Heart Failure
Your client is being treated for heart failure with fluid overload with a loop diuretic. Which of the following would indicate the client is responding to treatment?
a. Decrease in urine output
b. Decrease in troponin
c Increase in urine output
d. decrease in potassium
Increase in urine output
What else would you monitor as well?
what should be included in teaching a client when they have a new A-V fistula?
A. encourage hand exercises to increase size of vessels
b. Can be used within a month of the procedure
c. The fistula is not permanent
d. Small bore needles are used to access the fistula
A. Encourage hand exercises
When assessing a client with abdominal aortic aneurysm, which symptom indicates a possible sign of rupture and requires immediate attention?
a. severe back or abdominal pain
b. productive cough
c. blood pressure of 140/90
d. Crackles
low back pain
may be present because of pressure of the aneurysm on the lumbar nerves
When reviewing lab results, what would you expect to see in your client with DIC?
a. low plt count, low fibrinogen level and prolonged prothrombin time
b. High plt, high d-dimer, and normal prothrombin time
c. Low platelet count, low fibrinogen level, and normal prothrombin time
d. Low d-dimer, high fibrinogen, and shortened PT
Low platelet, low fibrinogen, and prolonged PT
Diagnostic tests indicating DIC include prolonged PT, aPTT, INR, elevated D-dimer, low platelets and low fibrinogen levels.
You are doing training modules on surviving the sepsis guidelines for your ICU training. What is the best summary of these guidelines?
a. Instructional material to help families understand the complex pathophysiology and treatment of sepsis
b Guidelines which prescribe early interventions for sepsis within vulnerable populations
c. A campaign to prevent the occurrence of Sepsis within vulnerable populations
d. Protocols to address the care of the client with sepsis after they have been stabilized
b
The following symptoms indicate that my client is experiencing right heart failure? Select all that apply
a. crackles
b. distended neck veins
c peripheral edema
d. cough
b. and c
The patient client receiving hemodialysis can experience several different complications when receiving dialysis. Which of the following can be a potential complication? Select all that apply
Arrythmias
Hypotension
Fluid overload
Air embolism
Low Phosphorous levels
a,b,c,d
Rationale: Potential complications of hemodialysis are SOB due to fluid overload between treatments, hypotension, muscle cramping arrythmias, air embolism, chest pain, and cerebral fluid shifts
What should be included in care of a client who has a stable Abdominal aortic aneurysm (AAA) that is 3 cm in diameter?
a strict fluid restriction
b. Monitor sodium intake
c. bed rest
d. monitor blood pressure
d. Monitor BP
A client presents to the ER after falling form a ladder at home. The nurse is monitoring the client for signs of DIC. Which manifestations would indicate the client is experiencing DIC? Select all that apply
a. Bloody stool
B. Petechiae
c. increased temp
D. cold extremities
a,b,d
Signs related to thrombosis include decreased temperature, decreased sensation, cyanosis, hypoxia, dyspnea. signs of bleeding: bruising, hematuria,tachycardia,bloody stools
The nurse is caring for a 41-year-old male client newly diagnosed with systolic heart failure. The echocardiogram shown an ejection fraction of 25% and blood pressure is 110/58. The client is prescribed Lisinopril 2.5 mg daily. The client asks “why are you giving me a blood pressure medication? My blood pressure has always been fine.” What is the best response by the nurse?
A. “You are right, I will call the doctor. This medication is not appropriate for you.”
B. “This medication relaxes the blood vessels and allows the heart to pump blood easier.”
C. “This medication will help get the water off of your body and reduce your edema.”
D. “This medication will prevent you from having any cardiac arrhythmias.”
Answer b
ACE inhibitors slow the progression of HF, improve exercise tolerance. Vasodilatation reduces resistance to the left ventricular ejection of blood, and helps the hearts workload.
The nurse is doing her morning assessment on her client with heart failure. The nurse should report which findings to the health care provider as a priority finding in her assessment?
A. Apical heart rate of 90 beats per minute
B. Blood pressure 112/62
C. Oxygen saturation of 95%
D. Crackles
D. Crackles
The clinical manifestations of pulmonary congestion include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels.
The nurse is teaching a client about performing peritoneal dialysis at home. What should the nurse include in the instructions to help prevent abdominal cramping during treatment?
a.Drain fluid slowly over 1-2 hours after dwell time.
b.Warm fluid prior to body temperature instilling.
c.Take prophylactic antibiotics prior to treatment.
d.Lay flat during dwell time.
e. Position yourself with your legs elevated
b
dialysate is warmed to body temperature to prevent patient from suffering from abdominal cramping
A 70 year old male with a history of hypertension and smoking presents to the clinic for a routine check up. During assessment, the nurse palpates a pulsatile mass in the abdomen just above the umbilicus. The patient denies any pain. Which of the following is the most appropriate nursing action?
a. apply firm pressure to assess the size of the mass
b. Notify the healthcare provider immediately
c. Instruct the patient to perform abdominal exercises to reduce the mass
d. Document the finding and schedule the patient for a routine ultrasound in 6 months
b. Notify the physician immediately
a pulsatile abd mass is a classic sign of a AAA, which can be life threatening. Palpating is dangerous and could lead to rupture
A nurse is caring for a client and is monitoring for signs of DIC. Which assessment finding indicates the development of DIC?
a. hematuria
b. lung crackles
c. rash
a. hematuria
The nurse is caring for a client with a central venous catheter pressure monitoring system. Which of the following interventions should the nurse perform to prevent a catheter-related bloodstream infection? Select all that apply.
a.Place tape over the edges of dressing that are no longer occlusive.
b.Remove the dressing to assess the site once a shift.
c.Perform hand hygiene before and after caring for the line.
d.Change the tubing if the line becomes contaminated.
e.Clean the skin every 48 hours with a 2% chlorahexadine wash
c, d
Rationale: wash hands before and after line care, dress the site with a sterile transparent, dressing, change the dressing every 2 days, change the tubing if it becomes contaminated or every 96 hrs. Clean the skin daily with a 2% chlorahexadine wash
The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS) The nurse's plan of care should include which intervention?
a. Encourage the family to stay hopeful and educating them that the prognosis is good
b. Encourage the family to leave the hospital and take time for themselves as acute care of MODS may last several months
c. promote communication with the client and family with addressing end of life issues
d. Discussing organ donation on a number of different occasions to allow for the family to adjust to the idea
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The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS) The nurse's plan of care should include which intervention?
a. Encourage the family to stay hopeful and educating them that the prognosis is good
b. Encourage the family to leave the hospital and take time for themselves as acute care of MODS may last several months
c. promote communication with the client and family with addressing end of life issues
d. Discussing organ donation on a number of different occasions to allow for the family to adjust to the idea
answer: C