pRNciples week 9
A client who is scheduled for a colonoscopy was instructed to stop taking warfarin (Coumadin) five days before the procedure. The client asks the nurse the reason for stopping the medication? Which of the following statements made by the nurse is appropriate?
'Coumadin could cause significant bleeding' Principle: Bleeding is a key complication of anticoagulant therapy ;
Which statement by the client indicates that discharge instructions regarding the pacemaker was understood?
'I should avoid lifting weights for at least 2 weeks.' Principle: Avoid raising the hands over the head for 2 weeks or heavy lifting followng the insertion of a cardiac device
The nurse is caring for a client with venous insufficiency. Which of the following statements made by the client indicates to the nurse that additional instruction is required prior to discharge?
'I should keep my legs in a dependent position when seated.' Principle: Instruct the patient to lower the extremities below the level of the heart in the setting of arterial insufficiency and to raise the extremity in the setting of venous insufficiency
When preparing a client with a history of ventricular fibrillation and who recently had an implantable cardioverter defibrillator (ICD) inserted, the nurse knows the client understands the purpose of the device when which of the following statements is made?
'If electrical activity to my heart stops, the ICD will send electrical charges to my heart.' Principle: Impaired cardiac conduction between the sinoatrial node, atrial ventricular node, bundle of His, right and left bundle branch and the Purkinje fibers contributes to dysrhythmias ;
The nurse administers the first dose of warfarin (Coumadin) to a client on intravenous heparin. Which of the following is the best response to the client who asks about an increased risk of bleeding by being on both medications?
'The heparin will be discontinued as soon as the warfarin is at a therapeutic level.' Principle: Heparin and coumadin may be given together until the international normalized ration (INR) is therapeutic between 2-3
The nurse is caring for a client with peripheral vascular disease. Which of the following findings is consistent with arterial insufficiency?
+1 pedal pulse Principle: Determine changes in arterial blood flow by assessing for pain, pallor, paresthesia, paralysis, poikilothermia/polar, pulselessness and capillary refill
The nurse observes an absence of P waves on the client's electrocardiogram (ECG). When auscultating the client's apical pulse, the nurse expects the heart rate will be in which of the following ranges?
40-60 beats per minute Principle: The sinoatrial (SA) node initiates the impulse that causes atrial contraction which is observed by a p wave on the electrocardiogram (EKG) ;
A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority?
A client who is having ventricular fibrillations Principle: Ventricular fibrillation causes ineffective quivering of the ventricles and is not compatible with lif
The client returns from surgery for an abdominal aneurysm repair. The client has a history of peripheral vascular disease. Which situation would alert the nurse to a potential complication?
A pedal pulse of + 1 bilaterally Principle: Clinical manifestations of arterial insufficiency include pain, diminished pulse, pallor, dependent rubor, cool temparture, absence of hair, thickened nails ; Page# 851
When applying compression stockings to a post-surgical client, the nursing actions include which of the following?
Apply compression stockings with legs elevated prior to getting out of bed Principle: Apply compression stockings prior to the patient getting out of bed and remove at night
When preparing a client for surgery, the nurse knows that which of the following interventions best helps to decrease the client's risk for deep vein thrombosis?
Applying sequential compression devices Principle: Ambulation, sequential compression devices, and anti-embolism stockings promote venous return
The nurse is caring for a client on telemetry. The nurse observe a U wave on the client's electrocardiogram strip. The client denies any chest pain or palpitations. Which action should the nurse take next?
Assess client's potassium level Principle: On an EKG, the p wave represents atrial depolarization, the QRS represents ventricular depolarization, the T wave represents ventricular repolarization, the ST segment indicates early ventricular repolarization, U wave is sometimes seen in the setting of hypokalemia
The nurse includes which of the following discharge instructions for a client following pacemaker insertion? Select all that apply.
Avoid reaching for objects above the head for 2 weeks. Pacemaker should be monitored every month. Principle: Avoid raising the hands over the head for 2 weeks or heavy lifting followng the insertion of a cardiac device ;Pacemakers are typically monitored every 4 weeks ;
A client's diet is modified to eliminate foods that act as cardiac stimulants. What should the nurse teach this client to avoid? (Select all that apply.)
Black tea Hot chocolate Caffeinated energy drinks Principle: Exercise, fever, and catecholamines increase sympathetic stimulation and could result in dysrhythmias
The client complains of feeling heart palpitations at rest. The nurse notes frequent premature ventricular contractions (PVCs) on the electrocardiogram (ECG). What is the priority nursing assessment for this client?
Blood pressure. Principle: Dysrhythmias can impair the heart rate and rhythm and result in a decrease in blood pressure
The nurse is caring for a client with chronic venous insufficiency. Which assessment finding is consistent with this disorder?
Brown discolored skin to legs Principle: Peripheral vascular disease is marked by an inability of arterial blood flow to meet the oxygen demand of tissue in the periphery or an impaired ability to bring venous blood flow back to the heart ;
The client presents to the health clinic with a complaint of feeling skipped beats. The electrocardiogram (ECG) shows normal sinus rhythm with occasional premature ventricular contractions (PVCs). The nurse should assess the client's intake of which of the following? Select all that apply.
Caffeine Alcohol Tobacco Principle: Alcohol, caffeine or nicotine could contribute to premature ventricular contractions
The nurse is preparing to administer atropine. Which action should the nurse perform prior to administering the medication?
Check heart rate. Principle: Atropine (an anticholinergic) is given to block vagal stimulation and increase heart rate during sinus bradycardia
The nurse interprets the client's electrocardiogram (ECG) rhythm as Ventricular Tachycardia (VT). Which nursing intervention takes first priority?
Check the client's apical pulse Principle: Three or more continuous premature ventricular contractions at a rate greater than 100 beats per minute is defined as ventricular tachycardia
A client who had a thoracoscopy performed returns to the unit and is requesting breakfast. Which of the following actions is a nursing priority?
Check the client's heart rate and blood pressure Principle: Bleeding is always a risk of angiograpy and procedures ending in oscopy (ex. bronchoscopy)!
Which nursing diagnosis is a priority when planning the care for a client with a cardiac dysrhythmia?
Decreased cardiac output Principle: A priority action in the setting of dysrhythmias is to maintain cardiac output ;
Surgical procedures could increase a client's risk for complications. When developing a plan of care for a client who had surgery to the vertebral column, the nurse understands that the client has the greatest risk for which of the following complications?
Deep vein thrombosis Principle: Stress increases the risk for hypercoagulation! ; Page# 465 Virchow's triad consists of three risk factors for venous thromboembolism, venous stasis, blood vessel damage, altered coagulation
The nurse is caring for a client with a history of peripheral arterial disease. The health care provider has ordered an ankle-brachial index test. The nurse understands that this exam will
Determine the degree of stenosis in the client's leg Principle: The ankle-brachial index is used to determine the degree of stenosis in the extremities ;
When teaching disease management for a client with peripheral vascular disease, which of the following actions should the nurse recommend to the client to help prevent complications from arterial insufficiency?
Do not elevate your legs above the level of your heart Principle: Elevating the legs promotes venous return but is contraindicated with arterial insufficiency ;
When evaluating blood flow through the major arteries following vascular surgery, the nurse expects which of the following will be used as part of the assessment?
Doppler ultrasound Principle: Use a doppler to evaluate blood flow following vascular surgery ;
The nurse suspects a client has a deep vein thrombosis (DVT). Which of the following assessment findings supports the possibility of a DVT. Select all that apply
Edema to the extremity Warmth to palpation Tenderness to palpation Principle: Classic signs of deep vein thrombosis include edema to the extremity, warmth, tenderness or fullness in the leg
A client returns to the doctor's office to discuss the laboratory results. The client said to the nurse all my blood results are normal except for my cholesterol. Why is it such a big deal. Which response made by the nurse is most appropriate?
Elevated cholesterol can increase your risk for CAD' Principle: Cholesterol levels greater than 200 mg/dL increases the risk for coronary artery disease ;
A client who has osteoarthritis complains of increased shoulder pain. Which of the following findings best supports inflammation?
Elevated serum C-reactive protein Principle: Elevated C-reactive protein levels suggests inflammation
The nurse provides discharge instructions to a client who smokes, has a body mass index of 23 and has coronary artery disease by teaching the client to help increase high density level (HDL) lipoproteins in which of the following ways? Select all that apply.
Engage in regular physical activity and exercise. Adhere to a smoking cessation program. Principle: High-density lipoproteins bring cholesterol from the blood to the liver to be broken down while Low-density lipoproteins invade the wall of vessels contributing to plaque formation and a narrowed lumen
A client who has a pacemaker inserted 10 years ago complains of shortness of breath, fatigue, and weakness. Which of the following assessment findings suggests a complication related to the pacemaker?
Heart rate of 48 and dizziness Principle: Pacemaker malfunction could result in bradycardia and a decrease in heart rate
Which assessment finding is most important for the nurse to report to the health care provider regarding a client diagnosed with atrial fibrillation and is taking coumadin?
Hematemesis with a BP 90/60 Principle: Bleeding is a key complication of anticoagulant therapy
The client presents with hypotension, dyspnea, and decreasing level of consciousness. The client's electrocardiogram (ECG) shows a heart rate 190 beats per minute with QRS complexes measuring 0.06 seconds. The nurse prepares to perform which of the following actions?
IV rapid push of Adenocard (adenosine) Principle: Adenosine must be administered rapidly and is used to abort tachycardia in the setting of atrial flutter or sinus tachycardia with hemodynamic instability
Which of the following statements made by the client on warfarin (Coumadin) indicates to the nurse that the client needs additional instruction before discharge?
If I get a blood clot the warfarin will help my body dissolve it.' Principle: Anticoagulants can be given to prevent clots from getting larger but they do NOT dissolve clots
A 66-year old female reports to the emergency room and is diagnosed with an aortic aneurysm. The nurse assess for which of the following clinical manifestations when determining if the aneurysm has ruptured? Select all that apply
Increased back pain Drop in blood pressure Decrease in hematocrit Principle: Severe back pain or abdominal pain, falling blood pressure, and a drop in the hematocrit suggest the aneurysm has ruptured
The nurse notes that the client has a capillary refill time greater than 3 seconds. Which of the following nursing diagnoses is most appropriate for this client?
Ineffective peripheral tissue perfusion. Principle: Capillaries are a single layer which allows for gas and nutrient exchange ;
A client is found unresponsive and without a pulse. The client's electrocardiogram (ECG) shows ventricular tachycardia. The nurse knows the most effective treatment to increase this client's chance for survival is which of the following?
Initiating cardiac defibrillation for the client. Principle: The treatment of choice for unconscious patients with pulseless ventricular tachycardia is defibrillation!
After abdominal surgery a client suddenly reports heaviness to the right leg. The nurse notes that the right calf looks bigger than the left calf. What would the nurse do first?
Instruct the client to remain in bed and notify the health care provider. Principle: Classic signs of deep vein thrombosis include edema to the extremity, warmth, tenderness or fullness in the leg
A client who had a total knee replacement two days ago complains of an aching pain to the left leg. The nurse notes that the distal part of the left leg is warm, erythematous and swollen. Which action by the nurse is a priority?
Keep the client in bed with the left leg elevated. Principle: Classic signs of deep vein thrombosis include edema to the extremity, warmth, tenderness or fullness in the leg ;
The nurse is assessing the neurovascular status of a client who has just returned from having a cardiac catheterization where the right femoral artery was used. Which action performed by the nurse is appropriate?
Lightly palpate the pulses in the right lower extremity Principle: Assess pulses using light palpation
A client receiving chemotherapy for cancer treatment reports a lack of appetite that has resulted in reduced dietary intake. The client has an albumin level that has dropped to 2.0 g/dL. Which of the following clinical manifestations should the nurse assess for when determining the validity of this lab?
Lower extremity edema Principle: Proteins like albumin create an oncotic pressure which pulls fluid from the interstitial compartment into the intravascular compartment to maintain volume.
The nurse is completing a preoperative assessment on a female client who is scheduled for kidney surgery. Which of the following findings increases the client's risk for deep vein thrombosis? Select all that apply:
Obesity Damage to blood vessels Blood pooling in the extremities Crosses legs when sitting Principle: Virchow's triad consists of three risk factors for venous thromboembolism, venous stasis, blood vessel damage, altered coagulation ; Page# 849Constricting blood vessels under the knees increases the risk for deep vein thrombosis
A client develops a deep vein thrombosis following a total hip replacement and is placed on a continuous heparin infusion. The client has an order for hydromorphone 2mg intramuscular injection every 6 hours for pain. Which of the following actions would the nurse implement?
Obtain an order to change the route of the demerol Principle: Bleeding is a key complication of anticoagulant therapy
When assessing a client in pulmonary edema, the nurse understands increased pulmonary hydrostatic pressure is responsible for which of the following clinical signs observed during assessment? Select all that apply.
Pink, frothy sputum. Crackles. Orthopnea. Principle: Hydrostatic pressure moves fluid from the intravascular compartment to the intercellular
Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?
Protamine sulfate Principle: Prepare to administer vitamin K for coumadin toxicity or protamine sulfate for heparin toxicity ;
A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. Which of the following clinical findings require the nurse to notify the practitioner?
Right-sided chest discomfort 4 days postoperatively Principle: Cancer, pregnancy, immobility and clotting disorders increase the risk for deep vein thrombosis and pulmonary embolism
The nurse is caring for a client who had a cocaine overdose. The nurse anticipates which dysrhythmia would be consistent with this situation?
Sinus Tachycardia Principle: Illicit drugs like amphetamines and cocaine can increase the heart rate and lead to dysrhythmias
The nurse is part of a code team caring for a client in cardiac arrest. The nurse has correctly applied the defibrillator pads to the client's chest and determined that the client is in ventricular fibrillation. What is the nurse's next action?
State 'All Clear' and verify no one has contact with client or bed. Principle: Defribillation safety consists of maintaining good contact between the skin and paddles (use a conductive medium) and confiming that no one is touching the patient ;
A client presents to the emergency department with a pulmonary embolus. The client has been started on a heparin drip. Which of the following observations by the nurse should be immediately reported to the health care provider?
Sudden onset of epistaxis Principle: Bleeding is a key complication of anticoagulant therapy ;
The nurse is caring for a client who had an open reduction internal fixation two days ago to repair a right hip fracture. The nurse is concerned that the client may have developed a deep vein thrombosis. Which of the following clinical manifestations best supports the diagnoses.
Swelling to the right calf Principle: Classic signs of deep vein thrombosis include edema to the extremity, warmth, tenderness or fullness in the leg ;
A client presents to the emergency department complaining of dizziness. The client has a history of atrial fibrillation and is on Coumadin. Which of the following assessment findings indicates bleeding?
Tachycardia Principle: Bleeding is a key complication of anticoagulant therapy
The nurse is preparing a client who started on warfarin (Coumadin) for discharge. Which of the following teaching points must the nurse include in the discharge instructions? Select all that apply.
Take warfarin at the same time each day. Use a soft-bristled tooth brush for oral care. Notify health care provider if tarry stools occur. Principle: Instruct patients to take the anticoagulant at the same time every day and to notify their provider with any signs of bleeding (reddish or brownish urine, epistaxis, tarry stools) ;
Several clients on a surgical unit have had surgery. Who should the nurse see first after receiving report?
Two-days post-operative client with swelling and tenderness in left calf when ambulating Principle: Classic signs of deep vein thrombosis include edema to the extremity, warmth, tenderness or fullness in the leg
The nurse includes which of the following discharge instructions for a client who had pacemaker insertion?
Use cell phones on the opposite side of insertion site Principle: Instruct patients to place cell phones 6-12 inches away from the pacemaker generator and handheld screening devices used in airports may interfere with the pacemaker ;
A client presents with complaints of palpitations and dizziness. The electrocardiogram (ECG) shows Sinus Tachycardia with a heart rate of 180 beats per minute. The nurse expects which of the following treatments may be ordered for this client?
Vagal maneuvers. Principle: Stimulation of the parasympathetic nervous system results in vagal nerve innervation and a slowing of the heart rate
When completing an assessment on a client with severe heart failure, the client asks the nurse why the lower extremities are swollen. Which of the following responses by the nurse is most appropriate?
Your fluid volume has increased resulting in fluid being pushed into your tissue Principle: Edema could result from an increase in hydrostatic pressure or a decrease in oncotic pressure
When assessing the heart rate of a client , the nurse uses which of the following methods to measure the number of heartbeats per minute?
count the number of R waves in 6 seconds, multiply by 10 Principle: Assess heart rate by counting the R-R intervals in 6 seconds and multiply by 10 or count the number of large boxes within the R-R interval and divide 300 by that number ;
The nurse is caring for a client with severe bradycardia and frequent syncopal episodes. The client complains of being too tired to get out of bed or eat. Which of the following is the priority nursing diagnosis?
educed cardiac output Principle: A decrease in cardiac output may result in dizziness, fatigue, chest pain, and palpitations
A male client has been on warfarin (Coumadin) for three days and is still receiving intravenous heparin. The nurse notes that the blood pressure is 110/60, heart rate 136 and red blood cell (RBC) count of 3.9 cells/mcL. Based on the findings, the nurse anticipates which of the following complications?
internal bleeding Principle: Heparin and coumadin may be given together until the international normalized ration (INR) is therapeutic between 2-3
When assessing a client who has arterial insufficiency to the lower extremities, the nurse knows that which of the following is important to teach the client?
keep legs below the level of the heart Principle: Instruct the patient to lower the extremities below the level of the heart in the setting of arterial insufficiency and to raise the extremity in the setting of venous insufficiency