Prep U 4: perfusion
The client, newly diagnosed with diabetic retinopathy, asks what caused this disorder. What is the nurse's best response?
Inability of oxygen to diffuse to tissues in the eye
The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond?
"It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain"
A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply.
"My hands get pale and bluish, and feel numb and painful when I'm really stressed" "This problem is caused by a temporaty lack of circulation in my hands" "I will have to discuss medication that might treat this problem with my health care provider" "I probably got this disorder because I am also diagnosed with lupus"
A nurse is providing instructions for home cast care. Which response by the parent indicates a need for further teaching?
"Pale, cool, or blue skin coloration is to be expected"
The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is:
20 mL/hour
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?
7
An older adult client has been diagnosed with chronic heart failure. He is prescribed an ACE inhibitor to treat the symptoms and improve his quality of life. This drug will alleviate the client's symptoms of heart failure by:
Blocking the conversion of angiotensin I to angiotensin II
A client has developed chronic hypoxia and has developed pulmonary hypertension (HTN). The nurse recognizes that the most likely cause of pulmonary hypertension would be:
Constriction of the pulmonary vessels in response to hypoxemia
Which cause of pressure injuries (decubitus injuries or bedsores) impairs the flow of blood in the capillary beds?
External pressure
The nurse is reviewing the history of an older adult female client who was recently diagnosed with coronary heart disease. What factors are known to contribute to this condition? Select all that apply.
He has hypertension for 15 years Smoked 1 pack/day for 20 years Used hormone therapy for 5 years
A client with a history of emphysema is experiencing hypoxemia after a taxing physical therapy appointment. Which physiologic phenomenon will occur as a consequence of hypoxemia?
Increased heart rate
The nurse is preparing a client for a complete blood count test. Which actions would the nurse perform? Select all that apply.
Inform the client that specimen collection takes approx 5-10 minutes Explain that, based on results, additional testing may be performed Inform the client that this test can assist in evaluating the body's response to illness
A client has been told she has elevated levels of low-density lipoproteins (LDL). The client says, "I have always followed a low-cholesterol diet, so how could it be elevated?" How should the nurse respond?
LDL needs to be taken up into the intracellular space and this process does not work well in some people, causing LDL elevations in the blood
You are precepting a new graduate nurse on your unit. The two of you are caring for a client with malignant hypertension. The new nurse asks what malignant hypertension can cause. What would be your best answer?
Left ventricular failure
Which treatment should take place immediately in a client experiencing autonomic dysreflexia?
Position the client in upright position, and correct the initiating stimulus
What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?
Promote arterial and venous circulation
A nurse is assessing a client who is receiving vancomycin intravenously. While the drug is being administered, the client reports a throbbing sensation in the neck and back and paresthesias. The client's blood pressure has dropped and the neck and back are erythematous. The nurse suspects which adverse finding?
Red man syndrome
The nurse is caring for a client during a prolonged hospital stay for congestive heart failure. The client has a prescription for thigh high antiembolism stockings. In regard to the antiembolism stockings, what is the priority action by the nurse?
Remeasure the client's legs routinely
Your client is going to have a stress test. What radionuclide would most likely be used to diagnose ischemic heart disease during this test?
Thallium-201
A client comes to the emergency room with all the symptoms of a myocardial infarction. Which lab value, known to have a high specificity for myocardial tissue considered the primary biomarker test for diagnosing an MI, does the nurse suspect the physician will order?
Troponin assays
Which blood vessel layer is composed primarily of smooth muscle cells?
Tunica media
The nurse is caring for an infant diagnosed with a ventricular septal defect. Which assessment findings does the nurse anticipate?
a harsh murmur
The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients?
cardiac volume intolerance
A client is admitted with frostbite. What will the nurse tell the client about the changes that have occurred due to cold exposure?
cold increases blood viscosity and thrombosis
Which disease is caused by calcified scar tissue that develops between the visceral and parietal layers of the serous pericardium?
constrictive pericarditis
The nurse is developing a plan of care for a client with heart failure. The most important information for the nurse to consider would be:
decreased cardiac output
While intubated for surgery, a client has inadvertently had his vagus nerve stimulated. What effect would the surgical team expect to observe?
Decreased heart rate as a result of parasympathetic innervation of the heart
The healthcare provider orders digoxin for the client with congestive heart failure. What should the nurse include in the client's teaching concerning the administration of digoxin? Select all that apply.
Digoxin can cause swelling of the face, lips, or tongue Digoxin can cause a fast, irregular heartbeat
An 80-year-old male client arrives for his yearly physical without any complaints, and following the checkup the physician explains that he has noted atrial fibrillation (AF) on the client's ECG. Before the physician can explain the disorder, the client becomes very upset and states he thinks he is going to die. The physician explains that atrial fibrillation involves the top chambers of the heart and that:
many people live with atrial fibrillation without even knowing they have it
The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of greatest concern?
elevated blood pressure
With buccal medications, what factor affects absorption?
integrity of the mucous membranes
A client is scheduled for a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory value to the health care provider (HCP) prior to the stress test?
troponin level
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?
head elevated, grasping knees, breath out
A client with malignant hypertension is at risk for a hypertensive crisis, including the cerebral vascular system often causing cerebral edema. The nurse would assess this client for which signs and symptoms?
headache and confusion
A client is admitted to the cardiac unit with a diagnosis of a myocardial infarction (MI). The nurse notes that the client is having regular premature ventricular contractions (PVCs). Why would the nurse be concerned?
Blood is not efficiently pumped from the heart with PVCs
