NUR213 cardio questions – Flashcards
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An elderly client is diagnosed with dilated cardiomyopathy. The nurse realizes this type of cardiomyopathy is due to: 1. Hypertension. 2. Heredity. 3. Alcohol intake. 4. Myocardial fibrosis.
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3. Alcohol intake. Rationale: Dilated cardiomyopathy is usually idiopathic but may be secondary to chronic alcohol intake or myocarditis. Heredity and hypertension are causes for hypertrophic cardiomyopathy. Myocardial fibrosis can cause restrictive cardiomyopathy.
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A client diagnosed with cardiomyopathy is being discharged to home. Which of the following would suggest that discharge teaching has been effective for this client? 1. I will eat foods containing sodium only if drinking water with them. 2. I will see the physician to discuss implanting a cardiac defibrillator next week. 3. I will exercise as much as possible regardless of feeling weak and short of breath. 4. My pants getting tight around the waist means I'm eating too much and short cut back on food.
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2. I will see the physician to discuss implanting a cardiac defibrillator next week. Rationale: Evidence that discharge instruction is effective for a client with cardiomyopathy would be the statement "I will see the physician to discuss implanting a cardiac defibrillator next week" since sudden cardiac death can occur with this medical diagnosis. The other client statements would indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.
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The nurse assessing a child with a congenital heart defect should include which of the following when assessing the cardiac status? 1. Observe for abdominal distention 2. Inspect the chest for heaving 3. Auscultate breath sounds 4. Measure urine output
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2. Inspect the chest for heaving Rationale: The nurse should inspect the client's chest for heaving, which is a lifting of the chest during contractions. Observing for abdominal distention would be done during the assessment of the client's fluid status. Auscultating breath sounds would be included in the assessment of the respiratory status. Measuring urine output is not a feature of any particular status and may or may not need to be done.
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The nurse caring for a pediatric client recovering from surgery to repair a congenital heart defect would include which of the following interventions to support the client's fluid status? 1. Limit fluids 2. Maintain intravenous therapy until day before discharge 3. Encourage fluids 4. Monitor output
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3. Encourage fluids Rationale: The child should be encouraged to begin oral fluids and nutrition when permitted. Although oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and antibiotics should be provided as ordered until the child's oral intake is normal. Once normal, the line can be converted to a heparin or saline lock. Both intake and output should be monitored.
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Which of the following would indicate that the parents of a child recovering from surgery to repair a congenital heart defect understand discharge instructions provided by the nurse? 1. The client will need to take antibiotics prior to having dental surgery. 2. The client should be restricted in play and activity for at least 6 months. 3. Fluids should be restricted to maximize lung function. 4. The client should not return to normal activities for at least 2 years.
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1. The client will need to take antibiotics prior to having dental surgery. Rationale: Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for invasive procedures. The child should not be restricted in play and activities for at least 6 months. The child should not restrict fluids. The parents should be encouraged to have the child live a normal life and not be restricted for 2 years.
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. A client with angina complains that the angina pain is prolonged, severe, and occurs at the same time each day while the client is resting. There are no precipitating factors to the pain. How would the nurse describe this type of angina pain? 1. Stable angina 2. Unstable angina 3. Atypical angina (Prinzmetal's angina) 4. Non-anginal pain
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3. Atypical angina (Prinzmetal's angina) Rationale: Atypical or Prinzmetal's angina often occurs at the same time each day and typically at rest. Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina is not relieved by rest or nitroglycerin and is less predictable. The client has been diagnosed with angina, and, therefore, the pain the client is experiencing is angina.
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A client is admitted with irregular chest pain and shortness of breath. The client complains of fatigue with activity and has a body mass index (BMI) of 30.5. The nurse diagnosis that might be a priority for the client at this time would be: 1. Fear. 2. Ineffective Coping. 3. Fluid Volume Deficit. 4. Imbalanced Nutrition: More than Body Requirements.
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4. Imbalanced Nutrition: More than Body Requirements Rationale: The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and shortness of breath and complains of fatigue with activity. The priority nursing diagnosis for the client at this time would be imbalanced nutrition: more than body requirements. Fear and ineffective coping would be applicable to the client diagnosed with an acute myocardial infarction. There is no evidence that the client has a fluid deficit.
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The nurse is instructing an elderly client about atorvastatin to treat elevated cholesterol. What precautions should the nurse advise the client to report to the healthcare provider? 1. Shortness of breath 2. Muscle pain and weakness 3. Headaches 4. Bruising and excessive bleeding
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2. Muscle pain and weakness Rationale: Side effects of statin drugs, such as atorvastatin, include liver inflammation, elevated enzymes, and muscle pain and weakness. Clients are to be advised to report these symptoms while on these medications. The other symptoms are unrelated to taking statin drugs.
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The nurse is providing care to a client who has experienced several episodes of angina. What is the primary outcome for this client? 1. The client will experience relief of chest pain with anticoagulant therapy. 2. The client will experience relief of chest pain with therapeutic lifestyle changes. 3. The client will experience relief of chest pain with aspirin therapy. 4. The client will experience relief of chest pain with nitrate therapy.
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4. The client will experience relief of chest pain with nitrate therapy. Rationale: A primary goal in the treatment of angina is to reduce the intensity and frequency of angina episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina episode. Anticoagulant therapy is used to prevent additional thrombi from forming postmyocardial infarction; it will not relieve angina pain. Therapeutic lifestyle changes are significant if the client is to maintain a healthy heart, but they will not relieve chest pain; this is accomplished with medications. Aspirin therapy following an acute myocardial infarction dramatically reduces mortality due to its antiplatelet function; it will not relieve angina pain.
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Aspirin has been prescribed for a client following a myocardial infarction. Teaching about this medication should include: 1. Take at a different time of day than warfarin. 2. Report any itching after seven days of taking. 3. Do not skip any scheduled appointments to have blood drawn for labs. 4. Check with your health care provider before taking herbal remedies.
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4. Check with your health care provider before taking herbal remedies. Rationale: Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can increase the effect of the aspirin. Itching is not a common side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently. No lab appointments will be made just for aspirin therapy.
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The nurse has completed medication education with the client who is receiving nitroglycerine as therapy for angina. The nurse determines that teaching is effective when the client makes which statement? 1. "I can take 3 tablets, one every 10 minutes, but not more than 3 tablets in 30 minutes." 2. "I can take 1 tablet under the tongue every 5 minutes, but not more than 3 tablets in 15 minutes." 3. "I can keep taking tablets until the pain is gone, but I should not use more than 5 tablets." 4. "I should call my doctor if my pain is not gone after 15 minutes of taking these tablets."
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2. "I can take 1 tablet every 5 minutes, but not more than 3 tablets in 15 minutes." Rationale: Clients must be instructed to take one nitroglycerine tablet sublingual every 5 minutes until pain is relieved, or up to 3 doses. Nitroglycerine tablets should be taken every 5 minutes, not every 10 minutes. Clients should follow the timeframe of taking a nitroglycerine tablet every 5 minutes and not exceed 3 tablets. Calling the physician is appropriate, but the client must still know the protocol for taking nitroglycerine tablets.
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A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain and shortness of breath. The nurse suspects pulmonary embolism and should do which of the following actions first? 1. Increase the rate of heparin infusion 2. Apply oxygen and elevate the head of the bed 3. Reassure the client and notify family members 4. Assess pulse, respirations, and blood pressure
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2. Apply oxygen and elevate the head of the bed Rationale: Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate of heparin infusion will not provide any information on the client's activated partial thromboplastin time (aPTT) level, nor would it provide any information on the physician's order regarding regulating the infusion according to the aPTT level. Reassuring the client and notifying family members are not the priority, although these measures are designed to decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation.
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The nurse is planning an in-service educational program to instruct clients on disseminating intravascular coagulation (DIC). The nurse should identify which of the following as risk factors for this condition? (Select all that apply.) 1. Diabetes mellitus 2. Abruptio placentae 3. Prolonged retention of a fetus after demise 4. Multiparity 5. Preterm labor
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2. Abruptio placentae 3. Prolonged retention of a fetus after demise Rationale: Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC. Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that triggers DIC.
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A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. The nurse would expect to provide which of the following for the client? 1. Heparin 2. Coumadin 3. Aspirin 4. Fresh frozen plasma and platelets
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4. Fresh frozen plasma and platelets Rationale: When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given to restore clotting factors and platelets. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.
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During hospitalization for congestive heart failure, a client awakens during the night frightened and short of breath. This client most likely is experiencing: 1. Multisystem heart failure. 2. Cardiomyopathy. 3. Paroxysmal nocturnal dyspnea. 4. High-output failure.
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3. Paroxysmal noctural dyspnea. Rationale: Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.
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The nurse would determine that which of the following clients has the greatest risk of developing heart failure? 1. A 50-year-old African American female who smokes 2. A 69-year-old African American male with hypertension 3. A 75-year-old Caucasian male who is overweight 4. A 52-year-old Caucasian female with asthma
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2. A 69-year-old African American male with hypertension Rationale: Age, race, and hypertension lead to an increased risk for developing heart failure. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, being African American, and having hypertension. Asthma is not considered a significant risk factor in the development of heart failure.
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A child with congestive heart failure (CHF) has been admitted. While assessing this client, the nurse would find which of the following? 1. Weight loss 2. Bradycardia 3. Tachycardia 4. Increased blood pressure
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3. Tachycardia Rationale: Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.
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The nurse is reviewing assessment data for a client with a history of congestive heart failure who was admitted for shortness of breath. The client reported not having enough money to purchase medications. Which of the following nursing diagnoses will be of the greatest initial importance when planning care? 1. Activity Intolerance related to shortness of breath 2. Fatigue related to shortness of breath 3. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications 4. Excess Fluid Volume related to shortness of breath
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4. Excess Fluid Volume related to shortness of breath Rationale: The client is experiencing acute shortness of breath because of the excess fluid. Excess fluid volume is the nursing diagnosis that is the priority at this time. Activity intolerance and fatigue will improve once the excess fluid volume is addressed. Ineffective management of therapeutic regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.
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Which of the following would be included in the nursing care of an infant with congestive heart failure? 1. Force fluids appropriate for age 2. Monitor respirations during active periods 3. Organize activities to allow for uninterrupted sleep 4. Give larger feedings less often to conserve energy
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3. Organize activities to allow for uninterrupted sleep Rationale: It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the heart. Fluids should be restricted to those that are high in calories and low in volume in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor during active periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
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The nurse is assessing a client being treated for congestive heart failure. Which of the following physical findings would indicate that the client's condition is not improving? 1. Temperature of 98.6°F (37°C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes
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4. Wheezing of breath sounds in all lobes Rationale: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.
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A client is receiving enalapril for treatment of heart failure. Which of the following assessment findings should the nurse be concerned about following the initial administration of this drug? 1. Ototoxicity 2. Serious rash 3. Low blood pressure 4. Irregular pulse
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3. Low blood pressure Rationale: Severe hypotension, known as first-dose phenomenon, can occur after the initial administration of enalapril. Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse are adverse effects of beta-blockers.
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A client diagnosed with left-sided cardiac failure would be most comfortable in which sleeping position? 1. Lying on either side with the head of the bed elevated 30° 2. Seated in a recliner with 2-3 pillows under head 3. Lying on the left side with the head of the bed elevated 30° 4. Seated in a recliner with 2-3 pillow under feet
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2. Seated in a recliner with 2-3 pillows under head Rationale: The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the work of breathing. Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not needed for sleep.
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A client has a nighttime cough related to taking enalapril. What is the best nursing intervention to promote rest in this client? 1. Contact the physician for an order for a cough-suppressant medication 2. Have the client sleep on 2 or 3 pillows at night 3. Have the client sit up at an 80°angle in a comfortable chair at night 4. Contact the physician for an order for a sedative-hypnotic medication
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2. Have the client sleep on 2 or 3 pillows a night Rationale: The client should sleep with the head elevated if a cough becomes troublesome when in supine position. A cough induced by an angiotensin-converting enzyme inhibitor- will not be relieved by cough medication. Sitting up at an 80°angle would be effective but would be too uncomfortable for the client. A sedative-hypnotic medication would put the client to sleep, but it does nothing to address the client's cough.
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During a blood pressure screening an elderly male tells the nurse he experiences a fluttering in his chest while doing yard work. He reports no other symptoms, and the frequency is intermittent. The nurse would interpret this finding to be consistent with: 1. Underlying illness that requires a medical evaluation. 2. Nonspecific cardiac changes with aging. 3. Hypothyroidism. 4. Exercise intolerance.
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1. Underlying illness that requires a medical evaluation. Rationale: New onset atrial fibrillation and other arrythmias may signal the onset of a serious underlying illness that requires further medical evaluation. Chest fluttering can be a sign of hyperthyroidism, not hypothyroidism. These symptoms are not normal cardiac changes. Exercise intolerance would include shortness of breath, which the client does not report.
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2. The nurse assessing an elderly client with a cardiac dysrhythmia realizes that this health problem in older adults is most commonly associated with: 1. Loss of cells in the sinoatrial node. 2. Increased peripheral resistance. 3. Hypertension. 4. Atherosclerosis.
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1. Loss of cells in the sinoatrial node. Rationale: Loss of cells in the sinoatrial node because of age-related changes is the most common cause of dysrhythmias in the older adult. Increased peripheral resistance, hypertension, and atherosclerosis are not common causes of cardiac dysrhythmias in older adults.
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Which of the following should the nurse do to assist an unstable infant with supraventricular tachycardia? (Select all that apply.) 1. Apply of ice to the face 2. Administer intravenous adenosine 3. Administer intravenous amiodarone 4. Prepare for cardioversion 5. Roll the baby onto the stomach
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2. Administer intravenous adenosine 3. Administer intravenous amiodarone 4. Prepare for cardioversion Rationale: The baby is unstable and therefore should be given adenosine or amiodarone if vagal maneuvers are not successful in breaking the rhythm. Cardioversion is used in an urgent situation. Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants the application of ice or iced saline solution to the face could reduce the heart rate.
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Barry Marks, a 56-year-old man with a history of coronary artery disease, is admitted with reports of dyspnea and fatigue. Upon physical examination, you auscultate crackles halfway up Mr. Marks's lung fields. An echocardiogram reveals reduced cardiac output. Which response should you provide to Mr. Marks when he asks you to explain why a heart problem makes it is hard for him to breathe? "The right side of your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs." "Your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs." "The right ventricle of your heart is not pumping properly." "The right side of your heart is too weak to pump enough blood to your lungs."
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"Your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs." Pulmonary edema develops as a consequence of left-sided heart failure. Symptoms include shortness of breath, pink, frothy sputum, labored breathing increased respiratory rate, fine crackles, and wheezes. Right-sided failure involves failure of the right ventricle, causing blood to accumulate in the systemic venous system.
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Max Katzer, a 57-year-old man with a history of type 2 diabetes mellitus and ischemic heart disease, is admitted to the hospital with systolic heart failure. During your shift, Mr. Katzer suddenly starts to report shortness of breath and he coughs up pink, frothy sputum. Upon physical examination, you notice that his breathing is labored and that his respiratory rate is 38 breaths/min. Upon auscultating his chest, you hear fine crackles and faint wheezes over all of his lung fields. Which finding explains Mr. Katzer's physical assessment findings? Decreased pulmonary hydrostatic pressure Pulmonary edema Hepatic engorgement Increased myocardial contractility
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Pulmonary edema Pulmonary edema develops as a consequence of heart failure. Symptoms include shortness of breath, pink, frothy sputum, labored breathing, increased respiratory rate, fine crackles, and wheezes. Myocardial contractility is decreased. Pulmonary hydrostatic pressure is increased. Hepatic engorgement is not associated with these symptoms, but can occur.
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Mae Jones, an 83-year-old woman with a history of hypertension, is admitted with reports of dyspnea on exertion. When you perform a physical assessment on Ms. Jones, you auscultate S3 and S4 heart sounds over her left sternal border and fine crackles over the bottom half of her lung fields. Her breathing is labored, and her oxygen saturation is 88% while breathing room air. Which intervention would you include for Ms. Jones's nursing plan of care? Administer oxygen as prescribed. Give foods high in sodium. Encourage liberal fluid intake. Instruct her to stop taking diuretics.
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Administer oxygen as prescribed Pulmonary edema develops as a consequence of heart failure. Symptoms include shortness of breath, pink, frothy sputum, labored breathing, increased respiratory rate, fine crackles and wheezes. Administering oxygen as prescribed would be included in the nursing plan of care. Fluid restrictions may be implemented. Liberal fluids are not encouraged. Stopping diuretics would exacerbate her symptoms, and she should not be instructed to stop taking them. A sodium-restricted diet is recommended.
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A nurse is describing the pathophysiology of heart failure to a client. Which changes caused by compensatory mechanisms in the development of heart failure should the nurse describe? (Select all that apply.) A. The kidneys release renin to retain sodium and water in an attempt to maintain cardiac output. B.Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output. C. Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation. D. The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume. E. Increased cardiac output causes the aortic baroreceptors to stimulate the sympathetic nervous system.
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A, B, C, E Rationale: Initially, cardiac output is increased because the cardiac muscles are able to accommodate the additional workload. This situation cannot last. Over time, the cardiac muscle will weaken, and cardiac output will begin to decrease. Decreased cardiac output causes the aortic baroreceptors to stimulate the sympathetic nervous system. The heart develops structural changes to accommodate additional fluid volume. The heart chambers and heart muscles enlarge to accommodate the additional fluid. As the cardiac output decreases, perfusion to the kidneys decreases. The kidneys respond by releasing renin to increase the vascular volume and venous return. Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation. Atrial natriuretic peptide is a hormone that helps balance the effects of other hormones.
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A nurse is preparing discharge teaching for a client newly diagnosed with heart failure. Which information should the nurse include in this teaching? Restrict sodium intake to 3 g/day. Allow rest periods throughout the day. Eat three large meals daily. Strenuous exercise is encouraged as manifestations improve.
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Allow rest periods throughout the day. Rationale: Activity intolerance is common in clients with heart failure. The client will need to cluster activities and allow rest periods throughout the day. Strenuous exercise is not recommended. A client needs to be educated about restricting sodium intake to 1.5dash-2 g/day. The client should also eat small frequent meals instead of three large meals.
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A client reports weakness, fatigue, and decreased exercise tolerance. Based on the reported symptoms, the nurse anticipates that the healthcare provider will diagnose the client as having which classification of heart failure? Diastolic Right-sided Left-sided Systolic
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Systolic Rationale: Weakness, fatigue, and decreased exercise tolerance are clinical manifestations of systolic heart failure. Diastolic, left-sided, and right-sided heart failure have different manifestations than those reported by the client.
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A nurse is caring for a client newly diagnosed with heart failure. The client is placed on venous pressure monitoring. Which information about the heart function does venous pressure monitoring provide? (Select all that apply.) Normal range, 2 to 6 mmHg Left ventricular and cardiac functioning Right heart filling pressures Direct and continuous arterial blood pressures Fluid status
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Normal range, 2 to 6 mmHg Right heart filling pressures Fluid status Rationale: Venous pressure monitoring includes right heart filling pressures and can be used to monitor fluid status. The normal central venous pressure is 2dash-6 mm Hg. Intra-arterial pressure monitoring provides direct and continuous arterial blood pressures. Pulmonary artery pressure monitoring is used to evaluate left ventricular and cardiac functioning.
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A nurse is providing care to a client diagnosed with heart failure. Which interventions should the nurse implement when monitoring the client's fluid volume? (Select all that apply.) Allow for rest periods. Record hourly urine outputs. Monitor intake and output. Weigh the client daily. Auscultate lung sounds every 4 hours.
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Record hourly urine outputs. Monitor intake and output. Weigh the client daily. Auscultate lung sounds every 4 hours. Rationale: When caring for a client diagnosed with heart failure, the nurse should auscultate lung sounds every 4 hours, weigh the client daily, monitor intake and output, and record hourly urine outputs. These interventions will assist in monitoring the client's fluid volume status. Allowing for rest periods will assist with the client's activity. It is not used to monitor the client's fluid volume.
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A nurse is providing care for a client with heart failure. The client has weakened ventricular contractions and deceased cardiac output. The nurse anticipates an order for which medication to improve contractility? Digitalis glycosides Nitrates Loop diuretics Alpha-blockers
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Digitalis glycosides Rationale: Digitalis glycosides increase contractility by improving systolic contractions, which improves cardiac output and perfusion. Nitrates are vasodilators, both venous and arterial. They will not improve contractility. Loop diuretics cause the kidneys to release water through the loop of Henle. They reduce volume, but will not improve contractility. Alpha-blockers are typically not used in the treatment of heart failure.
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A client with preeclampsia at 32 weeks' gestation has been admitted to the hospital with signs of a worsening condition. She tells the nurse that she is worried about injury to her baby. Which action may the nurse take to help the client remain calm about her own and her baby's condition? (Select all that apply.) A. Keep the client and her family informed about fetal status B. Inform the client that a preterm delivery may be unavoidable if she does not remain calm and her blood pressure continues to rise C. Invite the client to identify and discuss any concerns she has about her baby's well-being D. Inform the client that a nurse will be with her to offer support during the administration of any tests for fetal well-being E. Educate the client on how to monitor and record fetal movement throughout the day
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A, C, D, E Rationale: The nurse can and should offer support and practical help to the client and her family during this difficult time. When the client knows how to monitor her own symptoms in order to be able to report worsening conditions that will affect her baby, it can ease her mind. Some of her fears of the unknown can be allayed when she and her family are kept informed of any tests that are being performed and how the baby is doing. Talking about her concerns lets the nurse know how to best help her. Emphasizing the possibility of a preterm delivery will not contribute to a calm environment for the client.
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A postpartum client with preeclampsia voices concerns about avoiding a second pregnancy. What information can the nurse provide her? A. Information about postpartum onset of HELLP syndrome B. Information about various forms of contraception C. Information about recurrence of preeclampsia with a subsequent pregnancy D. Information about postpartum depression
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B Rationale: The nurse should provide the client and her partner with information about family planning and the various methods of contraception without bias or judgment, allowing them to make an informed decision. Information concerning postpartum depression, the recurrence of preeclampsia, or HELLP syndrome will not address her concerns about avoiding a second pregnancy.
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A nurse is caring for a pregnant client who is being monitored for gestational hypertension. Which assessment finding indicates a worsening of gestational hypertension and the need to notify the healthcare provider? Client complains of blurred vision and a headache Blood pressure 140/90 mmHg Increased urine output Edema 2+
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Client complains of blurred vision and a headache Rationale: Complaints of blurred vision, headache, and/or epigastric pain are indications that the condition is worsening. Baseline BP for preeclampsia is 140/90 mmHg. Any increase of 30 systolic and 15 diastolic can indicate possible gestational hypertension. Gestational hypertension will cause a decrease in urine output, not an increase. Edema of 2+ is a normal finding.
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At a prenatal visit, a client with gestational hypertension laments the amount of weight she has gained since her last appointment. Her blood pressure and other vital signs are within acceptable limits. What does the client say that indicates that she needs additional education about good nutrition? A. "I have stopped drinking diet soda." B. "I couldn't taste much of a difference when I made my curried goat with half as much salt, but my family could." C. "I try not to eat more than 1,200 calories a day." D. "I go for a walk around my neighborhood most evenings."
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C Rationale: Restricting her calorie intake to less than 1,200 calories daily is not only counterproductive to weight control, it will not provide the nutrients the client needs for good health for herself and her baby. When discussing appropriate intake, it is important for the nurse to explore any cultural restrictions on diet. Walking each evening, limiting salt intake, and cutting out diet soda are positive practices.
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A nurse is caring for a pregnant client with preeclampsia. The nurse is at the bedside and notes that the client has now progressed to eclampsia. Which would be the nurse's first priority? Administer oxygen by mask Maintain an open airway Administer magnesium sulfate IV Assess BP and fetal heart rate
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Maintain an open airway Rationale: When the client progresses from preeclampsia to eclampsia, a seizure is involved. A patent airway is the immediate priority when someone is having a seizure. The other options are all actions that would be taken, but maintaining a patent airway is the priority.
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A client with severe preeclampsia is 12 hours postpartum after delivering a healthy baby. Why has the health care provider ordered a magnesium sulfate infusion to be continued for this client? A. There is the possibility of seizures after delivery. B. There is indication that fluid intake and output is inadequate after delivery. C. There is a need to control postpartum bleeding. D. There is a need to suppress lactation after delivery.
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A Rationale: Magnesium sulfate may be infused up to 48 hours after delivery in order to prevent a seizure in a client with severe preeclampsia, or to prevent a repeat seizure in a client who has eclampsia. Magnesium sulfate does not aid diuresis, control bleeding, or suppress lactation.
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_______________ is a hypertensive disorder that occurs in the second half of pregnancy and is associated with proteinuria.
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Preeclampsia
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_______________ is a life-threatening hypertensive disorder of pregnancy that is associated with seizure and/or coma.
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Eclampsia
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___________________ occurs prior to 20 weeks? gestation, or is present prior to pregnancy.
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Chronic hypertension
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_____________ occurs in the second half of pregnancy and is generally not associated with proteinuria.
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Gestational hypertension
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What are some predisposing risk factors for preeclampsia? (Select all that apply.) Obesity History of kidney disease Twin pregnancy Maternal age below 35 Birthplace in South America
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Obesity History of Kidney Disease Twin Pregnancy
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The nurse is caring for a woman admitted to the labor and delivery unit with severe preeclampsia. Which medication would the nurse anticipate being ordered for the management of this client? Magnesium sulfate Labetalol Hydralazine Meperidine
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Magnesium sulfate Magnesium sulfate can be used to prevent severe preeclampsia from advancing to eclampsia. It can also be used as an anticonvulsant in women with eclampsia. Hydralazine and labetalol are antihypertensive agents. Meperidine is an analgesic narcotic used to relieve pain.
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A nurse is caring for a woman with preeclampsia, and is trying to keep her environment calm and quiet. What effect can over-stimulation have on a client with preeclampsia? Seizure activity Weight gain Sodium retention Placental separation
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Seizure activity Over-stimulation causes central nervous system changes, which can cause hyperreflexia, headache, and seizures. It does not cause weight gain, sodium retention, or placental separation. The client with preeclampsia should be encouraged to remain quiet and calm, with low lights and limited phone calls.
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Which nursing interventions can assist the client with preeclampsia after her delivery and return home? (Select all that apply.) A. Educating about nutritious meal choices B. Educating about recognizing the signs of infection C. Educating about the possibility of delivering by cesarean section D. Educating about pain management during delivery E. Educating about community resources and support groups
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A, B, E
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The nurse will educate the client with preeclampsia on which antepartum management practices? (Select all that apply.) Monitoring weight daily Eating foods high in protein Performing fetal kick counts daily Self-assessment of blood pressure Checking blood glucose daily
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Monitoring weight daily Eating foods high in protein Performing fetal kick counts daily Self-assessment of blood pressure Management of clients diagnosed with preeclampsia may lead to positive health outcomes for both the mother and the baby. The nurse will educate the client to assess her blood pressure and weight daily, maintain a diet high in protein, and perform fetal kick counts daily. It is not necessary for the client with preeclampsia to check blood glucose levels daily.
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While performing an assessment on Margie Sawyer, a client with preeclampsia who is in active labor, the nurse notes that the client is confused and irritable when responding to questions, and has hyperreflexia. These may be signs of which impending condition? Hemorrhage Premature rupture of membranes Seizure Hypovolemic shock
answer
Seizure These changes in the central nervous system can indicate that mild-to-moderate preeclampsia is advancing to severe preeclampsia and then to eclampsia, which can be accompanied by seizures. Signs of an impending seizure include confusion, positive clonus, right upper quadrant pain, and signs of cerebral irritability. Rupture of the membranes while in active labor is not premature. These signs are not suggestive of the risk of hemorrhage or hypovolemic shock.
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Yael Nasir is a 27-year-old woman who is at 30 weeks' gestation with her first child. She has mild preeclampsia and presents for a routine prenatal exam with swollen hands and ankles. The nurse suspects that the client is not adhering to the suggested meal plan but wants to be mindful of her cultural background. Which intervention would be appropriate with this client? a. Instruct the client on the risks of seizures and premature delivery if she does not eat properly b. Tell the client to go home and elevate her feet c. Arrange for a consultation with a dietitian who will take into consideration the client's cultural dietary restrictions d. Have the client admitted to the hospital, where her diet will be strictly monitored
answer
C The focus of nursing care is to maintain the safety of the mother with delivery of a healthy baby. The client's cultural practices, values, and beliefs are factors that must be considered when implementing any treatment plan. A dietitian can help this client develop a diet plan customized to reflect her culture, lifestyle, and financial situation. If the client is stable, she does not need to be admitted to the hospital. Instructing the client that she may risk her pregnancy if she does not eat properly is neither therapeutic nor helpful. Advising the client to go home and elevate her feet does not address the potential problem.
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Crystal Evans, a 37-year-old client with preeclampsia, is in labor and will have a vaginal delivery. In preparation for delivery, the nurse responsible for intrapartum care has educated the client on the delivery position in which the client lies on her left side. Which delivery position does the nurse anticipate the physician/midwife will recommend for this client? Semi-sitting position Prone position Sims' position Lithotomy position
answer
Sims' position Lying on the left side in Sims' position increases venous return, circulatory volume, and placental and renal perfusion, which lowers blood pressure. If she is stable enough to deliver vaginally, a client can benefit from this less restrictive delivery position. The semi-sitting position is also recommended; but as its name suggests, the client does not lie on her left side. The lithotomy position has the client lie on her back with the legs lifted and supported. The prone position requires a client to lie face down and is not used for childbirth.
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A physician orders magnesium sulfate IV for a primigravida client at 37 weeks' gestation diagnosed with severe preeclampsia. Which medication would the nurse have readily available at the client's bedside? Phenytoin (Dilantin) Hydralazine (Apresoline) Diazepam (Valium) Calcium gluconate
answer
Calcium gluconate Rationale: Because the client is receiving magnesium sulfate IV, she is at risk of magnesium toxicity. Calcium gluconate is the antidote for magnesium toxicity. Diazepam (Valium) and phenytoin (Dilantin) are used to treat a client having seizures; Hydralazine (Apresoline) is used to treat hypertension.
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What are some interventions that may be appropriate to include in the plan of care for the client with gestational hypertension? (Select all that apply.) A. Educating the client about treatment alternatives for an ectopic pregnancy B. Consider cultural limitations when educating the client about nutritious meal planning C. Taking frequent blood pressure readings D. Assessing the client's blood glucose level once daily before breakfast E. Educating the client about the effect of the disease process on pregnancy
answer
B, C, E Rationale: Assessing blood pressure more frequently, educating the client about proper nutrition, and helping the client maintain her physical and emotional comfort are important nursing interventions. It is important to take cultural considerationsinto account during the educational process to help ensure compliance. The client with gestational hypertension has no need for information about ectopic pregnancy. Blood glucose levels do not need to be monitored in a woman with gestational hypertension.
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The nurse is making a plan of care for a client with severe preeclampsia. Which of the following laboratory values would indicate the client has developed HELLP syndrome? (Select all that apply.) Low liver enzymes Elevated liver enzymes Low hemoglobin Low hematocrit Low platelets
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Elevated liver enzymes Low hematocrit Low platelets Rationale: A client with HELLP syndrome will have a low hematocrit, (hemolysis), elevated liver enzymes, and low platelets. Low hemoglobin and low liver enzymes are not indicators of HELLP syndrome.
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Which observation might lead a nurse to modify the plan of care for a client with preeclampsia? The client cannot verbalize the implications of treatment. The client is seizure-free. The client is monitoring her blood pressure frequently when she is at home. The client is responding to nursing interventions.
answer
The client cannot verbalize the implications of treatment. Rationale: The nurse relies on feedback from the client to devise and implement a plan of care. The nurse may modify her plan of care to include improving communication and helping the client identify and discuss all matters that affect her health and her baby's health. The nurse will need to explore any cultural implications, or the possibility that a language barrier is preventing full understanding or verbalization. If the client is responding to interventions, is monitoring her blood pressure at home, and has remained seizure-free, the plan of care does not need to be modified as these are successful outcomes.
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A client with pregnancy-induced hypertension desires to deliver vaginally. In which position will the nurse place this client to facilitate a vaginal birth? High-Fowler position Lithotomy position Prone position Sims' position
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Sims' position Rationale: For a client who wishes to deliver vaginally, the nurse would position the client in the Sims' (left side) or semi-sitting position. Lithotomy, high- Fowler, and prone positioning are not recommended for a vaginal birth in a client diagnosed with pregnancy-induced hypertension.
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A 34-year-old client with preeclampsia delivers a baby whose birth weight graphs in the 10th percentile although he is full term and the delivery was uncomplicated. Which causal factor of preeclampsia may have contributed to the low birth weight? Maternal obesity Preterm delivery Vasospasm Proteinuria
answer
Vasospasm Rationale: Vasospasm is the constriction of blood vessels. This condition leads to decreased blood flow to the uterus and placenta. The baby then receives less oxygen and fewer nutrients, restricting fetal growth. Preterm delivery, proteinuria, and maternal obesity are not causal factors of preeclampsia.
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A nurse should educate the client receiving pravastatin (Pravachol) to immediately report which finding? 1.Fatigue 2.Diarrhea 3.Sore throat 4.Muscle pain
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4.Muscle pain Rationale: Pravastatin is used to treat hyperlipidemia. Muscle pain could indicate rhabdomyolysis, a serious complication of this medication. It must be reported immediately. Options 1, 2, and 3 are not associated concerns with the medication.
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A client with heart disease is taking digoxin (Lanoxin) and complains of having no appetite, and experiencing diarrhea and blurry vision. The nurse notes that the client's serum potassium (K) level is 3.0 mEq/L. Based on analysis of the data, what might the nurse expect to note when reviewing the digoxin level results? 1. Digoxin level of 1.8 ng/mL 2. Digoxin level higher than 2 ng/mL 3. Digoxin level lower than 0.5 ng/mL 4. Digoxin level of 0 ng/mL because of diarrhea
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2. Digoxin level higher than 2 ng/mL Rationale: When a client is taking digoxin, digoxin toxicity is a concern. The therapeutic digoxin level is 0.5 to 2 ng/mL. Anorexia, diarrhea, and visual disturbances are symptoms of digoxin toxicity. In addition, a low serum potassium level potentiates the risk for digoxin toxicity. This client's potassium level is low at 3.0 mEq/L. The client's complaints are indicative of digoxin toxicity. Therefore the only correct choice is option 2.
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A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? 1.Prothrombin time of 12.5 seconds 2.Activated partial thromboplastin time of 60 seconds 3.Activated partial thromboplastin time of 28 seconds 4.Activated partial thromboplastin time longer than 120 seconds
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2.Activated partial thromboplastin time of 60 seconds Rationale: Common laboratory ranges for activated partial thromboplastin time are 20 to 36 seconds. Because the activated partial thromboplastin time should be 1.5 to 2.5 times the normal value, the client's activated partial thromboplastin time would be considered therapeutic if it was 60 seconds.
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A client is admitted to a hospital with acute myocardial infarction and is started on tissue plasminogen activator (tPA, Activase) by infusion. Of the following parameters, which one should a nurse determine requires the least frequent assessment to detect complications of therapy with tPA? 1.Neurological signs 2.Blood pressure and pulse 3.Presence of bowel sounds 4.Complaints of abdominal and back pain
answer
3.Presence of bowel sounds Rationale: Thrombolytic agents dissolve existing clots, and bleeding can occur anywhere in the body. The nurse monitors for any obvious signs of bleeding and also for occult signs of bleeding, which would include hemoglobin and hematocrit values, blood pressure and pulse, neurological signs, assessment of abdominal and back pain, and the presence of blood in the urine or stool.
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The nurse is preparing to administer furosemide (Lasix) 40 mg by intravenous (IV) injection (IV push) to a client. The nurse should administer the medication over which time period? 1. 10 seconds 2. 30 seconds 3. 1 minute 4. 5 minutes
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3. 1 minute Rationale: When furosemide is administered by IV injection, each 40 mg or fraction thereof should be given over a 1- to 2-minute period. Options 1 and 2 identify administration times that are too rapid and could cause adverse effects. Option 4 is too slow of a time period for administration and may affect effectiveness of the IV medication
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The nurse is caring for a child with heart failure (HF). The nurse provides instructions to the mother regarding the procedure for administration of the prescribed digoxin (Lanoxin). Which statement by the mother indicates a need for further teaching? 1. "I will make sure to mix the medication with food." 2. "I need to take the child's pulse before administering the medication." 3. "If more than one dose is missed, I need to call the health care provider." 4. "If the child vomits after being given the medication, I should not repeat the dose."
answer
1. "I will make sure to mix the medication with food." Rationale: Medication should not be mixed with food, because this method of administration would not ensure that the child received the prescribed dose. The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Additionally, the parents should be instructed that if a dose is missed and is not identified until 4 or more hours later, the dose should not be administered. If more than one dose is missed, the health care provider (HCP) needs to be notified.
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The nurse is caring for a client who is pulseless and experiencing this ventricular tachycardia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? 1.Prepare for cardioversion. 2.Prepare to administer epinephrine. 3.Prepare to administer digoxin (Lanoxin). 4.Provide cardiopulmonary resuscitation (CPR). 5.Prepare to administer amiodarone (Cordarone).
answer
2.Prepare to administer epinephrine. 4.Provide cardiopulmonary resuscitation (CPR). 5.Prepare to administer amiodarone (Cordarone). Rationale: Pulseless ventricular tachycardia is treated the same way as ventricular fibrillation with measures that include defibrillation, CPR and medication therapy, with agents such as vasopressin, epinephrine, amiodarone, lidocaine, and magnesium sulfate.
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The nurse is caring for a client diagnosed with septic shock. Which assessment finding should the nurse report immediately to the healthcare provider? a. Bradycardia with an elevated temperature of 102.4degrees°F b. Hyperactive bowel sounds with abdominal distention c. Elevated blood pressure and warm, dry skin d. Urine output of 15 mL/hr and BP of 82/45
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d. Urine output of 15 mL/hr and BP of 82/45 Rationale: Oliguria and hypotension are considered part of the cold phase or late septic shock. In this phase, in addition to blood pressure and urine decreases, hypovolemia and compensatory mechanisms result, such as rapid, shallow, or dyspneic respirations. The skin becomes cool, pale, and edematous; the client becomes lethargic to comatose mental status. There is decreased CVP, tachycardia, and arrhythmic pulses, and normal to decreased body temperatures. Death may occur during this phase due to respiratory, cardiac, and/or renal failure.
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The nurse is concerned that a client admitted to the cardiac care unit (CCU) after a motor vehicle crash is demonstrating signs of septic shock. Which assessment finding supports this concern? Pulse 60 Blood pressure 110/72 CVP is 1 O2 saturation of 92%
answer
CVP IS 1 Rationale: When assessing a client with sepsis, the nurse monitors the client's hemodynamic status with a central venous pressure IV line or pulmonary artery catheter. Normal CVP is 2-8 mmHg and is decreased with septic shock.
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The nurse is caring for a client diagnosed with septic shock. Which arterial blood gas (ABG) finding would indicate that the client is in shock? Decreased CO2 level Decreased PaCO2 Increased O2 level Decreased pH level
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Decreased pH level Rationale: Arterial blood gas (ABG) test results in clients with septic shock will indicate a decrease in pH (indicating acidosis), a decrease in PaO2 and total oxygen saturation, and an increase in PaCO2.
question
A nurse assigned to the intensive care unit (ICU) should closely monitor which client who is at most risk for septic shock? A 22-year old male with spontaneous pneumothorax A 46-year old female with mitral valve prolapse A 34-year old male with a traumatic head injury A 66-year-old female with infectious pneumonia
answer
A 66-year-old female with infectious pneumonia Rationale The most common cause of bacterial sepsis is gram-positive infections from Staphylococcus and Streptococcus bacteria. The incidence of gram-negative bacterial infections has increased since 2003 with a 60% mortality rate despite treatment. This incidence has increased the most in older adults and non-White populations due to an increase in invasive procedures, immunosuppressive therapies, and antimicrobial resistance. Clients at risk for developing sepsis related to infections are those clients who are hospitalized, have debilitating chronic illnesses, have poor nutritional status, are post invasive procedure or surgery, are older adults, and those who are immunocompromised.
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The nurse is caring for several clients on a step down unit at a local hospital. Which client would require priority assessment for septicemia? Client with GERD who is NPO Client with a history of myocardial infarction with BP 130/90 Client with an indwelling urinary catheter and a temperature of 101.5oF Client with a nonruptured appendix with stable vital signs
answer
Client with an indwelling urinary catheter and a temperature of 101.5F Rationale: Indwelling catheters along with a temperature of 101.5oF indicate the client may be developing septicemia and may require a transfer to the ICU. The client with GERD who is NPO is not at risk for septicemia. A ruptured appendix, not a nonruptured appendix, would place the client at risk for septicemia. The client with a history of MI and an elevated blood pressure requires close monitoring, but not for septicemia.
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The nurse is caring for a client with sepsis. The client's family asks the nurse why there is a need for a blood culture when a diagnosis has already been issued. Which response by the nurse is the most appropriate? "The blood culture determines if liver damage is occurring." "The blood culture determines the most appropriate antibiotics." "The blood culture monitors potassium levels." "The blood culture will allow us to monitor oxygenation status."
answer
"The blood culture determines the most appropriate antibiotics." Rationale: A blood culture will determine specific pathogens and be useful for prescribing antibiotics that are the most effective to treat the sepsis. Arterial blood gases monitor oxygenation status. Serum enzymes determine liver damage. Serum electrolytes determine potassium levels.
question
Normal CVP is ___ to ___ mmHg and is __________ with septic shock.
answer
2-8 mmHg Decreased with shock
question
A client is at risk for infectious sepsis through which portals of entry? (Select all that apply.) Sexually transmitted infections Pulse oximetry monitoring Peptic ulcerations Surgical wounds Intravenous catheters
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Sexually transmitted infections Peptic ulcerations Surgical wounds Intravenous catheters Portals of entry for infection that may lead to sepsis include, but are not limited to, intravenous catheters, surgical wounds, sexually transmitted infections, and peptic ulcerations. Pulse oximetry is not an invasive procedure and is not a portal of entry for infectious sepsis.
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The progression of sepsis leads to reduced organ perfusion and eventually which syndrome? Systemic inflammatory response syndrome (SIRS) Systemic shock syndrome (SSS) Multiple-organ dysfunction syndrome (MODS) Toxic shock syndrome (TSS)
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Multiple-organ dysfunction syndrome (MODS) Sepsis injures blood cells, which can cause platelet aggregation and decreased blood flow, resulting in clots throughout microcirculation and leading to septic shock. This progression of sepsis leads to reduced organ perfusion and multiple-organ dysfunction syndrome (MODS) and ultimately death.
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Which diagnostic test results are expected for a client with septic shock? (Select all that apply.) Increased neutrophil count Normal white blood cell count An increase in PaCO2 Decreased glucose level Decreased BUN and creatinine
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Decreased glucose level Increased neutrophil count An increase in PaCO2 Expected lab findings for septic shock include decreasing levels of glucose and sodium, increased potassium levels;renal function declines as reduced perfusion and microclotting damage occurs and BUN, creatinine, urine specific gravity and osmolality increases. WBC count decreases as cells are destroyed and increased neutrophils and monocytes indicate acute bacterial infection. Septic shock causes a decrease in pH (indicating acidosis), a decrease in PaO2 and total oxygen saturation, and an increase in PaCO2.
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Your client has been diagnosed with sepsis and is taken to the intensive care unit (ICU). Which assessment helps you monitor your client's hemodynamic status? Monitoring the CVP line Palpating peripheral pulses Assessing the client's capillary refill Observing vital signs
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Monitoring the CVP line When assessing a client with sepsis, the nurse monitors hemodynamic status with a central venous pressure (CVP) line or a pulmonary artery catheter. Normal CVP is 2-8 mmHg and is decreased with septic shock.
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Which nursing diagnosis is appropriate for a client with sepsis? Risk for body image disturbance Altered nutritional status Ineffective peripheral tissue perfusion Risk for painful abdominal distention
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Ineffective peripheral tissue perfusion Nursing diagnoses that are appropriate for a client with sepsis include: risk for shock, impaired gas exchange, risk for ineffective renal perfusion, ineffective peripheral tissue perfusion, and risk for imbalanced fluid volume.
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Ms. Smith is a 54-year-old woman admitted to the critical care unit 2 days ago with community-acquired pneumonia and respiratory failure. Although she has been on antibiotics, she is requiring increased amounts of oxygen and is diagnosed with sepsis. Which therapy would be the most effective for Ms. Smith at this time? Lasix 40 mg IV q 12 hours Keflex 80 mg IVP q 6 hours Morphine 2 mg IV q 2hours NS @ 125 mL/hr
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NS @ 125 mL/hr Ms. Smith is an adult client who has received antibiotic therapy and has had a prolonged recovery in a critical care unit. Fluid replacement is the most effective treatment for septic shock (either IV fluids or blood) and can be used alone or in combination with other treatments. Blood and blood products increase oxygenation of cells and crystalloid and/or colloid solutions increase circulating blood volume and tissue perfusion.
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Mr. Ikaika, a 68-year-old man with a history of diabetes mellitus, is admitted with an infected diabetic foot ulcer. Upon admission you notice that he is confused and his vital signs are: temperature 102.6 °F, blood pressure 81/39 mmHg, and pulse 55. Which nursing diagnosis is indicative of his symptoms? Ineffective metabolic status Impaired nutritional status Ineffective tissue perfusion Imbalanced fluid volume
answer
Ineffective tissue perfusion Mr. Ikaika appears to be in septic shock. Appropriateness of responses and behavior reflects the adequacy of cerebral circulation, and an elevated temperature increases metabolic demands, depleting bodily energy reserves, increasing myocardial oxygen demands, and increasing the risk of hypoperfusion. Therefore, it is important to improve tissue perfusion because diminished tissue perfusion causes ischemia and hypoxia of major organ systems (significantly the kidneys, brain, heart, lungs, and gastrointestinal tract).
question
Mr. Hafner is a 43-year-old man recovering from a ruptured diverticulum. His vital signs are as follows: Temperature 102.2 °F, HR 120 beats/minute, BP 79/42 mmHg, and respiratory rate 24/minute. Upon examination you notice that he is confused, his skin is cool and pale, and there is a small amount of bleeding around his IV site. What would you expect Mr. Hafner's blood test to reveal? Multiple-organ dysfunction syndrome (MODS) Disseminated intravascular coagulation (DIC) Systemic inflammatory response syndrome (SIRS) Deep vein thrombosis (DVT)
answer
Disseminated intravascular coagulation (DIC) Mr. Hafner has a history and clinical manifestations that are consistent with septic shock. When SIRS is severe, sepsis develops and the risk of simultaneous bleeding and clotting throughout the vasculature, called disseminated intravascular coagulation (DIC) is increased. Sepsis injures blood cells, which can cause platelet aggregation and decreased blood flow, resulting in clots throughout microcirculation and leading to septic shock.
question
A nurse assigned to the intensive care unit is caring for a client diagnosed with septic shock. Which nursing interventions should the nurse include in the client's plan of care to anticipate complications of shock? (Select all that apply.) Monitor client's blood pressure and pulse Monitor fluid status with intake and output Provide emotional support to the client and family Assess the client's mental status Encourage the client to perform mobility exercises
answer
Monitor client's blood pressure and pulse Monitor fluid status with intake and output Assess the client's mental status Rationale: For the client with sepsis, nursing interventions are aimed at improving tissue perfusion because diminished tissue perfusion causes ischemia and hypoxia of major organ systems. Monitor the client's cardiopulmonary function by assessing/monitoring all vital signs. Monitor urinary output; this is a reliable indicator of renal perfusion.Assess the client's mental status and level of consciousness. Appropriateness of responses and behavior reflects the adequacy of cerebral circulation. Altered LOC is a result of cerebral hypoxia and the effects of acidosis on brain cells
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The nurse is caring for a client diagnosed with septic shock. Which neurological assessment findings require immediate nursing interventions? (Select all that apply.) Disorientation Restlessness Hypothermia Lethargy Acidosis
answer
Disorientation Restlessness Lethargy Rationale: Assess the client's mental status and level of consciousness. Appropriateness of responses and behavior reflects the adequacy of cerebral circulation. Restlessness and anxiety are common signs of early septic shock; lethargy and coma progression reflect later stages. Altered LOC is a result of cerebral hypoxia and the effects of acidosis on brain cells
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A client is brought to the emergency department following a motor vehicle crash. What diagnostic tests should you anticipate the healthcare provider ordering to help determine risk for shock?(Select all that apply.) Electromyography CT scan Gastric tonometry MRI Cardiac catheterization
answer
CT scan Gastric tonometry MRI Rationale: Gastric tonometry and sublingual PaCO2 are newer diagnostic methods that measure the partial pressure of carbon dioxide in the gastric lumen to help identify the cause of sepsis and assess the client's physical status. Other diagnostic tests include X-ray, CT scan, MRI scan, endoscopic exams, and echocardiograms.
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A client is brought to the emergency department for treatment of possible toxic shock syndrome. Which manifestation should the nurse anticipate when assessing this client? Elevated blood pressure Hyperactive bowel sounds Vomiting Anorexia
answer
Vomiting Rationale: Toxic shock syndrome is a virulent form of septic shock that occurs most frequently in menstruating women who use tampons incorrectly. Bacterial toxins from the vagina diffuse into circulation and cause widespread inflammatory response and septic shock. Clinical manifestations of toxic shock syndrome include extreme hypotension, hyperpyrexia, headache, myalgia, confusion, skin rash, vomiting, and diarrhea.
question
The nurse is providing care to several clients on a medical-surgical unit. Which clients would require priority assessment for the development of septic shock?(Select all that apply.) The client being treated for an STI The client with an indwelling urinary catheter The client admitted for a nonhealing surgical wound A client with latex allergies The client admitted with chronic renal failure
answer
The client being treated for an STI The client with an indwelling urinary catheter The client admitted for a nonhealing surgical wound The client admitted with chronic renal failure Rationale: Clients with the following portals of entry are at risk for infections that may lead to sepsis: clients with catheterizations, those undergoing respiratory therapies, and those with peptic ulcers, ruptured appendix, peritonitis, surgical wounds, IVs, decubitus ulcers, burns, and traumas. Female clients with STIs, who use tampons, or who have surgical abortions are at risk for septic shock. Other clients at risk for developing sepsis related to infections are those clients who are hospitalized, have debilitating chronic illnesses, have poor nutritional status, have had an invasive procedure or surgery, and those who are older adults or immunocompromised.
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A client is brought to the emergency department for treatment of possible sepsis. Which pharmacologic therapy is a priority for this client? Opioid medications Broad-spectrum antibiotics Vasoactive medications Inotropic medications
answer
Broad-spectrum antibiotics Rationale: The priority pharmacologic therapy for a client with sepsis is the administration of a broad-spectrum antibiotic. Antimicrobials are the primary pharmacologic treatment for sepsis. Vasoactive and inotropic medications are considered if fluid replacement is not effective. Opioid medications may be given for comfort, but this is not the priority.
question
The nurse is planning care for a client with septic shock who is scheduled to have a central line placed. Which independent nursing intervention will the nurse implement to decrease the client's feelings of anxiety? Placing client away from nurse's station to provide for privacy Explaining all procedures and therapies ordered Administering antianxiety medications as ordered Discouraging visitors to maintain therapeutic environment
answer
Explaining all procedures and therapies ordered Rationale: To prevent anxiety in a client with shock, the nurse should explain all procedures and therapies. The nurse may also administer antianxiety medications as ordered. However, this is a collaborative nursing intervention, not an independent intervention. Placing the client away from the nurse's station and discouraging visitors are nontherapeutic for a client with anxiety related to shock.
question
A nurse is caring for a client in Stage I cardiogenic shock. The nurse understands that capillary hydrostatic pressures may be altered during this stage of shock. What is true regarding capillary hydrostatic pressures in Stage I shock? (Select all that apply.) When increased, causes fluid shifts from interstitial space into the capillaries When decreased, causes fluid shifts from capillaries into the interstitial space Decreases as mean arterial pressure (MAP) decreases Increases as mean arterial pressure (MAP) decreases When decreased, causes fluid shifts from interstitial space into the capillaries
answer
Decreases as mean arterial pressure (MAP) decreases When decreased, causes fluid shifts from interstitial space into the capillaries During Stage I cardiogenic shock, the body alters capillary hydrostatic pressures in order to maintain fluid volume and preserve cardiac output. Decreases in MAP decrease capillary hydrostatic pressures. Also, when these pressures are decreased, fluid shifts from the interstitial space into the capillaries. The other answer choices are incorrect.
question
The nurse is caring for a client with cardiogenic shock who appears anxious and short of breath. The healthcare provider orders morphine sulfate for the treatment of the client's symptoms. What is the nurse's best understanding about the reason for this order? (Select all that apply.) This medication constricts the coronary arteries. This medication improves gas exchange. This medication improves myocardial contractility. This medication decreases anxiety. This medication increases perfusion to the myocardium.
answer
This medication decreases anxiety. This medication increases perfusion to the myocardium. Morphine sulfate, used to decrease pain, also decreases the client's anxiety and dilates the coronary arteries, improving perfusion to the myocardium. This medication does not improve gas exchange or myocardial contractility.
question
The nurse is caring for a client with anaphylactic shock after the client was exposed to latex at a dental appointment. Which diagnostic finding, unique to anaphylactic shock, will the nurse expect to find? Increased basophils Decreased hemoglobin Increased eosinophils Decreased WBC
answer
Increase eosinophils Acute inflammatory responses, such as in anaphylactic shock, increase the levels of eosinophils in the client's serum. Decreased WBC, decreased hemoglobin and increased basophils are not found in anaphylactic shock.
question
As shock progresses, glucose and sodium _________ . Potassium ___________.
answer
decrease increases
question
What is the term for the amount of blood that the left ventricle pumps with each cardiac contraction? Cardiac output Blood pressure Stroke volume Mean arterial pressure
answer
Stroke volume Stroke volume is the amount of blood that the left ventricle pumps with each cardiac contraction. Mean arterial pressure (MAP) is the average blood pressure and is the product of cardiac output (CO) and systemic vascular resistance (SVR). Blood pressure is the pressure within the blood vessels. Cardiac output is the amount of blood the left ventricle pumps per minute.
question
Which diagnostic test identifies the causative organism in septic shock? Arterial blood gas WBC with differential Blood culture Serum electrolytes
answer
Blood culture Blood cultures identify the causative organism in septic shock. The WBC with differential will be elevated in those with septic shock; however, this test does not identify the causative organism in septic shock. Arterial blood gases (ABGs) are used to measure the pH, oxygen, and carbon dioxide levels of the blood. Serum electrolytes are used to monitor the severity of shock.
question
Which nursing intervention is most appropriate for the goal of preserving cardiac output in the client with shock? Explain all procedures and tests Measure and record intake and output Place client in high-Fowler position Maintain oxygenation of 90% or better
answer
Measure and record intake and output The nurse will measure and record intake and output in order to monitor the perfusion to the renal system, assessing cardiac output. The nurse will place the client in shock position, a supine position with the legs elevated to approximately 20 degrees, abdomen flat, head and shoulders elevated higher than the chest (almost equals≈10 degrees). The nurse will maintain the client oxygenation of 94% or greater. The nurse will explain all tests and procedures; however, this is more focused on relieving client anxiety, not preserving cardiac output.
question
A nurse is caring for 32-year-old Gary Peters, who has hypovolemic shock secondary to a massive hemorrhage from a liver laceration that occurred during a motorcycle crash. Gary is orally intubated and mechanically ventilated. Gary's nurse is monitoring his vital signs and calculates Gary's trending pulse pressures. What is the most likely finding the nurse will discover after calculating Gary's pulse pressure? Narrowing pulse pressure Decreased pulse pressure Elevated pulse pressure Widening pulse pressure
answer
Narrowing pulse pressure Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure. Terms used to describe pulse pressures are 'widening' or 'narrowing.' In hypovolemic shock, which is what Gary has, a narrowing pulse pressure is evident. A widening pulse pressure occurs with septic shock. 'Elevated' and 'decreased' are not terms used to describe pulse pressures.
question
A nurse is caring for Sid Morris, a 74-year-old male with septic shock secondary to bilateral pneumonia. Sid was intubated and placed on mechanical ventilation an hour ago after progressively worsening arterial blood gas (ABG) values. Sid's nurse is reviewing the most recent ABG values which necessitated intubation. Which ABG result is most likely the reason for Sid's intubation? pH increased, PaCO2 increased, PaO2 decreased pH decreased, PaCO2 decreased, PaO2 increased pH decreased, PaCO2 increased, PaO2 decreased pH increased, PaCO2 decreased, PaO2 decreased
answer
pH decreased, PaCO2 increased, PaO2 decreased Sid likely has respiratory acidosis due to worsening septic shock and respiratory failure. This is evidenced by an ABG with a decreased pH (acidosis), increased PaCO2 (hypercapnia), and decreased PaO2 (hypoxia). The other answer choices are incorrect.
question
A nurse is caring for 58-year-old Ken Nguyen, who presented to the hospital with crushing midsternal chest pain and dyspnea. After a cardiac work up, Ken's healthcare provider diagnosed Ken with a left anterior wall myocardial infarction (MI) and subsequent cardiogenic shock. Ken appears anxious and has cool, clammy extremities. What is the most appropriate collaborative nursing intervention for Ken? Allow Ken's family to visit with Ken Administer ordered medication to decrease anxiety Explain all procedures and tests Assess the cause of anxiety
answer
Administer ordered medication to decrease anxiety While all of these interventions are appropriate for relieving Ken's anxiety, the only collaborative intervention is administering an ordered medication to decrease anxiety. All other answer choices are independent nursing interventions.
question
A nurse is caring for a client with septic shock who is intubated and mechanically ventilated. Upon assessment, the nurse cannot palpate the client's peripheral pulses and the client's blood pressure appears to fluctuate with every recording. What is the nurse's best response? Use Doppler device for assessment of both blood pressure and pulses Your answer is not correct. Contact the healthcare provider and suggest the use of a vasoactive medication Record pulses as nonpalpable and blood pressure as fluctuating Contact the healthcare provider and suggest hemodynamic monitoring
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Contact the healthcare provider and suggest hemodynamic monitoring The client is likely experiencing severe systemic vasoconstriction, causing nonpalpable pulses and also causing the blood pressure monitor to fluctuate with each recording. The nurse should contact the healthcare provider and suggest hemodynamic monitoring in an effort to obtain accurate recordings of the client's cardiovascular status. Though the use of a Doppler device is not incorrect, the best action is to begin hemodynamic monitoring. The nurse should not simply record the client findings. The client's pulse and blood pressure are not accurate and suggesting a vasoactive medication is inappropriate.
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A nurse is caring for a client with cardiogenic shock after suffering from a myocardial infarction (MI). The nurse understands that this client is prone to alterations of gastrointestinal (GI) function. What is true regarding shock and GI alterations? Metabolic alkalosis occurs due to inability to remove lactic acid Shock decreases gastric motility Shock increases gastric motility Respiratory acidosis occurs due to inability to remove lactic acid
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Shock decreases gastric motility Due to decreases in GI perfusion, shock decreases gastric motility. Metabolic acidosis occurs due to the liver's inability to remove lactic acid.
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The nurse is caring for a client in cardiogenic shock who has severe hypotension and cool, clammy skin. The healthcare provider orders an inotropic medication for the treatment of the client's symptoms. What is the nurse's best understanding about the reason for this order? This type of medication increases cardiac contractility. This type of medication prevents dysrhythmia. This type of medication prevents heart failure. This type of medication increases intravascular volume.
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This type of medication increases cardiac contractility. Inotropic medications are often ordered in the collaborative therapy of a client in cardiogenic shock. This type of medication increases cardiac contractility, improving venous return and perfusion to the myocardium. Inotropes do not increase the intravascular volume or prevent dysrhythmia. This medication is also used in heart failure, but it does not prevent heart failure.
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The nurse is caring for a client with hypovolemic shock secondary to a hemorrhage. The client has received six blood transfusions in order to maintain blood volume. Which additional order by the healthcare provider will the nurse anticipate in the collaborative care of this client? Sodium bicarbonate to treat metabolic acidosis which occurs with blood transfusions Corticosteroids to decrease inflammatory response from blood transfusions Calcium chloride to replace the calcium lost during blood transfusions Antibiotics to decrease risk from infection from blood transfusions
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Calcium chloride to replace the calcium lost during blood transfusions Calcium chloride replaces the calcium lost during blood transfusions. Though this client may receive the additional therapies, the rationales for these medications are incorrect. Corticosteroids are not routinely given after blood transfusions. Antibiotics are not given due to blood transfusions. Sodium bicarbonate does treat metabolic acidosis; however, a blood transfusion itself does not cause metabolic acidosis.
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A nurse is performing an assessment on a client in shock. The nurse notes that the client has cool and clammy extremities. What nursing intervention is used to promote tissue perfusion? Assessing mental status Monitoring changes in pupil size Assessing breath sounds Monitoring for changes in abdominal girth
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Assessing mental status Assessing the client's mental status assesses cerebral perfusion. While the other interventions are appropriate, they do not specifically address tissue perfusion.
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A nurse is planning care for a client with septic shock who is hospitalized and requires supplemental oxygenation in order to preserve cardiac output to the tissues. What nursing intervention will the nurse implement that will help the client's condition? Encourage frequent deep breathing and coughing to promote mobilization of secretions. Place client in supine position with legs in the dependent position to promote venous return. Adjust oxygen flow rate to achieve an oxygenation of 90% or better. Monitor client intake and output to determine renal perfusion.
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Monitor client intake and output to determine renal perfusion. Urine output decreases as cardiac output decreases due to decreased renal perfusion. The nurse should monitor client intake and output to determine renal perfusion. The nurse should encourage strict bed rest and decrease excessive activity. While encouraging deep breathing is normally a positive thing; in this case, the client should not have increased oxygen demand. The nurse should place the client in the supine position with the legs slightly elevated (about 20 degrees). The nurse should adjust oxygen flow rate as ordered to achieve an oxygenation of 94% or better.
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When planning care for a client admitted with a cardiac dysrhythmia, the nurse should include which of the following? 1. Encourage bed rest 2. Monitor serum electrolyte levels 3. Restrict fluids 4. Instruct in a low-fat diet
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2. Monitor serum electrolytes Rationale: The nurse should monitor serum electrolyte levels because electrolyte imbalances affect cardiac depolarization and repolarization and may cause dysrhythmias. More information is needed before determining whether the client needs to be on bed rest. There is no evidence to suggest the client needs to have fluids restricted. There is no evidence to suggest the client needs instruction on a low-fat diet.
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A client asks the nurse, "My doctor said I need cardioversion for my dysrhythmia. Why can't I just take medication?" Which of the following should the nurse respond to this client? 1. "Antidysrhythmic medications have many side effects; cardioversion is considered safer." 2. "Antidysrhythmic medications don't really work very well for most dysrhythmias." 3. "Special diets are necessary with antidysrhythmic medications, and they are hard to follow." 4. "There is a high risk of seizures when you take antidysrhythmic medications."
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1. "Antidysrhythmic medications have many side effects; cardioversion is considered safer." Rationale: Antidysrhythmic medications can cause serious side effects and are normally reserved for clients with overt symptoms or for clients whose condition cannot be controlled by other means, such as cardioversion. Medications are effective for dysrhythmias; however they have many side effects. There is no need for a special diet when a client is taking an antidysrhythmic drug. Antidysrhythmic drugs do not commonly cause seizures
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The nurse is assessing a client with a third-trimester pregnancy in the obstetrical office. Which of the following findings would require immediate intervention by the nurse? 1. Weight gain of one pound in a week 2. Pulse of 92 beats per minute 3. Respiratory rate of 24 per minute 4. Blood pressure of 142/92
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4. Blood pressure of 142/92 Rationale: A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.
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The community nurse is working with a client at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching? 1. "I should call the doctor if I develop a headache or blurred vision." 2. "Lying on my left side as much as possible is good for the baby." 3. "My urine may become darker and smaller in amount each day." 4. "Pain in the top of my abdomen is a sign my condition is worsening."
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3. "My urine may become darker and smaller in amount each day." Rationale: Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician.
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A client with preeclampsia begins to seize. The nurse should do which of the following to protect the client and fetus from injury? 1. Place the client on the left side and protect the airway 2. Place the client in the supine position 3. Elevate the head of the bed 4. Elevate the client's legs
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1. Place the client on the left side and protect the airway Rationale: The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in the supine position. The head of the bed should not be elevated. The client's legs should not be elevated.
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Which of the following are signs of early hypovolemic shock in children? (Select all that apply.) 1. Bradycardia 2. Increased work of breathing 3. Prolonged capillary refill time 4. Decreased blood pressure 5. Tachycardia
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2. Increased work of breathing 3. Prolonged capillary refill time 5. Tachycardia Rationale: Increased work of breathing is an early sign of shock, indicating compensation for decreased cardiac output and volume. Decreased capillary refill time is an early indicator of decreased fluid volume and compensation. Tachycardia is an early compensatory mechanism for hypovolemia in a child. Bradycardia is a late and ominous sign of shock indicating that the child is no longer able to compensate. Decreased blood pressure is a later finding, and would not occur until other compensatory mechanisms were exhausted.
question
A client is experiencing hypovolemic shock as a result of severe burns. The physician orders a low dose of dopamine. The nurse would expect to find which of the following in the client following the administration of this medication? 1. Urinary output of at least 50 mL/hour 2. Increased cardiac output 3. Vasoconstriction and increased blood pressure 4. Stabilization of fluid loss
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1. Urinary output of at least 50 mL/hour Rationale: At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading to vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs with high, not low, doses of dopamine when beta1-adrenergic receptors are stimulated. Vasoconstriction and increased blood pressure occurs with high, not low, doses of dopamine when alpha-adrenergic receptors are stimulated. Dopamine does not prevent or stabilize fluid loss.
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A client is prescribed intravenous dopamine as part of treatment for shock. Which of the following medications should be available to the nurse when administering this medication? 1. Epinephrine (Adrenalin) 2. Naltrexone (Revia) 3. Phentolamine (Regitine) 4. Flumazenil (Romazicon)
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3. Phentolamine (Regitine) Rationale: Extravasation of dopamine can cause severe, localized vasoconstriction resulting in tissue necrosis. The antidote for this is phentolamine (Regitine). Epinephrine (Adrenalin) is used for anaphylaxis. Naltrexone (Revia) is used for opiate overdose. Flumazenil (Romazicon) is used for benzodiazepine overdose.
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An elderly client is diagnosed with dilated cardiomyopathy. The nurse realizes this type of cardiomyopathy is due to: 1. Hypertension. 2. Heredity. 3. Alcohol intake. 4. Myocardial fibrosis.
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3. Alcohol intake. Rationale: Dilated cardiomyopathy is usually idiopathic but may be secondary to chronic alcohol intake or myocarditis. Heredity and hypertension are causes for hypertrophic cardiomyopathy. Myocardial fibrosis can cause restrictive cardiomyopathy
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A client is admitted with complaints of shortness of breath of 2 weeks duration. Which of the following laboratory findings would support the finding that the client is at risk for an alteration in perfusion? 1. Increased hematocrit 2. Decreased BUN 3. Increased blood sugar 4. Increased sedimentation rate
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1. Increased hematocrit Rationale: Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the body's attempt to increase oxygen-carrying capacity by increasing erythrocyte production. This can lead to an alteration in the client's perfusion. BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity. Increases in blood sugar and sedimentation rate are not directly a measure of oxygenation.
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An elderly client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. The nurse would expect that which of the following would be indicated for this client? 1. Nitrate medications 2. Digoxin 3. Beta blocker 4. Encourage fluids
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3. Beta blocker Rationale: Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Nitrates should be avoided because they increase blood pressure. Digoxin should be avoided because it increases the force of contractions. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.
