LIPPINCOTT Perfusion – Flashcards

A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action? a) A low, grade 1 intensity mitral regurgitation murmur. b) SpO2 is 94% on 2 liters of oxygen via nasal cannula. c) The client has become more somnolent. d) Urine output has decreased from 60 mL/hour to 40 mL over the last hour.

A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.

A client is scheduled for a cardiac catheterization. The nurse should do which of the following pre-procedure tasks? Select all that apply. a) Administer all ordered oral medications. b) Check for iodine sensitivity. c) Verify that written consent has been obtained. d) Withhold food and oral fluids before the procedure. e) Insert a urinary drainage catheter.

A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial post-procedure nursing assessment for this client? a) Monitor the laboratory values. b) Observe neurologic function every 15 minutes. c) Observe the puncture site for swelling and bleeding. d) Monitor skin warmth and turgor.

A 70-year-old female is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client's childhood health history included: a) Chickenpox. b) Poliomyelitis. c) Rheumatic fever. d) Meningitis.

A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority? a) Assess the 12-lead EKG. b) Assess the blood pressure. c) Assess the lung sounds. d) Assess the urine output.

A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time? a) Medication therapy. b) Diet modification. c) Activity restrictions. d) Dental care.

In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that: a) The client will remain in the ICU for 5 days. b) The client will sleep most of the time while in the ICU c) Noise and activity within the ICU are minimal. d) The client will receive medication to relieve pain.

A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply. a) Begin Warfarin (Coumadin). b) Check the postoperative CBC, INR, PTT, & platelet levels. c) Confirm availability of blood products. d) Monitor the mediastinal chest tube drainage. e) Start a Dopamine (Intropin) drip for a systolic BP < 100.

The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: a) Observe careful hand-washing procedures. b) Clean the incisional area with an antiseptic. c) Use prepackaged sterile dressings to cover the incision. d) Place soiled dressings in a waterproof bag before disposing of them.

For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? a) Ensure a liberal fluid intake. b) Provide an alkaline-ash diet. c) Prevent constipation. d) Enrich the client's diet with dairy products.

Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: a) A manual toothbrush. b) An electric toothbrush. c) An irrigation device. d) Dental floss.

Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of post-surgery activity restrictions. Which of the following should the client not engage in until after the 1-month post-discharge appointment with the surgeon? a) Showering. b) Lifting anything heavier than 10 lb. c) A program of gradually progressive walking. d) Light housework.

Three days after mitral valve surgery, a 45-year-old female comments that she hears a "clicking" noise coming from her chest and her "rather large" chest incision. The nurse's response should reflect the understanding that the client may be experiencing which of the following? a) Anxiety related to altered body image. b) Anxiety related to altered health status. c) Altered tissue perfusion. d) Lack of knowledge regarding the postoperative course.

When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply. a) Take and record daily pulse rate. b) Avoid air travel because of airport security alarms. c) Immobilize the affected arm for 4 to 6 weeks. d) Avoid using a microwave oven. e) Avoid lifting anything heavier than 3 lb.

A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first? a) Prepare for transcutaneous pacing. b) Prepare to defibrillate the client at 200 joules. c) Administer an I.V. lidocaine infusion. d) Schedule the operating room for insertion of a permanent pacemaker.

A 74-year-old female is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to: a) Maintain skin integrity. b) Maintain cardiac conduction stability. c) Decrease cardiac output. d) Increase activity level

The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client: a) Selects a low-cholesterol diet to control coronary artery disease. b) States a need for bed rest for 1 week after discharge. c) Verbalizes safety precautions needed to prevent pacemaker malfunction. d) Explains signs and symptoms of myocardial infarction (MI).

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first? a) IV fluid solution. b) Pedal pulses. c) Nasal cannula flow rate. d) Capillary refill.

The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? a) Auscultate the pulses with a stethoscope. b) Call the physician. c) Use a Doppler ultrasound device. d) Inspect the lower left extremity.

A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. 1. Urine output. 2. Peripheral pulses. 3. Urine output. 4. Incision site.

The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of: a) Atrophy. b) Contraction. c) Gangrene. d) Rubor.

A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: a) Showing the location of the obstruction and the collateral circulation. b) Scanning the affected extremity and identifying the areas of volume changes. c) Using ultrasound to estimate the velocity changes in the blood vessels. d) Determining how long the client can walk

A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to: a) Administer epinephrine. b) Inform the physician. c) Administer oxygen. d) Inform the client that the procedure is almost over.

A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to: a) Maintain circulation. b) Prevent infection. c) Relieve pain. d) Provide education.

A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period? a) Assess the temperature in the affected arm. b) Monitor the radial pulse in the affected arm. c) Protect the extremity from cold. d) Avoid using the arm for a venipuncture.

A client is admitted to the hospital with peripheral vascular disease (PVD) of the lower extremities. He is scheduled for an amputation of the left leg. The client says, "I've really tried to manage my condition well." Which of the following routines should the nurse evaluate as having been appropriate for him? a) Resting with his legs elevated above the level of his heart. b) Walking slowly but steadily for 30 minutes twice a day. c) Minimizing activity. d) Wearing antiembolism stockings at all times when out of bed.

While the nurse is providing preoperative teaching, the client says, "I hate the idea of being an invalid after they cut off my leg." The nurse's most therapeutic response should be: a) "You'll still have one good leg to use." b) "Tell me more about how you're feeling." c) "Let's finish the preoperative teaching." d) "You're fortunate to have a wife who can take care of you."

The client asks the nurse, "Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?" The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on: a) The need to remove as much of the leg as possible. b) The adequacy of the blood supply to the tissues. c) The ease with which a prosthesis can be fitted. d) The client's ability to walk with a prosthesis

A client has undergone an amputation of several toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which of the following leg positions is contraindicated for her while sitting in a chair? a) Crossing the legs. b) Elevating the legs. c) Flexing the ankles. d) Extending the knees.

The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. The nurse should immediately: a) Apply a tourniquet. b) Assess vital signs. c) Call the physician. d) Elevate the surgical extremity with a large pillow.

The client has had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client in stump care. Which of the following statements by the client indicates that she understands how to implement her plan of care? a) "I should inspect the incision carefully when I change the dressing every other day." b) "I should wash the incision, dry it, and apply moisturizing lotion daily." c) "I should rewrap the stump as often as needed." d) "I should elevate the stump on pillows to decrease swelling."

The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectivenss of this medication by assessing the client for: a) Relief of anxiety. b) Sedation. c) Vasoconstriction. d) Vasodilation.

A client is receiving Pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking the client: a) If he has improved circulation in the legs. b) If he can wiggle his toes. c) If he is urinating more frequently. d) If he is less dizzy.

A client with peripheral vascular disease is recovering from an aorto-femoral-popliteal bypass graft. When developing a postoperative education plan, which question by the nurse will provide the most helpful information? a) "How did you manage your health before admission?" b) "How far could you walk without pain before surgery?" c) "What is your home environment like?" d) "Do you have problems with urine retention?"

The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below: History And Physical 1) Smokes four cigars a month. 2) Vital signs: blood pressure, ranges from 150/76 mm Hg to 170/98 mm Hg; heart rate, 90 to 100 beats per minute; respirations, 12-18 per minute; temperature, 99.9° F (37.8° C). 3) +1 bilateral ankle edema. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan? a) Food intake b) Fluid volume c) Skin integrity d) Tissue perfusion

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. Vital Signs Date: 05/07/07 Time: 10:00 am Blood pressure 160/90 mm Hg Heart rate 74 bpm Respirations 20 per minute G. Fuentes, RN At 10:30 a.m., the client complains of sharp mid-chest pain after having a bowel movement. What should the nurse do first? a) Assess the client's vital signs. b) Administer a bolus of lactated Ringer's solution. c) Assess the client's neurologic status. d) Contact the physician.

Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first: a) Assess the urine output. b) Place a large bore I.V. c) Position onto the left side. d) Insert a nasogastric tube.

A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has: a) Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days. b) Heart rate of 100 beats per minute after ambulating 200 feet. c) Urine output of 2,000 mL in 24 hours. d) Weakness and numbness in the lower extremities.

A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to: a) Maintain circulation. b) Manage pain. c) Prepare the client for emergency surgery. d) Teach postoperative breathing exercises.

Before surgery for a known aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for: a) Loss of consciousness. b) Anxiety. c) Headache. d) Disorientation.

A client has sudden, severe pain in his back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The code cart is brought into the room because one complication of a dissecting aneurysm is: a) Cardiac tamponade. b) Stroke. c) Pulmonary edema. d) Myocardial infarction.

Which of the following increases the risk of having a large abdominal aortic aneurysm rupture? a) Anemia. b) Dehydration. c) High blood pressure. d) Hyperglycemia.

The nurse is planning care for a client who has returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for: a) Alteration in renal perfusion. b) Electrolyte imbalance. c) Ineffective coping. d) Wound infection.

A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown: Date:07/07/07 Time: 10:00 pm Progress Notes: The client is receiving D5W, 1,000 mL q 8 h. The NG tube is attached to low suction and draining well. The client has been NPO except ice chips. The client has had 10 mg morphine for pain at 6 a.m. E. Levine, RN What is most likely contributing to the client's abdominal distention? a) Nasogastric (NG) tube. b) Ice chips. c) I.V. fl uid intake. d) Morphine.

A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the physician before having: a) Blood drawn. b) An I.V. line inserted. c) Major dental work. d) An X-ray examination

A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should: a) Position the client on a firm mattress. b) Keep the involved extremity warm with blankets. c) Position the left leg at or below the body's horizontal plane. d) Encourage the client to raise and lower his leg four times every hour.

A client with a history of hypertension and peripheral vascular disease underwent an aorto-bifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2 ° C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50 to 70 mL/ hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment- Recommendation) technique for communication, the nurse recommends that the primary care provider: a) Continues the pentoxifylline. b) Increases the I.V. fl uids. c) Restarts the metoprolol. d) Resumes the furosemide.

The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests an order for a different, or stronger, pain medication. The physician tells the nurse that the current order for pain medication is sufficient for this client and that the client will feel better in several days. The nurse should next: a) Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as ordered. b) Ask the hospitalist to write an order for a stronger pain medication. c) Wait until the next shift and ask the nurse on that shift to contact the physician. d) Report the incident to the team leader.