After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.8° C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client’s temperature?
A fever increases the cardiac output.
Temperatures of 102° F (38° C) or greater lead to an increased metabolism and cardiac workload.
A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client’s question?
There is leakage of red blood cells (RBCs) through the vascular wall.
Increased venous pressure alters the permeability of the veins, allowing extravasation of RBCs; lysis of RBCs causes brownish discoloration of the skin.
A nurse is leading a discussion in a senior citizen center about the risk factors for developing coronary heart disease (CHD) for women versus men. What should the nurse respond when asked to identify the most significant risk factor?
iabetes is twice as high a predictor of coronary heart disease in women than in men. Diabetes cancels the cardiac protection that estrogen provides premenopausal women. Obesity as a risk factor is common to both women and men. An elevated CRP level, a marker of the inflammatory process, is heart-specific in predicting the likelihood of future coronary events in both women and men.
During a party, an individual reports intense chest pain and begins to perspire profusely. Which action should the nurse take first when the client is brought to the emergency department?
Start an intravenous infusion in the client’s arm.
An infusion should be started to provide circulatory access for future therapeutic interventions. The client may be experiencing a myocardial infarction; if the client has a cardiac arrest, shock may impede the ability to access a vein.
A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.
decrease urine output less than 30ml
cool clammy skin
poor peripheral pulses
A client complains of foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. The nurse concludes that further teaching is needed when the client states, “I will:
Elevate my foot”
Elevating the leg decreases the flow of blood to the lower extremity because it must flow without the assistance of gravity.
The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first?
Obtain the other vital signs.
The radial pulse of a client with chronic atrial fibrillation may range from 50 to 180 beats per minute. Other vital signs should be assessed before notifying the health care provider. Although rechecking the pulse to verify the rate may be done, it is not necessary because a pulse of 136 beats per minute is not unusual for a client with chronic atrial fibrillation.
A client is receiving Coumadin (warfarin). The nurse explains the need for careful regulation of dietary intake of vitamin K. What physiologic process does vitamin K promote that makes this instruction essential?
Prothrombin formation by the liver
Vitamin K promotes the liver’s synthesis of prothrombin, an important blood clotting factor, and will reverse the effects of warfarin.
An older client exhibits typical clinical indicators of pulmonary edema. List the following clinical indicators of pulmonary edema in the order they typically appear.
2. increased respirations
5. frothy bloody tinged sputum
The primary health care provider has prescribed a stat chest x-ray and electrocardiogram for an 85-year-old client with a history of congestive heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. The nurse’s immediate actions include which of the following? Select all that apply.
Tell a staff member to get the electrocardiogram machine.
Notify the x-ray department that a chest x-ray must be done stat.
Have a staff member notify the nursing supervisor of the change in client status.
Notify the health care provider of the change in the oxygen saturation to ask what to do.
A nurse is caring for a client who has a prescription for a 2-gram sodium diet and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) level 42 mg/dL and creatinine 1.1 mg/dL. Considering the assessment findings, what is the most appropriate intervention by the nurse?
Expecting an increase in the oral fluid intake
Diuretics cause dehydration, increasing the BUN; increasing fluid intake will result in a decrease in the BUN level.
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.
decreased unrine output
Place the steps to obtaining an orthostatic blood pressure assessment in order.
1.Obtain correct size blood pressure cuff
2.Explain procedure to client
3.Have client in supine position for five minutes and take blood pressure
4.Assist client to a sitting position
5.Obtain blood pressure in sitting position after waiting three minutes
6.Have client stand and take blood pressure immediately
7.Take blood pressure with client standing after three minutes
8.Document blood pressures, pulses, and client toleranc
A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery?
Promoting physical and emotional rest
The major goal is to decrease the workload of the heart; physical and emotional rest reduces cardiac oxygen demand. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase.
The client is admitted with supraventricular tachycardia at a rate of 140 beats per minute. The client’s blood pressure is 110/55 mm Hg, and he is asymptomatic except for a “fluttering feeling” in his chest. Which of the following treatments would be appropriate? Select all that apply:
IV beta blockers
IV Ca channel blockers
If the rate is over 150 beats per minute and the client is symptomatic, emergent cardioversion is considered.
Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. The statement by the client that indicates the teaching was effective is, “I should:
… take one tablet before attempting to climb two flights of stairs.”
The response about taking one tablet before attempting to climb two flights of stairs indicates that the client understands the nurse’s teaching. Taking a nitroglycerin tablet before such an activity probably will prevent an episode of angina, which is an example of prophylactic use of a medication.
What nursing action should be included in the plan of care for a client who had a permanent fixed (asynchronous) pacemaker inserted?
Teach the client to keep daily accurate records of the pulse.
A permanent fixed (asynchronous) pacemaker is set at a predetermined rate; if a pulse rate is more or less than the preset rate, the pacemaker may be malfunctioning.
A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first?
Remove any medication patches.
Medication patches must be removed before application of electrodes because of possible electrical conduction in the area of the patch causing a burn.
A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client’s physiologic responses?
Inflammation in the myocardium causes a rise in the systemic body temperature.
Temperature may increase within the first 24 hours as a result of the inflammatory response to tissue destruction and persist as long as a week. Diaphoresis is caused by activation of the sympathetic NS, Pain is persistent and constant, not intermittent; it is caused by oxygen deprivation and the release of lactic acid. The blood pressure increases initially but then drops because there is a decrease in cardiac output.
A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For what other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply.
headache- cerebral edema from hypervolemia
A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. When describing the purpose of this drug to the client, the nurse explains that it:
Prevents extension of the clot.
Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins.
A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.
Absence of hair on the toes
Reports of pain associated with exercising (intermittent claudication)
ulcer associated with arterial insufficiency is deep, well demarcated, and may be gangrenous
superficial ulcer with irregular edges is associated with venous insufficiency
Pitting edema of the lower extremities
Increased pigmentation of the medial and lateral malleolus areas