CARDIAC
A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect?
A. Heart rate of 120 beats/min
B. Cool, clammy skin
C. Oxygen saturation of 90%
D. Respiratory rate of 8 breaths/min
ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.
After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding. Which statement indicates that the client correctly understood the teaching?
A. “I must drink a quart (liter) of water or other liquid each day.”
B. “I will weigh myself each morning before I eat or drink.”
C. “I will use a salt substitute when making and eating my meals.”
D. “I will not drink liquids after 6 p.m., so I won’t have to get up at night.”
ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.
A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, “Is my anemia related to my kidney problem?” How would the nurse respond?
A. “Red blood cells produce erythropoietin, which increases blood flow to the kidneys.”
B. “Your anemia and kidney problem are related to inadequate vitamin D and a loss of bone density.”
C. “Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow.”
D. “Kidney insufficiency inhibits active transportation of red blood cells throughout the blood.”
ANS: C
Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia and renal insufficiency are not manifestations of vitamin D deficiency. The kidneys do not play a role in the transportation of red blood cells or any other cells in the blood.
A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which assessment would the nurse perform first?
A. Cardiac rate and rhythm
B. Skin and mucous membranes
C. Musculoskeletal strength
D. Level of orientation
ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. The nurse responds by performing a thorough cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal system, and neurologic system, but assessing for the cardiovascular complications comes first.
A nurse reviews a client’s laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
A. Total cholesterol: 280 mg/dL (7.3 mmol/L)
B. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L)
C. Triglycerides: 200 mg/dL (2.3 mmol/L)
D. Serum albumin: 4 g/dL (5.8 mcmol/L)
E. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L
ANS: A, C, E
A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.
A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart rate is 48 beats/min. What action would the nurse take first?
A. Document the finding in the chart.
B. Initiate external pacing.
C. Assess the client’s medications.
D. Administer 1 mg of atropine.
ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However, the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent.
A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
A. Increased respiratory rate from 12 to 22 breaths/min
B. Decreased skin turgor on the client’s posterior hand and forehead
C. Increased urine specific gravity from 1.012 to 1.030 g/mL
D. Decreased orthostatic changes when standing
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity are all indicators of continuing dehydration.
A nurse reviews a client’s laboratory results. Which results from the client’s urinalysis would the nurse recognize as abnormal?
A. pH of 5.6
B. Ketone bodies present
C. Specific gravity of 1.020
D. Clear and yellow color
ANS: B
Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally, no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy. A pH between 4.6 and 8, specific gravity between 1.005 and 1.030, and clear yellow urine are normal findings in a urinalysis.
A nurse assesses a client who is prescribed furosemide for hypertension. For which acid–base imbalance does the nurse assess to prevent complications of this therapy?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
ANS: D
Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an actual acid deficit.
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.)
A. Thrombophlebitis
B. Stroke
C. Pulmonary embolism
D. Myocardial infarction
E. Cardiac tamponade
F. Dysrhythmias
ANS: A, C, E
Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of left-sided heart catheterizations
A nurse assesses a female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect?
A. Excruciating pain on inspiration
B. Left lateral chest wall pain
C. Fatigue and shortness of breath
D. Numbness and tingling of the arm
ANS: C
In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not known to be specific symptoms for women having and MI.
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates that the client correctly understood the teaching?
A. Slices of smoked ham with potato salad
B. Bowl of tomato soup with a grilled cheese sandwich
C. Salami and cheese on whole-wheat crackers
D. Grilled chicken breast with glazed carrots
ANS: D
Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.
A nurse reviews a client’s laboratory results. Which results from the client’s urinalysis would the nurse identify as normal? (Select all that apply.)
A. pH: 6
B. Specific gravity: 1.015
C. Protein: 1.2 mg/dL
D. Glucose: negative
E. Nitrate: small
F. Leukocyte esterase: positive
ANS: A, B, D
The pH, specific gravity, and glucose are all within normal ranges. The other values are abnormal.
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base imbalance. For which manifestation of this acid–base imbalance would the nurse assess?
A. Agitation
B. Kussmaul respirations
C. Seizures
D. Positive Chvostek sign
ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign are signs and symptoms of the electrolyte imbalances that accompany alkalosis.
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
A. Blood pressure of 140/88 mm Hg
B. Serum potassium of 2.9 mEq/L (2.9 mmol/L)
C. Warmth and redness at the site
D. Expanding groin hematoma
E. Rhythm changes on the cardiac monitor
F. Oxygen saturation 93% on room air
ANS: B, D, E
After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding hematoma signifies bleeding. Rhythm changes on the monitor are a known complication. These findings would require prompt action. The client’s blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours. The oxygen saturation is slightly low but not critical and there is no baseline to compare it to.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next?
A. Elevate the leg and apply a sandbag to the entrance site.
B. Increase the flow rate of intravenous fluids.
C. Assess the color and temperature of the left leg.
D. Document the finding as “left pedal pulse of +1/4.”
ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client’s problem.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?
A. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
B. A 50 year old with an infection who is prescribed a sulfonamide antibiotic.
C. A 67 year old who is experiencing pain and is prescribed ibuprofen.
D. A 73 year old with tachycardia who is receiving digoxin.
ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.
A nurse reviews the health history of a client with an oversecretion of renin. Which disorder would the nurse correlate with this assessment finding?
A. Alzheimer disease
B. Hypertension
C. Diabetes mellitus
D. Viral hepatitis
ANS: B
Renin is secreted when special cells in the distal convoluted tubule, called the macula densa, sense changes in blood volume and pressure. When the macula densa cells sense that blood volume, blood pressure, or blood sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause secretion of the hormone aldosterone. This hormone increases kidney reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels. Inappropriate or excessive renin secretion is a major cause of persistent hypertension. Renin has no impact on Alzheimer disease, diabetes mellitus, or viral hepatitis.
A nurse assesses a client who is admitted with an acid–base imbalance. The client’s arterial blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L). The most recent blood gases show a drop in the pH. What action does the nurse take next?
A. Assess client’s rate, rhythm, and depth of respiration.
B. Measure the client’s pulse and blood pressure.
C. Document the findings and continue to monitor.
D. Notify the primary health care provider.
ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings would be documented, but simply continuing to monitor is not sufficient. Before notifying the primary care provider, the nurse must have more data to report.
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.)
A. Decrease in cardiac output
B. Increase in cardiac output
C. Decrease in blood pressure
D. Increase in blood pressure
E. Decrease in urine output
F. Increase in urine output
ANS: A, C, E
Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
A. Urinary output less than intake
B. Bruising at the insertion site
C. Slurred speech and confusion
D. Discomfort in the left leg
ANS: C
A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may not be significant.
A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
A. Depth of respirations
B. Bowel sounds
C. Grip strength
D. Electrocardiography
ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client’s respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client’s respiratory status.
A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/kg (1200 mmol/kg). Which action would the nurse take?
A. Contact the primary health care provider to recommend a low-sodium diet.
B. Prepare to administer an intravenous diuretic.
C. Encourage the client to drink more fluids.
D. Obtain a suction device and implement seizure precautions.
ANS: C
Normal urine osmolality ranges from 300 to 900 mOsm/kg (300 to 900 mmol/kg). This client’s urine is more concentrated, indicating dehydration. The nurse would encourage the client to drink more water. Dehydration can be associated with elevated serum sodium levels. Although a low-sodium diet may be appropriate for this client, this diet change will not have a significant impact on urine osmolality. A diuretic would increase urine output and decrease urine osmolality further. Low serum sodium levels, not elevated serum levels, place the client at risk for seizure activity. These options would further contribute to the client’s dehydration or elevate the osmolality.
A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client’s compensatory mechanisms?
A. Increased rate and depth of respirations
B. Increased urinary output
C. Increased thirst and hunger
D. Increased release of acids from the kidneys
ANS: A
This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are signs and symptoms of hyperglycemia, but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.
A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client’s teaching? (Select all that apply.)
A. “Until your incision is healed, do not submerge your pacemaker. Only take showers.”
B. “Report any pulse rates lower than your pacemaker settings.”
C. “If you feel weak, apply pressure over your generator.”
D. “Have your pacemaker turned off before having magnetic resonance imaging (MRI).”
E. “Do not lift your left arm above the level of your shoulder for 8 weeks.”
ANS: A, B, E
The client would not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client would be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client would be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client would never apply pressure over the generator and would avoid tight clothing. The client would never have MRI because, whether turned on or off, the pacemaker contains metal. The client would be advised to inform all health care providers that he or she has a pacemaker.