Perfusion 1
A client is admitted to the hospital with severe headache, tinnitus, and a BP of 202/122 mmHg after running out of medications. After being treated for hypertensive emergency, which approach by the nurse at discharge is best?
1. Assess for barriers to taking the prescribed medication.
2. Instruct the client’s spouse to manage medication.
3. Instruct the client to count the number of pills left at home.
4. Tell the client to purchase a medication organizer.
1
Malignant hypertension, or hypertensive emergency, is most commonly caused by untreated or uncontrolled hypertension. This may occur when a client misses medication doses, resulting in abrupt cessation of the drug. Clients should be counseled about the importance of taking medications as prescribed. Hypertensive emergencies are life-threatening. Less-common causes of hypertensive emergencies include illicit drug use, neoplasms, glomerulonephritis, hyperthyroidism, and pheochromocytoma (tumor of the adrenal gland).
Nurses have an important role in assessing factors for nonadherence to medications. Keeping schedules simple and affordable promotes adherence. Assessing for adverse effects and avoiding unnecessary refills also helps avoid confusion and error with regard to dosing.
What clinical sign does the nurse find when assessing a client with right-sided heart failure?
Clubbing
Leg Edema
Pulmonary crackles
Dry Cough
Leg Edema
Congestive heart failure symptoms are caused by a diminished ability of the right ventricle to pump blood, allowing it to back up into the vena cava (increased preload). This causes blood to pool in the extremities, abdomen, neck, and liver.
A client with intermittent claudication at rest asks the nurse about symptom relief. The nurse teaches what symptom relief measure?
Wrap the affected leg
Elevate the legs above the level of the heart
Apply a cold compress when in pain
Avoid smoking
Avoid smoking
Intermittent claudication refers to pain in the extremities due to limited arterial blood flow and resultant tissue hypoxia in the legs. The narrowed or occluded arteries decrease blood flow to the leg muscles. Pain is most commonly caused by partial or complete occlusion of arteries in the one or both lower extremities.
Symptoms can be mild or severe depending on what arteries are affected. Symptoms at rest indicate severe disease. Exercise typically exacerbates symptoms. When walking or exercising, oxygen demands for the leg muscles increase, so the inadequate blood flow and oxygen delivery cause a cramping pain in the muscles. Monitored exercise programs are sometimes prescribed to prevent worsening of claudication and possibly promote the growth of new arterial pathways to bypass the affected arteries. Clients with pain should rest and elevate their legs slightly but not above the level of the heart.
A client with multiple pulmonary emboli (PE) is scheduled for placement of an inferior vena cava (IVC) filter. What statement by the nurse explains the purpose of this intervention?
“The device is inserted to dissolve blood clots in the heart.”
“Medication is delivered to enhance anticoagulation therapy.”
“It alerts the health care provider when clots develop.”
“The device trap blood clots traveling to the lungs.”
“The device trap blood clots traveling to the lungs.”
Many pharmacological and mechanical methods are used to prevent venous thromboembolism (VTE). IVC filters are vascular filters implanted in the inferior vena cava and used to trap emboli floating in the vena cava. They help prevent pulmonary emboli by preventing any circulating clots from traveling to the lungs. They are usually placed using fluoroscopy. They are typically used for clients with a history of deep vein thrombosis or recurrent PE but may be used prophylactically for those at high risk for PE. These filters can be temporary (retrievable) or permanent.
The nurse assesses a client who is scheduled for same-day surgery. The client reports chest and shoulder pain, perspiration, and shortness of breath. Which action does the nurse take first?
Complete the preoperative checklist and call for transport to the operating room.
Initiate protocol for the Medical Emergency Team, and notify the physician.
Request a chest x-ray and call for an ECG to be completed.
Check the client's electrolytes and perform a CBC.
Initiate protocol for the Medical Emergency Team, and notify the physician.
These signs and symptoms are consistent with suspected acute myocardial infarction, a medical emergency that warrants activating an inpatient Medical Emergency Team or Rapid Response Team. Hospitals and facilities have protocols in place to help the nurse with a client experiencing a suspected myocardial infarction.
At discharge, a client with heart failure due to systolic dysfunction is prescribed lisinopril, an angiotensin-converting enzyme (ACE) inhibitor. Which teaching does the nurse include for this medication?
1. “It relaxes blood vessels, which lowers blood pressure.”
2. “This drug can make it easier to exercise.”
3. “It is safe to take during pregnancy.”
4. “This drug may contribute to hyperkalemia.”
5. "Report a cough immediately.”
6. "ACE inhibitors will help improve your ability to exercise"
1,2,4,5,6
Lisinopril is an ACE inhibitor, which are frequently used to treat heart failure and hypertension. ACE inhibitors improve lung function by increasing alveolar-capillary membrane diffusing capacity and pulmonary vascular function. Side effects include hypotension, acute renal failure, and hyperkalemia.
ACE inhibitors occasionally induce life-threatening angioedema. While the risk is low, the wide use of these drugs requires that nurses be alert for reports of asymmetric swelling of nondependent tissue, especially in the face. Face, tongue, lips, and upper airway swelling can lead to rapid airway compromise.
The nurse cares for a client with left-sided heart failure. Which actions does the nurse implement?
(SATA)
Administer diuretic as prescribed
Document rhythm strips every shift
Assess HR every hour
Assess peripheral pulses for strength and quality
Provide a low sodium diet
Assess HR every hour and watch out for tachycardia
Administer diuretic as prescribed
Document rhythm strips every shift
Assess HR every hour
Assess peripheral pulses for strength and quality
Provide a low sodium diet
Frequent assessment to monitor changes in pulses, cardiac rhythm, vital signs, and symptoms allows for prompt intervention. Common dysrhythmias for clients with reduced cardiac output include premature atrial contractions, premature ventricular contractions, and paroxysmal atrial tachycardia. Changes in the ST segment may indicate myocardial ischemia from decreased coronary artery perfusion.
After a cardiac catheterization procedure, the nurse monitors a client for which common complications?
Heart Block
MI
Hematoma
Retroperitoneal hemorrhage
Pseudoaneurysm
Hematoma
Retroperitoneal hemorrhage
Pseudoaneurysm
Cardiac catheterization is a minimally invasive procedure. The most common problems are local complications at the catheter insertion site. They include hematoma, arteriovenous fistula formation, pseudoaneurysm of the vessel entered, and retroperitoneal hemorrhage inside the cavity if the vessel perforates. Many of these complications are avoided by proper vessel compression.
The nurse evaluates a client with decreased cardiac output (CO) related to recent myocardial ischemia. What best indicates improved CO for this client?
HR 80 beats/min
Walk down a flight of stair w/o dyspnea
Relief od chest pain with prescribed nitroglycerin
Standing w/o reports of dizziness
Walk down a flight of stair w/o dyspnea
Many factors, including chronic conditions and fluid status, impact whether CO is sufficient. Normal CO is 4–8 L/min. Decreased CO can cause angina and dyspnea with activity. Improvement of CO is evidenced by resolution of these symptoms.
A nurse assesses a client with chronic hypertension. What signs does the nurse identify as a chronic complication of hypertension? (SATA)
1. Weakness
2. Dyspnea at rest
3. Protein in urine
4. Leg pain when climbing staris
5. Vomiting
2,3,4
Dyspnea at rest is associated with congestive heart failure. High blood pressure contributes directly to the development of congestive heart failure by increasing the heart’s workload and leading to thickening of the ventricle walls. Proteinuria and albuminuria are early indicators of renal injury, a serious complication that can be caused by chronic hypertension. High pressures damage the kidneys’ ability to filter toxins, and evidence of this damage is seen as proteins leak out into the urine. Peripheral artery disease is a complication of hypertension in which plaques in leg arteries and hardened vessel walls compromise blood flow to the legs. The condition causes pain, aching, or heaviness in the legs, feet, and buttocks after activity.
The nurse on the cardiac step-down unit plans a meal tray for a client recovering from myocardial infarction (MI) after stent placement. Which diet choices does the nurse offer that are consistent with Dietary Approaches to Stop Hypertension (DASH)? (SATA)
Slice of apple pie
Macaroni & Chesse
Pork Chop & Green beans
Whole-grain toast & jelly
Fresh fruit Cup
Whole-grain toast & jelly
Fresh fruit Cup
The DASH diet suggests limits for calories, sodium, and fat. It also encourages avoidance of a sedentary lifestyle.
The diet recommends less than 2,300 mg of sodium daily, but people with comorbidities such as diabetes and heart disease should have less. Water is drawn to sodium, which is why thirst worsens when eating salty snacks such as potato chips. Increased sodium intake causes fluid retention, which increases BP because more fluid is in the bloodstream and blood vessels. Decreasing sodium intake can help reduce the amount of excess fluid in the blood, decreasing BP.
The nurse reviews the prescribed medications for a client with asthma, diabetes, and acute heart failure. Which pharmacological intervention is prescribed to reduce myocardial workload? (SATA)
Metoprolol
Dobutamine
Montelukast
Salmeterol
Morphine Sulfate
Beta2 agonists
Metoprolol
Dobutamine
Morphine Sulfate
Refractory heart failure with low ejection fraction leading to reduced cardiac output (CO) often requires sodium and fluid volume management, hemodynamic monitoring, mechanical support, and pharmacologic interventions.
Both left- and right-sided heart failure result in low cardiac CO. Left-sided heart failure (formerly congestive heart failure) falls into two types: systolic (decreased contractility resulting in pulmonary congestion) or diastolic (inadequate ventricular filling). Interventions for both types of left-sided failure are the same. Right-sided heart failure may be caused by left-sided failure, myocardial infarction, or pulmonary hypertension.
High-output heart failure, which is less common than left- and right-sided heart failure, is caused by excessive metabolic needs (sepsis)
The nurse suspects that a client has a venous thromboembolism (VTE). What test would gather evidence in support of this diagnosis?
Weber Test
Tinel Sign
D-dimer
Venography
Venous ultrasound
D-dimer
Venography
Venous ultrasound
The nurse must be familiar with common tests for VTE and educate and prepare the client as needed. Common signs for DVT are unilateral swelling (measure calf diameter), warmth, tenderness, and erythema. Less-common diagnostic tests for VTE include MRI and CT.
A client has just returned to the nursing unit following a cardiac catheterization. What nursing intervention does the nurse perform first?
Assess the insertion site for hematoma formation
Administer IV normal saline
Evaluate for uriticaria or SOB
Administer pain medication
Assess the insertion site for hematoma formation
The insertion site is at risk for bleeding due to the high pressure of the femoral artery and the large diameter of the catheter. Use the airway, breathing, circulation (ABC) framework to prioritize actions: airway and breathing are assessed first, then bleeding is categorized as a circulation issue. Pain, hydration, and elimination are lower priorities than the ABCs.
After assessing a client, the nurse teaches the client about peripheral vascular disease (PVD). The nurse reviews what test used in diagnosing PVD?
Ankle brachial pressure index
Echocardiogram
Allen test
Cardiac stress test
Ankle brachial pressure index
The ankle brachial index is the BP ratio between the lower legs and the arms. It is calculated after taking measurements in the upper and lower extremities. BP in the lower legs is normally higher than in the arms, and abnormalities indicate narrowing of arteries (i.e., PVD).
The nurse teaches the client about symptoms for hypertension. Additional education is required when the client states which symptom indicates elevated blood pressure?
Leg swelling
Blurred Vision
Headaches
Head Fullness
Leg Swelling
Hypertension is rarely accompanied by symptoms. When symptoms do occur, they vary depending on what organ is affected (e.g., eye, kidney, heart, or brain). Symptoms can include headache, nausea or vomiting, tinnitus, blurred vision, confusion, dizziness, or a feeling of fullness in the head.
The nurse provides discharge instructions to a client with congestive heart failure (CHF). Which food does the nurse instruct the client to avoid?
Spinach
Deli ham
Orange Juice
Ice Cream
Steak Sauce
Monitoring and limiting sodium intake is important to help reduce fluid retention and hypertension. Clients with CHF should weigh themselves daily to help monitor fluid retention, which can exacerbate CHF symptoms.
A client arriving in the ER reports chest pain radiating to the shoulder and shortness of breath that began two days earlier. What lab test is most important to evaluate?
Lactate dehydrogenase
Creatinine kinase-MB
Troponin- l
Myoglobin
Troponin- l
When myocardial tissue is damaged, several biomarkers are released into the blood that can be best detected with lab tests at particular intervals. Onset time of chest discomfort is used to guide which tests will be helpful. Troponin-I is the preferred lab test to support the diagnosis of myocardial infarction (MI). An ECG is the most important diagnostic test to perform for suspected MI.
The nurse prepares to remove the femoral sheath for a client after percutaneous transluminal coronary angioplasty (PTCA). To prevent complications, the nurse pulls the sheath when the activated partial thromboplastin time (aPTT) meets what criteria?
40 seconds or less
55 seconds or less
65 seconds or less
100 seconds or less
40 seconds or less
The nurse is caring for clients on the cardiac unit. Which conditions affect cardiac output by reducing preload? (SATA)
1. Postpartum hemorrhage
2. Sinus bradycardia
3. Urinary Sepsis
4. Upper thoracic spinal cord injury
5. Chronic renal failure
1,3,4 Postpartum hemorrhage Urinary Sepsis
Upper thoracic spinal cord injury
Uncontrolled bleeding leads to hypovolemia, which reduces venous return to the heart and thereby reduces preload. Tachycardia and hypotension result in reduced preload in sepsis and is treated with IV fluid resuscitation. Injuries above the sixth thoracic vertebra lead to spinal shock, decreased vasomotor tone, and decreased preload due to decreased venous return. This condition also decreases afterload due to decreased peripheral vascular resistance.
Preload is determined by how much the muscles of the heart stretch due to the blood volume that has filled the ventricles at the end of diastole. Preload is decreased by conditions that reduce circulating volume, venous return, or right ventricular volume.
A client diagnosed with primary hypertension asks the nurse about risk factors for this condition. The nurse confirms the client’s understanding of teaching with what response? (SATA)
1. “Taking too much ibuprofen increases my risk.”
2. “My kidney disease worsened my blood pressure.”
3. “I may be eating too much dietary sodium.”
4. “Obesity often leads to primary hypertension.”
5. "Lack of exercise makes hypertension more likely.”
6. "Diabetes mellitus"
3,4,5,6
Sodium intake greater than 3,000 mg per day increases risk for hypertension, and reducing sodium intake reduces blood pressure. Weight gain is associated with higher risk for primary hypertension. Inactivity is a risk factor for the development of primary hypertension.
Major risk factors for primary hypertension (formerly called essential hypertension) include high salt and fat intake, obesity, inactive lifestyle, age, family history, race, excessive alcohol consumption, personality traits or depression, and cardiovascular risk factors such as dyslipidemia and diabetes.
Secondary hypertension has identifiable causes, including (but not limited to) medications, renal disease, Cushing syndrome, hyperthyroidism, hyperaldosteronism, pheochromocytoma, obstructive sleep apnea, and coarctation of the aorta (especially in children).
The nurse questions a client with acute exacerbation of heart failure about recent medical history and medication usage. The nurse recognizes that what medications or conditions may contribute to this client’s exacerbation of heart failure? (SATA)
Anemia
Daily ibuprofen use
Daily metformin use
Irritable bowel syndrome
Hyperthyroidism
Anemia
Daily ibuprofen use
Daily metformin use
Hyperthyroidism
Chronic congestive heart failure can easily exacerbate and decompensate. Exacerbations arise from from infections, arrhythmias, hypertension, anemia, hyperthyroidism, hypothyroidism, inadequate diet, and use of nonsteroidal anti-inflammatory drugs. Diabetes is a known risk factor for heart failure.
The nurse cares for a client with venous insufficiency. What does the nurse teach the client about the condition?
Sclerotherapy is the only cure for varicose veins.
Discomfort is directly related to the size of the varicosities.
Varicose veins are more common in men than in women.
Varicose veins are a result of a familial predisposition.
Varicose veins are a result of a familial predisposition.
Varicose veins are weak-walled, engorged, and tortuous. They often have defective valves that fail to prevent reflux (backflow). Blood pools in the veins, causing enlargement, deformity, and pain. Varicose veins occur more frequently in clients with occupations that involve standing for long periods of time. Supportive treatment includes the "3 Es": Elastic compression, Elevation, and Exercise.
The nurse teaches a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What response by the client demonstrates understanding of this procedure?
“The procedure inserts a mesh device that keeps the coronary artery patent.”
“The purpose of the procedure is to measure the coronary artery pressure.”
“The procedure will cauterize the plaque blocking the coronary artery.”
“The balloon-tipped catheter compresses plaque against the walls of the coronary arteries.”
“The balloon-tipped catheter compresses plaque against the walls of the coronary arteries.”
PTCA, commonly called balloon angioplasty, involves the insertion of a balloon-tipped catheter via the femoral or radial artery which is then advanced into the coronary arteries. There, the balloon is carefully inflated to compress the plaque against the walls of the vessel, widening the lumen of the vessel and restoring perfusion to the myocardium.
When the nurse plans interventions for a client with a deep vein thrombosis (DVT), which interventions are included? (SATA)
1. Ambulate frequently.
2. Elevate the affected leg.
3. Wear compression stockings.
4. Apply heat to the affected leg.
5. Administer pain medication.
2,3,4,5
Rest and elevation are appropriate nursing interventions when caring for a client with a venous thromboembolism. Graduated compression stockings are recommended for those at risk for or with a resolving DVT.
Applying warm, moist heat increases client comfort, promotes healing, and is an appropriate (if underutilized) nursing intervention when caring for a client with a venous thromboembolism. Moist heat decreases overall inflammation, decreasing the damage to the extremity and possibly reducing inflammatory processes and stasis that contribute to the clot itself.
Just as recent evidence suggests ambulation is safe after anticoagulation has begun, relieving the pain of the clot is safe after anticoagulation has begun. Additionally, this action keeps circulation going past the clot so that the extremity distal to the clot maintains circulation. Treating pain as prescribed is an appropriate nursing intervention when caring for a client with a venous thromboembolism.