. The nurse needs to have some assistance in managing this client. After the seizure, the client needs intensive monitoring. An airway can be inserted, if appropriate, after the seizure ends. Noting the time the seizure begins and ends and turning the client to her left side should be done after assistance is obtained.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last? All options must be used. 1 Call for immediate assistance. 2 Turn the client to her side. 3 Maintain airway. 4 Assess for ruptured membranes

Call for immediate assistance. Turn the client to her side. Maintain airway. Assess for ruptured membranes. Explanation: If a client begins to have a seizure, the first action by the nurse is to remain with the client and call for immediate assistance. Next, the nurse should turn the client to her side and then maintain the airway by keeping the neck hyperextended. When the seizure is over, the nurse should assess the client for ruptured membranes and the fetal status.

A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication should the nurse monitor for? Select all that apply. A Cardiac dysrhythmias B Respiratory arrest C Pulmonary embolism D Cardiac arrest E Nausea and vomiting

Cardiac dysrhythmias Respiratory arrest Cardiac arrest Explanation: Pulmonary edema is fluid accumulation in the lungs, which interferes with gas exchange in the alveoli. It represents an acute emergency and is a frequent complication of left-sided heart failure. Cardiac dysrhythmias and cardiac or respiratory arrest are associated complications. Nausea and vomiting are not complications but are symptoms of many disorders. The client is not at increased risk for the development of pulmonary embolism with pulmonary edema.

A 62-year-old female who is 2 weeks CABG returns to her cardiologist due to new symptoms, including heaviness in her chest and pain between her breasts. She reports that leaning forward decreases the pain. The cardiologist admits her to the hospital to rule out pericarditis. Which of the following is a contributing cause to pericarditis? Select all that apply. A Cardiac surgery B Pneumonia C Tuberculosis D Myocarditis E Chest trauma

Cardiac surgery Tuberculosis Myocarditis Chest trauma Explanation: Pericarditis usually is secondary to endocarditis, myocarditis, chest trauma, or MI (heart attack) or develops after cardiac surgery.

A 74-year-old male client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock? A Distributive shock B Cardiogenic shock C Hypovolemic shock D Obstructive shock

Cardiogenic shock Explanation: Cardiogenic shock is caused by decreased force of ventricular contraction. Both myocardial infarction and cardiac dysrhythmia may cause cardiogenic shock. This type of shock is characterized by an impaired filling of heart with blood due to mechanical impediment, such as cardiac tamponade, dissecting aneurysm, or tension pneumothorax. This type of shock is caused by the enlargement of the vascular compartment and redistribution of intravascular fluid from arterial circulation to venous or capillary areas. Hypovolemic shock is caused by decreased blood volume with decreased filling of the circulatory system. Typical examples are hemorrhage, extreme dieresis, and third-spacing.

Which of the following type of shock are older adults more likely to develop? A Cardiogenic shock B Septic shock C Anaphylactic shock D Neurogenic shock

Cardiogenic shock Explanation: Older adults, particularly those with cardiac disease, are prone to cardiogenic shock. Older adults are not prone to developing neurogenic, septic, or anaphylactic shock.

A client has been prescribed furosemide (Lasix) 80 mg twice daily. The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigeminy lasting 2 minutes. During the assessment, the nurse determines that the client is asymptomatic and has stable vital signs. Which of the following actions should the nurse perform next? A Summon the nurse-manager. B Check the client's potassium level. C Call the physician. D Administer potassium.

Check the client's potassium level. Explanation: The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the physician. Because the client is taking furosemide (Lasix), a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the physician with a more complete database. The physician will need to be notified after the nurse checks the latest potassium level. Calling the nurse-manager is not indicated at this time. Administering potassium requires a physician's order.

A 73-year-old male client is diagnosed with dilated cardiomyopathy. The nurse is aware that which of the following is the most likely cause of his condition? A Chronic alcohol abuse B Heredity C Scleroderma D Previous myocardial infarction

Chronic alcohol abuse Explanation: Chronic alcohol ingestion is one of the main causes of dilated cardiomyopathy. Other causes include history of viral myocarditis, an autoimmune response, and exposure to other chemicals in addition to alcohol. Heredity is considered the main cause of hypertrophic cardiomyopathy. This a connective tissue disorder is thought to cause restrictive cardiomyopathy. Scar tissue that forms after a myocardial infarction is thought to be a cause of restrictive cardiomyopathy.

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse A Begins the enteral nutritional supplement at 100 mL/hr to ensure adequate calories B Measures the nasogastric tube from earlobe to xiphoid process and marks the tube with tape at this level C Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) D Obtains consent by a family member for placement of a percutaneous endoscopic gastrostomy (PEG) tube

Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Explanation: Pantoprazole tablets are not to be broken, crushed, or chewed. Lansoprazole is substituted for this medication. The nurse consults with the physician about substituting another proton pump inhibitor for pantoprazole. Enteral feedings are initiated at a slow rate to ensure adequate digestion. The nasogastric tube is measured from earlobe to xiphoid process and 6 inches are added to the length of the tube to be inserted. Placement of a PEG tube is not necessary at this time. The client is unstable. The tube is meant for long-term, not short-term, placement.

A 34-year-old female client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? A Control the shivering. B Place client on a warming blanket. C Keep client dry and covered. D Maintain client in a supine position with legs elevated 12 inches.

Control the shivering. Explanation: Hyperthermia may develop related to altered temperature regulation secondary to sepsis. Because the act of shivering increases body heat through the contraction of skeletal and pilomotor muscles in the skin, it is important to get the shivering under control. This would not be an appropriate intervention because this client is septic and hyper thermic. Conduction and radiation transfer heat, which would increase the client's body temperature. Hyperthermia may develop related to altered temperature regulation secondary to sepsis. This intervention would not help this client because measures that prevent evaporation and heat loss from radiation interfere with the loss of body heat. This intervention is appropriate for clients with ineffective peripheral tissue perfusion.

A patient is complaining of chest pain. You obtain a 12-lead EKG and see ST elevation in leads II, III, AVF. What area of the heart does this represent?* A. Lateral B. Septal C. Anterior D. Inferior

A patient taking Lovenox is having a severe reaction. What is the antidote for this medication?* A. Activated Charcoal B. Acetylcysteine C. Narcan D. Protamine sulfate

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is A Packed red blood cells B Hetastarch C Salt-poor albumin D Dextran

Dextran Explanation: Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

A woman with preeclampsia is receiving magnesium sulfate via infusion pump at 1 gram/hour. The nurse's assessment includes: temperature 36.7° C; pulse 78; respirations 12/minute; B/P 128/82; urinary output 90 mLs in last 4 hours via Foley catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 beats per minute; cervix 4 cm dilated, 80% effaced, station -1. a) Increase fluid intake intravenously and measure intake and output. b) Document findings and continue to monitor her progress in labor. c) Assess the Foley catheter for kinks in the drainage tubing and obtain a urine sample. d) Discontinue the magnesium sulfate infusion and notify the health care provider (HCP).

Discontinue the magnesium sulfate infusion and notify the health care provider (HCP). Explanation: The nurse must be alert to signs of magnesium sulfate toxicity that include loss of deep tendon reflexes, which is often the first sign (patellar-tendon response is the most common reflex tested); urinary output decreases (should have at least 30 mls/hr); respirations decrease (12 respirations/min is low and could be developing respiratory distress). First action would be to stop magnesium sulfate infusion and notify the HCP . The Foley catheter tubing maybe kinked; however, looking at all findings would indicate the woman is experiencing magnesium sulfate toxicity. It is not a priority to obtain a urine sample. Documentation is extremely important to complete; however, the nurse must intervene by stopping the magnesium sulfate and notifying the primary care provider. Increasing fluid intake at this point is not appropriate with a woman who has magnesium sulfate toxicity. Intake and output should be ongoing for a client on intravenous fluids and magnesium sulfate and a diagnosis of preeclampsia.

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent? A Disrupting the heart during the critical period of atrial repolarization B Disrupting the heart during the critical period of ventricular repolarization C Disrupting the heart during the critical period of ventricular depolarization D Disrupting the heart during the critical period of atrial depolarization

Disrupting the heart during the critical period of ventricular repolarization Explanation: It is similar to defibrillation. One difference is that the machine that delivers the electrical stimulation waits to discharge until it senses the appearance of an R wave. By doing so, the machine prevents disrupting the heart during the critical period of ventricular repolarization. Therefore, options A, C, and D are incorrect.

A female client returns for a follow-up visit to the cardiologist 4 days after a trip to the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn in the hospital shows: A Elevated troponin levels B Decreased LDH levels C Decreased myoglobin levels D Increased C-reactive protein levels

Elevated troponin levels Explanation: Troponin is present only in myocardial tissue; therefore, it is the gold standard for determining heart damage in the early stages of an MI. LDH1 and LDH2 may be elevated in response to cardiac or other organ damage during an MI. Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage during an MI. C-reactive protein, erythrocyte sedimentation rate, and the WBC count increase on about the third day following MI because of the inflammatory response that the injured myocardial cells triggered. These levels would not be elevated during the MI event.

A patient with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The patient's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of which of the following? A Heart failure B Renal failure C Embolic stroke D Myocardial infarction

Embolic stroke Explanation: Intervention is implemented to prevent the development of an embolic event/stroke. Patients with a history of previous stroke, transient ischemic attack (TIA), embolic event, mitral stenosis, or prosthetic heart valve and who develop atrial fibrillation are at significant risk of developing an embolic stroke. Antithrombotic therapy is indicated for all patients with atrial fibrillation, especially those at risk of an embolic event, such as a stroke, and is the only therapy that decreases cardiovascular mortality. These patients are often placed on warfarin, in contrast to patients who have no risk factors, who are often prescribed 81 to 325 mg of aspirin daily.

During each prenatal checkup, a nurse obtains a client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup? a) Measuring the client's hemoglobin (Hb) level b) Evaluating the client for edema c) Determining the client's Rh factor d) Obtaining pelvic measurements

Evaluating the client for edema Explanation: During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of gestational hypertension. If edema exists, the nurse should assess for high blood pressure and proteinuria — other signs of gestational hypertension. Hb is measured during the first prenatal visit and again at 24 to 28 weeks' gestation and at 36 weeks' gestation. The pelvis is measured and the Rh factor is determined during the first prenatal visit.

A patient with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The senior nursing student recognizes these symptoms occur when A The pericardial space is eliminated with scar tissue and thickened pericardium. B Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. C The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. D Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. Explanation: The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (eg, compression of the heart).

The nurse assessing a multigravida at 36 weeks' gestation plans to assess the client for symptoms of preeclampsia. The nurse determines the highest priority assessment would be of the client's: A Face. B Reflexes. C Pulse. D Ankles.

Face. Explanation: The most consistent signs of preeclampsia are sudden, excessive weight gain and facial and finger edema. Reflexes of 3+ to 4+ confirm a diagnosis of preeclampsia; however, such a result on its own will not necessarily suggest this condition. Checking the client's pulse will not give information relevant to preeclampsia. Ankle and leg edema is common in pregnant women due to the fluid volume shifts associated with pregnancy. Therefore, it is not a reliable indicator of preeclampsia.

Which of the following is an early warning symptom of acute coronary syndrome (ACS) and heart failure (HF)? A Fatigue B Change in level of consciousness C Weight gain D Hypotension

Fatigue Explanation: Fatigue is an early warning symptom of ACS, heart failure, and valvular disease. Other signs and symptoms of cardiovascular disease are hypotension, change in level of consciousness, and weight gain.

The nurse is planning care for a client who has experienced a myocardial infarction. Which of the following would be appropriate nursing diagnoses for the nurse to select for this client? (Select all that apply.) A Fear related to change in health status B Pain related to cardiac tissue damage C Abnormal cardiac rhythm D Pulmonary edema E Determine cardiac function

Fear related to change in health status Pain related to cardiac tissue damage Explanation: Fear and pain are appropriate nursing diagnoses that can be addressed by nursing care. Abnormal cardiac rhythm is an etiology. Pulmonary edema is a medical diagnosis. Determining cardiac function is the physician's domain.

You are caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client? A Fluttering B Nausea C Hypotension D Fever

Fluttering Explanation: Premature ventricular contractions usually cause a flip-flop sensation in the chest, sometimes described as "fluttering." Associated signs and symptoms include pallor, nervousness, sweating, and faintness. Symptoms of premature ventricular contractions are not nausea, hypotension, and fever.

A pregnant client at 32 weeks' gestation has mild preeclampsia. She is discharged to home with instructions to remain on bed rest. She should also be instructed to call her physician if she experiences which symptoms? Select all that apply. A Headache. B Increased urine output. C Blurred vision. D Difficulty sleeping. E Epigastric pain. F Severe nausea and vomiting.

Headache. Blurred vision. Epigastric pain. Severe nausea and vomiting. Explanation: Headache, blurred vision, epigastric pain, and severe nausea and vomiting can indicate worsening maternal disease. Decreased, not increased, urine output is a concern because it could indicate renal impairment. Difficulty sleeping, a common complaint during the third trimester, is only a concern if it's caused by any of the other symptoms.

A client has a medical diagnosis of an advanced AV block and is symptomatic due to a slow heart rate. With what initial treatment(s) should the nurse be prepared to assist? A IV bolus of atropine or temporary pacing B Cardioversion or IV bolus of dopamine C A maze procedure or IV bolus of furosemide D Cardiac catheterization

IV bolus of atropine or temporary pacing Explanation: The initial treatment of choice is an IV bolus of atropine. If the client does not respond to atropine, has advanced AV block, or has had an acute MI, temporary pacing may be started. A permanent pacemaker my be necessary if the block persists.

A patient who has had a recent myocardial infarction develops pericarditis and complains of level 6 (on a scale of 0-10) chest pain with deep breathing. Which of these ordered pro re nata (PRN) medications will be the most appropriate for the nurse to administer? A Acetaminophen (Tylenol) 650 mg per os (po) every 4 hours B Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours C Ibuprofen (Motrin) 800 mg po every 8 hours D Morphine sulfate 6 mg IVP every 2-4 hours

Ibuprofen (Motrin) 800 mg po every 8 hours Explanation: Pain associated with pericarditis is caused by inflammation, thus nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. A Increased paCO² levels B Reports of chest pain C Loss in consciousness D Ecchymoses and petechiae E Decreases in liver enzymes

Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activites of the liver are impaired, and liver enzymes will increase.

Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis? A Irreversible B Progressive C Precompensatory D Compensatory

Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention? a) Urine specific gravity 1.010. b) Serum sodium 140 mEq/L. c) Serum potassium 4 mEq/L. d) Ketones in urine.

Ketones in urine. Correct Explanation: Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L, and a serum sodium level of 140 mEq/L are all within normal limits.

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following? A Right atrial function B Right ventricular function C Left ventricular function D Left atrial function

Left ventricular function Explanation: The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

The nurse is caring for a patient with a central venous line in place for the treatment of shock. Which of the following nursing interventions are essential for the nurse to complete to reduce the risk of infection? Select all that apply. A Maintain sterile technique when changing the central venous line dressing. B Always perform hand hygiene before manipulating or accessing the line ports. C Wear clean gloves prior to accessing the line port. D Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub. E Instruct the patient to wear a face mask and gloves while the central venous line is in place.

Maintain sterile technique when changing the central venous line dressing. Always perform hand hygiene before manipulating or accessing the line ports. Wear clean gloves prior to accessing the line port. Explanation: The following nursing interventions are essential to reduce the risk of infection: maintain sterile technique when changing the central venous line dressing; always perform hand hygiene before manipulating or accessing the line ports; wear clean gloves prior to accessing the line port; and perform a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub; this reduces biofilm on the hub that may contain pathogens.

Which of the following nursing interventions must a nurse perform when administering prescribed vasopressors to a patient with a cardiac dysrhythmia? A Keep the patient flat for one hour after administration B Administer every five minutes during cardiac resuscitation C Document heart rate before and after administration D Monitor vital signs and cardiac rhythm

Monitor vital signs and cardiac rhythm Explanation: The nurse should monitor the patient's vital signs and cardiac rhythm for effectiveness of the medication and for side effects and should always have emergency life support equipment available when caring for an acutely ill patient. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria. It is not necessary to place a patient flat during or after vasopressor administration. When administering cholinergic antagonists, documentation of the heart rate is necessary.

Which of the following is the analgesic of choice for acute MI? A Morphine sulfate B Aspirin C Demerol D Motrin

Morphine sulfate Explanation: The analgesic of choice for acute MI is morphine sulfate administered in IV boluses to reduce pain and anxiety. Aspirin is an antiplatelet medication. Demerol and Motrin are not the analgesics of choice.

A female patient is being seen in the ER complaining of fatigue and shoulder blade discomfort. She is also short of breath. Based on these symptoms, the nurse should suspect which of the following? A Myocardial infarction (MI) B Deep vein thrombosis (DVT) C Stroke D Intracerebral hemorrhage

Myocardial infarction (MI) Explanation: Women often present with symptoms different from those seen in men, therefore a high level of suspicion is associated with vague complaints such as fatigue, shoulder blade discomfort, and/or shortness of breath. The clinical manifestations noted are not consistent with DVT, stroke, or intracerebral hemorrhage. Reference:

After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time? A Troponin I B Myoglobin C WBC (white blood cell) count D C-reactive protein

Myoglobin Explanation: Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels due not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.

Which of the following vasoactive medications may be used in the treatment of cardiogenic shock? Select all that apply. A Norepinephrine (Levophed) B Milrinone (Primacor) C Amrinone (Inocor) D Vasopressin (Pitressin) E Phenylephrine (Neo-Synephrine)

Norepinephrine (Levophed) Milrinone (Primacor) Amrinone (Inocor) Explanation: Vasoactive agents that may be used in managing cardiogenic shock include Levophed, Adrenalin, Primacor, Inocor, Pitressin, and Neo-Synephrine. Each of these medications stimulates different receptors of the sympathetic nervous system.

The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage? A Fluoroscopy B Nuclear cardiology C Serum blood work D Chest radiography

Nuclear cardiology Explanation: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting muscle damage.

The nurse is developing a discharge plan for a client who has had a myocardial infarction. Planning for discharge for this client should begin: A on discharge from the hospital. B on discharge from the cardiac care unit. C on admission to the hospital. D four weeks after the onset of illness.

On admission to the hospital. Explanation: A basic principle of rehabilitation, including cardiac rehabilitation, is that rehabilitation begins on hospital admission. Early rehabilitation is essential to promote maximum functional ability as the client recovers from an illness. Delaying rehabilitation activities is associated with poorer client outcomes.

The nurse is evaluating a client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? A Weight loss B Unsteady gait C Organ damage D Liver dysfunction

Organ damage Explanation: When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs which fail. Weight fluctuations may occur if the body holds fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client is not able to ambulate.

Which of the following tends to be prolonged on the electrocardiogram (ECG) during a first-degree atrioventricular (AV) block? A QRS B T wave C P wave D PR interval

PR interval Explanation: First-degree AV block occurs when atrial conduction is delayed through AV node resulting in a prolonged PR interval. The QRS complex, T wave, and P wave are not prolonged in first-degree AV block.

Which of the following terms is used to describe a tachycardia characterized by abrupt onset, abrupt cessation, and a QRS of normal duration? A Paroxysmal atrial tachycardia B Sinus tachycardia C Atrial fibrillation D Atrial flutter

Paroxysmal atrial tachycardia Explanation: PAT is often caused by a conduction problem in the AV node and is now called AV nodal reentry tachycardia. Sinus tachycardia occurs when the sinus node regularly creates an impulse at a faster-than-normal rate. Atrial flutter occurs in the atrium and creates an atrial rate between 250 to 400 times per minute. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature.

The nurse recognizes that the treatment for a non-ST elevation myocardial infarction (NSTEMI) differs from that of a patient with a STEMI, in that a STEMI is more frequently treated with which of the following? A Percutaneous coronary intervention (PCI) B IV heparin C IV nitroglycerin D Thrombolytics

Percutaneous coronary intervention (PCI) Explanation: The patient with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used. 1 Position electrodes on the chest. 2 Take vital signs. 3 Administer the prescribed dose of morphine. 4 Obtain a history of which drugs the client has used recently

Position electrodes on the chest. Take vital signs. Administer the prescribed dose of morphine. Obtain a history of which drugs the client has used recently. Explanation: The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.

A client with a gastrointestinal bleed has vomited 600 mL of frank red blood and is now pale and diaphoretic. Vital signs are BP 88/50 mm Hg, HR 120 bpm, RR 24 breaths/min. What are the priority nursing interventions for this client? Place in order of priority. Use all options. 1 Position the client on the left side. 2 Initiate two large-bore intravenous lines. 3 Notify the physician. 4 Reassess vital signs and oxygen saturation. 5 Prepare the client for the operating room

Position the client on the left side. Initiate two large-bore intravenous lines. Notify the physician. Reassess vital signs and oxygen saturation. Prepare the client for the operating room. Explanation: The client would immediately be placed on his/her side to avoid aspiration of bloody vomitus. Next, IVs would need to be inserted as the BP has decreased and the client is in danger of hypovolemic shock. The physician would be notified, followed by reassessment of vital signs and preparing the client for surgery.

When the nurse observes an ECG tracing on a cardiac monitor with a pattern in lead II and observes a bizarre, abnormal shape to the QRS complex, the nurse has likely observed which of the following ventricular dysrhythmias? A Ventricular tachycardia B Premature ventricular contraction C Ventricular bigeminy D Ventricular fibrillation

Premature ventricular contraction Explanation: A PVC is an impulse that starts in a ventricle before the next normal sinus impulse. Ventricular bigeminy is a rhythm in which every other complex is a PVC. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles.

A 48-year-old female client presents to the ED with a myocardial infarction. Prior to administering a prescribed thrombolytic agent, the nurse must interview the client to determine if she has which of the following absolute contraindications to thrombolytic therapy? A Prior intracranial hemorrhage B Recent consumption of a meal C Shellfish allergy D Use of heparin

Prior intracranial hemorrhage Explanation: History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. An allergy to iodine, shellfish, radiographic dye, and latex are of primary concern before a cardiac catheterization but not a known contraindication for thrombolytic therapy. Administration of a thrombolytic agent with heparin increases risk of bleeding; the primary healthcare provider usually discontinues the heparin until thrombolytic treatment is completed.

You are a student nurse being precepted in the ICU. You are caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body? A Secretion of epinephrine and norepinephrine B Activation of renin-angiotensin-aldosterone system C Production of antidiuretic hormone and corticosteroid hormones D Release of catecholamines

Production of antidiuretic hormone and corticosteroid hormones Explanation: Thus, they play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones, then, promote fluid re absorption and retention. The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. The release of catecholamines stimulates secretion of epinephrine and norepinephrine.

When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as which of the following? A Pulmonary artery wedge pressure B Cardiac output C Pulmonary artery pressure D Central venous pressure

Pulmonary artery wedge pressure Explanation: When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take? A Administer the medication as ordered. B Discontinue the medication. C Question the physician about the order. D Inform the client that he should discuss his MI with the physician.

Question the physician about the order. Explanation: Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

Which activity would be appropriate to delegate to unlicensed assistive personnel (UAP) for a client diagnosed with a myocardial infarction who is stable? A Evaluate the lung sounds. B Help the client identify risk factors for CAD. C Provide teaching on a 2-g sodium diet. D Record the intake and output.

Record the intake and output. Explanation: UAP are able to measure and record intake and output. The nurse is responsible for client teaching, physical assessments, and evaluating the information collected on the client.

When caring for a client with preeclampsia, which action is a priority? A Monitoring the client's labor carefully and preparing for a fast delivery B Continually assessing the fetal tracing for signs of fetal distress C Checking vital signs every 15 minutes to watch for increasing blood pressure D Reducing visual and auditory stimulation

Reducing visual and auditory stimulation Explanation: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although monitoring the client's labor, preparing for a fast delivery, assessing the fetal tracing, and checking vital signs are important actions, they're lower priorities than reducing stimulation.

When caring for a client with preeclampsia, which action is a priority? a) Reducing visual and auditory stimulation b) Continually assessing the fetal tracing for signs of fetal distress c) Monitoring the client's labor carefully and preparing for a fast delivery d) Checking vital signs every 15 minutes to watch for increasing blood pressure

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock? A Restlessness and confusion B High blood pressure C Increased urinary output D Hyperactive bowel sounds

Restlessness and confusion Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromised? A Pulmonary artery B Right ventricle C Aorta D Right atrium

Right ventricle Explanation: There are four chambers to the heart. The right and left ventricles is the heart's major pumping chamber. The right ventricle pumps to the lungs to oxygenate the blood. The left ventricle pumps blood to the tissues and cells. The pulmonary artery and aorta are not of the heart.

The nurse is caring for a patient presenting to the emergency department (ED) complaining of chest pain. Which of the following electrocardiographic (ECG) findings would be most concerning to the nurse? A ST elevations B Isolated premature ventricular contractions (PVCs) C Sinus tachycardia D Frequent premature atrial contractions (PACs)

ST elevations Explanation: The first signs of an acute MI are usually seen in the T wave and ST segment. The T wave becomes inverted; the ST segment elevates (usually flat). An elevation in ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e. ST elevation myocardial infarction, STEMI). This patient requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions. Reference:

A client with heart failure has been receiving an intravenous infusion at 150 mL/hr. Now the client is short of breath. The nurse auscultates crackles bilaterally and notes neck vein distention and tachycardia. Using critical thinking skills, what should the nurse do first? A Slow the infusion and notify the physician. B Administer a prescribed diuretic. C Discontinue the infusion. D Notify the physician.

Slow the infusion and notify the physician. Explanation: The client has fluid overload, so the nurse should first slow the infusion to prevent additional overload, and then notify the physician to obtain further orders. Notifying the physician without slowing the infusion would increase the client's risk. Discontinuing the infusion is not appropriate, because having a vascular access will be important. Administering a diuretic without turning down the intravenous infusion rate is counterproductive.

When a patient is in the compensatory stage of shock, which of the following symptoms occurs? A Tachycardia B Urine output of 45 mL/hr C Respiratory acidosis D Bradycardia

Tachycardia Explanation: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply. A Tachycardia B Hypotension C Mild epigastric pain D A rigid, board-like abdomen e Diarrhea

Tachycardia Hypotension A rigid, board-like abdomen Explanation: Signs and symptoms of perforation include sudden, severe upper abdominal pain (persisting and increasing in intensity); pain, which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock. Perforation is a surgical emergency.

The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following? A Fluid overload and tissue perfusion status B The force of the contraction related to the sympathetic nervous system C The amount of resistance to the ejection of blood from the ventricles D The amount of blood presented to the ventricles just before systole

The amount of blood presented to the ventricles just before systole Explanation: Preload is the amount of blood presented to the ventricles just before systole. It increases pressure in the ventricles, which stretches the ventricle wall. Like a piece of elastic, the muscle fibers need to be stretched to produce optimal recoil and forceful ejection of blood. Afterload refers to the amount of resistance to the ejection of blood from the ventricle. To eject blood, the ventricles much overcome the resistance caused by tension in the aorta, systemic vessels, and pulmonary artery.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? A The development of left-sided heart failure B The development of chronic obstructive pulmonary disease (COPD) C The development of corpulmonale D The development of right-sided heart failure

The development of left-sided heart failure Explanation: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Corpulmonale is a condition in which the heart is affected secondarily by lung damage.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which of the following organs? A The kidneys B The lungs C The liver D The brain

The lungs Explanation: During MODS, the organ failure usually begins in the lungs and is followed by failure of the liver, GI system, and kidneys.

A nurse is caring for a dying client following myocardial infarction. The client is experiencing apnea with a falling blood pressure of 60 per palpation. Which documentation of pulse quality does the nurse anticipate? A Weak pulse B A pulse deficit C Thready pulse D Bounding pulse

Thready pulse Explanation: The nurse is most correct to anticipate a thready (barely palpable) pulse quality. A bounding pulse indicates a strong cardiac output. A weak pulse indicates a lower pulse quality. A pulse deficit occurs when the pulses between the apex of the heart differs from the radial pulse.

Which of the following is a classic sign of cardiogenic shock? A Tissue hypoperfusion B Hyperactive bowel sounds C High blood pressure D Increased urinary output

Tissue hypoperfusion Explanation: Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). Low blood pressure is a classic sign of cardiogenic shock. Hypoactive bowel sounds are classic signs of cardiogenic shock. Decreased urinary output is a classic sign of cardiogenic shock.

A client with gestational hypertension receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? a) To inhibit labor b) To block dopamine receptors c) To lower blood pressure d) To prevent seizures

To prevent seizures Correct Explanation: Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors

The nurse is awaiting results of cardiac biomarkers for a patient with severe chest pain. The nurse would identify which cardiac biomarker as remaining elevated the longest when myocardial damage has occurred? A CK-MB B Myoglobin C Brain natriuretic peptide (BNP) D Troponin T and I

Troponin T and I Explanation: After myocardial injury, these biomarkers rise early (within 3 to 4 hours), peak in 4 to 24 hours, and remain elevated for 1 to 3 weeks. These early and prolonged elevations may make very early diagnosis of acute myocardial infarction (MI) possible and allow for late diagnosis in patients who have delayed seeking care for several days after the onset of acute MI symptoms. CK-MB returns to normal within 3 to 4 days. Myoglobin returns to normal within 24 hours. BNP is not considered a cardiac biomarker. It is a neurohormone that responds to volume overload in the heart by acting as a diuretic and vasodilator.

The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first? A Sustained asystole B Supraventricular tachycardia C Atrial fibrillation D Ventricular fibrillation

Ventricular fibrillation Explanation: Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs attention first because there is no cardiac output, and it is an indication for CPR and immediate defibrillation. Sustained asystole either is from death, or the client is off of the cardiac monitor. Supraventricular tachycardia and atrial fibrillation is monitored and reported to the physician but is not addressed first.

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant? A Pacemaker B Intra-aortic balloon pump (IABP) C Implanted cardioverter-defibrillator (ICD) D Ventricularassistdevice (VAD)

Ventricularassistdevice (VAD) Explanation: VADs may be used for one of three purposes:(1) a bridge to recovery, (2) a bridge to transport, or (2) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? A Withhold anticoagulant therapy. B Assess distal pulses. C Inform client of diagnostic tests. D Remove hair from skin insertion sites.

Withhold anticoagulant therapy. Explanation: The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.

The nurse is planning care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first? A an 18-year-old G2 P2 with an uncomplicated spontaneous vaginal birth 12 hours ago who has abdominal cramps B a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm C a 16-year-old G1 P1 with a caesarean section 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h; reflexes are 2+, and the nurse's notes indicate she has a headache; vital signs are T 99.4 F (37.4 C), P 88, R 20, BP 128/86 mm Hg D an 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain; vital signs are T 99.8 F (37.7 C), P 96, R 22

a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm Explanation: The criteria for hemorrhage is saturating one pad per hour. The 35-year-old who delivered 4 hours ago had saturated a peripad per hour. Even though her fundus is firm, she may have experienced a cervical laceration, which would be the source of the bleeding. She needs to be evaluated first, based on the bleeding. The 18-year-old who has abdominal cramps is within normal limits for a G2 P2 and is experiencing afterbirth pains normally seen in a multiparous client; she will need pain medication. The 16-year-old status post cesarean section on magnesium sulfate is stable with adequate urinary output and normal reflexes. Her vital signs are within normal limits for a postpartum client. The headache is the one area of concern for this client. The 18-year-old who is 2 days postpartum with breast pain may be experiencing her milk coming in, although it does not indicate whether she is breast- or bottle-feeding; either situation may find a mother with milk developing within her system. The vital signs for this client are slightly elevated, but this may be from the milk coming in and would require nursing evaluation but is not emergent.

The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most appropriate for this client? a) a darkened private room as close to the nurses' station as possible b) a semiprivate room midway down the hall from the nurses' station c) a brightly lit private room at the end of the hall from the nurses' station d) a private room with many windows that is near the operating room

a darkened private room as close to the nurses' station as possible Correct Explanation: A primigravid client diagnosed with preeclampsia has the potential for developing seizures (eclampsia). This client should be in a room with the least amount of stimulation possible to reduce the risk of seizures and as close to the nurses' station as possible in case the client requires immediate assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risk of seizures, as can being in a semiprivate room with roommate, visitors, conversation, and noise.

A client at 36 weeks' gestation, begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for: a) transverse lie b) uterine atony c) placenta accreta d) abruptio placentae

abruptio placentae Explanation: After an eclamptic seizure, the client is at risk for abruptio placentae due to severe vasoconstriction resulting in hemorrhage into the decidua basalis. Abruptio placentae is manifested by a board-like abdomen and an abnormal fetal heart rate tracing. Transverse lie or shoulder presentation, placenta accreta, and uterine atony are not related to eclampsia. Causes of a transverse lie may include relaxation of the abdominal wall secondary to grand multiparity, preterm fetus, placenta previa, abnormal uterus, contracted pelvis, and excessive amniotic fluid. Placenta accreta, a rare phenomenon, refers to a condition in which the placenta abnormally adheres to the uterine lining. Uterine atony, or relaxed uterus, may occur after childbirth, leading to postpartum hemorrhage

Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate? a) decreased generalized edema within 8 hours b) decreased urinary output during the first 24 hours c) sedation and decreased reflex excitability within 48 hours d) absence of any seizure activity during the first 48 hours

absence of any seizure activity during the first 48 hours Explanation: The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours

The primary health care provider (HCP) prescribes intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which medication would be most important for the nurse to have readily available? a) calcium gluconate b) hydralazine c) diazepam d) phenytoin

calcium gluconate Correct Explanation: The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam is used to treat anxiety, and usually it is not given to pregnant women. Hydralazine would be used to treat hypertension, and phenytoin would be used to treat seizures.

A client returns to the medical-surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/min, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply. A cyanotic mucous membrane B warm, dry skin C vital sign changes D oxygen saturation

cyanotic mucous membrane vital sign changes oxygen saturation Explanation: When assessing a postoperative client for perfusion and the manifestation of shock, nursing assessment should include an inspection for cyanotic mucous membranes; cold, moist, pale skin; and the level of oxygen saturation in relation to hemoglobin. The nurse should also compare the client's postoperative vital signs with his preoperative vital signs to determine how much physiologic stress has occurred during the intraoperative period.

The client has been managing angina episodes with nitroglycerin. Which finding indicates that the therapeutic effect of the drug has been achieved? A decreased chest pain B increased blood pressure C decreased blood pressure D decreased heart rate

decreased chest pain Explanation: Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerine, it is only secondary and not related to the angina the client is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerine.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia? a) tingling in the toes b) rapid pulse rate c) decreased deep tendon reflexes d) cool skin temperature

decreased deep tendon reflexes Explanation: Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia

The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply. A dry, flushed skin B decreased urine output C tachycardia D widening pulse pressure E rapid respirations F thirst

decreased urine output tachycardia rapid respirations thirst Explanation: The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure.

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week, and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? A abruptio placentae B HELLP syndrome C disseminated intravascular coagulation D threatened abortion

disseminated intravascular coagulation Explanation: A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae, such as sharp pain and "woody," firm consistency of the abdomen (abruption). HELLP syndrome is a complication of preeclampsia that does not occur before 20 weeks gestation unless a molar pregnancy is present. There is no evidence that she is threatening to abort as she has no cramping or vaginal bleeding.

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week, and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? a) disseminated intravascular coagulation b) abruptio placentae c) HELLP syndrome d) threatened abortion

disseminated intravascular coagulation Correct Explanation: A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae, such as sharp pain and "woody," firm consistency of the abdomen (abruption). HELLP syndrome is a complication of preeclampsia that does not occur before 20 weeks gestation unless a molar pregnancy is present. There is no evidence that she is threatening to abort as she has no cramping or vaginal bleeding.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to: a) take a vitamin and mineral supplement. b) divide daily food intake into five or six meals. c) eat three well-balanced meals per day. d) exercise 1 hour before each meal. divide daily food intake into five or six meals.

divide daily food intake into five or six meals. Correct Explanation: To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue

A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. The client's blood pressure is 164/110 mm Hg. Which finding would alert the nurse that the client may be about to experience a seizure? A decreased contraction intensity B decreased temperature C epigastric pain D hyporeflexia

epigastric pain Explanation: Epigastric pain or acute right upper quadrant pain is associated with the development of eclampsia and an impending seizure; this is thought to be related to liver ischemia. Decreased contraction intensity is unrelated to the severity of the preeclampsia. Typically, the client's temperature increases because of increased cerebral pressure. A decrease in temperature is unrelated to an impending seizure. Hyporeflexia is not associated with an impending seizure. Typically, the client would exhibit hyperreflexia.

A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. The client's blood pressure is 164/110 mm Hg. Which finding would alert the nurse that the client may be about to experience a seizure? a) hyporeflexia b) decreased contraction intensity c) epigastric pain d) decreased temperature

The primary care provider prescribes 5% dextrose in Ringer's solution and magnesium sulfate intravenously for an adolescent client with preeclampsia. Before administering the magnesium sulfate, what is the most important assessment the nurse should make? A fetal heart rate variability B maternal urinary output C fetal position D maternal respiratory rate

maternal respiratory rate Explanation: Magnesium sulfate is a central nervous system depressant used as an anticonvulsant for severe preeclampsia. It may depress respirations to a dangerously low and even life-threatening level. Therefore, the nurse must assess the client's respiratory rate before administering the drug. If the client's respiratory rate is below 12 breaths/minute, the primary care provider should be notified and the drug should be withheld. Although fetal heart rate variability is an important assessment, it is not the priority assessment in this situation. Fetal heart rate variability would be a priority assessment if the umbilical cord becomes compressed. Although maternal urinary output is an important assessment, it is not the priority assessment in this situation. Assessing maternal urinary output would be a priority after administering magnesium sulfate. Although fetal position, determined by Leopold's maneuvers, is an important assessment, it is not the priority assessment in this situation.

A 39-year-old multigravid client who is visiting the clinic at 14 weeks' gestation tells the nurse that she has had severe nausea and vomiting since becoming pregnant. The client's fundal measurement is 20 cm. The nurse should assess the client for signs and symptoms of which problem? A molar pregnancy B multifetal pregnancy C increased fetal activity D history of polycythemia

molar pregnancy Explanation: Severe nausea and vomiting that continue throughout the first trimester of pregnancy and into the second trimester in conjunction with the client's enlarged fundus for her gestational age may be indicative of a hydatidiform mole. A molar pregnancy, occurring more often in multigravid clients, is associated with early symptoms of preeclampsia and an enlarged fundus. An enlarged fundus may be associated with multifetal pregnancies but not with the client's symptoms of severe nausea and vomiting. A molar pregnancy, suggested by the severe nausea and vomiting in conjunction with the enlarged fundus, is not associated with increased fetal activity because there is no fetus. A molar pregnancy, suggested by the severe nausea and vomiting in conjunction with the enlarged fundus, is not associated with polycythemia.

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. Appropriate interventions include (Select all that apply) A obtaining a urine specimen for culture B maintaining the IV site inserted on admission C instituting vital signs every 4 hours D administering pantoprazole (Protonix) IV daily E monitoring urine output every hour

obtaining a urine specimen for culture administering pantoprazole (Protonix) IV daily monitoring urine output every hour Explanation: The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole, would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours.

A 16-year-old primigravida at 35 weeks' gestation in active labor with severe preeclampsia is admitted to the hospital's labor unit. The nurse should notify the primary care provider immediately about which finding? A 2+ deep tendon reflexes B 3+ proteinuria C platelet count of 80,000/mcL (80 X 109/L) D clear to whitish vaginal discharge

platelet count of 80,000/mcL (80 X 109/L) Explanation: A platelet count of less than 100,000/mcL (100 X 109/L) indicates thrombocytopenia, a component of HELLP syndrome. HELLP syndrome, which consists of hemolysis, elevated liver enzymes, and low platelet count, is associated with severe pre-eclampsia. Notifying the primary health care provider immediately is crucial because this syndrome is associated with high rates of morbidity and mortality for the mother and her fetus. Deep tendon reflexes of 2+ are normal and not a cause of concern. The client has severe pre-eclampsia, so proteinuria of 3+ to 4+ would be expected. A clear to whitish vaginal discharge is a normal finding.

As a nurse begins the shift on the obstetrical unit, there are several new admissions. The client with which condition would be a candidate for induction? A preeclampsia B active herpes C face presentation D fetus with late decelerations

preeclampsia Explanation: The client with preeclampsia would be a candidate for the induction process because ending the pregnancy is the only way to cure preeclampsia. A client with active herpes would be a candidate for a cesarean section to prevent the fetus from contracting the virus while passing through the birth canal. The woman with a face presentation will not be able to give birth vaginally due to the extended position of the neck. The client whose fetus exhibits late decelerations without oxytocin would be at greater risk for fetal distress with use of this drug. Late decelerations indicate the fetus does not have enough placental reserves to remain oxygenated during the entire contraction. This client may require a cesarean section.

The nurse is caring for a 38-year-old primigravida in the third trimester of pregnancy. The nurse plans to assess the client for symptoms of: a) cardiac overload. b) preeclampsia. c) ruptured membranes. d) pelvic inflammatory disease.

preeclampsia. Explanation: There is a strong association between advanced maternal age and preeclampsia as well as chronic hypertension. The incidence of preeclampsia is greatest among primigravidas. Preeclampsia is much more common than pelvic inflammatory disease. The client in the third trimester rarely exhibits symptoms of pelvic inflammatory disease. Although the older client is at risk for preterm labor and birth, this client does not present any symptoms of preterm labor, such as ruptured membranes. Cardiac overload may occur with clients who have been diagnosed with cardiac disease. Cardiac adjustment in healthy women occurs during pregnancy, labor, and birth.

A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which signs and symptoms? A pregnancy-induced hypertension B gestational diabetes C hypothyroidism D polycythemia

pregnancy-induced hypertension Explanation: Hydatidiform mole is suspected when the following are present: gestational hypertension before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gestational age, and increased human chorionic gonadotropin levels. Gestational diabetes is related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs occasionally with hydatidiform mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and fetus from cardiac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia from blood loss is associated with molar pregnancies.

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to: a) prevent seizures. b) reduce blood pressure. c) slow the process of labor. d) increase diuresis.

prevent seizures. Correct Explanation: The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system caused by preeclampsia by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium

A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include: blood pressure 140/90 mm Hg; pulse 80 beats/min; respiratory rate 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic? a) headaches b) peripheral edema c) blood glucose level d) proteinuria

proteinuria Explanation: The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension. The peripheral edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. While, the preeclamptic client may significant edema in the face and hands, edema can be caused by other factors and is not part of the diagnostic criteria. Headaches are significant in pregnancy-induced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis

A client with acute chest pain is receiving I.V. morphine sulfate. Which is an expected effect of morphine? Select all that apply. A reduces myocardial oxygen consumption B promotes reduction in respiratory rate C prevents ventricular remodeling D reduces blood pressure and heart rate E reduces anxiety and fear

reduces myocardial oxygen consumption reduces blood pressure and heart rate reduces anxiety and fear Explanation: Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.

When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, which type of diet should the nurse discuss? A high-residue diet B low-sodium diet C regular diet D high-protein diet

regular diet Explanation: For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.

When caring for a client with preeclampsia during labor, the nurse should: a) give a fluid bolus before the second stage of labor. b) refrain from administering any fluids during labor. c) restrict the amount of fluid administered. d) give extra fluids throughout labor.

restrict the amount of fluid administered. Explanation: The volume of fluids administered during labor to a client with preeclampsia should be restricted. Clients usually receive between 60 and 150 ml/hour.

When developing the plan of care for a multigravid client with class III heart disease, the nurse should expect to assess the client frequently for which problem? a) tachycardia b) dehydration c) iron-deficiency anemia d) nausea and vomiting

tachycardia Correct Explanation: Assessing for signs and symptoms associated with cardiac decompensation is the priority. Class III heart disease during pregnancy has a 25% to 50% mortality. These clients are markedly compromised, with marked limitation of physical activity. They frequently experience fatigue, palpitations, dyspnea, or anginal pain. A pulse rate greater than 100 bpm or a respiratory rate greater than 25 breaths/min may indicate cardiac decompensation that could result in cardiac arrest. Additional symptoms include dyspnea, peripheral edema, orthopnea, tachypnea, rales, and hemoptysis

The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. What are desired outcomes of this therapy? Select all that apply. A temperature, 98° F (36.7° C); pulse, 72 beats/min; respiratory rate, 14 breaths/min B urinary output less than 30 mL/h C fetal heart rate with late decelerations D blood pressure less than 140/90 mm Hg E deep tendon reflexes 2+ F magnesium level = 5.6 mg/dL (2.8 mmol/L)

temperature, 98° F (36.7° C); pulse, 72 beats/min; respiratory rate, 14 breaths/min deep tendon reflexes 2+ magnesium level = 5.6 mg/dL (2.8 mmol/L) Explanation: The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by blocking peripheral neuromuscular transmissions and decreasing the amount of acetylcholine liberated. The primary goal of magnesium sulfate therapy is to prevent seizures. While being used, the temperature and pulse of the client should remain within normal limits. The respiratory rate needs to be greater than 12 respirations per minute (rpm). Rates at 12 rpm or lower are associated with respiratory depression and are seen with magnesium toxicity. Renal compromise is identified with a urinary output of less than 30 mL/hour. A fetal heart rate that is maintained within the 112 to 160 range is desired without later or variable decelerations. While extreme elevations of blood pressure must be treated, achieving a normal pressure carries the risk of decreasing perfusion to the fetus. Deep tendon reflexes should not be diminished or exaggerated. The therapeutic magnesium sulfate level of 5 to 8 mg/dL (2.5 to 4 mmol/L) is to be maintained.

A primigravid client at 32 weeks' gestation with ruptured membranes is prescribed to receive betamethasone 12 mg intramuscularly for two doses 24 hours apart. When teaching the client about the medication, what should the nurse include as the purpose of this drug? a) to accelerate fetal lung maturity b) to prevent potential infection c) to improve the fetal heart rate pattern d) to reduce contraction frequency

to accelerate fetal lung maturity Explanation: Corticosteroids, such as betamethasone, are prescribed for clients who are preterm to accelerate fetal lung maturity and reduce the incidence and severity of respiratory distress syndrome. Infection would be treated with antibiotics. Tocolytic therapy is used to reduce contractions. The nurse should monitor the fetal heart rate pattern, but betamethasone will not improve the fetal heart rate.

Following an eclamptic seizure, the nurse should assess the client for which complication? a) uterine contractions b) polyuria c) hypotension d) facial flushing

uterine contractions Explanation: After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.

When the nurse is obtaining a health history on an elderly client who has had a previous myocardial infarction, the daughter states, "I have been giving my father ginkgo biloba every day, as he is beginning to have some memory loss." How does the nurse respond to the daughter's statement? A "Stop giving your father the herbal drug immediately." B "How much of the herbal drug are you giving your father every day?" C "Did you ask your health care provider before giving him the herbal drug?" D "This may interfere with other medications your father is taking."

"How much of the herbal drug are you giving your father every day?" Explanation: The nurse's response should be "How much of the herbal drug are you giving your father every day?" Using the nursing process, always assess the situation first.

A client recovering from a myocardial infarction asks why he needs to take a stool softener. He says, "I had a heart attack; I don't have a problem with constipation." Which explanation should the nurse use to answer the client's question? A "If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous." B "Hospital food causes constipation." C "Your doctor ordered this stool softener for you." D "Everyone who has a heart attack takes stool softeners."

"If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous." Explanation: When straining during defication, the client bears down, which momentarily may cause the heart to slow and cause fainting or syncope in the client.

A client with chronic bronchitis asks the nurse about why it's important to exercise. What would be the nurse's best response? A "It enhances cardiovascular fitness." B "It improves respiratory muscle strength." C "It reduces the number of acute attacks." D "It worsens respiratory function and is discouraged."

"It enhances cardiovascular fitness." Explanation: Exercise can improve cardiovascular fitness and it helps the client to better tolerate periods of hypoxia, perhaps reducing the risk of heart attack. Most exercise has little effect on respiratory muscle strength, and these clients can't tolerate the type of exercise necessary to do this. Exercise won't reduce the number of acute attacks. In some instances, exercise may be contraindicated. The client should check with his health care provider before starting any exercise program.

A client with an acute myocardial infarction is receiving nitroglycerin by continuous I.V. infusion. Which client statement indicates that this drug is producing its therapeutic effect? A "I have a bad headache." B "My chest pain is decreasing." C "I feel a tingling sensation around my mouth." D "My vision is blurred, so my blood pressure must be up."

"My chest pain is decreasing." Explanation: Nitroglycerin, a vasodilator, increases the arterial supply of oxygen-rich blood to the myocardium. This action produces the drug's intended effect: relief of chest pain. Headache is an adverse effect of nitroglycerin. The drug shouldn't cause a tingling sensation around the mouth and should lower, not raise, blood pressure.

The nurse performs a routine prenatal assessment on a woman at 35 weeks gestation and finds vital signs: blood pressure 138/88 mm Hg, pulse 82/min, respirations 18/min, temperature 99.1° F (37.3°C). Which statement is most appropriate for the nurse to make at this time? a) "You have a slight temperature. Do you feel hot?" b) "Your pulse is low. Do you exercise a lot?" c) "Your vital signs are all normal. I will document them on your chart." d) "Your blood pressure is slightly high. I will check it again before you leave."

"Your blood pressure is slightly high. I will check it again before you leave." Correct Explanation: A blood pressure reading of 138/88 mm Hg is nearing hypertension range and could be a sign of developing gestational hypertension. Conversely, the client may be experiencing "white coat" syndrome or could be anxious during the prenatal visit. In order to obtain an accurate blood pressure reading, the nurse should allow the woman to rest for a period of time and recheck the blood pressure in the same arm and while the woman is in the same position. This blood pressure is considered approaching high. All other vitals are within normal range

Which PR interval presents a first-degree heart block? A 0.18 seconds B 0.24 seconds C 0.14 seconds D 0.16 seconds

0.24 seconds Explanation: In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block.

66. A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes 1. 4. Blood pressure 140/90.

1 This client has likely developed dis- seminated intravascular coagulation (DIC). The nurse should watch for pink-tinged urine.

10. A client is admitted to the hospital with severe preeclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? 1. Strike the woman's patellar tendon. 2. Palpate the woman's ankle. 3. Dorsiflex the woman's foot. 4. Position the woman's feet flat on the floor.

3 3. To assess clonus, the nurse should dorsiflex the woman's foot.

1 During a prenatal interview, a client tells the nurse, "My mother told me she had toxemia during her pregnancy and almost died!" Which of the following questions should the nurse ask in response to this statement? 1. "Does your mother have a cardiac condition?" 2. "Did your mother tell you what she was toxic from?" 3. "Does your mother have diabetes now?" 4. "Did your mother say whether she had a seizure or not?"

4 4. Toxemia is not related to a cardiac condition. Toxemia is not related to a toxic substance. Toxemia is not directly related to dia- betes mellitus. This is the appropriate question. The nurse is asking whether or not the client's mother developed eclampsia.

A client with preeclampsia is prescribed magnesium sulfate to prevent seizure activity. The nurse is reviewing the results of the client's serum magnesium level and determines that the client's level is therapeutic based on which result? a) 9.2 mEq/L (4.6 mmol/L) b) 16 mEq/L (8 mmol/L) c) 11.5 mEq/L (5.75 mmol/L) d) 6.8 mEq/L (3.4 mmol/L)

6.8 mEq/L (3.4 mmol/L) Correct Explanation: The therapeutic level of magnesium for clients with preeclampsia ranges 4 to 8 mEq/L (2 to 4 mmol/L). A serum magnesium level of 8 to 10 mEq/L (4 to 5 mmol/L) may cause the absence of reflexes in the client. Serum levels of 10 to 12 mEq/L (5 to 6 mmol/L) may cause respiratory depression, and a serum level of magnesium greater than 15 mEq/L (7.5 mmol/L) may result in respiratory paralysis

The nurse is assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment? A A client with atrial dysrhythmias B A new myocardial infarction client C A client with poor kidney perfusion D A client with third-degree heart block

A client with atrial dysrhythmias Explanation: The nurse is correct to identify a client with atrial dysrhythmias as a candidate for cardioversion. The goal of cardioversion is to restore the normal pacemaker of the heart, as well as, normal conduction. A client with a myocardial infarction has tissue damage. The client with poor perfusion has circulation problems. The client with heart block has an impairment in the conduction system and may require a pacemaker.

Which of the following would be a factor that may decrease myocardial contractility? A Acidosis B Alkalosis C Sympathetic activity D Administration of digoxin (Lanoxin)

Acidosis Explanation: Contractility is depressed by hypoxemia, acidosis, and certain medications, such as beta-adrenergic blocking medications. Contractility is enhanced by sympathetic neuronal activity, and certain medications, such as Lanoxin.

The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor ofthe client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record? A Bigeminy B Couplets C Multifocal PVCs D R-on-T phenomenon

Bigeminy Explanation: The nurse is correct to note bigeminy on the permanent record when every other beat is a PVC. Couplets are two PVCs in a row. Multifocal PVCs originate from more than one location. R-on-T phenomenon occurs when the R wave falls on the T wave.

7. On an EKG, the lateral view of the heart is represented with leads?* A. V1, V2, V3 B. II, II, AVF C. I, AVL, V5, V6 D. V1, V2, V6

A middle-aged male presents to the ED complaining of severe chest discomfort. Which of the following patient findings is most indicative of a possible MI? A Chest discomfort not relieved by rest or nitroglycerin B Intermittent nausea and emesis for 3 days C Cool, clammy, diaphoretic, and pale appearance D Anxiousness, restlessness, and lightheadedness

Chest discomfort not relieved by rest or nitroglycerin Explanation: Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with ACS (acute coronary syndrome) or MI, may also occur with angina and, alone, are not indicative of an MI.

The nurse is preparing to apply ECG electrodes to a male patient who requires continuous cardiac monitoring. Which of the following should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? A Once the electrodes are applied, change them every 72 hours. B Clean the patient's chest with alcohol prior to application of the electrodes. C Apply baby powder to the patient's chest prior to placing the electrodes. D Clip the patient's chest hair prior to applying the electrodes.

Clip the patient's chest hair prior to applying the electrodes. Explanation: The nurse should complete the following actions when applying cardiac electrodes: Clip (do not shave) hair from around the electrode site, if needed; if the patient is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer). Change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); examine the skin for irritation and apply the electrodes to different locations.

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. A Cool, moist skin B Increasing blood pressure C Increasing heart rate D Delayed capillary refill E Increasing urine volume

Cool, moist skin Increasing blood pressure Increasing heart rate Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.

A doctor has ordered cardiac enzymes on a patient being admitted with chest pain. You know that _____________ levels elevate 2-4 hours after injury to the heart and is the most regarded marker by providers.* A. Myoglobin B. CK-MB C. CK D. Troponin

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which of the following indicates that cardiac tamponade has been relieved? A Increase in CVP B Decrease in central venous pressure (CVP) C Absence of cough D Decrease in blood pressure

Decrease in central venous pressure (CVP) Explanation: A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.

The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. The client is symptomatic due to the slow heart rate. The most appropriate nursing diagnosis for this client would be which of the following? A Decreased cardiac output B Ineffective health maintenance C Ineffective breathing pattern D Risk for vascular trauma

Decreased cardiac output Explanation: Based on assessment data for this client, the most logical nursing diagnosis will be decreased cardiac output. Third-degree AV block that is causing symptoms will be a slow rhythm that will produce a decreased cardiac output.

A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function. A Causes atrial tachycardia B Increases myocardial contractility C Causes ventricular tachycardia D Decreases myocardial contractility

Decreases myocardial contractility Explanation: Hypermagnesemia can cause depression of myocardial contractility and excitability heart block and asystole. Hypomagnesemia predisposes patient to atrial or ventricular tachycardias.

In which type of shock does the patient experience a mismatch of blood flow to the cells? A Distributive B Cardiogenic C Hypovolemic D Septic

Distributive Explanation: Distributive or vasogenic shock results from displacement of blood volume, creating a relative hypovolemia. Cardiogenic shock results from the failure of a heart as a pump. In hypovolemic shock, there is a decrease in the intravascular volume. In septic shock, overwhelming infection results in a relative hypovolemia.

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance? A Elevate the legs higher than the heart. B Shake the client to arouse. C Cover the client with a blanket. D Place a cool compress on head.

Elevate the legs higher than the heart. Explanation: The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to A Contact a spiritual advisor to provide comfort to the family. B Encourage the family to touch and talk to the client. C Inform the family that everything is being done to assist with the client's survival. D Open up discussion among the family members about nursing home placement.

Encourage the family to touch and talk to the client. Explanation: The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

Which of the following medications is categorized as a loop diuretic? A Chlorothiazide (Diuril) B Chlorthalidone (Hygroton) C Spironolactone (Aldactone) D Furosemide (Lasix)

Furosemide (Lasix) Explanation: Lasix is commonly used in the treatment of cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide is categorized as a thiazide diuretic. Chlorthalidone is categorized as a thiazide diuretic. Spironolactone is categorized as a potassium-sparing diuretic.

A patient in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the telemetry monitor. Which of the following is a potential cause of PEA? A Hyperkalemia B Hypervolemia C Small pulmonary embolism D Hypokalemia

Hyperkalemia Explanation: PEA can be caused by hypovolemia, hypoxia, hypothermia, hyperkalemia, massive pulmonary embolism, myocardial infarction, and medication overdose (beta blockers, calcium channel blockers).

The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient's prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? A Partial thromboplastic time (PTT) B Complete blood count (CBC) C International normalized ratio (INR) D Sodium

International normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of Coumadin.

A nursing student is giving to a client with heart failure a medication with a positive inotropic effect on the heart. The student asks what a "positive inotropic" effect is. The correct response would be which of the following? A It increases the force of the myocardial contraction. B It increases the heart rate. C It increases the respiratory rate. D It causes the kidneys to retain fluid and increase intravascular volume.

It increases the force of the myocardial contraction. Explanation: A positive inotropic effect increases the force of myocardial contraction. A positive chronotropic effect increases the heart rate. A positive inotropic effect will usually help slow respiratory rate and will increase blood flow through the kidneys, so fluid output will increase.

The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation? A It is a scheduled procedure 1 to 10 days in advance. B The client is sedated before the procedure. C It is used to eliminate ventricular dysrhythmias. D It uses less electrical energy than cardioversion.

It is used to eliminate ventricular dysrhythmias. Explanation: The only treatment for a life-threatening ventricular dysrhythmia is immediate defibrillation, which has the same effect as cardioversion, except that defibrillation is used when there is no functional ventricular contraction. It is an emergency procedure performed during resuscitation. The client is not sedated but is unresponsive. Defibrillation uses more electrical energy (200 to 360 joules) than cardioversion.

A 44-year-old male client has avoided shock but is now at risk for which of the following secondary but life-threatening complications? Select all that apply. A GERD B Hypoglycemia C Acute respiratory distress syndrome D Disseminated intravascular coagulation E Kidney failure

Kidney failure Disseminated intravascular coagulation Acute respiratory distress syndrome Explanation: When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position? a) Left lateral b) Supine c) Semi-Fowler's d) Right lateral

Left lateral Explanation: The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately? a) Place a pillow under the left buttock. b) Insert a padded tongue blade into the mouth. c) Maintain a patent airway. d) Pad the side rails.

Maintain a patent airway. Explanation: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure. Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure. Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? A Limit interaction with visitors. B Arrange personal care supplies nearby. C Avoid heavy meals. D Maintain activity restriction to bedrest.

Maintain activity restriction to bedrest. Explanation: Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.

Which positioning strategy should be used for the patient diagnosed with hypovolemic shock? A Semi-Fowler's B Modified Trendelenburg C Prone D Supine

Modified Trendelenburg Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood.

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? A Monitor daily weights and urine output. B Limit visitation by family and friends. C Provide client education on medications and diet. D Reduce pain and myocardial oxygen demand.

Reduce pain and myocardial oxygen demand. Explanation: Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

Decreased pulse pressure reflects which of the following? A Elevated stroke volume B Reduced distensibility of the arteries C Reduced stroke volume D Tachycardia

Reduced stroke volume Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

Morphine sulfate has which of the following effects on the body? A No effect on preload or afterload B Reduces preload C Increases preload D Increases afterload

Reduces preload Explanation: In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).

The nurse is caring for a client who has developed junctional tachycardia with a heart rate (HR) of 80 bpm. Which of the following actions should the nurse complete? A Request a digoxin level be ordered. B Withhold the patient's oral potassium supplement. C Prepare for emergent electrical cardioversion. D Prepare to administer IV lidocaine.

Request a digoxin level be ordered. Explanation: The nurse should request a digoxin level be obtained. Junctional tachycardia generally does not have any detrimental hemodynamic effect; it may indicate a serious underlying condition, such as digitalis toxicity, myocardial ischemia, hypokalemia, or chronic obstructive pulmonary disease (COPD). Potassium supplements do not cause junctional tachycardia. Lidocaine is indicated for the treatment of premature ventricular contractions (PVCs). Because junctional tachycardia is caused by increased automaticity, cardioversion is not an effective treatment; in fact, it causes an increase in ventricular rate.

A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? Select all that apply. A Notched T-wave B Presence of a U-wave C T-wave inversion D Prolonged PR-interval E ST-segment elevation

T-wave inversion ST-segment elevation Explanation: T-wave inversion, ST-segment elevation, and a pathologic Q-wave are all signs of tissue hypoxia which occur during an MI. Ischemia results from inadequate blood supply to the myocardial tissue and is reflected by T-wave inversion. Injury results from prolonged ischemia and is reflected by ST-segment elevation. A notched T-wave may indicate pericarditis in an adult client. The presence of a U-wave may or may not be apparent on a normal ECG; it represents repolarization of the Purkinje fibers. A prolonged PR-interval is associated with first-degree atrioventricular block.

A patient is experiencing Heparin-Induced Thrombocytopenia from Heparin therapy. The doctor orders Heparin to be discontinued. The patient will most likely be placed on what other medication?* A. Argatroban B. Lovenox C. Levophed D. Tridil

The answer is A. Argatroban or Angiomax may be prescribed in place of Heparin for a patient experiencing HIT (heparin-induced thrombocytopenia).

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? A The client with pneumonia in the left lower lobe of the lung B The client with a BMI of 25 who has lost 3 pounds as the result of vomiting C The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs) D The client with testicular cancer who is receiving intravenous chemotherapy

The client with testicular cancer who is receiving intravenous chemotherapy Explanation: Risk factors for septic shock include immunosuppression, such as with the client who has testicular cancer and is receiving chemotherapy. Other risk factors include age younger than 1 year or greater than 65 years, malnourishment, chronic illness, and invasive procedures. None of the other clients meets these risk factors or has a greater risk for invasive procedures than the client with testicular cancer.

A client is unstable and receiving dopamine (Inotropin) to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all answers that apply. A Administer through an intact peripheral line. B Assess vital signs every hour. C Use an intravenous controller or pump. D Verify dosage and pump settings with another RN. E Measure urine output every hour.

Use an intravenous controller or pump. Verify dosage and pump settings with another RN. Measure urine output every hour. Explanation: It is recommended to administer vasoactive drugs, such as dopamine, through a central line. The nurse assesses vital signs every 15 minutes until stable. The nurse uses an intravenous controller or pump to ensure accurate infusion and verifies the dosage and pump settings with another RN. The nurse also measures urine output every hour.

The nurse knows that women and the elderly are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause? A Chest pain is typical B Vague symptoms C Decreased sensation to pain D Gender bias

Vague symptoms Explanation: Often, women and elderly do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? A Hemoglobin: 14.2 g/dL B Potassium: 4.8 mEq/L C WBC: 42,000/mm3 D ESR: 19 mm/hour

WBC: 42,000/mm3 Explanation: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches (157.5 cm) tall has gained a total of 20 lb (9.1 kg), with a 1-lb (0.45 kg) gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which factors increases her risk for preeclampsia? A total weight gain B short stature C adolescent age group D proteinuria

adolescent age group Explanation: The central nervous system (CNS) functioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hypertension or stroke, oxygenation status is compromised, and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system, but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

Which of the following conditions would most likely cause a pregnant woman with type 1 diabetes the greatest difficulty during her pregnancy? A Placenta previa B Hyperemesis gravidarum C Abruptio placentae D Rh incompatibility

b. extreme nausea and vomiting as part of hyperemesis gravidarum would cause fluid and electrolyte imbalances and would alter blood glucose levels tremendously. With placenta previa, the placenta is dislocated, not malfunctioning; it would not have as much of an impact on the pregnancy as would an imbalance of fluids and electrolytes. Abruptio placentae would place the mother at risk for hemorrhage, but the placenta does not govern the blood glucose levels of the mother. Rh incompatibility affects the fetus, not the mother, by causing hemolysis of the red blood cells in the fetus. This process would not influence the mother's glucose levels.

A client is receiving I.V. magnesium sulfate for severe preeclampsia. The nurse should monitor for: A anemia. B decreased urine output. C hyperreflexia. D increased respiratory rate.

decreased urine output. Explanation: Decreased urine output is a potential adverse effect of magnesium sulfate. If output decreases, the drug may accumulate to toxic levels. Urine output should be maintained at a rate of 30 ml/hour. Anemia isn't associated with magnesium sulfate therapy. Magnesium infusions may cause depression of deep tendon reflexes or hyporeflexia, not hyperreflexia. The client should be monitored for respiratory depression (not an increased respiratory rate) and paralysis when serum magnesium levels reach about 15 mEq/L.

A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which agent should the nurse expect the health care provider (HCP) to prescribe? a) magnesium sulfate b) warfarin sodium c) fresh-frozen platelets d) meperidine hydrochloride

fresh-frozen platelets Explanation: To stop the process of DIC, the underlying insult that began the phenomenon must be halted. Treatment includes fresh-frozen platelets or blood administration. The HCP also may prescribe heparin before the administration of blood products to restore the normal clotting mechanism. Immediate birth of the fetus is essential. Magnesium sulfate is given for pregnancy-induced hypertension or preterm labor. Heparin, not warfarin sodium, is used to treat DIC. Meperidine hydrochloride is used for pain relief.

Which finding provides the most evidence that a fetus might have a gastrointestinal tract anomaly? A meconium in the amniotic fluid B low implantation of the placenta C increased amount of amniotic fluid D preeclampsia in the last trimester

increased amount of amniotic fluid Explanation: Maternal hydramnios occurs when the fetus has a congenital obstruction of the gastrointestinal tract, such as in the presence of a tracheoesophageal fistula. The fetus normally swallows amniotic fluid and absorbs the fluid from the gastrointestinal tract. Excretion then occurs through the kidneys and placenta. Most fluid absorption occurs in the colon. Absorption cannot occur when the fetus has a gastrointestinal obstruction. Meconium in the amniotic fluid, low implantation of the placenta, and preeclampsia could occur but are more specifically associated with fetal hypoxia.

You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client? IV lidocaine Chemical cardioversion Immediate defibrillation Electric cardioversion

mmediate defibrillation Explanation: Defibrillation is used during pulseless ventricular tachycardia and ventricular fibrillation.

When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain? a) disposable tongue blades b) padding for the side rails c) oxytocin infusion solution d) portable ultrasound machine

padding for the side rails Correct Explanation: The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.

The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate that within the next week: A the client will develop preeclampsia. B the fetus will develop mature lungs. C the client will not develop preterm labor. D the fetus will not develop gestational diabetes.

the client will not develop preterm labor. Explanation: The absence of fetal fibronectin in a vaginal swab between 22 and 37 weeks' gestation indicates there is less than 1% risk of developing preterm labor in the next week. Fetal fibronectin is an extra cellular protein normally found in fetal membranes and deciduas and has no correlation with preeclampsia, fetal lung maturation, or gestational diabetes.

A 16-year-old unmarried client visiting the prenatal clinic at 32 weeks' gestation and currently weighing 140 lb (63.5 kg) is being closely monitored for early signs of preeclampsia. The client is 5 feet, 2 inch (158 cm) tall and weighed 120 lb (54.4 kg) before the pregnancy. Which factor would be most important to assess? a) proteinuria b) ABO incompatibility c) fluid intake d) small-for-gestational-age fetus

proteinuria Correct Explanation: Because the client is being closely monitored for early signs of preeclampsia, checking the urine for proteinuria is most important. Proteinuria, even in the absence of an elevated blood pressure, is indicative of preeclampsia. Although adolescent pregnancy is associated with an increase in the number of small-for-gestational-age fetuses, this is not indicative of preeclampsia. ABO incompatibility, occurring when the mother has type O blood and the fetus is type A, B, or AB blood, is not associated with preeclampsia. Fluid intake is an important assessment for any pregnant client. However, it is not a primary indication of preeclampsia. Edema of the hands and face is a more important indicator than fluid intake.

At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean birth. The nurse explains to the client that childbirth helps to prevent which complication? A neonatal hyperbilirubinemia B congenital anomalies C perinatal asphyxia D stillbirth

stillbirth Explanation: Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a cesarean section is necessary. Induction and cesarean section do not prevent neonatal hyperbilirubinemia, congenital anomalies, or perinatal asphyxia.

A couple have presented to the healthcare provider for a follow up visit following the husbands myocardial infarction (MI) one week ago. The nurse knows that education on resuming intimate sexual contact should be discussed. Which of the following is correct regarding the timeline for returning to sexual intercourse? A one week if no symptoms of chest pain B three weeks if no symptoms of chest pain C one month if no symptoms of chest pain D three months if no symptoms of chest pain

three months if no symptoms of chest pain Explanation: Activities of daily living, including sexual activity, should be resumed gradually, and stressors such as overexertion, alcohol consumption, and emotional upheavals should be avoided. After an uncomplicated MI, sexual activity may begin at about the third week of recovery, beginning with masturbation to partial erection in the male. Generally, this activity is gradually increased until 3 months after the MI, when sexual intercourse may be resumed. Any chest pain that occurs should be discussed with the healthcare provider prior to resuming sexual intercourse.

A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse? A "Removing the patch at night prevents drug tolerance while keeping the benefits." B "Contact dermatitis and skin irritations are common when the patch remains on all day." C "You do not need the effects of nitroglycerine while you sleep." D "Nitroglycerine causes headaches, but removing the patch decreases the incidence."

"Removing the patch at night prevents drug tolerance while keeping the benefits." Explanation: Tolerance to antiangina effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerine are headaches and contact dermatitis but not the reason for removing the patch at night. It is true that while you rest, there is less demand on the heart but not the primary reason for removing the patch.

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? A "The client is in shock because all peripheral blood vessels have massively dilated." B "The client is in shock because your loved one is not responding and brain dead." C "The client is in shock because the blood volume has decreased in the system." D "The client is in shock because the heart is unable to circulate the body fluids."

"The client is in shock because the blood volume has decreased in the system." Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.

A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between ventricular tachycardia and ventricular fibrillation when I look at the EKG strip?" The best reply by the nurse is which of the following? A "Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast with wide QRS complexes." B "The two look very much alike; it is difficult to tell the difference." C "The QRS complex in ventricular fibrillation is always narrow, while in ventricular tachycardia, the QRS is of normal width." D "The P-R interval will be prolonged in ventricular fibrillation, while in ventricular tachycardia the P-R interval is normal."

"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast with wide QRS complexes." Explanation: Ventricular fibrillation is irregular with undulating waves and no QRS complex, while ventricular tachycardia is usually regular and fast with wide QRS complexes.

A patient is admitted to the emergency department (ED) following a motorcycle accident. Upon assessment, the patient's vital signs reveal blood pressure (BP) of 80/60 mm Hg and heart rate (HR) of 145 beats per minute (bpm). The patient's skin is cool and clammy. Which of the following patient medical orders will the nurse complete first? A Two large-bore IVs and begin crystalloid fluids B 100% oxygen per nonrebreather mask C-spine x-rays D Type and cross match

100% oxygen per nonrebreather mask Explanation: The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address the metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied per a nonrebreather mask. The other orders should be completed after the patient's airway is secured.

A patient presents to the emergency room complaining of chest pain. The patient's orders include the following elements. Which order should the nurse complete first? A 12-lead ECG B Oxygen 2 liters nasal cannula C Troponin level D Aspirin 325 mg orally

12-lead ECG Explanation: The nurse should complete the 12-lead ECG first. The priority is to determine if the patient is suffering an acute MI and implement appropriate interventions as quickly as possible. The other orders should be completed after the ECG.

Heparin therapy is usually considered therapeutic when the aPTT is A 1 to 1.5 times the normal aPTT value. B 1.5 to 2 times the normal aPTT value. C 2 to 2.5 times the normal aPTT value. D 2.5 to 3 times the normal aPTT value.

2 to 2.5 times the normal aPTT value. Explanation: Heparin therapy is usually considered therapeutic when the aPTT is 2 to 2.5 times the normal aPTT value. The other values are not within therapeutic range.

A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? A A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. B A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces. C Generally caused by decreased blood volume. D Due to severe hypersensitivity reaction resulting in massive systemic vasodilation.

A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Explanation: Shock may have different causes (e.g., hypovolemic, cardiogenic, septic) but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Option B could reflect dependant edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock.

A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce T-wave inversion. You obtain the patient's vital signs and find the following: Blood pressure 190/98, HR 110, oxygen saturation 96% on room air, and respiratory rate 20. Select-all-that-apply in regards to the MOST IMPORTANT nursing interventions you will provide based on the patient's current status:* A. Obtain a 12-lead EKG B. Place the patient in supine position C. Assess urinary output D. Administer Nitroglycerin sublingual as ordered per protocol E. Collect cardiac enzymes as ordered per protocol F. Encourage patient to cough and deep breath G. Administer Morphine IV as ordered per protocol H. Place patient on oxygen via nasal cannula I. No interventions are needed at this time

A, D, E, G, H

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next A Administers oxygen by nasal cannula at 2 liters per minute B Re-assesses the vital signs C Contacts the admitting physician D Calls the Rapid Response Team

Administers oxygen by nasal cannula at 2 liters per minute Explanation: The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? A Antimetabolite drugs B Adrenergic drugs C Anticholinergic drugs D Hormone antagonist drugs

Adrenergic drugs Explanation: Adrenergic drugs are the main medications used to treat shock. This makes options A, B, and D incorrect.

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits A Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute B Adventitious breath sounds C A change in apical pulse rate from 102 to 88 beats/min D Troponin levels less than 0.35 ng/mL

Adventitious breath sounds Explanation: The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

Which of the following colloids is expensive but rapidly expands plasma volume? A Hypertonic saline B Lactated Ringer's C Albumin D Dextran

Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer's and hypertonic saline are crystalloids, not colloids.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which of the following patient findings requires immediate intervention by the nurse? A Altered level of consciousness B Minimal oozing of blood from the IV site C Presence of reperfusion dysrhythmias D Chest pain: 2 of 10 (1-to-10 pain scale)

Altered level of consciousness Explanation: A patient receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low, and indicates the patient's chest pain is subsiding, an expected outcome of this therapy.

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? A Red blood cells (RBCs) and hemoglobin count findings B Arterial blood gas (ABG) findings C Oxygen saturation level D White blood cell differential

Arterial blood gas (ABG) findings Explanation: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.

Which of the following EKG changes are abnormal findings that may indicate ischemia or injury to the cardiac muscle found on a 12-lead EKG? SELECT-ALL-THAT-APPLY:* A. Lengthening p-waves B. ST-segment elevation C. T-wave inversion D. Tall t-waves E. QT interval narrowing F. ST-segment depression

B, C, D, and F.

A nurse is providing morning care for a patient in the ICU. Suddenly, the bedside monitor shows ventricular fibrillation and the patient becomes unresponsive. After calling for assistance, what action should the nurse take next? A Begin cardiopulmonary resuscitation. B Prepare for endotracheal intubation. C Provide electrical cardioversion. D Administer intravenous epinephrine.

Begin cardiopulmonary resuscitation. Explanation: In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the patient as soon as possible. If defibrillation is not readily available, CPR is begun until the patient can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention, which includes endotracheal intubation and administration of epinephrine. Electrical cardioversion is not indicated for a patient in ventricular fibrillation.

During the compensation stage of shock, what is the consequence of the release of catecholamine sin the skeletal muscles? A Blood supply to the skeletal muscles increases. B Blood supply to the body decreases. C Amount of air that enters the lungs decreases. D The liver releases glycogen to provide energy.

Blood supply to the skeletal muscles increases. Explanation: Catecholamines cause the dilatation of arterioles in the skeletal muscles that increases their blood supply. The release of catecholamines increases the heart rate and the blood supply to the body. The release of catecholamines causes bronchial dilatation to increase the amount of air that enters the lungs. This is a consequence of the release of catecholamineson the liver, not the skeletal muscles.

The nurse is aware that a client who has been diagnosed with Prinzmetal's angina will present with which of the following symptoms? A Prolonged chest pain that accompanies exercise B Chest pain of increased frequency, severity, and duration C Chest pain that occurs at rest and usually in the middle of the night D Radiating chest pain that lasts 15 minutes or less

Chest pain that occurs at rest and usually in the middle of the night Explanation: A client with Prinzmetal's angina will complain of chest pain that occurs at rest, usually between 12 and 8 AM, is sporadic over 3-6 months, and diminishes over time. Client with stable angina generally experience chest pain that lasts 15 minutes or less and may radiate. Clients with Cardiac Syndrome X experience prolonged chest pain that accompanies exercise and is not always relieved by medication. Client with unstable angina experience chest pain of increased frequency, severity, and duration that is poorly relieved by rest or oral nitrates.

The nurse is caring for a patient who was admitted to the telemetry unit with a diagnosis of rule/out acute MI. The patient's chest pain began 3 hours ago. Which of the following laboratory tests would be most helpful in confirming the diagnosis of a current MI? A Creatinine kinase-myoglobin (CK-MB) level B Troponin C level C Myoglobin level D CK-MM

Creatinine kinase-myoglobin (CK-MB) level Explanation: Elevated CK-MB assessment by mass assay is an indicator of acute MI; the levels begin to increase within a few hours and peak within 24 hours of an MI. If the area is reperfused (due to thrombotic therapy or PCI), it peaks earlier. CK-MM (skeletal muscle) is not an indicator of cardiac muscle damage. There are three isomers of troponin: C, I, and T. Troponin I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results are an excellent parameter for ruling out an acute MI.

In which type of shock does the patient experience a mismatch of blood flow to the cells? A Septic B Distributive C Cardiogenic D Hypovolemic

You are a nursing student preparing to care for an ICU client with shock. Your instructor asks you to name the different categories of shock. Which of the following is a category of shock? A Restrictive B Hypervolemic C Cardiotonic D Distributive

Distributive Explanation: The four main categories of shock are hypovolemic, distributive, obstructive, and cardiogenic, depending on the cause. This makes options A, C, and D incorrect.

The nurse and student nurse are observing a cardioversion procedure completed by a physician. At which time is the nurse most correct to identify to the student when the electrical current will be initiated? A During stimulation of the SA node B During repolarization of the heart C During ventricular depolarization D During the QRS complex

During ventricular depolarization Explanation: The electrical current is initiated at the R wave when ventricular depolarization occurs. The electrical current completely depolarizes the entire myocardium with the goal of restoring the normal pacemaker of the heart. The other options focus on an incorrect timing that will not restore the normal electrical conduction.

Dysrhythmias can be fatal to a client during the acute phase following a myocardial infarction. The nurse understands that the primary cause of this event is due to which of the following? A Effects on depolarization and repolarization of the myocardial cells B Arterial spasms are common after a myocardial infarction. C After a myocardial infarction, leukocytosis occurs. D Scar tissue has replaced healthy cardiac tissue.

Effects on depolarization and repolarization of the myocardial cells Explanation: Dysrhythmias during the acute phase occur because the affected areas are electrically unstable due to the shifting of electrolytes and accumulation of lactic acid, which affect the depolarization and repolarization of the myocardial cells. Arterial spasms can be a cause of MI, not a result. Leukocytosis does occur after a MI but not the cause of dysrhythmias. Scar tissue formation takes weeks to form and does not occur in the acute phase.

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. A Lansoprazole (Prevacid) B Desmopressin (DDAVP) C Famotidine (Pepcid) D Furosemide (Lasix) E Ranitidine (Zantac)

Famotidine (Pepcid) Ranitidine (Zantac) Lansoprazole (Prevacid) Explanation: Antacids, H2 blockers (Pepcid, Zantac), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. DDVAP is used in the treatment of diabetes insipidus. Lasix is a loop diuretic and does not prevent ulcer formation.

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? A Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration B Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids C Hanging tape on the bedside table when changing a wet-to-dry sterile dressing D Rubbing the hands together with antiseptic solution until dry when exiting the client's room

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Explanation: The Centers for Disease Control and Prevention do not recommend hanging tape on bedside tables, siderails, linens, or clothing to use for dressings. The other options are activities that are proper infection control practices.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? A Diabetes B Myocardial infarction C Multiple sclerosis D Head injury

Head injury Explanation: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries

A 16-year-old victim of a motor vehicle collision is brought into your ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply. A Blood volume decreases. B Nausea C Peripheral vascular dilation D Heart fails as effective pump. E Blunt force trauma

Heart fails as effective pump. Blood volume decreases. Peripheral vascular dilation Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate (Wedro, 2012).

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply. A Neurogenic shock; diabetes B Septic shock; infection C Anaphylactic shock; nuts D Cardiogenic shock; myocardial infarction E Obstructive shock; kidney stone F Hypovolemic shock; blood loss

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? A Increase in arterial oxygenation B Decreased depressive symptoms C Decreased white blood cell count D Regulation of sodium and potassium

Increase in arterial oxygenation Explanation: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? A Dilate the bronchial tree B Increase the force of myocardial contraction C Depress the central nervous system D Slow the heart rate

Increase the force of myocardial contraction Explanation: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.

A patient has been recently placed on nitroglycerin. Which of the following should be included in the patient teaching plan? A Instruct the patient on side effects of flushing, throbbing headache, and tachycardia. B Instruct the patient to renew the nitroglycerin supply every 3 months. C Instruct the patient not to crush the tablet. D Instruct the patient to place nitroglycerin tablets in a plastic pill box.

Instruct the patient on side effects of flushing, throbbing headache, and tachycardia. Explanation: The patient should be instructed about side effects of the medication, which include flushing, throbbing headache, and tachycardia. The patient should renew the nitroglycerin supply every 6 months. If the pain is severe, the patient can crush the tablet between the teeth to hasten sublingual absorption. Tablets should never be removed and stored in metal or plastic pillboxes. Nitroglycerin is very unstable and should be carried in its original container.

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: A Decreased pulse rate to 110 beats/minute B Vesicular breath sounds C Jugular venous distention D Positive increase in the fluid balance ratio

Jugular venous distention Explanation: When administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? A Normal B Low C Unable to measure D High

Low Explanation: The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

A patient is receiving anticoagulant therapy. The nurse should be alert to potential signs and symptoms of external or internal bleeding, as evidenced by which of the following? A Low blood pressure B High blood pressure C Decreased heart rate D Elevated hematocrit

Low blood pressure Explanation: The patient receiving anticoagulation therapy should be monitored for signs and symptoms of external and internal bleeding, such as low blood pressure, increased heart rate, and decreased serum hemoglobin and hematocrit.

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess A Skin perfusion B Lung sounds C Mental status D Bowel sounds

Lung sounds Explanation: The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? A Cleanse the site with disinfectants and dress the wound appropriately B Refrain from sexual activity for one month C Monitor the site for bleeding or hematoma. D Normal activities of daily living can be resumed the first day post op

Monitor the site for bleeding or hematoma. Explanation: The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or development of a hard mass indicative of hematoma. A nurse does not advise the patient to clean the site with disinfectants or refrain from sexual activity for one month.

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death? A Multiple organ failure B Limited gas exchange C Brain death D Endotoxins in the system

Multiple organ failure Explanation: In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a "point of no return" despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.

Cardiogenic shock is most commonly seen in which patient population? A Head injury B Stroke C Myocardial infarction D Spinal cord injury

Myocardial infarction Explanation: Cardiogenic shock is seen most often in patient with myocardial infarction.

Which of the following vasodilator medications is used in the treatment of shock? A Norepinephrine (Levophed) B Dopamine (Intropin) C Nitroglycerin (Tridil) D Dobutamine (Dobutrex)

Nitroglycerin (Tridil) Explanation: Tridil is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Intropin and Dobutrex are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Levophed is a vasoconstrictor used to increase BP by vasoconstriction.

n the treatment of shock, which of the following vasoactive drugs results in reduced preload and afterload, reducing the oxygen demand of the heart? A Methoxamine (Vasoxyl) B Dopamine (Intropin) C Epinephrine (Adrenaline) D Nitroprusside (Nipride)

Nitroprusside (Nipride) Explanation: A disadvantage of nitroprusside is that it causes hypotension. Dopamine improves contractility, increases stroke volume, and increases cardiac output. Epinephrine improves contractility, increases stroke volume, and increases cardiac output. Methoxamine increases blood pressure by vasoconstriction.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: A Dopamine (Intropin) intravenous solution B NS at 60 mL/hr via an intravenous line C Morphine 2 mg intravenously D Oxygen at 2 L/min by nasal cannula

Oxygen at 2 L/min by nasal cannula Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation? A Pedal pulse stronger B Temperature within normal limits C Heart rate increased D Respiratory rate decreased

Pedal pulse stronger Explanation: The ventricular assist device (VAD) is a medical mechanical device used to improve cardiac output and redistribute blood. The best evidence to confirm successful implementation is by identifying a strong pedal pulse in a lower extremity. Respiratory rate decreases as a client rests. Heart rate decreases when the tissues obtain the needed oxygen. The temperature within normal limits does not confirm successful implementation.

A patient diagnosed with coronary artery disease is being placed on nitroglycerin. The nurse understands that the premise behind administration of nitrates in this patient population includes which of the following? A It increases myocardial oxygen consumption. B Preload is reduced. C It functions has a vasoconstrictor. D More blood returns to the heart.

Preload is reduced. Explanation: Nitroglycerin dilates primarily the veins, and in higher dosages, also the arteries. Dilation of the veins causes venous pooling of the blood throughout the body. As a result, less blood returns to the heart, and filling pressure (preload ) is reduced. Nitroglycerine is administered to reduce myocardial oxygen consumption, which decreases ischemia and relieves pain.

When the nurse observes that the patient's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc per hour, the nurse recognizes that the patient is demonstrating which stage of shock? A Refractory B Irreversible C Compensatory D Progressive

Progressive Explanation: In compensatory shock, the patient's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In progressive shock, the patient's skin appears mottled and mentation demonstrates lethargy. In refractory or irreversible shock, the patient requires complete mechanical and pharmacologic support.

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? A Irreversible B Compensatory C Progressive D Refractory

Progressive Explanation: In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the patient does not respond to treatment and cannot survive. In the compensatory state, the patient's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as A Compensatory B Neurogenic C Progressive D Hypovolemic

Progressive Explanation: The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin.

A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse A Turns the client to a side-lying position B Elevates the head of the client's bed C Raises the foot of the client's bed D Places the client in a Trendelenburg position

Raises the foot of the client's bed Explanation: The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return.

Vasoactive drugs, which cause the arteries and veins to dilate thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as A sodium nitroprusside (Nipride). B dopamine (Intropin). C norepinephrine (Levophed). D furosemide (Lasix).

Sodium nitroprusside (Nipride). Explanation: Sodium nitroprusside is used in the treatment of cardiogenic shock. Norepinephrine (Levophed) is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine (Intropin) tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide (Lasix) is a loop diuretic that reduces intravascular fluid volume.

A patient's morning lab work shows a potassium level of 6.3. The patient's potassium level yesterday was 4.0 The patient was recently started on new medications for treatment of myocardial infarction. What medication below can cause an increased potassium level?* A. Losartan B. Norvasc C. Aspirin D. Cardizem

The answer is A. Losartan is an ARB. ARBs (angiotensin receptor blockers) and ACE inhibitors (angiotension converting enzyme inhibitors) can cause an INCREASE potassium level because of it affects of decreasing aldosterone. A normal potassium level is 3.5-5.1.

In regards to the patient in the previous question, after administering the first dose of Nitroglycerin sublingual the patient's blood pressure is now 68/48. The patient is still having chest pain and T-wave inversion on the cardiac monitor. What is your next nursing intervention?* A. Hold further doses of Nitroglycerin and notify the doctor immediately for further orders. B. Administer Morphine IV and place the patient in reverse Trendelenburg position. C. Administer Nitroglycerin and monitor the patient's blood pressure. D. All the options are incorrect.

The answer is A. Nitroglycerin can cause hypotension, however, if there is a significant drop in blood pressure with SBP <90, further doses of Nitroglycerin should be held. The doctor should be notified for further orders, especially since the patient is still having chest pain and t-wave inversion. Morphine should NOT be given because it can cause hypotension.

A patient is complaining of a nagging cough that is continuous. Which medication below can cause this side effect?* A. Losartan B. Lisinopril C. Cardizem D. Lipitor

The answer is B. ACE inhibitors, such as Lisinopril, can cause a nagging cough that is continuous. The patient may be switched to an ARB (angiotensin receptor blocker) if the cough is troublesome.

2. You note in the patient's chart that the patient recently had a myocardial infarction due to a blockage in the left coronary artery. You know that which of the following is true about this type of blockage?* A. A blockage in the left coronary artery causes the least amount of damage to the heart muscle. B. Left coronary artery blockages can cause anterior wall death which affects the left ventricle. C. Left coronary artery blockage can cause posterior wall death which affects the right ventricle. D. The left anterior descending artery is least likely to be affected by coronary artery disease.

The answer is B. The LCA (if blocked) can cause the MOST amount of damage to the heart muscle. It affects the ANTERIOR part of the heart which affects the LEFT ventricle. The left descending artery is MOST likely to be affected by coronary artery disease.

1. You're educating a patient about the causes of a myocardial infarction. Which statement by the patient indicates they misunderstood your teaching and requires you to re-educate them?* A. Coronary artery dissection can happen spontaneously and occurs more in women. B. The most common cause of a myocardial infarction is a coronary spasm from illicit drug use or hypertension. C. Patients who have coronary artery disease are at high risk for developing a myocardial infarction. D. Both A and B are incorrect.

The answer is B. The most common cause of a myocardial infarction is CORONARY ARTERY DISEASE...not coronary spasm which is uncommon.

After a myocardial infraction, at what time (approximately) do the macrophages present at the site of injury to perform granulation of the tissue?* A. 24 hours B. 2 days C. 10 days D. 6 hours

The answer is C.

A patient is being discharged home after receiving treatment for a myocardial infarction. The patient will be taking Coreg. What statement by the patient demonstrates they understood your education material about this drug?* A. "I will take this medication at night." B. "I will take this medication as needed." C. "I will monitor my heart rate and blood pressure while taking this medication."

The answer is C. It is the only correct option that reflects Coreg. This medication doesn't have to be taken at night, preferably in the morning. It is taken daily (not as needed), and must be avoided with grapefruit juice because it slow down the absorption of Coreg.

A patient recovering from a myocardial infarction is complaining of the taste of blood in their mouth. On assessment, you note there is bleeding on the anterior gums. Which medication can cause this?* A. Coreg B. Cardizem C. Lovenox D. Lipitor

The answer is C. Lovenox is an antithrombotic. An adverse side effect of this medication is bleeding. Coreg (beta-blocker), Cardizem (calcium channel blocker), and Lipitor (statin) do NOT cause excessive bleeding.

3. A patient is 36 hours status post a myocardial infarction. The patient is starting to complain of chest pain when they lay flat or cough. You note on auscultation of the heart a grating, harsh sound. What complication is this patient mostly likely suffering from?* A. Cardiac dissection B. Ventricular septum rupture C. Mitral valve prolapse D. Pericarditis

The answer is D. A complication of a myocardial infarction is PERICARDITIS, especially 24-36 hours post MI. This is because of neutrophils being present at the site which causes inflammation. The patient's signs and symptoms are classic pericarditis.

A patient is on a Heparin drip post myocardial infarction. The patient has been on the drip for 4 days. You are assessing the patient's morning lab work. Which of the following findings in the patient's lab work is a potential life-threatening complication of Heparin therapy and requires intervention?* A. K+ 3.7 B. PTT 65 seconds C. Hgb 14.5 D. Platelets 135,000

The answer is D. Platelet value of <150,000 indicates thrombocytopenia and is found in patients with Heparin-Induced Thrombocytopenia. The potassium and hemoglobin level are normal. The PTT level is therapeutic (60-80 seconds) for Heparin and isn't a cause for concern

A client receives alteplase (t-PA). It is most important for the nurse to intervene when A The client's cardiac rhythm changes to normal sinus with few PVCs. B The client's Glasgow Coma Score changes from 15 to 13. C A small amount of bleeding occurs at venous puncture sites. D The client reports joint pain in the knees and elbows.

The client's Glasgow Coma Score changes from 15 to 13. Explanation: Alteplase is a thrombolytic. It is important for the nurse to assess for bleeding. A change in the Glasgow Coma Score may indicate cerebral hemorrhage. Bleeding at venous puncture sites and possibly in the joints is less critical. A normal sinus rhythm with few premature ventricular contractions may be an improvement in the client's cardiac status and indicates lysis of thrombi in the coronary arteries.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? A The difference between an apical and radial pulse B The difference between the systolic and diastolic pressure C The difference between the arterial and venous blood pressure D The difference between an upper extremity and lower extremity blood pressure

The difference between the systolic and diastolic pressure Explanation: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: A The balloon deflates prior to systole. B Vesicular breath sounds are audible in the lung periphery. C Bilateral pedal pulses are 1+. D The right foot is cooler than the left foot.

The right foot is cooler than the left foot. Explanation: When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot. Pedal pulses of 1+ bilaterally would not be a complication of this therapy but of other problems. The balloon is supposed to deflate prior to systole. It is normal for vesicular breath sounds to be audible in the lung periphery.

Which heart rhythm occurs when the atrial and ventricular rhythms are both regular, but independent of each other? A Third-degree atrioventricular (AV) heart block B Second-degree heart block C First-degree AV block D Asystole

Third-degree atrioventricular (AV) heart block Explanation: In third-degree AV heart block there is no relationship or synchrony between the atrial and ventricular contraction. Each is beating at its own inherent rate and is independent of each other, thus the cardiac output is affected. Second-degree AV block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. First-degree AV block occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval. During asystole, there is no electrical activity.

A client is unstable and receiving dopamine (Inotropin) to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all answers that apply. A Verify dosage and pump settings with another RN. B Administer through an intact peripheral line. C Use an intravenous controller or pump. D Assess vital signs every hour. E Measure urine output every hour.

How should vasoactive medications be administered? A Using a central venous line B Through a peripheral IV line C Intramuscularly (IM) D By rapid intravenous (IV) push

Using a central venous line Explanation: Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push.

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. Appropriate interventions include (Select all that apply) A maintaining the IV site inserted on admission B monitoring urine output every hour C obtaining a urine specimen for culture D administering pantoprazole (Protonix) IV daily E instituting vital signs every 4 hours

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