TARGETED MEDICAL-SURGICAL: CARDIOVASCULAR

TARGETED MEDICAL-SURGICAL: CARDIOVASCULARA nurse in an emergency room is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for? o Confusion (bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion; nurse should monitor the clients mental status) o Friction rub o Hypertension o Dry skin A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the clients aPTT is 96 seconds? o Increase the heparin infusion flow rate by 2 mL/hr o Continue to monitor the heparin infusion as prescribed o Request a prothrombin time (PT) o Stop the heparin infusion (the nurse should identify that the client’s aPTT is above the critical value & the client is displaying manifestation of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately & notify the provider to reduce the risk of client injury) A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? o Ventricular depolarization o Guillain-Barre syndrome o Myelodysplastic syndrome o Valvular disease (occurs as a result of inflammation of the endocardium) A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessment to help differentiate between an arterial ulcer and a venous stasis ulcer? o Explore the clients family history of peripheral vascular disease o Note the presence or absence of pain at the ulcer site o Inquire about the presence or absence of claudication o Ask if the client has had a recent infection A nurse is an emergency department is caring for a client who had an anterior myocardial infarction. The client’s history. The client’s history reveals she is 1 week postoperative following an open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? o Administering IV morphine sulfate o Administering oxygen at 2L/min via nasal cannula o Helping the client to the bedside commode o Assisting with thrombolytic therapy A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? o Serosanguineous drainage on dressing o Severe pain with coughing o Urine output of 20 mL/hr o Increase in temperature from 36.80C (98.20F) to 37.50C (99.50F)