Perfusion Flashcards
1) The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate?
A) “You will need to have an echocardiogram to determine the reason for the extra sound.”
B) “You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy.”
C) “You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy.”
D) “You have what is known as atrial gallop, and this is cause for concern.”
C.; Rational: Two other heart sounds may be present in some healthy individuals. The third heart sound (S3) may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can also be present in health individuals.
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client’s potential health problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return
B.; Rational: The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.
3) An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be prescribed for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids
A.; Rational: Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.
4) The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric
C.; Rational: The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.
5) The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply. A) Limit exercise to 15 minutes a day B) Reduce saturated fats in the diet C) Avoid cigarette smoking D) Wear elastic hose E) Limit fluid intake
B. & C.; Rational: Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.
6) The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse? A) At the fifth intercostal space B) At the left nipple C) At the right nipple D) At the eighth intercostal space
B.; Rational: When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.
7) The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor). What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.
B.; Rational: Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.
8) Which statements are correct regarding the various layers of the heart? Select all that apply.
A) The endocardium covers the entire heart and great vessels.
B) The endocardium is the muscular layer of the heart that contracts during each heartbeat.
C) The outermost layer of the heart is the epicardium.
D) The myocardium consists of myofibril cells.
E) The myocardium has four layers.
C. & D.; Rational: The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.
9) A client’s stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute (bpm). What is the client’s cardiac output (CO) rounded to the nearest liter?
6 Liters; Rational: CO = SV × HR
85mL = 0.085 L
CO = 0.085 × 71 = 6.035 = 6 L
10) Blood pressure is influenced by all except which factor? A) Pumping action of the heart B) Peripheral vascular resistance C) Heart rate D) Blood volume
C.; Rational: The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.
11) Which nursing intervention related to perfusion can be performed independently?
A) Administration of drug regimens
B) Insertion of device to measure central venous pressure (CVP)
C) Teaching relaxation techniques
D) Thoracentesis
C.; Rational: The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.
12) The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern? A) Pulse 103 bpm B) Blood pressure 108/70 C) Hematocrit 24% D) WBC count 10,340/mm3
C.; Rational: During pregnancy, red blood cell (RBC) production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.
1) The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)? A) Shortness of breath after activity B) Two-plus palpable pedal pulses C) Swelling in one leg with edema D) Sharp pain in both legs
C.; Rational: Manifestations of DVT include swelling in one leg with pitting edema because the clot is obstructing the venous return from the leg. Shortness of breath that subsides after activity and two-plus palpable pulses are not manifestations of DVT. Pain in the affected extremity is usually dull and aching, not sharp.
2) The nurse is planning care for a group of clients. Which client should the nurse identify as having the greatest risk for developing deep venous thrombosis (DVT)?
A) The client recovering from laparoscopic gallbladder surgery
B) The client admitted with new-onset type II diabetes mellitus
C) The client admitted with community-acquired pneumonia
D) The client recovering from knee replacement surgery
D.; Rational: Between 40% and 85% of clients recovering from total knee replacement surgery develop a DVT because of the procedure and prolonged immobility after surgery. The client admitted with new-onset type II diabetes mellitus, the client admitted with community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery would be at a lower risk for DVT because prolonged immobility will not occur.
3) The nurse is caring for a breastfeeding client recovering from a cesarean section. The physician diagnoses her with superficial venous thrombosis. Which intervention should the nurse anticipate carrying out first?
A) Encourage to ambulate freely
B) Aspirin 650 mg every 4 hours
C) Apply warm, moist compresses
D) Provide methylergonovine (Methergine) IM
C.; Rational: The treatment for superficial venous thrombosis involves resting the extremity, administering anti-inflammatory agents, and applying warm, moist compresses over the affected vein. Ambulation would increase the inflammation. Heparin or warfarin is preferred over aspirin for treatment of venous thrombosis, and both are safe for lactating mothers. Methylergonovine is given only for postpartum hemorrhage and would cause vasoconstriction of an already inflamed vessel.
4) The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client? A) Infection B) Fluid volume C) Peripheral perfusion D) Sleep pattern
C.; Rational: Ineffective peripheral tissue perfusion is the priority, because it is related to obstructed venous return, which is the underlying cause of the DVT. Risk for infection would be a priority if complications of infection were present; however, this is not the case. Excess fluid volume and disturbed sleep pattern are incorrect because they are not related to the underlying cause.
5) The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply. A) Avoid crossing the legs B) Avoid long car trips C) Avoid prolonged standing or sitting D) Take frequent walks E) Take a daily aspirin dose of 650 mg
A. & C. & D.; Rational: The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should also be instructed to avoid prolonged standing or sitting, which contributes to venous stasis. The client should also be instructed to take frequent walks to promote venous return. The client does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips. The client should not be instructed to take a daily aspirin, because it will increase anticoagulant activity and could interact with other medication prescribed for the treatment of the DVT.
6) A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
A) The client will not disturb the intravenous infusion.
B) The client will comply with dietary restrictions.
C) The client will not experience bleeding.
D) The client will keep the right leg elevated on two pillows.
C.; Rational: An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important, but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important, but not as high a priority as an absence of bleeding.
7) A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?
A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion.
B.; Rational: 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. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation. Although reassuring the client and notifying family members are important, they are not a higher priority than promoting oxygenation. Increasing the rate of heparin infusion cannot be done by the nurse without an order from a healthcare provider.
8) A client being treated for a deep venous thrombosis (DVT) is experiencing pain. Which interventions should the nurse implement? Select all that apply.
A) Apply an egg-crate mattress on the bed.
B) Maintain bedrest as ordered.
C) Apply warm moist heat to the area four times a day.
D) Encourage position changes every 2 hours.
E) Measure calf and thigh diameter daily.
B. & C. & E.; Rational: Interventions to address pain include applying warm moist heat to the area four times a day, maintaining bedrest as ordered, and measuring calf and thigh diameter daily. Applying an egg-crate mattress on the bed and encouraging position changes every 2 hours would be appropriate for the client experiencing Ineffective Peripheral Tissue Perfusion.
