Unit 1: Iggy 10th Ed Practice Questions Flashcards

Question

What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear? Suctioning the tracheostomy tube Remove the inner cannula of the tracheostomy Humidifying the oxygen source Increasing the percentage of oxygen

Answer 1

Suctioning the tracheostomy tube The best first action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure. Humidifying the oxygen source may help mobilize secretions but is not an immediate helpful action. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.

Answer 2

Assessing for adequate oxygenation The best first action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the client’s anxiety.

Answer 3

Collaborating with the pulmonary health care provider to lower the FiO2 level Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The pulmonary health care provider needs to be notified when PaO2 levels are greater than 90 mm Hg. Preventing harm from oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present. The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation. Suction is performed when rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway) are present. Crackles and diminished breath sounds reflect fluid or poor exchange in the lower airway, not the need for suctioning. Although prone-positioning has been used for clients with acute respiratory distress syndrome (ARDS), is not the priority action and this client has not been diagnosed with ARDS.

Answer 4

Auscultating the client’s breath sounds The nurse will first listen to the client’s breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high-pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax. The nurse is concerned with the assessment of the client first, not with the ventilator or ventilator settings and does not turn off the alarms before assessing the client. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse’s first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

Answer 5

Synchronized intermittent ventilation (SIMV) Synchronized intermittent mandatory ventilation (SIMV) is a ventilation mode in which volume and ventilatory rate are preset. It allows spontaneous breathing at the patient’s own rate and tidal volume between the ventilator breaths to coordinate breathing between the ventilator and the client. BiPAP and CPAP are not used for clients who have an endotracheal tube. With assist-control ventilation, the preset tidal volume continues even when the client’s own respiratory rate increases, which could lead to over-ventilation.

Answer 6

Removing the endotracheal tube and ventilating the client with a bag-valve-mask A reading of 0 for the end-tidal carbon dioxide and the very low SpO2 level indicate that the endotracheal tube is not in the airway. Immediate action is needed. While it is present in the client’s throat, its presence is preventing air from reaching the airways. Removing the tube and ventilating the client with a bag-valve-mask device is critical to saving the client’s life. The nurse will perform these actions while having another health care worker call the Rapid Response Team. If the client’s SpO2 was in the normal range, obtaining a different monitor and rechecking end-tidal carbon dioxide level would be a good action. However, the low oxygen saturation level indicates there is no time for rechecking the carbon dioxide level.

Answer 7

Respiratory acidosis with an acid excess When a person being mechanically ventilated is insufficiently ventilated respiratory acidosis occurs with retention of carbon dioxide. The retained carbon dioxide is converted to hydrogen ions resulting in an acid excess. Bases have neither been lost nor retained in an acute respiratory acidosis. Insufficient ventilation does not cause any form of metabolic acidosis.

Answer 8

Exhale The nurse instructs the client to inhale deeply right before extubation while the nurse deflates the tube cuff. The tube is removed while the client exhales. The nurse instructs the client to cough immediately after extubation.

Answer 9

Dull With a hemothorax, percussion on the involved side produces a dull sound because the blood in the lung area prevents air from filling the area. Lung crackling sounds cannot be percussed, although skin crackling with subcutaneous emphysema can. Tympanic sounds on percussion are associated with abdominal assessment, not pulmonary. Any degree of resonance is associated with air-filled lung areas, not blood-filled areas.

Answer 10

Chest is asymmetrical and trachea deviates toward the right side. Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal. Flail chest has paradoxical chest movement with a “sucking inward” of the loose chest area during inspiration and “puffing out” of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

Answer 11

A 50 year old being mechanically ventilated who has tracheal deviation. The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock. The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.

Answer 12

Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia. The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention. The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.

Answer 13

Inspiratory chest pain Dizziness and syncope Tachycardia Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE. Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over 2 weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.

Answer 14

A 30 year old with a C-5 spinal cord injury A 55 year old with a brainstem tumor A 65 year old with COVID-19 pneumonia A 40 year old with acute pancreatitis Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and inter-costal muscles are affected. Opioids used in client-controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure. Pneumonia, whether bacterial or viral, can result in oxygenation respiratory failure, especially in an older client who often has respiratory muscle weakness. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

Answer 15

Leak in the ventilator tubing circuit. Client is not breathing. Cuff leak in the endotracheal or tracheostomy tube. Common causes of alarms indicating low-pressure include: cuff leaks in the endotracheal or tracheostomy tube, client stops breathing when a ventilator is in the “support” mode, and when a leak is present in the ventilator tubing circuit. Presence of increased airway secretions or mucous plugs, client coughing or gaging, client fighting or “bucking” the ventilators, anything that decreases airway size (i.e., bronchospasms), presence of a pneumothorax, displacement of the endotracheal tube further into the tracheal bronchial tree, and external obstruction of the tubing result in high-pressure, not low-pressure.

Answer 16

PaCO2 = 60 mm Hg The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.

Answer 17

Changing to a nasal cannula during meals The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes. Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bedsides for this potential emergency.

Answer 18

Increasing the oxygen flow rate Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician. Changing the client’s position to less upright, would not improve gas exchange.

Answer 19

Client report of increased dyspnea Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity.

Answer 20

A 60 year old admitted 2 hours ago who has a 90–pack-year smoking history and is receiving 50% oxygen by Venturi mask. There is insufficient data to determine if this client is stable. The client is at risk for oxygen toxicity and must be assessed frequently. The postoperative client is receiving the low oxygen therapy typical for anyone having postoperative therapy who has no other respiratory problems. The client who meets discharge criteria does not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.

Answer 21

Absorptive atelectasis Absorptive atelectasis occurs when high oxygen levels are delivered that causes nitrogen dilution when oxygen diffuses from the alveoli into the blood. The alveoli collapse, which is detected as crackles and decreased breath sounds on auscultation. The problem is in the alveoli, not the airways. Although decreased breath sounds accompany pneumonia, crackles are not present with the increased density.

Answer 22

Hyperoxygenating the client before and after suctioning The client needs to be preoxygenated/hyperoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client needs to be hyperoxygenated for 1 to 5 minutes, or until the client’s baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning can be performed as needed for up to three total suction passes. Any additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult and is traumatic to the airway. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; a suction pass should last 10 to 15 seconds.

Answer 23

Securing the tube in a midline position Tracheal stenosis, a narrowed tracheal lumen, is caused to scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure. Securing the tube in the midline position is critical regardless of whether the tube is secured with commercial tube holders or standard tape ties. Although assessing breath sounds bilateral is an important action whenever a client has a tracheostomy, but does not prevent harm from tracheal stenosis.

Answer 24

Ensuring effective communication One of the many roles of the SLP is helping health care professionals work with clients who have communication problems to find the most effective means of maintaining communication. They also may be involved in assessing clients for aspiration risk. They are not involved in vocal cord assessment (primary health care provider responsibility), infection assessment, or determining correct cuff pressure (respiratory therapist responsibility).

Answer 25

Auscultating lung sounds The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client’s lungs and assessing the client’s respiratory status. Suction is not needed if the lungs and airways are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube. Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.

Answer 26

Ensure that the tubing is patent and that oxygen flow is high. The nurse needs to first ensure that the tubing is patent and that the O2 flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a nonrebreather mask kinks, or if the oxygen source disconnects or is not set to high-flow levels. The chaplain and the family member of record would not be notified until assessment confirms that death is imminent at this time. The RRT team can be called but the client may not want to be intubated, as indicated in the DNR orders. The RRT needs to know the client’s wishes when they arrive. Comforting the client must be done but is not the first action by the action.

Answer 27

Oxygen reservoir deflates during inspiration. The nurse takes action immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask. It is anticipated that the client’s color is now pink. The client’s color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum.

Answer 28

Observing for tachypnea It is essential for the nurse to assess the client for tachypnea. Tachypnea can indicate hypoxia. Assessing secretions, checking arterial blood gas values, and measuring cuff pressure are all appropriate interventions, after assessing airway and breathing.

Answer 29

Teaching the client to “tuck” the chin down in the forward position to swallow Maintaining the client upright for 30 minutes after eating Providing small, frequent meals Interventions that must be noted in the client’s plan of care include having the client remain upright for at least 30 minutes after eating to reduce the chance of aspiration. Also, making sure that small frequent meals are available for the client. Shorter and more frequent intervals of eating tire the client less and also reduce the chance for aspiration. Teaching the client how to tuck the chin down in the forward position helps to open the upper esophageal sphincter and again reduces the risk of aspiration. Sipping from a cup is contraindicated. Liquids are consumed using a spoon to ensure that the client is attempting to swallow only small volumes of liquid. Controlled small amounts of thickened liquids are given. Thin liquids such as water should be avoided because they are easily aspirated. The tracheostomy cuff needs to be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

Answer 30

Can only be used safely by alert clients. Masks must have a tight seal for effective ventilation. The system operates with either room air or oxygen. Vomiting with potential aspiration can occur.

Answer 31

“I can only take baths, but no showers.” “I will be unable to wear a necklace.” “I should put cotton or foam over the tracheostomy hole.” “I can put normal saline in my tracheostomy to keep the secretions from getting thick.” Need for teaching is indicated when the client says that only baths and no showers can be taken. The client is permitted to shower with the use of a shower shield over the tracheostomy, which prevents water from entering the airway. Also, the client does not instill anything into the artificial airway unless prescribed. The client would not put cotton or foam over the tracheostomy hole; this action may cause airway obstruction. The stoma may be covered loosely with a small cotton cloth or light scarf to protect it during the day. This filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. The client is correct when commenting about learning to suction self, and will be taught clean suction technique to use at home. Also, foul-smelling secretions or drainage indicates possible infection and needs to be reported to the primary health care provider.

Answer 32

Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.

Answer 33

Fine crackles Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.

Answer 34

Asking the client about whether any breathlessness is present Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea. The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.

Answer 35

An area of increased density Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air. Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a “crackling” in the skin and subcutaneous tissues, not within any part of the respiratory tract.

Answer 36

Recheck the value on the forehead. Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.

Answer 37

B) Sensation of air hunger D) Cyanosis of oral mucous membranes F) Tracheal deviation Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of “nagging” cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax.

Answer 38

Inability to state name and date of birth. The nurse would further assess the client who is unable to state name and date of birth. The older client has a higher risk for hypoxemia than a younger client, and often becomes confused during acute respiratory conditions. The other assessment findings are considered normal age-related conditions in an older client and do not warrant additional investigation.

Answer 39

Validate that the client has remained NPO. The essential nursing action the nurse must take is to validate that the client scheduled for a TEE has remained NPO. Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur, so auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test as it is uncomfortable. However, with sedation, the goal is to maintain client comfort during the procedure.

Answer 40

“Keep your affected leg straight for 2 to 6 hours.” The client undergoing cardiac catheterization must be taught to keep the affected leg straight for 2 to 6 hours after the test. The client will remain in bed and the affected leg kept straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the primary health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure, so antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating. They are not taken when the client is NPO for procedures or surgery.

Answer 41

Reports of pressure in the upper abdomen and sternum and diaphoresis The client with pain most consistent with an MI is the client with pressure in the mid-abdomen and diaphoresis. Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

Answer 42

Troponin 3.2 ng/mL (3.2 mcg/L) Normal troponin would be less than 0.03 ng/mL (0.03 mcg/L). Normal C-reactive protein would be less than 1 mg/dL (10 mg/L). This tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides would be 35 to 135 mg/dL (0.40 to 1.50 mmol/L) for females and 40 to 160 mg/dL (0.45 to 1.81 mmol/L) for males. This tests for risk for CAD, not ACS. Normal lipoprotein-a is less than 30 mg/dL (1.07 mcmol/L). This also tests for risk for CAD, not ACS.

Answer 43

Perform a neurologic assessment and notify the primary care provider. The first action the nurse must do when a client recovering from a cardiac angiography develops slurred speech is to perform a complete neurologic assessment and notify the primary health care provider. Based on the assessment finding, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness must be reported immediately for prompt intervention. Keeping the client NPO and waiting for symptoms to resolve are not appropriate. While the nurse can call for help from another nurse, this assessment does not warrant a second opinion and action is required immediately. While it is appropriate to assess the site of the procedure for bleeding, the slurred speech is not from bleeding at the site, rather it is likely a neurologic event so the priority is neurologic assessment.

Answer 44

B. Hematoma developing at insertion site Following cardiac catheterization the client is at risk for bleeding at the insertion site. Hematoma formation is an indication that the artery is bleeding internally, and the priority nursing action is to apply manual pressure to the insertion site immediately. While the client’s blood pressure is slightly elevated the priority of care remains responding to the development of the hematoma at the insertion site. After the client is stable, the nurse can then address the client’s headache and thirst.

Answer 45

A. “Please roll onto your left side.” If the nurse is having difficulty hearing the heart sounds while auscultating, the nurse can ask the client to roll to the left side or lean forward. This positions the heart closer to the chest wall and can make the heart sounds more audible. Taking the pulse instead of auscultating is not an appropriate nursing action, nor is asking the client to hold their breath for an undetermined time period. Asking the client to lay on their back will make it more difficult to hear sounds versus easier.

Answer 46

C. Normal Sinus Rhythm The nurse will document this rhythm interpretation as normal sinus rhythm. The heart rate does not reflect tachycardia or bradycardia and the rhythm is not irregular. All other assessment parameters are within normal sinus rhythm interpretation.

Answer 47

D. History of smoking The client’s potassium, magnesium, and heart rate are within normal limits. Nicotine can be a cause of premature ventricular contractions (PVSs) and should be discussed with this provider and the client.

Answer 48

C. Notify the Rapid Response Team D. Get the crash cart/AED B. Check carotid pulse (for 5-10 seconds) A. Begin chest compressions E. Provide rescue breaths

Answer 49

B. Stop suctioning the patient. Removing the noxious stimuli causing the vagal response would be the first action. If this does not resolve the bradycardia, second action would be to administer atropine and call provider. Continuing to suction is not appropriate as this is the cause of the vagal episode.

Answer 50

D. Assess the client and check lead placement. ALWAYS check the client first. Cardiac monitors are a tool for assessment, but they do not replace hands on nursing assessment.

Answer 51

Heart rate The monitoring of the patient’s heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand. ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.

Answer 52

Heparin The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin, warfarin, and novel oral anticoagulants, when nonvalvular, such as dabigatran, rivaroxaban, apixaban, or edoxaban) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke). Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.

Answer 53

Continue to monitor. The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs. Atropine is used in emergency treatment of symptomatic bradycardia. This patient has a normal sinus rhythm. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.

Answer 54

A 64-year-old client admitted for weakness with sinus bradycardia and heart rate 58 beats/min. The 64-year-old client has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the patient develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This patient can be managed by a nurse with less cardiac dysrhythmia training. The 71-year-old client is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old client is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old client is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse.

Answer 55

Prepare for defibrillation. Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols. After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.

Answer 56

“Use a stool softener.” The nurse will advise the client to use a stool softener. Patients at risk for bradydysrhythmias would avoid bearing down or straining during a bowel movement. The Valsalva maneuver associated with bearing down can cause bradycardia. Patients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the patient is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people would stop smoking, patients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.

Answer 57

A P wave precedes every QRS complex. A P wave is generated by the SA node and represents atrial depolarization and needs to be followed by a QRS complex. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead. The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Normal PR level is up to 0.20 seconds. Elevation of the ST segment indicates myocardial injury.

Answer 58

Pacemaker spikes are noted, but no P wave or QRS complex follows. Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode. Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 beats/min with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly. Demand pacing would cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.

Answer 59

Setting the defibrillator to the synchronized mode Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation. Cardioversion is usually performed starting at a lower rate of 120 to 200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.

Answer 60

Sinus tachycardia These are the characteristics of sinus tachycardia. A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.

Answer 61

Heart rate Heart rhythm QT interval Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed. Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.

Answer 62

Chest discomfort Hypotension Palpitations Tachycardia is a heart rate greater than 100 beats/min; the patient with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope (“blackout”) from hypotension. Chest discomfort and palpitations may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue. In this situation, the patient will have pale, cool skin and not flushing of the skin. Also, reduced cardiac output and possible development of heart failure will cause fatigue and not increased energy.

Answer 63

Advancing age High blood pressure Excessive alcohol use Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and African Americans. Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.

Answer 64

Do not lean over electrical or gasoline motors. Be sure that you remember the rate at which your pacemaker is set. Avoid sudden, jerky movements for 8 weeks. Clients with a new pacemaker should be taught to take their pulse daily for 1 full minute each day. It is important to be aware of the rate the pacemaker is set to know which rate changes that are important to report to your health care provider. Clients with pacemakers can use microwave ovens and may bathe normally, in either the shower or bath. Sudden, jerky movements should be avoided for 8 weeks to allow the pacemaker to settle in place. Leaning over electrical or gasoline motors should be avoided and it is important to make sure electrical devices are properly grounded.

Answer 65

Ensure electrodes are in place for continued monitoring. Assess the chest for burns. Document results of procedure. Administer oxygen. The nurse would not allow the client to eat a meal immediately following a cardioversion. The nurse will assess level of consciousness and overall client status and start with sips of liquid once the client is fully awake. The nurse will continue to carefully monitor the client, ensuring that electrodes are in place and assessing for chest burns from the electrodes used during the cardioversion. The nurse will administer oxygen until the client is fully awake. The nurse will not provide continued sedation. The nurse will document the procedure and the crash cart should remain in the room until the client is stable as lethal arrhythmias can occur during and after cardioversion.

Answer 66

B. Crackles in both lungs C. Tachycardia E. Tachypnea F. S3 gallop For a client with left sided heart failure the nurse will anticipate assessment findings of crackles in both lungs, tachypnea, tachycardia, and a third heart sound, usually an S3 gallop. Peripheral edema and ascites are associated with right sided heart failure.

Answer 67

C. “I need to take a full course of antibiotics prior to my colonoscopy.” Antibiotics are only required prior to dental procedures. Good oral hygiene is the best prevention for endocarditis. The statement in option A is correct and shows the patient understands the need for oral hygiene. The patient with a mechanical valve will be on warfarin thus, foods high in Vitamin K should be avoided. This statement in option B is correct and shows the patient understands foods that are LOW in Vitamin K. This statement in option D is also correct and shows that the patient understands the importance of regular BP assessment as well as when to call the provider based on the assessment.

Answer 68

B. Renal infarction The classic clinical signs of renal infarction, associated with embolization from infective endocarditis, are flank pain, hematuria, and pyuria.

Answer 69

C. Place the client in a high Fowler’s position. The first action of the nurse is to place the client in high Fowler’s position. This position allows for maximal lung expansion. The nurse can also place pillows under each arm to maximize chest expansion. Repositioning the client with heart failure can improve overall gas exchange. If dyspnea continues the nurse may contact respiratory therapy for a breathing treatment, assess arterial blood gases (as prescribed) or increase oxygen if warranted by ABG results.

Answer 70

Place the client in high-Fowler position with the legs down. The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler position with the legs down. High-Fowler position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member’s presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

Answer 71

Position the client to alleviate dyspnea.

Answer 72

Splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

Answer 73

A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. The nurse would first assess the 46 year old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical signs and symptoms of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia. The 55 year old is stable and can be assessed after the client with aortic stenosis. The 68 year old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79 year old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

Answer 74

Blood pressure (BP) 192/102 mm Hg The problem that must be addressed immediately in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture. The nurse must consider the client’s usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.

Answer 75

“I just started to feel a pain in my belly and low back.” The nurse suspects dissection of an AAA when the client says that “I just started to feel a tearing pain in my belly.” Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA. The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

Answer 76

Urine output of 20 mL over 2 hours The nurse caring for a client who had an AAA repair would be most alarmed with the client’s urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria. Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output. +3 pedal pulses is a normal physical assessment finding.

Answer 77

A 70 year old with a history of diabetes who has “tearing” back pain and is diaphoretic. The client who just arrived in the ED and needs immediate medical evaluation is the 70 year old with a history of diabetes who has “tearing” back pain and is diaphoretic. This client’s history and clinical signs and symptoms suggest possible aortic dissection. The nurse will immediately assess the client’s blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery. The 64 year old is most stable and can be seen last. The 60 year old and the 69 year old would both be seen soon, but the 70-year-old client must be seen first.

Answer 78

B. Sudden, severe low back pain and bruising along the flank A sudden onset of low back pain with flank bruising is a classic sign of aneurysm rupture. This is a medical emergency requiring immediate nursing intervention.

Answer 79

A. ST changes C. Pain lasts 15-25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased. A normal troponin value is anticipated with unstable angina. A troponin value of 0.6ng/mL is elevated and would be indicative of a myocardial infarction. All other assessment data can accompany unstable angina.

Answer 80

A. Heart rate of 50 beats/min A heart rate of 50 beats per minute is a risk for decreased perfusion. All other choices are not risks for decreased perfusion or normal parameters.

Answer 81

A. Denial is a common reaction to chest pain. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD. Denial is a common reaction to chest pain that often causes a delay in seeking treatment. Age is a significant risk factor in the development of CAD, with risk increasing with age. Women are more likely to experience atypical symptoms of chest pain such as indigestion. Atherosclerosis is the primary factor in development of CAD. A myocardial infarction evolves over hours, not minutes. Exercise for 20 minutes 3 to 4 times a week is not often enough or long enough.

Answer 82

C. “I have a bandage on my sternum to collect the drainage.” Sternal wound infections can develop between 5 days and several weeks following CABG surgery. The client should not be experiencing any drainage from sternum at this time, and the need for a bandage to collect the drainage is indicative of sternal infection. This requires immediate notification of the healthcare provider. It is expected that the client will have chest discomfort when sneezing or coughing because of the sternotomy incision. Resting after walking or walking until tired is also an appropriate method to build stamina following surgery. It is not uncommon to have a decreased appetite for 5 -6 weeks following CABG surgery.

Answer 83

B. Muffled heart sounds with the presence of JVD Symptoms are part of Beck’s Triad, which are indicative of tamponade. Incisional pain is expected. While sternal wound drainage is a problem, it is not an indicator of cardiac tamponade. With tamponade, blood pressure will decrease and the heart rate will increase.

Answer 84

“This is a warning sign and I need to change my lifestyle to prevent a heart attack.” The statement by the client that angina is a warning sign and needing to alter lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of progression in unstable angina and/or MI. Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.

Answer 85

Placing a chair in the shower for independent hygiene Placing a chair in the shower is an activity performed in phase 1 cardiac rehabilitation. It begins with the acute illness and ends with discharge from the hospital. Phase 1 focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities. Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning. It consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart’s ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.

Answer 86

Respiratory rate 28 breaths/min The activity should be terminated when the nurse assesses the client’s respiration rate of 28 breaths/min. This indicates activity intolerance. Pulse 72 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.

Answer 87

Client with third-degree heart block on the monitor The client with the third-degree heart block needs to be seen first. Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved. This type of block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client’s uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.

Answer 88

Crackles in the lung fields Signs and symptoms of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.

Answer 89

“These arteries remain open longer.” The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts. Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.

Answer 90

Chest tube drainage 175 mL last hour The nurse needs to report chest drainage over 150 mL/hr to the surgeon. Although some bleeding is expected after surgery, 175 mL/hr is excessive. This requires immediate nursing action to notify the health care provider. Although hypothermia is a common problem after surgery, a temperature of 98.2° F (36.8° C) is a normal finding. Serum potassium of 3.9 mEq/L (3.9 mmol/L) is a normal finding. Incisional pain of 6 on a scale of 0-10 is expected immediately after major surgery; the nurse would administer prescribed analgesics.

Answer 91

Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.

Answer 92

Obtains the client’s description of the chest discomfort. A description of the chest discomfort must be obtained first, before further action can be taken. Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first. Remaining calm and staying with the client are important but are not matters of highest priority.

Answer 93

“My angina will be gone for good.” In this situation, further teaching is needed when the client states that angina will be gone after the PTCA. The client’s angina may not be eliminated. Reocclusion is possible after PTCA. The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access.

Answer 94

The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea. The nurse needs to first assess the client with acute coronary syndrome with dyspnea and weight gain. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate.

Answer 95

Dyspnea Extreme fatigue Dizziness Many women who experience an MI present with dyspnea, light-headedness and dizziness, and fatigue. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.

Answer 96

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected. All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/min is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.

Answer 97

A care bundle is a group of two or more interventions that have been shown to be effective when applied in a timely sequence. The following are included in the Hour-1 Sepsis bundle: 1. Measure lactate level. 2. Obtain blood cultures before administering antibiotics. 3. Administer broad-spectrum antibiotics. 4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L. 5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mm Hg.

Answer 98

Acid-deficit alkalosis A ventilator set at either too high a ventilation rate and/or at too great a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid-deficit respiratory alkalosis.

Answer 99

Cardiovascular system During acidosis, the body attempts to bring the pH closer to normal by moving free hydrogen ions into cells in exchange for potassium ions. This exchange can cause hyperkalemia, which alters all excitable membranes. In the heart, hyperkalemia can block electrical conduction through the heart and cause severe bradycardia and even cardiac arrest. Although all body systems are affected to some degree, the cardiovascular system must be assessed first to institute actions to prevent death.

Answer 100

Client with multiple rib fractures A client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion. A client who is anxious and breathing rapidly is at risk for respiratory alkalosis, not acidosis. A normal saline bolus does not result in respiratory acidosis. An increased urinary output would not be a stimulus for a respiratory acid–base imbalance.

Answer 101

E) Overproduction of hydrogen ions Unlike metabolic acidosis, respiratory acidosis results from only one cause—retention of CO2, causing overproduction of free hydrogen ions. Bicarbonate is not involved as a cause or as a compensatory mechanism. Recall that carbon dioxide and hydrogen ions are directly related in human physiology. An increase in one always causes an increase in the other. Retention of CO2 is the problem, not failure of the body to directly eliminate hydrogen ions.

Answer 102

A) Ventilator at too low a tidal volume B) Sepsis C) Severe diarrhea D) Hypovolemic shock Sepsis and hypovolemic shock result in anaerobic metabolism and increased production of carbon dioxide, lactic acid, and free hydrogen ions. When a ventilator is set at too low of a tidal volume for the client’s size, hypoventilation occurs with poor gas exchange and retained carbon dioxide. Severe diarrhea causes excess loss of bicarbonate ions in the stool, resulting in a base-deficit metabolic acidosis. Hyperventilation can result in respiratory alkalosis, not acidosis. Prolonged nasogastric suctioning results in a loss of hydrochloric acid and leads to an acid-deficit metabolic alkalosis.

Answer 103

B) Acute confusion C) Lethargy D) Hypotension F) Tall T-waves When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, hypotension, and fatigue. Clients with acidosis have problems associated with decreased excitable tissues, including hypotension and decreased perfusion, impaired memory and cognition, increased risk for falls, and reduced neuromuscular responses (not hyperactive deep tendon reflexes). The pH will be below 7.35, which is a characteristic of acidosis. Acute confusion occurs because of reduced gas exchange and reduced cognition.

Answer 104

Heart rate 120 beats/min Tachycardia is an early symptom of shock. Heart and respiratory rates increased from the client’s baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal (not hypotensive). Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal and not abnormally low. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock and are related to lack of oxygen to the heart.

Answer 105

Client with severe ascites A client with severe ascites best demonstrates the problem with the highest risk for hypovolemic shock. Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle, but no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

Answer 106

Discussion with family and provider regarding palliative care When caring for a client in the refractory stage of shock, the nurse considers discussing palliative care with the family and provider. In this irreversible phase, therapy is not effective in saving the client’s life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal. A discussion on palliative care would be considered. Rehabilitation or returning home is unlikely. The client with sustained tissue hypoxia is not a candidate for organ transplantation.

Answer 107

A client with esophageal varices The client with esophageal varices is at risk for hypovolemic shock. Esophageal varices are caused by portal hypertension where the portal vessels are under high pressure. With this high pressure, the portal vessels are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Arthritis and daily acetaminophen use do not cause GI bleeding and hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen may predispose the client to gastrointestinal (GI) bleeding and hypovolemia. Although a kidney stone may cause hematuria, massive blood loss or hypovolemia generally does not occur.

Answer 108

Post kidney transplant A client with post kidney transplant is the highest risk for sepsis. This client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a greater risk for infection, sepsis, and death.

Answer 109

Lactate 81 mg/dL (9.0 mmol/L) The client with septic shock and a lactate level of 81 mg/dL (0.9 mmoL/L) indicates that severe tissue hypoxia is present. Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid. Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis, but this value is decreased and is not consistent with septic shock.

Answer 110

Compare these vital signs with the last several readings. The nurse will take the vital sign trends into consideration. A BP of 90/60 mm Hg may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment must be used when vital signs are taken postoperatively.

Answer 111

Ensure that blood cultures were drawn. The nurse’s first action when planning to administer an antibiotic to a newly admitted patent in septic shock is to ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. An intravenous line will be needed, but the nurse must ensure that blood cultures have been drawn. Monitoring the client’s vital signs is important, but the antibiotic must be administered within 1 hour of shock recognition.

Answer 112

The RN with 2 years of experience in intensive care unit (ICU). The RN with 2 years ICU experience would be assigned to care for an intubated client with septic shock due to a MRSA infection. This RN with current intensive care experience who is not caring for a postoperative client is an appropriate nurse to care for this client. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. A client who is experiencing septic shock is too complex for the new RN. Although the RN who is also caring for the post-CABG client is experienced, this assignment will put the post-CABG client at risk for MRSA infection.

Answer 113

Measure hourly urine output. The nurse delegates to an experienced ICU AP the measurement of hourly urine output for a client with hypovolemic shock. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment. The nurse will evaluate the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

Answer 114

Check the airway and respiratory status. The nurse’s first action when caring for an obtunded client admitted with shock is to check the client’s airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client’s mental status.

Answer 115

Low-grade fever and mild hypotension Low-grade fever and mild hypotension in a postoperative client can indicate very early sepsis. With treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate severe sepsis. Reduced urinary output and increased respiratory rate indicate active (not early) sepsis.

Answer 116

A) Ask family members to stay with the client. D) Remain with the client. E) Reassure the client that everything is being done for him or her. To support the psychosocial integrity of a client in early shock, the nurse would have a familiar person nearby to comfort the client. The nurse would also remain with the client and offer genuine support to reassure the client that everything is being done for her. The health care provider would be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client’s psychosocial integrity.

Answer 117

B) Measure lactate levels. D) Administer broad-spectrum antibiotics. E) Begin rapid administration of crystalloids for hypotension. F) A bundle is a group of two or more interventions that has been shown to be effective when applied in a sequence. A care bundle is a group of two or more interventions that have been shown to be effective when applied in a timely sequence. The following are included in the Hour-1 Sepsis bundle: 1. Measure lactate level. 2. Obtain blood cultures before administering antibiotics. 3. Administer broad-spectrum antibiotics. 4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L. 5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mm Hg.

Answer 118

A) A 40-year-old female with a history of a double lung transplant 4 years ago. D) A 38-year-old male with HIV who has a low viral load. E) A 54-year-old female with breast cancer who is receiving chemotherapy. F) A 44-year-old male client who has a history of alcoholism and diabetes mellitus. G) An 86-year-old male with acute onset confusion. While any person can develop sepsis, there are certain conditions that predispose clients to sepsis and septic shock. The 54-year-old female is at higher risk due to cancer and chemotherapy. The 86-year-old male is higher risk due to an age above 80 years. The 44 year old has a higher risk due to alcoholism and diabetes. The 38 year old has an increased risk due to immunosuppression and HIV. The 40 year old is at higher risk due to immunosuppression and transplant status. A closed fracture does not increase risk, nor does anxiety and infertility.

Answer 119

A. Increasing pallor B. Increasing thirst D. Increasing heart rate E. Increasing respiratory rate H. Decreasing urine output Compensatory mechanisms attempt to maintain perfusion and gas exchange to vital organs. Thus these mechanisms shunt blood away from less vital organs and try to prevent further volume losses. The increasing pallor occurs because blood is shunted away from skin and mucous membranes to the heart, brain, liver, and lungs. Increasing thirst and decreasing urine output help to increase blood volume by stimulating the patient to drink and by preventing fluid loss through the urine. Increasing heart rate and respiratory rate work to maintain gas exchange to those selected organs that continue to be perfused. Increasing confusion indicates the compensatory mechanisms are failing and that the brain is not being adequately perfused. Decreasing systolic blood pressure also is an indication of worsening shock. Decreasing blood pH is not a compensatory action; it is an indication of inadequate gas exchange.

Answer 120

C. PaCO2 49 mmHg The client with hypovolemic shock is most likely experiencing anerobic cellular metabolism. As such, the nurse will anticipate decreased pH, decreased PaO2, increased PaCO2, and increased lactate levels.

Answer 121

D. Apply direct pressure to the area of overt bleeding. The priority nursing action is to apply direct pressure to the area of overt bleeding. The nurse will first apply pressure then elevate the client’s feet, administer supplemental oxygen if oxygen saturations are below 92% and insert a large bore IV catheter.

Answer 122

B. “The client’s change in behavior and lethargy may be associated with septic shock.” C. “Antibiotics, as prescribed, will be started within the hour to treat the sepsis.” A recent change in behavior or altered level of consciousness are often indicators of sepsis and septic shock. Part of the sepsis bundle of care is the administration of antibiotics within one hour of recognizing sepsis. The blood cultures may or may not confirm he diagnosis of septic shock. Bacteremia may not be present. Insulin therapy is used to maintain blood glucose levels between 140 mg/dL (7.7 mmol/L) and 180 mg/dL (10 mmol/L) (Stapleton & Heyland, 2018). Keeping the blood glucose level below 110 mg/dL (6.1 mmol/L) is associated with increased mortality. Septic shock is not easily treated.

Answer 123

D. Serum lactate and serum potassium levels are declining. Serum lactate levels and serum potassium levels both rise when shock progresses and more tissues are metabolizing under anaerobic conditions. A decline in both values indicates that the client is responding to the current interventions for hypovolemic shock. Oxygen saturation staying the same suggests that the shock is not progressing at this time but does not indicate the interventions are correcting shock. The increase in body temperature is not great enough to indicate improvement or worsening of shock. The fact that the client can correctly state the month and the year by itself does not indicate improvement because information is not provided about his or her earlier cognition or level of consciousness.

Answer 124

A. Heart rate 118 With the initial stage of shock, an increase is heart rate is often the first indicator. Because stroke volume is decreased the pedal pulses are often difficult to palpate and easily blocked. A normal pedal pulse (2+) would not be anticipate. The nurse would not anticipate bilateral fine crackles in the lungs with hypovolemic shock. The nurse would anticipate a narrow pulse pressure change (versus a widened pulse pressure). With vasoconstriction, diastolic pressure increases, but systolic pressure remains the same. This creates a narrow pulse pressure.

Answer 125

A. BP change from 86/50 to 100/64 C. Cool and clammy skin D. Petechiae along the gum line As sepsis progresses, cardiac output is higher as are heart rate and blood pressure. The nurse would interpret the increasing blood pressure as an indication of worsening condition versus improvement. As sepsis progresses, circulation is compromised and presents as cool, clammy skin, with pallor and cyanosis. DIC can occur with sepsis progression causing petechiae and ecchymoses, occurring anywhere on the body. The decrease in heart rate is not associated with progression of shock (the heart rate, like the BP would increase). The urine output is within normal limits and would not indicate progression of shock.