Perfusion study guide exam
what is the ABI reading for the following patient BP in L ankle 135/86 BP in L arm 145/72
0.93 highest systolic in ankle divided by highest systolic in arm.
which signs and symptoms are related with arterial ulcers of the lower extremities?
A.Pulses diminished or absent B.Hair loss to the extremity C. dependent rubor D. skin color
the student nurse studied shock understands that common manifestations of this conditions are directly related to which problem?
Anarobic metabolism, hypotension
the nurse is reviewing the laboratory results for a patient with a chief complaint of dyspnea. Which diagnostic test differentiates between heart failure and lung dysfunction?
B-type natriuretic peptide
UNSTABLE ANGINA
New onset change in pattern, pain that worsens, and more intensified •Less exertion casus pain
after receiving a dose of penicillin the client develops dyspnea and hypotension the clients lips and eyes began to swell what should the nurse do first?
Epi
when is graft occlusion for arterial revascularization with graft placement likely to occur?
First 24 hours
a client has peripheral arterial disease. Which statement by the client indicates missed understanding about self management activities?
I can use a heating pad
a client with a known AAA reports dizziness and severe abdominal pain. the nurse assesses the clients BP 82/40 which action by the nurse
assess distal pulses notify rapid response team take initial VS Q 5 minutes
the nurse is assessing the client following cardiac surgery which should be of the greatest concern to the nurse?
JVD, and muffled heart sounds
a client is 4 hours post op from a popliteal bypass, client has throbbing leg pain on the effective right side 7/10 what action takes priority?
assess distal pulses and skin color.
which assessment data would indicate the client experienced a complication secondary to vent?
asymmetrical chest expansion
a nurse working in the ER knows that which factors are commonly related to aneurysm formation?
atherosclerosis, HTN, hyperlipidemia, smoking
The nurse is caring for. client on the vascular unit which lab data warrants immediate interventions by the nurse?
PTT 98 sec with pulmonary embolism or DVT
the nurse is providing discharge instructions to the client with peripheral venous disease The nurse should include which information to the client?
avoid prolonged sitting and place legs on pillows
which category of medication blocks sympathetic stimulation of the heart and decreases heart rate?
beta blockers
a pt comes to the ED with anterior chest pain described as "tearing" sensation. the patient is diaphoretic, nauseated, and apprehensive. BP of 200/130mm/Hg. which medication is most likely to be ordered?
Sodium nitroprusside (niacin)
the nurse assesses a client who experiences shock from a MI. which statement by the nurse best indicates an understanding of the shock?
a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.
a client is receiving norepinephrine shot what assessment finding would indicate therapeutic effect?
alert and orientated and answering questions
a patient with A Fib is scheduled to have an elective cardio version. The nurse ensures that the patient has a prescription for a supply of which type of medication?
anticoagulant
a nurse is caring for a client after surgery the clients RR has increased from 12 to 18 and pulse rate from 86 to 98. Since assessed 4 hours ago what action by the nurse is the best?
assess clients MAP tissue perfusion further
a nurse is assessing a client with PAD the client states "walking 5 blocks is possible without pain what question asked by the nurse will give best information?
could you walk better 5 months ago?
which of the following outcomes is desired when a client with arterial insufficiency poor perfusion in the extremities?
extremities warm to touch decreased muscle pain with activity
a client with severe sepsis is non responsive to fluid resuscitation. what would nurse anticipate health care provider to do?
give vasopressor
the nurse in the vascular care unit is working with an LPN who is pulled to the unit as a result to high census. which task is most appropriate for the nurse to assign to the LPN?
hang the bag of heparin for the client with a Pulmonary Embolism (Intravenous piggyback)
VARICOSE VeINS! what caused me to get to this? which response is best by the nurse?
incompetent valves in the veins in the legs tx: 3 E's 1. Elastic compression hose 2. Exercise 3. Elevation
a patient is at risk for sepsis. which assessment finding suggests the hyperdynamoc activity that occurs with infection initially?
increased pulse rate
a client with shock brought on by sepsis has a temp of 96.4, HR 140 RR 28 and BP of 60/30 the nurse should question which physicians order?
infuse fluids at 83 ml/hr.
the nurse is taking care of a client with sepsis and expects the client is developing severe sepsis. Which findings would confirm severe?
lactic acid 3, bilirubin <4 platelets decrease <80
a nurse caring for a client notes the following assessment WBC 3,800 glucose 198 which action by the nurse takes priority?
notify HCP immediately
the client presents to the Emergency room with abdominal pain and upper GI bleeding, sweating, and appears to be in moderate distress. Which nursing action would be priority?
obtain vital signs
a nursing student is caring for a client with an abdominal aneurysm what action by the student requires the RN to interfere?
placing client in treneldenburg position.
a client with Raynauds is prescribed diltiazem what is the expected outcome?
reduced episode of finger numbness
a client with dislipidemias has been prescribed statin what's the priority instructions for the nurse to give to the client?
report any muscle tenderness to HCP
a family with a client in the refectory stage of shock has decided to withdraw life support a family member states " I dont want to be there when he dies I want to remember him as he was." the nurses best response would be?
reserving the memories I'll support you in your decision.
what is the primary difference between sepsis and severe sepsis?
severe sepsis has acute organ dysfunction and sepsis only has two or more systemic inflammatory response criteria(red, swollen, pain, stiffness,)
the client receiving PRBC's begins to chill and develop hivesWhich action should be the nurses FIRST response?
stop the transfusion and change the tubing at the hub
Which client should the nurse see first?
the client that took a dose of captopril and needs to go to the bathroom
the nurse is caring for a non responsive client who experienced massive blood loss and is now experiencing non palpable pulses, dusky extremities, with necrosis, slow shallow response. and loss of kidney and liver function. the nurse knows this means?
to much cell death has occurred to reverse. (refractory stage of shock)
which assessment data would warrant immediate interventions with a client diagnosed with severe sepsis VS t 36.9, p 104, RR 26,
urinary output 90mL/4 hours
the client had a repair TAA (thoracic aorta aneurysm) 2 days ago which of the following findings should the nurse report to the physician immediately?
weakness and numbness in lower extremities
the nurse is providing disease management for a client experiencing reynard disease what intervention does the nurse suggest to prevent complication?
wear warm clothing when exposed to cool temperatures
mitral stenosis
•Rheumatic fever is the most common cause •Pulmonary congestion and right-sided heart failure occur first THEY HAVE A DIASTOLIC MURMUR
Stable Angina Pectoris
•Unchanging frequency, duration, and severity •Predictable •ST Segment depression during pain
