A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the following conditions?
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Solution
Cardiac tamponade
All of the client’s symptoms are found in both cardiac tamponade and hypovolemic shock except the increase in urinary output.
A client has the diagnosis of left ventricular failure and a high pulmonary capillary wedge pressure (PCWP). The physician orders dopamine to improve ventricular function. The nurse will know the medication is working if the client’s:
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Solution
Blood pressure rises
If dopamine as a positive effect, it will cause vasoconstriction peripherally, but increase renal perfusion and the blood pressure will rise. The cardiac index will also rise, and the PCWP should decrease.
Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Check all that apply.
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Solution
Answer: 1, 3, 5.
Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid thready pulse. Tamponade causes hypotension and a narrowed pulse pressure. As the tamponade increases, pressure on the heart interferes with the ejection of blood from the left ventricle, resulting in increased pressure on the right side of the heart, and the systemic circulation. As the heart because of more inefficient, there is a decrease in kidney perfusion and therefore urine output. The increased venous pressure caused JVD.
The most important assessment for the nurse to make after a client has had a femoropopliteal bypass for peripheral vascular disease would be:
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Solution
Capillary refill time
Checking capillary refill provides data about current perfusion of the extremity.
Option B: While the presence and quality of the pedal pulse provide data about peripheral circulation, it is not necessary to count the rate.
What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)?
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Solution
Deflate the balloon as soon as the PCWP is measured
While the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lung.
Option A: Bearing down will increase intrathoracic pressure and alter the reading.
Option C: While a supine position is preferred; it is not essential.
Option D: Agency protocols relative to flushing of unused ports must be followed.
When preparing a client for discharge after surgery for a CABG, the nurse should teach the client that there will be:
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Solution
Some increase in edema in the leg used for the donor graft when activity increases
The client is up more at home, so dependent edema usually increases. Serosanguineous drainage may persist after discharge.
The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:
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Solution
Left ventricular functioning
The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.
During a cardiac catheterization blood samples from the right atrium, right ventricle, and pulmonary artery are analyzed for their oxygen content. Normally:
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Solution
The samples of blood all contain about the same amount of oxygen
Blood samples from the right atrium, right ventricle, and pulmonary artery would all be about the same with regard to oxygen concentration. Such blood contains slightly less oxygen than does systemic arterial blood.
After open-heart surgery, a client develops a temperature of 102*F. The nurse notifies the physician because elevated temperatures:
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Solution
Increase the cardiac output
Temperatures of 102*F or greater lead to an increased metabolism and cardiac workload.
A nurse is assessing the neurovascular of a client who has returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:
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Solution
Normal because of increased blood flow through the leg
An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
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Solution
Ensure a liberal fluid intake
In an immobilized client, calcium leaves the bone and concentrates in the ECF fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated).
Option B: A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium.
Option C: Preventing constipation is not associated with excessive calcium excretion.
Option D: Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.
A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary artery pressure monitoring, including pulmonary capillary wedge pressures. The purpose of this is to help assess the:
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Solution
Pressure from fluid within the left ventricle
The pulmonary artery pressures are used to assess the heart’s ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricle end-diastolic pressure and guides the physician in determining fluid management for the client.
Option A: The degree of coronary artery stenosis is assessed during a cardiac catheterization.
Option B: The peripheral arterial pressure is assessed with an arterial line.
After cardiac surgery, a client’s blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following?
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Solution
95 mm Hg
MAP = (2 times the diastolic + systolic)/3 or (2d + s)/3 where d is diastolic and s is systolic
= 2 (80) + 126 / 3
= 160 + 126 / 3 = 286 / 3 = 95.33 or 95 mm HG
A paradoxical pulse occurs in a client who had a coronary artery bypass graft (CABG) surgery two (2) days ago. Which of the following surgical complications should the nurse suspect?
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Solution
Pericardial tamponade
A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Option A: Left-sided heart failure can cause
Option A: Left-sided heart failure can cause pulsus alternans (pulse amplitude alternation from beat to beat, with a regular rhythm).
Option B: Aortic regurgitation may cause bisferious pulse (an increased arterial pulse with a double systolic peak).
Option C: Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).
Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
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Solution
Plaques obstruct the artery
Option A: Arteries, not veins, supply the coronary arteries with oxygen and other nutrients.
Option C: Atherosclerosis is a direct result of plaque formation in the artery.
Option D: Hardened vessels can’t dilate properly and, therefore, constrict blood flow.