The Cardiovascular System Flashcards

Question 1

Q

Characteristics of Normal Sinus Rhythm

Answer

A

Normal P-wave
PR Interval between 0.12 - 0.20 seconds
QRS < 0.12 seconds
Rate: 60 - 100bpm
Regular in rhythm

Question 2

Q

Characteristics of Sinus Bradycardia

Answer

A

Normal P-wave
PR Interval between 0.12 - 0.20 seconds
QRS <0.12 seconds
Rate <60bpm
Regular in rhythm

Question 3

Q

Characteristics of Sinus Tachycardia

Answer

A

Normal P-wave
PR interval > .20 seconds
Rate > 100 bpm
Regular in rhythym

Question 4

Q

Causes of Sinus Tachycardia

Answer

A

caffeine, exercise, fever, pain, hypotension, volume depletion

Question 5

Q

Treatment for Sinus Tachycardia

Answer

A

fix the cause

Question 6

Q

First Degree Heart Block Characteristics

Answer

A

Normal P-wave
PR interval <0.12 seconds
Rate: 60 - 100bpm
Regularity
Prolonged impulse travel

Question 7

Q

Second Degree Heart Block (Mobitz type 1) Characteristics

Answer

A

Abnormal P-waves
Prolonged PR interval with drops
QRS < 0.12 seconds
Rate: 60 - 100bpm
regularity

Question 8

Q

Cause of Second Degree Heart Block

Answer

A

fix the cause; if asymptomatic, no treatment is required. If asymptomatic, pacing is required.

Question 9

Q

Second Degree Heart Block (Mobitz type 2) Characteristics

Answer

A

Abnormal P waves (1 p-wave per 2 QRS)
PR interval between 0.12 - 0.20
QRS < 0.12
Rate >100bpm
Regularity

Question 10

Q

Cause of Mobitz type 2 heart block

Answer

A

MI; Ischemia

Question 11

Q

Treatment of Mobitz Type 2 Heart Block

Answer

A

treat the cause; pacing

Question 12

Q

Third Degree Heart Block Characteristics

Answer

A

Normal P-wave (inconsistent)
PR interval varies
Rate <60bpm
irregular

Question 13

Q

Cause of Third Degree Heart Block

Answer

A

Myocardial damage; MI; heart valve disease; Rheumatic fever; sarcoidosis

Question 14

Q

Heart Block Rhyme

Answer

A

If the R is far from P, its a first degree
longer, longer, and drop, then you have a Wincheback (2nd degree, type 1). If some P’s dont get through, you have a Mobitz type 2. If P’s and Q’s dont agree, you have type three.

Question 15

Q

Longterm Treatment for Arrythmias

Answer

A

Pacemaker

Question 16

Q

Pacemaker Teaching

Answer

A

Do’s:
- keep pacemaker card on person
- bath and shower 48 hrs post-op
- safe to use appliances
- notify airport security
Don’ts:
- apply pressure over generator
- wear tight clothing
- get lead wires wet
- get an MRI

Question 17

Q

Atrial Fibrillation

Answer

A

arrhythmia characterized by funny P-waves

Question 18

Q

Causes of Atrial Fibrillation

Answer

A

HF, heart disease, MI, pericarditis, and CHF

Question 19

Q

Treatment for Atrial Fibrillation

Answer

A

Fix the cause
Cardioversion
Antiarrythmics
Amiodarone
Beta Blockers
Metoprolol
CCB’s (Diltiazem)

Question 20

Q

Atrial Flutter

Answer

A

irregular, saw-tooth like P-waves

Question 21

Q

Supraventricular Tachycardia Characteristics

Answer

A

Irregular P-waves
PR Interval is immeasurable
QRS < 0.12 seconds
Rate: 150 - 250 bpm
Regular

Question 22

Q

Causes of SVT

Answer

A

caffeine, HF, fatigue, hypoxia, altered pacemaker

Question 23

Q

Treatment of SVT

Answer

A

Fix the cause
Cardioversion
Adenosine

Question 24

Q

Ventricular Tachycardia

Answer

A

characterized by no atrial p-waves and a wide QRS complex with a regular rhythm.

Question 25

Q

Treatment for Ventricular Tachycardia

Answer

A

fix the cause
if there is a pulse, cardio version
No pulse, defibrillation
Epinephrine

Question 26

Q

Ventricular Fibrillation Characteristics

Answer

A

Fibrillation of the ventricles
irregular
usually no pulse

Question 27

Q

Cause Ventricular Fibrillation

Answer

A

MI; ischemia; hypoxia; acidosis; hypokalemia; hypotension

Question 28

Q

Treatment of Ventricular Fibrillation

Answer

A

Fix the cause
CPR
Defibrillation
Epinephrine

Question 29

Q

Asystole

Answer

A

Flat-lined; caused by hypothermia, v-fib, a-fib, acidosis, hypoxia, overdose
Treatment: CPR and epinephrine

Question 30

Q

Preload

Answer

A

amount of blood returning to the right side of the heart

Question 31

Q

Afterload

Answer

A

pressure against. which the left ventricle must pump to eject blood.

Question 32

Q

Compliance

Answer

A

how easily the heart muscle expands when filled with blood

Question 33

Q

contractility

Answer

A

strength of contraction of the heart muscle

Question 34

Q

Stroke Volume

Answer

A

Volume pumped out of ventricles with each contraction

Question 35

Q

Cardiac Output

Answer

A

important to tissue perfusion and end-organ function; CO = HR X SV

Question 36

Q

Signs and Symptoms of Poor Cardiac Output

Answer

A

decreased LOC; chest pain; weak peripheral pulses; SOB; crackles; rales; cool and clammy skin; mottled skin; decreased urine output.

Question 37

Q

Causes of decreased CO

Answer

A

bradycardia, arrhythmias, hypotension, MI, cardiac disease.

Question 38

Q

Causes of Increased CO

Answer

A

increased blood volume, tachycardia, drugs (ACE inhibitors, ARBs, Nitrates, Inotropes).

Question 39

Q

Enalapril

Answer

A

Pharm. Class: ACE inhibitors
Examples: Captopril, Enalapril, Lisinopril
Action: blocks conversion of angiotensin 1 and angiotensin 2, increases renin levels, and decreases aldosterone, leading to vasodilation.
Nursing Considerations: dry cough (discontinue the drug), monitor BP; contraindicated during pregnancy.

Question 40

Q

Losartan

Answer

A

Pharm. Class: ARB
Indication: HTN, DM, neuropathy, CHF
Action: inhibits vasoconstrictive properties of angiotensin II.
Nursing Considerations: monitor BP, fluid levels, renal/liver status; contraindicated in pregnancy.

Question 41

Q

Amlodipine

Answer

A

Pharm Class: CCBs
Indication: HTN, angina, A-fib, A-flutter
Action: blocks transport of calcium into muscles, inhibiting excitation and contraction, causing peripheral vasodilation.
Nursing Considerations: avoid grapefruit; blocks enzyme involved in metabolizing calcium channel blockers, causing their levels of increase; monitor bp (OH); can cause gingival hyperplasia (teach patients to use a soft toothbrush).

Question 42

Q

Propanolol

Answer

A

Pharm Class: antiarrythmic
Indication: HTN, angina, MI, cardiomyopathy, ETOH withdrawal, and anxiety.
Action: blocks beta 1 and beta 2 receptors, slowing the heart.
Nursing Considerations: do not discontinue abruptly; can mask signs of hypoglycemias (monitor BG); caution with asthma and COPD (may cause bronchospasm).

Question 43

Q

Adenosine

Answer

A

Pharm Class: Antiarrythmic
Indications: SVT
Action: Slows conduction through AV node, interrupting re-entry pathways through the AV node, restoring normal sinus rhythm.
Nursing Considerations: there will be a period of asystole after admin; warn client that I will feel like getting kicked in the chest; will flat line on monitor; rapid push or will not be effective; extreme caution with asthmatics.

Question 44

Q

Vasopressors

Answer

A

Increases BP and causes vasoconstriction
Drugs: norepinephrine, epinephrine, vasopressin, phenylphrine.

Question 45

Q

Normal Blood Pressure

Answer

A

120/80 mmHg

Question 46

Q

Pre-Hypertensive

Answer

A

120-129/80mmHg

Question 47

Q

Stage 1 HTN

Answer

A

> 130/>80 mmHg

Question 48

Q

Hypertensive Crisis

Answer

A

> 180/>120mmHg
Signs and Symptoms: vision changes, headaches, dizziness, epistaxis, SOB, angina
Risk Factors: stress, smoking, caffeine, high sodium intake, family history, African American descent, advanced age, obesity, hyperlipidemia, CAD
Complications: stoke, MI, RF, HF, vision loss.

Question 49

Q

Nursing Education for Hypertension

Answer

A

Medications:
- ACE inhibitors
- Beta Blockers
- CCBs
- Beta Blockers
Diet:
- DASH
- low sodium
-avoid caffeine and alcohol
- weight loss
- smoking cessation
- less sitting; more walking

Question 50

Q

Chronic Stable Angina

Answer

A

Chronic disease caused by narrowing of the arteries and plaque build up. There are periods of increased schema to the heart. Decreased blood flow to the heart leads to decreased O2 delivery, and schema of tissues. Ischemia causes chest pain.
Causes: venous and arterial dilation, decreasing after load, increasing CO.
Nursing Considerations: Nitroglycerine may be given S/L; 1 pill q 5 min x3 doses; do not swallow; keep bottle in cool, dark place; headache is expected; ECG after treatment; causes decreased BP.
Education: decrease workload on the heart by rest, not overeating, no smoking and avoiding extreme temperatures.

Question 51

Q

Unstable Angina (Acute Coronary Syndrome)

Answer

A

stable angina can progress to unstable angina, and subsequently MI if untreated. There is decreased blood flow to the heart, leading to schema and necrosis of the tissue. Goal is to treat quickly and limit damage to the heart.
Assessment: dull, midsternal chest pain; crushing pain; radiating to left arm and jaw; epigastric discomfort; fatigue; SOB; vomiting.
Treatment: if STEMI, send to Cath lab within 90 mins for PCI; give morphine for pain; administer O2 only if saturation is below 92%; nitroglycerine, aspirin.
Education: quit smoking, diet low in salt and cholesterol, weight loss by walking.

Question 52

Q

Heart Failure

Answer

A

inability of the heart to pump enough blood to meet the body’s demands for oxygen. There are two types: right sided and left sided heart failure; often occurs as complication to another disease; #1 cause is hypertension.
Causes: hypertension, cardiomyopathy, endocarditis, MI.
Treatment: decrease the workload of the heart
- ACE inhibitors: decrease afterload
- ARBs: decrease blood pressure and increases cardiac output
- Diuretics: reduce edema within the body and supports decrease in blood pressure.
Education: take diuretics in the am; monitor electrolytes with diuretics; low sodium diet; elevate HOB; daily weights; report weight gain of 2-3 lbs in 24 hrs*

Question 53

Q

Left Sided HF

Answer

A

the heart is unable to move blood forward to the rest of the body. The blood backs up into the lungs.
S & S: pulmonary congestion, dyspnea, cough, wet lung sounds (crackles), blood tinged sputum, murmur, orthopnea, tachycardia, cyanotic, confused.
Treatment: decrease the workload of the heart
- ACE inhibitors: decrease afterload
- ARBs: decrease blood pressure and increases cardiac output
- Diuretics: reduce edema within the body and supports decrease in blood pressure.

Question 54

Q

Right sided HF

Answer

A

the right side of the heart cannot move blood forward to the lungs. Blood backs up in the body.
S & S: JVD, dependent edema, hepatomegaly, spenomegaly, ascites, weight gain, fatigue, and anorexia.
Treatment: decrease the workload of the heart
- ACE inhibitors: decrease afterload
- ARBs: decrease blood pressure and increases cardiac output
- Diuretics: reduce edema within the body and supports decrease in blood pressure.

Question 55

Q

Peripheral Arterial Disease

Answer

A

Blood flow to lower extremities is impaired
S & S: pallor; hairlessness; eschar in wounds; dangle legs when pain occurs; pain stops with rest; absent pedal pulses.

Question 56

Q

Peripheral Vascular Disease

Answer

A

Blood flow back to the heart is affected
S & S: brown discolouration of skin; edema; pedal pulses present; focus on proper wound care.

Question 57

Q

Aortic Aneurysm

Answer

A

dilation of the aorta, typically caused by atherosclerosis, HTN, smoking, and family history.
S & S: abdominal/back pain that is sharp; severe pain; SOB; trouble swallowing
Considerations: dont palpate the mass*

Question 58

Q

Air Embolism

Answer

A

Air bubble enters the vein or artery; rare; may be complication of surgical procedure (placement of CVAD/arterial catheter)
Treatment: Durant’s Manuever
- Left lateral trandelenburg
- Prevents air from lodging in lungs

Question 59

Q

Shock

Answer

A

A state where the vital organs are not receiving enough oxygen. Lack of oxygen causes organ damage and forces cells to use anaerobic metabolism to produce energy, producing elevated lactate. Can have ineffective blood flow back to the heart, vasculature damage, or volume deficits.
1. Cardiogenic
2. Distributive
3. Hypovolemic

Question 60

Q

Cardiogenic Shock

Answer

A

The heart is not able to pump sufficient amount of blood to the organs; organs go into anaerobic metabolism and shock occurs.
Causes: MI; HF; hypotension; tachycardia (rapid and weak); tachypnea; diaphoresis with cool, clammy skin; arrhythmias; JVD.
Treatment: Treat the cause
- CABG/PCI for MI
- thombolytics for PE
- pericardiocentesis for tamponade

Question 61

Q

Distributive Shock

Answer

A

something causes immune or autoimmune. response in the body, which decreases vascular tone, which causes mass vasodilation in the periphery, decreased BP, anaerobic metabolism, and shock.
Causes: anaphylaxis (allergic reaction); neurogenic: spinal cord injury; septic: systemic inflammatory cytokine release
S & S: decreased spO2, hypotension, tachycardia, warm and flushed skin, tachypnea, decreased LOC.
Treatment:
Anaphylactic Shock:
- epinephrine
- corticosteroids
- bronchodilation
Neurological:
- cooling, supportive care
Septic: IV abx, IV fluids.

Question 62

Q

Hypovolemic Shock

Answer

A

Low blood flow, loss of circulating volume; not enough blood entering the heart; body vasoconstrictor to compensate; tissues turn ischemic and resort to anaerobic metabolism; shock ensues. Results in decreased intravascular volume, which reduces preload and stroke volume; HR increases; contractility increases; vasoconstriction occurs.
Causes: hemorrhage, trauma, dehydration with nausea and vomiting, diarrhea, and burns
Assessment: weak; pale; tachycardic; anxious; decreased LOC; cool and clammy skin; decreased urine output.
Treatment: Fix the cause.
- stop the bleeding (or diarrhea or vomtiing)
- replace fluid volume with NS or RL
- support perfusion with vasopressors
- blood products

Question 63

Q

Prinzmetal’s Angina

Answer

A

Variant Angina; occurs at about the same time every day; usually at rest; treated with calcium channel blockers

Question 64

Q

Hyphema

Answer

A

an ocular emergency that has been caused by blood in the anterior chamber of the eye. This injury results from trauma and should be addressed promptly. Initial nursing actions include: elevation of the head of the bed to 30 degrees to keep blood below the visual axis; application of eye shield to the affected eye to prevent further injury; prescribed medication should not include aspirin or NSAIDs; educate the client to avoid raising the intraoccular pressure such as with bending at the waist, vomiting, coughing, or crying.

Answer 65

A

Apply a tourniquet around the upper arm about 10 to 15 cm (4–6 inches) above the proposed insertion site
With your fingertip, palpate the vein at the intended insertion site by pressing downward. Note resilient, soft, bouncy feeling while releasing pressure
Release tourniquet temporarily
Perform skin antisepsis with alcohol-based 2% chlorhexidine solution using friction in a back-and-forth motion
Reapply the tourniquet 10 to 15 cm (4–6 inches) above the anticipated insertion site
Perform venipuncture. Anchor vein below anticipated insertion site by placing thumb over vein 4 to 5 cm (1½–2 inches) distal to site and gently stretching skin against direction of insertion
Observe for blood return in catheter or flashback chamber of catheter, indicating that bevel of needle has entered vein. Advance VAD approximately ¼ inch (0.6 cm) into vein and loosen stylet (needle) of the catheter. Continue to hold skin taut while stabilizing VAD and, with index finger on push-off tab of VAD, advance catheter off needle into vein until hub rests at venipuncture site
Release tourniquet or BP cuff with other. Apply gentle but firm pressure with middle finger of nondominant hand 3 cm (1¼ inches) above insertion site.
Quickly connect Luer-Lok end of short extension tubing with needleless connector to end of catheter hub
Take the previously attached 10-mL prefilled syringe that contains 0.9% sodium chloride (normal saline [NS]) and is connected to short extension set. Aspirate by pulling back on syringe to remove air and assess blood return. Then, slowly inject NS from syringe into VAD
Apply a sterile dressing to the area and document the procedure

Answer 66

A

✓ When establishing a vascular access device, the nurse should consider the intention of the therapy and the duration

✓ It is highly preferred that a site be selected on the client’s non-dominant arm

✓ To prevent skin injury, the nurse should consider using a blood pressure cuff instead of a tourniquet

✓ Good skin cleansing of at least thirty seconds is necessary to maintain an aseptic technique

Answer 67

A

24 gauge (yellow) – infants and peds
22 gauge (blue) – Peds and med-surg; IV contrast; easily blown veins
20 gauge (pink) – most adult patients; CT angiography; blood transfusions
18 gauge – massive trauma; Codes; RRTs

Answer 68

A

A port is a central venous line that is useful for individuals receiving chemotherapy. The nurse should utilize an aseptic technique to prevent central line-associated bloodstream infections (CLABSIs) when the port is accessed. This includes the nurse and the client wearing a mask as well as the nurse using sterile gloves. Occlusion is a common complication with a port, and prior to de-accessing, the nurse should flush heparin. Further, the client should be instructed to wear a mask to prevent contamination during dressing changes. Finally, the nurse must verify appropriate access by aspirating for blood return prior to medication administration.The nurse utilizes a non-coring needle to access a port. A 16-gauge catheter will be an option if a nurse starts a large-bore peripheral IV. When a port is accessed, it is accessed with a non-coring needle that is 0.5 to 2 inches, with the gauge being 19 to 22.When caring for a client with a port, it is essential to prevent CLABSIs through meticulous hand hygiene and aseptic dressing changes. The nurse should instruct the patient to avoid getting the accessed port wet and report signs of infection such as erythema. If the port is not in use, it needs to be accessed and flushed once a month to maintain patency.

Answer 69

A

Permissive hypertension during an ischemic stroke allows the blood pressure to go up to 185/110 mm Hg. This enables perfusion around the stroke to distal tissue. Thus, the nurse will continue to monitor because the blood pressure of 168/101 mmHg does not meet the threshold to notify the PCP. A blood pressure of 150/100 mm Hg is needed to maintain cerebral perfusion after an acute ischemic stroke.

Answer 70

A

labetalol

Answer 71

A

permissive hypertension (ensures perfusion to the brain)
Antithrombotics (TPA; breaks up clot to restore blood flow; must be done quickly; within 60 min)
percutaneous thrombectomy (surgical removal of clot; done in OR)

Answer 72

A

get bleeding under control
if caused by aneurysm, coiling or clipping procedure; craniotomy; EVD;

Answer 73

A

BNP; B-type natriuretic peptide (BNP) is a commonly ordered test for clients who may have heart failure. Elevations indicate worsening of heart failure as it is indicative of fluid retention.

Answer 74

A

Congestive heart failure (CHF) is a chronic condition that causes a decrease in cardiac output. The client will need to maintain a low sodium diet, so processed foods such as luncheon meat should be avoided. Annual immunizations are recommended because of the increased risk of complications from influenza. Complications from influenza are higher in those with co-morbidities such as CHF. The client should be taught to weigh themselves daily and to report a weight gain of five pounds or more within one week. The client must not wait until he/she gains 10lbs/week. NSAIDs such as ibuprofen may contribute toward fluid retention and should not be used in clients with CHF. ssessing the urinary ketones is only done for those with hyperglycemia secondary to diabetes mellitus. This is done to check for the potential development of ketoacidosis.
For a client with heart failure, self-management strategies include following the MAWDS approach.

Medications

✓ Take medications as prescribed and do not run out.

✓ Know the purpose and side effects of each drug.

✓ Avoid NSAIDs to prevent sodium and fluid retention.

Activity

✓ Stay as active as possible but don’t overdo it.

✓ Know your limits.

✓ Be able to carry on a conversation while exercising.

Weight

✓ Weigh each day simultaneously on the same scale to monitor for fluid retention.

Diet

✓ Limit daily sodium intake to 2 to 3 g as prescribed.

✓ Limit daily fluid intake to 2 L.

Symptoms

✓ Note any new or worsening symptoms and immediately notify the health care provider.

Answer 75

A

During SVT, P waves may not be visible, because the P waves are embedded in the preceding T wave. A client with SVT may be asymptomatic. If the client is symptomatic, they may exhibit manifestations such as palpitations, dizziness, dyspnea, and nervousness. Treatment includes vagal maneuvers. Vagal maneuvers include having the beardown, blowing through a straw, having the primary healthcare provider (PHCP) perform a carotid massage, and, if the client is an infant, applying a bag filled with ice and water to the face above the nose and mouth for 15 to 30 seconds. If that is not effective, another vagal maneuver would be pressing the infant’s knees to the chest for 15-30 seconds.

If these measures are ineffective, the nurse should prepare to administer the prescribed adenosine by rapid intravenous push (IVP) that is followed by a flush of 0.9% saline. When adenosine is administered, the emergency (code) cart should be nearby, and the nurse should always have additional personnel in the room.

Answer 76

A

The Parkland formula is a guide to determining the 24-hour fluid replacement following a major thermal burn. The phases of fluid replacement include the first eight hours and the remaining sixteen.

The client’s weight in kilograms will be multiplied by the total body surface area burned, then multiplied by 4 mL
After the 24-hour fluid total is determined, it should be divided by two (for the two phases)
The first eight hours begin at the time of injury - not hospitalization.
Deduct any fluids given pre-hospital
A central line is preferred to deliver this fluid
Lactated Ringer’s is commonly used as the fluid of choice because it may mitigate metabolic acidosis.
Urine output is monitored closely to determine if the client is responding to treatment (0.5mL/kg/hr)
The nurse should also monitor the mean arterial pressure (MAP) to determine if the client is responding (goal is > 65 mm Hg)

Answer 77

A

Varicose veins can be managed by recommending that the client

✓ Wear compression hose/stockings

✓ Keep the legs elevated to promote venous return

✓ Engage in frequent position changes of the legs

✓ Daily walks are recommended; high impact exercise may contribute to the development of varicose veins

Answer 78

A

Nursing care for those with PAD includes:

Mitigate factors such as appropriate blood pressure control, avoiding atherogenic foods, and smoking cessation. Having the legs dependent helps facilitate blood flow.
The nurse should educate the client to avoid applying heat to the affected extremity. The client should also avoid using constrictive clothing, garments, or devices.
Medical management includes pharmacotherapy, including cilostazol, clopidogrel, and pentoxifylline.

Answer 79

A

blood flow to lower extremities is impaired
pallor with dependent rubor
hairlessness
poor/absent pedal pulses
eschar in wounds
dangle legs when pain occurs
pain stops with rest

Answer 80

A

blood flow back to the heart is impaired
brown discolouration of legs
swelling in legs (elevate)
uneven wound edges around ankle
pedal pulse present
focus on proper wound care

Answer 81

A

used in asystole to restore vascular tone, increasing perfusion to brain and heart. This is the next essential action after completing CPR.

Answer 82

A

Asystole is a complete cessation of a ventricular rhythm. This produces no cardiac output. Using defibrillation or cardioversion is not an effective remedy for this arrhythmia because the heart has nothing to shock as it is at a complete standstill. The treatment recommended for asystole is high-quality CPR at a rate of 100-120 compressions per minute followed by intravenous epinephrine.

Answer 83

A

✓ Hemophilia is transmitted as an X-linked recessive disorder

✓ The two most common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia) and factor IX deficiency (hemophilia B, or Christmas disease)

✓ Severe forms of the disease may cause significant internal bleeding from a slight fall, a bruise, or the loss of deciduous teeth

✓ Bleeding is commonly found in the joints that manifest as joint stiffness, limited range of motion, and swelling

✓ A client with hemophilia should be educated to avoid contact sports, the manifestations of bleeding, and adherence to follow-up care

✓ Clients with hemophilia should avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) because they inhibit platelet function

Answer 84

A

irregular heart rate
known hypertension
peripheral vascular obstruction
shivering
seizures
excessive tremors
inability to cooperate
blood pressure less than 90 mmHg systolic

Answer 85

A

Alteplase is a thrombolytic indicated in the treatment of an ischemic stroke. To administer alteplase, the nurse must ensure that all invasive procedures are completed before the infusion to avoid bleeding. Two peripheral vascular access devices are needed, along with close monitoring of the client’s vital signs and neurological status.

Answer 86

A

A client with decreased cardiac output is at risk for hemodynamic instability. Having the client wear compression stockings is helpful because it promotes venous return to the heart. Increasing venous return will increase blood volume (preload). Either compression hose or intermittent sequential pneumatic compression devices may be helpful. Elevating the legs of a supine client redistributes blood to central organs and promotes the venous return to the heart, thereby increasing cardiac output. The client with decreased cardiac output is at greater risk for falls because of orthostatic hypotension. Implementing fall precautions and educating clients to change positions slowly will be beneficial. If a client strains during defecation, the preload will decrease due to a baroreflex. Therefore, the client should be educated not to strain during defecation, and the nurse may need to obtain a prescription for stool softeners (or a laxative).

Answer 87

A

Labetalol is an alpha- and beta-adrenergic blocking agent used to treat a hypertensive emergency. Considering that this client is both hypertensive and tachycardic, labetalol would be a good choice.
A hypertensive emergency (or sometimes termed hypertensive crisis) is defined as a blood pressure of 180/120 mmHg or greater. This blood pressure may cause end-organ damage and symptoms such as flushing, headache, dizziness, angina, and/or dyspnea. Nursing care aims to establish prompt intravenous (IV) access, position the client in the semi-Fowler’s position, initiate continuous cardiac monitoring, and monitor the blood pressure frequently. The blood pressure should be lowered gradually, with the mean arterial pressure lowered by 10-20 percent within the first hour.

Answer 88

A

Bacterial meningitis manifests as a stiff neck, photophobia, fever, altered mental status, and malaise. The nurse would need to perform an oral temperature and the Glasgow Coma Scale to discern the client’s current mental status.
✓ Symptoms of meningitis classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias.

✓ The nurse’s immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions.

✓ Close monitoring of the client’s neurological status is the priority, along with prompt administration of prescribed antibiotics after the lumbar puncture.

✓ The Glasgow Coma Scale is a quick and effective tool that monitors neurological status.

✓ The highest score on the GCS is 15 as it measures the client’s best eye-opening, verbal, and motor responses.

Answer 89

A

Infiltration occurs when the intravenous (IV) catheter has migrated out of the vein, and the fluid spills into the surrounding tissue. Manifestations of infiltration include swelling, coolness, tingling, or redness at the IV site. The nurse should stop the infusion, discontinue the IV catheter, elevate the affected extremity above the client’s heart, apply a warm compress to the affected area, and restart the IV in the opposite extremity.

Answer 90

A

✓ Infiltration occurs when the intravenous catheter migrates out of the vein.

✓ The intravenous catheter migration is often caused by the catheter not being secured to the client’s skin.

✓ When infiltration occurs, the medication leaks into the tissues around the vein.

✓ Manifestations of infiltration include swelling, coolness, tingling, or redness at the IV site.

✓ Treatment for infiltration includes pausing the infusion, discontinuing the IV catheter, and elevating the extremity above the heart.

✓ Extravasation is significantly worse than infiltration because the medication leaks into the surrounding tissue, and the medication is a vesicant.

✓ A vesicant is a medication with a low pH or may cause significant irritation to the surrounding tissue.

✓ If extravasation occurs, the nurse should pause the infusion and aspirate any medication in the IV catheter.

✓ The nurse should not flush the IV catheter, which will further cause more damage. The catheter should be discontinued, and the physician should be notified.

Answer 91

A

hyponatremia facilitates lithium toxicity

Answer 92

A

Lithium causes leukocytosis, which is a benign side effect. While this could mask acute infection and inflammation, this is an expected finding.

Answer 93

A

Digoxin is a cardiac glycoside used in the treatment of atrial fibrillation and congestive heart failure

✓ Frequent vomiting, poor feeding, or slow heart rate can be signs of digoxin toxicity

✓ If the child or infant vomits, do not give another dose and notify the prescriber

✓ The apical pulse must be at least 60/per minute for adults, 70/per minute for children, and 90/per minute for infants before administering

Answer 94

A

The client taking prescribed warfarin should avoid alternative therapies that may potentiate the anticoagulant effects and increase bleeding risk. Alternative therapies such as Ginkgo Biloba, ginger root, garlic, and saw palmetto increase the bleeding risk in a client taking warfarin. The client should be advised against taking these medications.

Answer 95

A

It is expected that the drainage system will be at a level below the client’s chest. This is what allows gravity to help drain fluid from the pleural space. If the drainage system were above the client’s chest, the chest tube would not work properly (Choice A). An occlusive dressing placed over the chest tube is appropriate. This is important to ensure that air does not enter the pleural space causing a pneumothorax. The nurse should check the dressing to ensure it is airtight (Choice D). The dressing is changed daily. Pain at the insertion site is expected and typically is aggravated when the client changes positions.
Tidaling refers to the up and down movement of water in the water seal
chamber. The water level rises during inspiration and falls during expiration. Absence of tidaling indicates that there is an obstruction in the chest tube or
that the lung has fully re-expanded.

Answer 96

A

The purpose of CPR is to move blood through the heart and to the body’s cells to prevent cell death. According to the American Heart Association (AHA), high-quality CPR includes a compression rate of 100-120 per minute to a depth of 2-2.4 inches. The provider must allow full chest recoil between each compressor. Full chest recoil allows the heart chambers to fill with blood between compressions. When the ventricles fill, more oxygenated blood will be available to the cells. Fatigue will result in less effective compressions, so the AHA recommends that the compressors rotate every 2 minutes or five cycles of compressions to prevent fatigue.
Pediatric guidelines for CPR include:

✓ 1 rescuer - cycles of 30 compressions to 2 breaths

✓ 2- rescuer - cycles of 15 compressions to 2 breaths

✓ compression depth is 1.5” for infants and 2” for children

Answer 97

A

An infusion of norepinephrine is indicated if the client is in shock. This medication helps restore vascular tone and is useful in treating life-threatening hypotension. This medication is a vesicant, and the preferred delivery is through a central line. If this is not possible, a large-bore intravenous catheter should be utilized. The patency of this catheter should be assessed frequently to prevent damaging extravasation. Blood pressure must be monitored continuously while this medication is administered to assess the desired response of increased vascular tone. This medication causes vasoconstriction, decreasing renal blood flow and decreasing urine output. Norepinephrine causes an increase in blood glucose because of its ability to cause the liver to discharge more glucose by breaking down glycogen.
Vasopressors are highly preferred to be administered via a central line. This is because these medications are vesicants and may cause serious extravasation if the peripheral IV is not patent. The nurse should ensure that the client has appropriate hemodynamic monitoring while receiving vasopressors such as continuous cardiac and blood pressure monitoring.

Answer 98

A

diltiazem may be used as a treatment. Diltiazem is a calcium channel blocker and may cause the client to develop heart failure because of its negative inotropic and chronotropic effects. An S3 heart sound is one of the earliest manifestations of heart failure. This, combined with pedal edema, supports the nurses’ decision to stop this infusion to prevent further clinical deterioration.
Key assessments for a client receiving diltiazem include -

Monitor HR and BP; bradycardia and hypotension are common side effects.
Teach clients to report dyspnea, orthopnea, distended neck veins, or swelling of the extremities; HF can occur, necessitating a decrease in dosage or discontinuation of the drug.

Answer 99

A

signs and symptoms of bleeding, including hematuria, frank or occult blood in the stool, ecchymosis, petechiae, altered mental status (indicating possible cranial bleeding), or pain (especially abdominal pain, which could indicate abdominal bleeding).
This risk of bleeding is substantial for a client receiving a continuous infusion of heparin. The UAP should be instructed to perform oral care with a soft bristle toothbrush to prevent gingival bleeding. An electric razor is preferred over a traditional razor because of the decreased risk of trauma. A lift sheet should be used to reposition the client over sliding the client, reducing the risk of shearing injuries. Nail clippers may cause skin trauma. Thus, an emery board is preferred.

Answer 100

A

Magnesium Sulfate is a prescription medicine used to treat the symptoms of low levels of magnesium (Hypomagnesemia), to prevent seizures in pregnant women with conditions such as pre-eclampsia, eclampsia and Toxemia of Pregnancy. Magnesium Sulfate may be used alone or with other medications.

Magnesium Sulfate belongs to a class of drugs called Antidysrhythmics, V; Electrolytes.

Answer 101

A

hives,
difficulty breathing, and
swelling of your face, lips, tongue or throat
lightheadedness,
sweating,
anxiety,
cold feeling,
flushing (warmth, redness, or tingly feeling),
weak or shallow breathing,
extreme drowsiness,
feeling very weak,
numbness or tingly feeling around your mouth,
muscle tightness or contraction, and
overactive reflexes

Answer 102

A

Magnesium sulfate (magnesium sulfate (magnesium sulfate injection) injection) is indicated in the following conditions:

Convulsions (treatment) - Intravenous magnesium sulfate (magnesium sulfate (magnesium sulfate injection) injection) is indicated for immediate control of life-threatening convulsions in the treatment of severe toxemias (pre-eclampsia and eclampsia) of pregnancy and in the treatment of acute nephritis in children.

Hypomagnesemia (prophylaxis and treatment) - Magnesium sulfate (magnesium sulfate (magnesium sulfate injection) injection) is indicated for replacement therapy in magnesium deficiency, especially in acute hypomagnesemia accompanied by signs of tetany similar to those of hypocalcemia.

Magnesium sulfate (magnesium sulfate (magnesium sulfate injection) injection) is also used to prevent or treat magnesium deficiency in patients receiving total parenteral nutrition.

Tetany, uterine (treatment) - Magnesium sulfate (magnesium sulfate (magnesium sulfate injection) injection) is indicated in uterine tetany as a myometrial relaxant.

Answer 103

A

Flushing, sweating, sharply lowered blood pressure, hypothermia, stupor and ultimately, respiratory depression.

Answer 104

A

The principle hazard in parenteral magnesium therapy is the production of abnormally high levels of magnesium in the plasma. Such high levels may cause flushing, sweating, hypotension, circulatory collapse and depression of cardiac and central nervous system function. The most immediate danger to life is respiratory depression.

During the period of parenteral therapy with magnesium salts, the patient should be watched carefully. A preparation of calcium, such as the gluconate or gluceptate should be at hand for intravenous administration as an antidote.

In the presence of severe renal insufficiency, no more than 20 grams of magnesium should be given within a forty-eight hour period. In eclampsia, however, renal function is not seriously impaired and magnesium may be more rapidly excreted.

This product contains aluminum that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Premature neonates are particularly at risk because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which contain aluminum.

Research indicates that patients with impaired kidney function, including premature neonates, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration.

Answer 105

A

a medication intended to assist an individual with smoking cessation. This medication should be started seven days before the planned quit date and gradually increased in dose. The medication may be prescribed for twelve weeks to ensure appropriate abstinence.The most common side-effects include nausea (feeling sick), insomnia (difficulty sleeping), abnormal dreams, headache and nasopharyngitis (inflammation of the nose and throat).[6]

Answer 106

A

Locating the upper third of the acromion process is the appropriate anatomical landmark to give an injection in the deltoid. When giving an IM in the deltoid, the client should sit or lie down. This best practice allows for the nurse to appropriately locate the anatomical landmarks. Additionally, if the client should develop syncope from the injection, this also prevents injury. Clean gloves should be worn for this procedure as the likelihood of coming into contact with blood is high.
✓ When injecting into the deltoid muscle, the nurse should locate the acromion process; inject only into the upper third of the deltoid muscle that begins about two fingerbreadths below the acromion.

✓ The essential advantage of giving an IM in the deltoid is faster absorption rates than gluteal sites and easily accessible with minimal removal of clothing

Answer 107

A

use of over-the-counter antacids such as Alka-Seltzer places the client at risk of developing metabolic alkalosis due to the high amount of sodium bicarbonate present in this medication. If the client uses the medication too frequently, the client’s HCO3 level can increase, resulting in metabolic alkalosis.

Answer 108

A

Clients at risk for metabolic acidosis include individuals experiencing diarrhea, renal disease, and/or diabetic ketoacidosis. These clients experience a decrease in their HCO3, causing their pH to become acidotic.

Answer 109

A

The types of clients at risk for respiratory acidosis include those with chronic obstructive pulmonary disorder, individuals experiencing respiratory depression following a medication overdose, or any client experiencing hypoventilation. These clients retain CO2, causing their pH to become acidotic.

Answer 110

A

Clients at risk for respiratory alkalosis include those who hyperventilate, such as one would when experiencing a panic attack. During hyperventilation, clients lose CO2, causing their pH to become alkalotic.

Answer 111

A

Mannitol is an osmotic diuretic indicated for cerebral edema. Mannitol may crystallize when exposed to low temperatures. Because of this, mannitol is always administered intravenously through intravenous tubing with a filter.
✓ Mannitol is used in treating patients in the early oliguric phase of acute renal failure.

✓ For it to be effective in this setting, however, enough renal blood flow and glomerular filtration must remain to enable the drug to reach the renal tubules.

✓ Mannitol can also promote the excretion of toxic substances, reduce intracranial pressure, and treat cerebral edema.

✓ The normal intracranial pressure is 10-15 mm Hg.

Answer 112

A

According to the AHA’s suspected stroke algorithm, the correct course for the treatment of the stroke patient is:

General assessment and stabilization within 10 minutes of arrival to the ED
Neurologic evaluation by the stroke team within 25 minutes of entry to the ED
CT scan and determination if there is intracranial hemorrhage within 45 minutes of entry to the ED
If ischemic stroke, determine if the patient is a candidate for fibrinolytic therapy using the fibrinolytic checklist
Administer rtPA within 60 minutes of entry to the ED
Admit to the stroke unit within 3 hours of entry to the ED

Answer 113

A

A combination of medications and behavioral therapy works best for smoking cessation rather than either treatment alone. Most smoking cessation medications work by reducing nicotine withdrawal and craving. Medicines for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion.

Varenicline is a preferred option for most patients. Varenicline is administered as an oral pill. It works by relieving nicotine withdrawal symptoms and blocking the smoking-related reward feeling. For a patient taking varenicline, starting the medication one week before quitting cigarettes is recommended. The patient may continue the treatment for up to twelve weeks. The most common side effect of varenicline is nausea. Adversely, neuropsychiatric effects such as vivid dreams, depression, and suicidal ideation have been reported. Varenicline should not be used in patients with a history of suicidal ideation or unstable psychiatric illness.
Nicotine replacement therapy (NRT) is available in various forms ( patch, lozenge, gum, inhaler, and nasal spray). NRT may be prescribed as a first-line choice based on the client’s preference. Adverse effects include insomnia and vivid dreams.
Bupropion is less effective compared to NRT or varenicline. However, it’s a preferred choice for patients with depression because bupropion can work as an anti-depressant. Additionally, bupropion promotes weight loss and may be preferred for clients wishing to avoid weight gain following smoking cessation. Bupropion reduces the seizure threshold, and consequently, it is contraindicated in patients with a seizure disorder.
Ongoing counseling should be pursued to enhance a patient’s success at smoking cessation.

Answer 114

A

People with heart failure may improve their symptoms by reducing the amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt. Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup. Patients should be encouraged to follow a low-sodium diet to help manage symptoms of hypertension and to reduce edema. One of the most natural things a patient can do at home is to reduce the amount of sodium intake. They can also eat fresh vegetables rather than canned. If canned vegetables are the only option, the patient should rinse the plants with clean water and cook them with unsalted water.

Answer 115

A

18
CK-MB, or creatine kinase myocardial muscle, levels measure muscle cell death and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels first begin elevating about 3 to 6 hours after a cellular injury or myocardial infarction and stay elevated for about 48 to 72 hours.

Answer 116

A

Depending on the surgical procedure and any unanticipated needs arising during surgery, the autologous units previously stored may be insufficient for the client’s needs. If so, the client may receive additional units of blood from the community blood bank.
To help maintain the client’s blood hemoglobin at an acceptable level, the HCP will often recommend iron supplements for clients who choose to provide autologous blood donations.
Although infectious disease testing is not traditionally performed on autologous blood donations, these donations receive ABO/Rh and antibody screenings.
Approximately half of all autologous blood collected in the United States is not utilized.
Severe transfusion reactions, including fluid overload causing heart failure, are not prevented by autologous donation.

Answer 117

A

To administer eye drops, the nurse should perform the following -

Perform hand hygiene and apply clean gloves. Ask the client to lie supine or sit back in the chair with head slightly hyperextended, looking up
If drainage or crusting is present along eyelid margins or inner canthus, gently wash away. Soak any dried crusts with a warm, damp washcloth or cotton ball over the eye for several minutes. Always wipe clean from inner to the outer canthus. Remove gloves and perform hand hygiene.
Explain that there might be a temporary burning sensation from drops.
Hold a clean cotton ball or tissue on the client’s cheekbone below the lower eyelid in the non-dominant hand.
With tissue or cotton ball resting below the lower lid, gently press downward with thumb or forefinger against the bony orbit, exposing the conjunctival sac. Never press directly against the client’s eyeball.
Ask the client to look at the ceiling. Rest a dominant hand on the client’s forehead; hold the filled medication eyedropper approximately 1 to 2 cm (½–1 inch) above the conjunctival sac.
Drop the prescribed number of drops into the conjunctival sac.
When administering drops with systemic effects, apply gentle pressure to the client’s nasolacrimal duct with clean tissue for 30 to 60 seconds over each eye, one at a time. Avoid pressure directly against the client’s eyeball.
After instilling drops, ask the client to close their eyes gently.

Answer 118

A

Hemophilia is a genetic disorder that causes a factor VIII deficiency. Factor VIII is produced by the liver and is necessary for the formation of thromboplastin in phase I of blood coagulation. Bleeding is commonly found in the joints (termed hemarthrosis), which causes joint stiffness, aches, and a decreased range of motion. Hematuria is also a clinical feature that may be evident (either grossly or by microscopy that would be shown on a urine analysis). Epistaxis is a feature as well if trauma to the nose occurs.
✓ Hemophilia is transmitted as an X-linked recessive disorder

✓ The two most common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia) and factor IX deficiency (hemophilia B, or Christmas disease)

✓ Severe forms of the disease may cause significant internal bleeding from a slight fall, a bruise, or the loss of deciduous teeth

✓ Bleeding is commonly found in the joints that manifest as joint stiffness, limited range of motion, and swelling

✓ A client with hemophilia should be educated to avoid contact sports, the manifestations of bleeding, and adherence to follow-up care

✓ Clients with hemophilia should avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) because they inhibit platelet function

Answer 119

A

Tidaling in the water seal chamber along with intermittent bubbling, is expected for a client with a pneumothorax. If tidaling and intermittent bubbling have stopped, it could indicate a positive finding such as the resolution of the pneumothorax. Considering that this client had this device placed three hours ago, a resolution is unlikely. The more likely finding is that a portion of the tubing is kinked or obstructed which has stopped the tidaling in the water seal chamber.

Answer 120

A

The vital signs show hypotension (90/60 mm Hg). The nurse should clarify the prescriptions of atenolol, spironolactone, and fentanyl. All these medications decrease blood pressure, and considering how low the client’s blood pressure is, it would be highly detrimental.
✓ Atenolol is a beta-blocker that lowers blood pressure and heart rate. The nurse should assess both before administration.

✓ Spironolactone is a potassium-sparing diuretic. This medication decreases fluid volume, therefore, reducing blood pressure.

✓ Fentanyl is an opioid that causes vasodilation, lowering blood pressure.

Answer 121

A

Cardiac tamponade is the condition the client is likely experiencing, as evidenced by the following:

The client’s history of SLE and pulmonary hypertension which elevates the risk for tamponade
The client’s narrowed pulse pressure, tachypnea, jugular venous distention, and tachycardia
The cardiac sounds, which were muffled, a common finding with cardiac tamponade
The chest x-ray report showed an enlarged cardiac silhouette with a pericardial effusion, a common finding in cardiac tamponade.
A pericardial effusion occurs when (20 to 50 mL) of fluid accumulates rapidly in the pericardium and causes a sudden decrease in cardiac output (CO).
No ST-segment changes and elevations of troponin exclude ACS.
Lung sounds were normal, and pulse oximetry was optimal, which excludes a pneumothorax.
The chest X-ray also showed no lung abnormalities, excluding a pneumothorax.

Answer 122

A

A thoracentesis is best performed with the client sitting upright and leaning slightly forward with arms supported. Unless there is a large volume of fluid in the pleural space, thoracentesis usually takes 10 to 15 minutes. During this time, most clients sit quietly on the edge of a chair or bed with their head and arms resting on a pillow positioned on a bedside table. Semi-Fowler’s position is not utilized.

Answer 123

A

The correct sequence of nasogastric tube insertion is as follows:

The nurse should explain the procedure to the patient. Then, place the client in a high-Fowlers’ position and the pillows behind the shoulders.
The nurse should then measure the tube length from the nose to the earlobe to the xiphoid process (NEX method).
Afterward, the nurse should insert the lubed nasogastric tube into a patent nostril. Once the tube enters the back of the throat, the client should be instructed to take a few sips of water to facilitate the passage of the tube.
The tube should then be advanced into the stomach.
Once the tube has been inserted to the pre-measured length, it should be secured to the patient’s nose with tape. If you send the patient to an X-ray without securing it, there is a potential for the tube to get mobilized to an incorrect position by the time an X-ray is performed.
Following this, a confirmation x-ray should be obtained. Obtaining an abdominal x-ray is the best way to confirm the location of the tube,

Answer 124

A

Cilostazol is a phosphodiesterase inhibitor approved to treat peripheral arterial disease. Its action mechanism decreases platelet aggregation and promotes vasodilation, allowing a client to ambulate distances without pain.
✓ Cilostazol is an effective treatment for a client with peripheral arterial disease (PAD).

✓ Manifestations of PAD include pain while walking (claudication), decreased peripheral pulses, and painful ulcers.

✓ Common side effects of this medication include diarrhea and headache.

✓ Under no circumstances should this medication be given to a client with heart failure as it may worsen the condition.

Answer 125

A

It is not possible to eliminate sodium from the diet, nor would it be recommended. Sodium is a principal cation and it plays a role in driving the sodium-potassium pump as well as regulating water balance, so wholly eliminating sodium is not a good idea.Canned vegetables do use a large amount of sodium to preserve flavor, so you should advise your client with hypertension to avoid them. The body indeed needs some sodium as it plays a vital role in water balance, so this is an appropriate teaching point for your client.

Answer 126

A

During SVT, P waves may not be visible, because the P waves are embedded in the preceding T wave. A client with SVT may be asymptomatic. If the client is symptomatic, they may exhibit manifestations such as palpitations, dizziness, dyspnea, and nervousness. Treatment includes vagal maneuvers. Vagal maneuvers include having the beardown, blowing through a straw, having the primary healthcare provider (PHCP) perform a carotid massage, and, if the client is an infant, applying an ice pack firmly to the infant’s head. If these measures are ineffective, the nurse should prepare to administer the prescribed adenosine by rapid intravenous push (IVP) that is followed by a flush of 0.9% saline. When adenosine is administered, the emergency (code) cart should be nearby, and the nurse should always have additional personnel in the room.

Answer 127

A

Peripheral pulses may be diminished following cardiac catheterization, but the complete absence of a pulse indicates a serious complication. If unable to palpate the patient’s pulse, the nurse’s priority action should be to attempt to locate it with a doppler.

Answer 128

A

For the client in shock, administering a beta-blocker would be contraindicated because it would decrease cardiac output (CO) that is already compromised. For individuals with shock, treatment aims to increase the cardiac output by increasing the vascular tone. Medications such as dopamine, norepinephrine, and vasopressin would be utilized to increase the CO.
Beta-adrenergic blockers, more commonly referred to as beta-blockers

Answer 129

A

Beta-adrenergic blockers, more commonly referred to as beta-blockers

✓ Beta-blockers block catecholamines from binding to the receptors found in the heart and lungs

✓ These medications block the beta receptors, the rate at which the pacemaker (sinoatrial [SA] node) fires decreases, and the time it takes for the node to recover increases

✓ Some beta-blockers are more cardioselective (metoprolol and atenolol) compared to nonselective beta-blockers (propranolol)

✓ Underlying restrictive and obstructive respiratory illness may worsen when beta-blockers are given because the medication causes bronchoconstriction

✓ The nurse needs to assess the client’s pulse (P) and blood pressure (BP) before administration

✓ These medications may raise the client’s risk for falls because they may cause orthostatic hypotension

✓ Beta-blockers should not be administered if the client is experiencing any atrioventricular (AV) block or bradyarrhythmia

✓ Examples of beta-blockers include propranolol, metoprolol, and carvedilol

Answer 130

A

Strokes associated with atrial fibrillation have an abrupt onset. These ischemic strokes are caused by an embolus from the left atrial appendage. The FAST assessment (facial drooping, arm weakness or drift, slurred speech, time of last known well) is a rapid screening tool for a stroke. Other assessments include the Glasgow Coma Scale and the NIH Stroke Scale. The immediate priority for caring for a client with a suspected stroke is to assess their airway, breathing, and circulation and conduct a Glasgow Coma Scale assessment coupled with an NIH Stroke Scale. Pertinent laboratory work should be obtained, including capillary blood glucose, to rule out hypoglycemia. The client should be NPO until a bedside swallow evaluation can be completed.

Answer 131

A

✓ Enoxaparin comes in prefilled syringes to prevent dosing errors. The bubble should not be expelled before administration. If the drop is expelled, part of the dose would be wasted.

✓ Enoxaparin is administered subcutaneously. It should be injected at either a 90 or 45-degree angle. This medication should only be administered in the abdomen and not rubbed afterward.

✓ Enoxaparin is a low molecular weight-based heparin that does not require monitoring the activated partial thromboplastin time (aPTT).

✓ The nurse still needs to monitor the client for bleeding as well as heparin-induced thrombocytopenia (HIT). HIT would manifest as a reduction of platelets and may seriously cause thrombosis elsewhere.

✓ Contraindications to administering enoxaparin include recent spinal surgery, epidural, peptic ulcer disease, thrombocytopenia, and uncontrolled hypertension.

✓ The antidote for enoxaparin is protamine sulfate.

Answer 132

A

Enoxaparin is a low molecular weight-based heparin (LMWH). One of the adverse events of enoxaparin is heparin-induced thrombocytopenia (HIT). This severe condition results in a 50% or more decrease in the platelet count while also causing thromboses. Therefore, it is reasonable to monitor the platelet count after the initiation of enoxaparin.

Answer 133

A

Manifestations of right-sided heart failure in children include

✓ Edema (swelling) in the feet, ankles, or legs

✓ Abdominal swelling or discomfort

✓ Enlarged liver

✓ Difficulty breathing, especially with exertion

✓ Fatigue or decreased activity tolerance

✓ Rapid heart rate

✓ Decreased urine output

Answer 134

A

The nurse should remain with the client during a transfusion’s first fifteen to thirty minutes to observe for a hemolytic or allergic reaction.

➢ A hemolytic blood transfusion may be fatal if not caught promptly. The primary cause of this reaction is the misidentification of the client and the blood product.

➢ Manifestations of a hemolytic reaction include low-back pain, chest pain, tachycardia, hypotension, and a feeling of impending doom.

➢ If a hemolytic reaction is assessed, the nurse should immediately discontinue the transfusion and save the tubing and unit of blood for further analysis.

➢ Immediate client care involves spiking a new bag of isotonic saline (with new tubing) and keeping the intravenous catheter patent.

Answer 135

A

The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

Answer 136

A

Hydralazine is primarily an arteriolar vasodilation.

✓ The nurse should take the client’s blood pressure before administering this medication.

✓ The client is at risk for falls with this medication related to orthostatic hypotension.

✓ Hydralazine toxicity or overdose produces hypotension, tachycardia, headache, and generalized skin flushing.

✓ Reflex tachycardia may occur with this medication because as the blood pressure declines, the heart rate will increase to maintain cardiac output.

Answer 137

A

Acetazolamide, a carbonic anhydrase inhibitor, is commonly prescribed to prevent or treat AMS. It acts by causing a bicarbonate diuresis, which rids the body of excess fluid and induces metabolic acidosis. The acidotic state increases the respiratory rate and decreases the occurrence of periodic respiration during sleep at night. In this way, it helps clients acclimate faster to a high altitude. By increasing the client’s respiratory rate, the client can perfuse more oxygen. It is preferred that this medication be taken 24 hours prior to the ascent.
Acute mountain syndrome (AMS) causes increased sympathetic nervous system activity, increased heart rate, blood pressure, and cardiac output. Pulmonary artery pressure rises as an effect of generalized hypoxia-induced pulmonary vasoconstriction. Cerebral blood flow increases to maintain cerebral oxygen delivery. All of these processes call for an increased need for oxygen. Treatment for AMS includes supplemental oxygen (if available) and getting the client to a lower altitude. The client may also benefit from prescribed acetazolamide.

Answer 138

A

Clonidine is an alpha2-adrenergic agonist and is indicated in the treatment of hypertension. The medication may be administered as a pill or transdermal patch for seven days. Clonidine should not be abruptly discontinued because of the risk of rebound hypertension due to a catecholamine surge. Clonidine has a sedative effect, and the client should not take this medication with alcohol or while driving/performing tasks requiring a high degree of concentration. An example of a calcium channel blocker would be diltiazem or nifedipine. An example of an aldosterone receptor antagonist would be spironolactone.

Answer 139

A

Losartan is an angiotensin receptor blocker ( ARB). It reduces the systemic blood pressure (afterload) by countering the angiotensin II. Losartan does not have direct inotropic action on the heart, but it helps the cardiac output by decreasing the afterload. Losartan improves the morbidity and mortality in heart failure, and hence it’s an important drug in treating heart failure.

Answer 140

A

Heart failure is associated with reduced cardiac output and reduced blood flow to organs, including the kidneys. Reduced renal blood flow stimulates renin release. Renin converts Angiotensinogen to Angiotensin I, which is further activated to Angiotensin II by the angiotensin-converting enzyme in the lungs. Angiotensin II is a vasoconstrictor, and it increases peripheral vascular resistance (afterload). When medications are used to reduce afterload, the heart pumps better and cardiac output increases.

Answer 141

A

In myocardial ischemia, the ST-segment may appear elevated or depressed. In the presence of acute myocardial ischemia, ST-segment changes result from lack of oxygen to a specific region of the cardiac muscle. If treatment has been successful, the ST-segment will return to baseline.
Nitroglycerine decreases cardiac oxygen demand.
Unstable angina, NSTEMI, and STEMI represent worsening degrees of myocardial ischemia and necrosis; the distinctions help differentiate prognosis and guide treatment.
Angina is the most common symptom of myocardial ischemia.
Ischemia (i.e., lack of oxygen) that occurs with angina is limited in duration and does not cause permanent myocardial tissue damage.
Under certain conditions, including myocardial ischemia (decreased blood flow), any cardiac cell may produce electrical impulses independently and create dysrhythmias.
Once an artery becomes 50% occluded, blood flow is impaired, creating myocardial ischemia when myocardial demand is increased.
Clients with unstable angina may present with ST changes on a 12-lead ECG but not have changes in troponin levels. Ischemia is present but is not severe enough to cause detectable myocardial damage or cell death. As troponins assays become more sensitive, the diagnosis of unstable angina is decreasing.
Silent myocardial ischemia increases the incidence of new coronary events and should be treated aggressively.

Answer 142

A

The PR interval represents the amount of time for atrial depolarization. The normal PR interval is 0.12 – 0.20 seconds. The normal QRS interval represents the time for ventricular depolarization. The normal is 0.04 – 0.12 seconds.

When assessing a cardiac rhythm strip, the nurse should first determine the rate. The rate can be determined by examining a six-second strip, taking each QRS complex, and multiplying it by ten.
The second step would be to determine the heart rhythm. To assess atrial regularity, use a pair of calipers to determine the distance between the P-P waves. Ventricular regularity may be assessed by using the calipers to measure the RR interval.
The third step would be to analyze the P waves. The P waves should be present, occurring in regularity and in front of each QRS complex.
Finally, the PR interval and QRS duration should be measured. The ST segment should then be analyzed, followed by the T-wave. The last measurement in this step would be assessing the QT interval.

Answer 143

A

Calcium channel blockers are contraindicated in systolic heart failure because they have a negative inotropic effect. Reducing the force of cardiac contraction would be detrimental to systolic heart failure because it would further reduce already limited cardiac output. Systolic heart failure is when the client’s ejection fraction is less than 40%.
✓ Calcium channel blockers include diltiazem, verapamil, nifedipine, and amlodipine

✓ Indications for CCBs include migraine headache prevention, peripheral vascular disease, hypertension, preterm labor, and atrial fibrillation

✓ Diltiazem and verapamil require blood pressure and the pulse to be obtained before administration

✓ CCBs should not be administered for systolic heart failure because they have a negative inotropic effect, further reducing already limited cardiac output

Answer 144

A

A chest tube comprises three chambers (collection, water seal, and suction).

Effluent from a chest tube should not exceed 70 mL/hr.
The water seal chamber should tidal and have intermittent bubbling. If this is not occurring, the nurse should check the connections. This also could be a beneficial sign indicating that the pneumothorax has resolved.
The suction control chamber should be adjusted to the amount of ordered suction. If wall suction is added, this chamber will continuously bubble for the wet system. If it is not, this is called a water seal and will not bubble.

Answer 145

A

Furosemide, Metformin, Ibuprofen, and Lisinopril are all medications that may lead to nephrotoxicity. Nephrotoxic medications require the nurse to closely monitor the client’s creatinine (normal 0.6 - 1.2 mg/dL). The laboratory data showed hypokalemia and increased creatinine, which should prompt the nurse to clarify the prescriptions with the PHCP.
✓ Elevations of the creatinine (normal: 0.6-1.2 mg/dL for males, 0.5-1.1 mg/dL for females) usually are caused by nephrotoxic medications such as an NSAID (ibuprofen), antibiotic (vancomycin), ACE inhibitors (lisinopril), and sulfa-based drugs.

Answer 146

A

Packed Red Blood Cells are indicated for hemoglobin of 7 g/dL or less. Additionally, the transfusion time for PRBCs is 2-4 hours. The blood product should be type-specific, but if not possible, O negative may be administered as it is the universal donor. When infusing PRBC’s, 0.9% saline should be spiked with the blood product using y-type tubing.

Answer 147

A

indicated for clotting factor replacement and volume expansion. FFP must be type specific and is administered over 15-30 minutes. To determine efficacy, the nurse should reassess the PT/INR after the transfusion.

Answer 148

A

Platelets are used to treat platelet dysfunction and thrombocytopenia. Platelet transfusions are indicated once the platelet count reaches 20,000-25,000 mm3. Platelets do not have to be type specific as they are pooled from as many as ten donors. The infusion time is 15-30 minutes.

Answer 149

A

Positive pressure ventilation (PPV) would be detrimental to a client experiencing cardiac tamponade. This order requires follow-up. PPV increases intrathoracic pressure, which decreases venous return to the heart. This reduction of venous return impairs ventricular filling and decreases cardiac output. This would be detrimental in a cardiac tamponade where the cardiac output is already impaired.
✓ Cardiac tamponade is compression of the myocardium by fluid that has accumulated in the pericardium.

✓ This fluid accumulating causes compression of the atria and the ventricles, prevents them from filling adequately and reduces cardiac output.

✓ Various infectious and noninfectious reasons may cause cardiac tamponade.

✓ Classic manifestations of cardiac tamponade include tachycardia, hypotension, jugular venous distention, distant muffled heart sounds, and pulsus paradoxus.

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The Cardiovascular System Flashcards

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