Med Surg ATI Cardiovascular and respiratory – Flashcards
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A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?
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Position the client supine with his legs elevated when in bed.
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A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? Administer antihypertensive medication for blood pressure. Monitor that urinary output is 20 mL/hr. Withhold pain medication to prepare for surgery. Take vital signs every 2 hr.
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The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.
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A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? Obtain blood samples to test platelet function. Prepare for replacement of the missing clotting factor. Administer aspirin for the client's pain. Place the bleeding joint in the dependent position
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Prepare for replacement of the missing clotting factor. Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints.
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A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? Plethoric appearance of facial skin Glossitis and weight loss Jaundice with an enlarged liver Petechiae and ecchymosis
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Petechiae and ecchymosis The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.
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A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? Decreased capillary refill Dyspnea Orthopnea Dependent edema
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Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to development of dependent edema.
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A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect? -Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. -The client is experiencing premature ventricular complexes at 12/min. -Telemetry monitoring shows pacing spikes with no QRS complexes -The client is experiencing hiccups
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Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min, because the client's intrinsic rate overrides the set rate of the pacemaker.
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A nurse is transfusing a unit of O-negative fresh frozen plasma to a client whose blood type is B positive. Which of the following actions should the nurse take? Continue to monitor for manifestations of a transfusion reaction. Remove the unit of plasma immediately and start an IV infusion of normal saline solution. Continue the transfusion and repeat the type and crossmatch. Prepare to administer a dose of diphenhydramine IV
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Remove the unit of plasma immediately and start an IV infusion of normal saline solution. A client who receives FFP that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.
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A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postprocedure plan of care? Instruct the client on a long-term cardiac conditioning program. Administer scheduled doses of acetaminophen. Check for peak laboratory markers of myocardial damage. Monitor for bleeding.
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Monitor for bleeding. Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client remains on bed rest until hemostasis is assured.
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A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? Midsternal chest pain Thrill Pitting edema in lower extremities Lower back discomfort
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Lower back discomfort Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
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A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? "I should eat foods high in saturated fat." "Before taking my medication, I will count my radial pulse rate." "I will exercise once per week for an hour at the health club." "I will stop taking my medication when my blood pressure is within a normal range."
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"Before taking my medication, I will count my radial pulse rate." A beta blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration.
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A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? Increased cardiac output Increased pulmonary congestion Decreased left atria pressure Decreased pulmonary artery pressure
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Increased pulmonary congestion Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure.
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A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? Potassium 2.8 mEq/L Digoxin level 0.7 ng/mL Hemoglobin 9.8 g/dL Calcium 8.0 mg
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Potassium 2.8 mEq/L A flattened T wave or the development of U waves is indicative of a low potassium level.
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A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? Bradycardia with S-T segment depression Relief of chest pain with deep inspiration Dyspnea with hiccups Chest pain that increases when sitting upright
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The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.
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pericarditis Chest discomfort
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Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac.
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A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? Hypokalemia Lead poisoning Hypercalcemia Iron toxicity
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Iron Toxicity The client who has received several blood transfusions is at risk for development of hemosiderosis, which is excess storage of iron in the body. The excessive iron can come from overuse of supplements or from receiving frequent blood transfusions, as in sickle cell anemia.
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A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching? Hospitalization is required when administering each treatment. The maximum effect of the medication will occur in 6 months. Hypertension is a common adverse effect of this medication. Blood transfusions are needed with each treatment.
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The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.
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A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? Pitting edema Areas of reddish-brown pigmentation Dry, pale skin with minimal body hair Sunburned appearance with desquamation
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Dry, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.
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A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? Prothrombin time WBC count Platelet count Hematocrit
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Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.
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A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) to a client who has anemia. Which of the following actions should the nurse take first? Hang an IV infusion of 0.9% sodium chloride with the blood. Check the client's identification number with the number on the blood Witness the informed consent. Obtain pretransfusion vital signs.
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The nurse should apply the least invasive priority-setting framework. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, as witnessing the informed consent is the least invasive, it is the action that should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion to a client.
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A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) Jugular vein distension Moist crackles Postural hypotension Increased heart rate Fever
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Jugular vein distension is correct. The increase in venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles is correct. This is an indicator of pulmonary edema that can quickly lead to death. Postural hypotension is incorrect. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in hypertension and tachycardia. Increased heart rate is correct. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses. Fever is incorrect. Fever is common in clients who are experiencing dehydration, not fluid volume excess.
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A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? Omega-3 fatty acids Antioxidants Vitamins A, D, and C Beta-carotene
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Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels.
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A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? Infective endocarditis Pericarditis Ventricular dysrhythmias Pulmonary emboli
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Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.
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A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? Administer ferrous sulfate supplementation. Increase dietary intake of folic acid. Initiate weekly injections of vitamin B12. Initiate a blood transfusion.
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The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.
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A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first? Maintain the IV access with 0.9% sodium chloride. Stop the infusion of blood. Send the blood container and tubing to the blood bank. Obtain a urine sample.
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Stop the infusion of blood The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.
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A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? Weight gain 1 kg (2.2 lb) in 1 day Pitting edema +1 Client report of nocturnal cough B-Type Natriuretic Peptide (BNP) level of 100 pg/mL
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A weight gain of 1 kg (2.2 lb) in 1 day alerts the nurse that the client is retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening.
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A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? Chest pain is relieved soon after resting. Nitroglycerin relieves chest pain. Physical exertion does not precipitate chest pain. Chest pain lasts longer than 15 min.
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The client who has unstable angina will have chest pain lasting longer than 15 min. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.
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A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? Coarse crackles Wheezes Rhonchi Friction rub
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Coarse Crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.
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A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? -P waves occurring at 0.16 seconds before each QRS complex -Atrial rate of 300/min with QRS complex of 80/min -Ventricular rate of 82/min with an atrial rate of 80/min -An irregular ventricular rate of 125/min with a wide QRS pattern
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Atrial rate of 300/min with QRS complex of 80/min The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.
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A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take? Check for hypertension. Auscultate for loud, bounding heart sounds. Auscultate blood pressure for pulsus paradoxus. Check for a pulse deficit.
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The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.
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A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? 0.45% sodium chloride Dextrose 5% in 0.9% sodium chloride Dextrose 10% in water 0.9% sodium chloride
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0.9% sodium chloride Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the blood stream and is the only solution to use when infusing blood products.
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Hypertonic solions
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The solution of dextrose 5% in 0.9% sodium chloride is a hypertonic solution and should not be used for fluid replacement. This solution will diffuse into the cells of the tissue, having no effect on circulating volume. When the fluid surrounding the cells is hypertonic or has more solutes than the cells, osmotic pressure pulls the fluid from the cells. The solution of dextrose 10% in water is a hypertonic solution and should not be used for fluid replacement. This solution will diffuse into the cells of the tissue, having no effect on circulating volume. When the fluid surrounding the cells is hypertonic or has more solutes than the cells, osmotic pressure pulls the fluid from the cells.
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Hypotonic solution
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The solution 0.45% sodium chloride is a hypotonic solution and should not be used for fluid replacement. This solution can cause lysis of red blood cells because it has fewer solutes than the cell, and osmotic pressure pulls the fluid into the few cells remaining.
