NUR 240 Cardiovascular, Hematologic, and Lymphatic Systems
b b b b b b
AbFoleybcatheterbwasbplacedbwithbanburimeterbforbabclientbwithbheartbfailurebreceivingbfurosem
ide.bTheboutputbisb45bmL/hour,bcloudy,bandbhasbsediment.bHowbshouldbthebnursebinterpretbthe
sebfindings?
b b Thebfurosemidebisbcausingbdehydration.
Cloudyburinebmaybbebindicativebofbinfection.
b Thebclientbhasbinadequatebhourlyburineboutput.b
b Allbofbthebindicationsbarebwithinbnormalbfindings.
Cloudyburinebmaybbebindicativebofbinfection,bwhichbisbalsobabriskbwithbFoleybcatheters.bAburinal
ysisbshouldbbebperformedbtobconfirmborbruleboutbaburinarybtractbinfection.bThebfurosemidebmayb
causebdehydration,bbutbotherbfindingsbwouldbhavebtobbebassessed,bsuchbasbskinbturgor.bHourl
yburineboutputbshouldbbebatbleastb30bmL,bwhichbisbbeingbsurpassed.bUrinebisbexpectedbtobbebcle
arbamberbcolored;bcloudybisbnotbwithinbexpectedbnormalbappearance.
Abnursebisbworkingbwithbanbunlicensedbassistivebpersonnelb(UAP)binbcaringbforbabgroupbofbclie
nts.bWhichbstatementbbybthebUAPbindicatesbabcorrectbunderstandingbofbthebUAP'sbrole?b
b "Ibwillbturnboff bclients'bIVsbthatbhavebinfiltrated."
"Ibwillbtakebclients'bvitalbsignsbafterbtheirbproceduresbarebover."
bb "Ibwillbusebunitbwrittenbmaterialsbtobteachbclientsbbeforebsurgery."
bb "Ibwillbhelpbbybgivingbmedicationsbtobclientsbwhobarebslowbinbtakingbpills."
MonitoringbvitalbsignsbafterbproceduresbisbwithinbthebscopebofbabUAP'sbrole.bRegisteredbprofes
sionalbnursesborblicensedbpracticalbnurses,bnotbUAPs,bshouldbperformbturningboffbclients'bintra
venousb(IV)binfusionsbthatbhavebinfiltrated.bUsingbunitbwrittenbmaterialsbtobteachbclientsbbefore
bsurgerybshouldbbebperformedbbybregisteredbprofessionalbnursesborblicensedbpracticalbnurses,
bnotbUAPs.bHelpingbbybgivingbmedicationsbtobclientsbwhobarebslowbinbtakingbpillsbshouldbbebper
formedbbybregisteredbprofessionalbnursesborblicensedbpracticalbnurses,bnotbUAPs.
Abclientbwhobjustbreturnedbfrombabcardiacbcatheterizationbreportsbtobthebnursebthatbthebpressur
ebbandagebonbthebrightbgroinbisbtight.bWhatbactionbshouldbthebnursebtake?
b b Loosenbthebdressingbslightly.
b Notifybthebprimarybhealthcarebprovider.b
b Assessbthebpulsesbdistalbtobthebdressing.
bb Havebthebclientbflexbthebjointsbofbthebrightbleg.
Assessingbthebcirculatorybstatusbofbthebextremitybwillbdeterminebwhetherbthebdressingbisbtoobti
ght.bLooseningbthebdressingbslightlybmaybresultbinbbleedingbfrombthebcatheterbinsertionbsiteban
dbisbcontraindicated.bNotifyingbthebprimarybhealthcarebproviderbisbpremature;bthebprimarybhe
althcarebproviderbshouldbbebnotifiedbifbcirculationbtobtheblegbisbcompromised.bHavingbthebclien
tbflexbthebjointsbofbthebrightblegbmaybresultbinbbleedingbfrombthebcatheterbinsertionbsitebandbisbc
ontraindicated.bTheblegbshouldbremainbextendedbforbseveralbhours.
,Abclientbwhobisbconsideringbsclerotherapybasksbthebnursebtobexplainbwhatbcausesbvaricosebvei
ns.bWhichbresponsebbybthebnursebisbbest?
b b "Thebcausebisbabnormalbconfigurationsbof bthebveins."
"Thebcausebisbincompetentbvalvesbofbsuperficialbveins."
b b "Thebcausebisbdecreasedbpressurebwithinbthebdeepbveins."b
b "Thebcausebisbatheroscleroticbplaquebformationbinbthebveins."
Incompetentbvalvesbresultbinbretrogradebvenousbflowbandbsubsequentbdilationbofbveins.bAbnor
malbconfigurationsbofbthebveinsbarebconsideredbabresultbof,bratherbthanbabcausebof,bvaricosebve
ins.bPressurebwithinbthebdeepbveinsbisbincreased,bnotbdecreased.bPlaquebformationbisbconside
redbanbarterial,bratherbthanbabvenous,bproblembandbisbassociatedbwithbatherosclerosis.
Abnursebinbthebpostanesthesiabcarebunitbisbcaringbforbabclientbwhobreceivedbabgeneralban
esthetic.bWhichbfindingbshouldbthebnursebreportbtobthebprimarybhealthcarebprovider?b
b Clientbpushesbthebairwaybout.
bb Clientbhasbsnoringbrespirations.
b Client’sbrespirationsbareb16bbreathsbperbminutebandbunlabored.b
Client’sbsystolicbbloodbpressurebdropsbfromb130btob90bmmbHg.
Abdropbinbbloodbpressure;brapidbpulsebrate;bcold,bclammybskin;bandboliguriabarebsignsbofbdecre
asedbbloodbvolumebandbshock,bwhichbifbnotbtreatedbpromptlybcanbleadbtobdeath.bThebclientbpus
hingbthebairwayboutbisbanbexpectedbresponse;bthebclientbwillbpushboutbthebairwaybasbthebeffectsb
ofbanesthesiabsubside.bRespirationsbofb16bbreathsbperbminutebisbabcommonbresponsebpostop
eratively.bIfbthebclientbisbexperiencingbabdepressantbeffectbofbanesthesia,bthebnursebwillbassessb
shallowbandbslowbrespirations.
Abnursebobservesbabwindowbwasherbfallingb25bfeetb(7.6bm)btobthebground.bThebnursebrushesbt
obthebscenebandbdeterminesbthatbthebpersonbisbinbcardiopulmonarybarrest.bWhatbshouldbthebn
ursebdobfirst?
b b Feelbforbabpulse
Beginbchestbcompressionsb
b Leavebtobcallbforbassistance
bb Performbthebabdominalbthrustbmaneuver
AccordingbtobthebAmericanbHeartbAssociationbandbHeartbandbStrokebFoundationbofbCanadabfor
bCPR,bthebfirstbstepbisbtobfeelbforbabpulsebafterbunresponsivenessbisbestablished.bInbthisbcase,bit
bhasbbeenbestablishedbthebclientbhasbnobpulseb(cardiopulmonarybarrest);bthereforebchestbcom
pressionsbarebinitiated.bDobnotbleavebthebclientbtobcallbforbassistance.bThebabdominalbthrustb(H
eimlich)bmaneuverbisbusedbtobrelievebairwaybobstructionbandbisbnotbappropriatebinbthisbinstanc
e.
Abclientbisbadmittedbtobthebhospitalbforbanbemergencybcardiacbcatheterization.bWhatbadaptatio
nbisbthebclientbmostblikelybtobcomplainbofbafterbthisbprocedure?
, b Fearbofbdying
bb Skippedbheartbeatsb
Painbatbthebinsertionbsite
bb Anxietybinbresponsebtobintensivebmonitoring
Painbatbthebarterialbpuncturebsitebisbattributablebtobentrybandbcannulationbofbthebarterybandbisbabc
ommonbcomplaintbafterbabcardiacbcatheterization.bFearbofbdyingbmightboccurbduringbthebprecat
heterizationbperiod.bAlthoughbskippedbheartbeatsbmayboccurbduringbthebprocedurebbecausebof
btraumabtobthebconductionbsystem,busuallybitbdoesbnotbcontinuebafterbthebprocedure.bAlthoughb
somebclientsbmaybbebanxious,bmanybfeelbsafebwhenbreceivingbongoingbmonitoring.
Thebnursebatbabhealthbfairbhasbtakenbabclient'sbbloodbpressurebtwice,b10bminutesbapart,binbthebs
amebarmbwhilebthebclientbisbseated.bThebnursebrecordsbthebtwobbloodbpressuresbofb172/104bm
mbHgbandb164/98bmmbHg.bWhatbisbthebappropriatebnursingbactionbinbresponsebtobthesebreadin
gs?
b Referbthebclientbtobabnutritionistbafterbprovidingbhealthbteachingbaboutbablow-sodium bdiet.b
b Placebthebclientbinbabrecumbentbpositionbandbcallbthebparamedicsbforbtransportbtobthe
hospital.
b b Talkbwithbthebclientbtobassessbwhetherbtherebisbstressbinbthebclient'sblifebandbreferbtoba
counselingbservice.
Takebthebclient'sbbloodbpressurebinbthebotherbarmbandbthenbschedulebabhealthcarebpractitioner'
sbappointmentbforbasbsoonbasbpossible.
AccordingbtobthebUnitedbStatesbDepartmentbofbHealthbandbHumanbServicesb(Canada:bCanadi
anbHeartbandbLungbAssociation),bbothbofbthesebreadingsbindicatebhypertensionbandbthusbrequir
ebfurtherbevaluationbbybabhealthcarebprovider;bhavingbabbaselinebforbbothbarmsbcanbassistbthebh
ealthcarebproviderbwithbthebmedicalbdiagnosis.bTeachingbaboutbablow-
sodiumbdietbisbanbinadequatebintervention.bAnbappointmentbwithbabhealthcarebprovider,bnotbabn
utritionist,bshouldbbebscheduledbasbsoonbasbpossible.bTherebarebinsufficientbdatabtobsupportbthi
sbemergencybinterventionb(callingbthebparamedics).bThebclient'sbelevatedbbloodbpressurebnee
dsbtobbebevaluatedbbybabhealthcarebproviderbandbthenbmedicalbtherapybimplemented.
Althoughbemotionalbstressbcanbprecipitatebhypertension,bphysicalbcausesbshouldbbebruledboutbf
irst.
Whatbisbthebmostbimportantbnursingbactionbwhenbmeasuringbabclient’sbpulmonarybcapillarybwe
dgebpressureb(PCWP)?
DeflatebthebballoonbasbsoonbasbthebPCWPbisbmeasured.b
bb HavebthebclientbbearbdownbwhenbmeasuringbthebPCWP.
bb PlacebthebclientbinbabsupinebpositionbbeforebmeasuringbthebPCWP.
bb FlushbthebcatheterbwithbabheparinbsolutionbafterbthebPCWPbisbdetermined.
Althoughbthebballoonbmustbbebinflatedbtobmeasurebthebcapillarybwedgebpressure,bleavingbthebb
alloonbinflatedbwillbinterferebwithbbloodbflowbtobtheblung.bBearingbdownbwillbincrease
b b b b b b
AbFoleybcatheterbwasbplacedbwithbanburimeterbforbabclientbwithbheartbfailurebreceivingbfurosem
ide.bTheboutputbisb45bmL/hour,bcloudy,bandbhasbsediment.bHowbshouldbthebnursebinterpretbthe
sebfindings?
b b Thebfurosemidebisbcausingbdehydration.
Cloudyburinebmaybbebindicativebofbinfection.
b Thebclientbhasbinadequatebhourlyburineboutput.b
b Allbofbthebindicationsbarebwithinbnormalbfindings.
Cloudyburinebmaybbebindicativebofbinfection,bwhichbisbalsobabriskbwithbFoleybcatheters.bAburinal
ysisbshouldbbebperformedbtobconfirmborbruleboutbaburinarybtractbinfection.bThebfurosemidebmayb
causebdehydration,bbutbotherbfindingsbwouldbhavebtobbebassessed,bsuchbasbskinbturgor.bHourl
yburineboutputbshouldbbebatbleastb30bmL,bwhichbisbbeingbsurpassed.bUrinebisbexpectedbtobbebcle
arbamberbcolored;bcloudybisbnotbwithinbexpectedbnormalbappearance.
Abnursebisbworkingbwithbanbunlicensedbassistivebpersonnelb(UAP)binbcaringbforbabgroupbofbclie
nts.bWhichbstatementbbybthebUAPbindicatesbabcorrectbunderstandingbofbthebUAP'sbrole?b
b "Ibwillbturnboff bclients'bIVsbthatbhavebinfiltrated."
"Ibwillbtakebclients'bvitalbsignsbafterbtheirbproceduresbarebover."
bb "Ibwillbusebunitbwrittenbmaterialsbtobteachbclientsbbeforebsurgery."
bb "Ibwillbhelpbbybgivingbmedicationsbtobclientsbwhobarebslowbinbtakingbpills."
MonitoringbvitalbsignsbafterbproceduresbisbwithinbthebscopebofbabUAP'sbrole.bRegisteredbprofes
sionalbnursesborblicensedbpracticalbnurses,bnotbUAPs,bshouldbperformbturningboffbclients'bintra
venousb(IV)binfusionsbthatbhavebinfiltrated.bUsingbunitbwrittenbmaterialsbtobteachbclientsbbefore
bsurgerybshouldbbebperformedbbybregisteredbprofessionalbnursesborblicensedbpracticalbnurses,
bnotbUAPs.bHelpingbbybgivingbmedicationsbtobclientsbwhobarebslowbinbtakingbpillsbshouldbbebper
formedbbybregisteredbprofessionalbnursesborblicensedbpracticalbnurses,bnotbUAPs.
Abclientbwhobjustbreturnedbfrombabcardiacbcatheterizationbreportsbtobthebnursebthatbthebpressur
ebbandagebonbthebrightbgroinbisbtight.bWhatbactionbshouldbthebnursebtake?
b b Loosenbthebdressingbslightly.
b Notifybthebprimarybhealthcarebprovider.b
b Assessbthebpulsesbdistalbtobthebdressing.
bb Havebthebclientbflexbthebjointsbofbthebrightbleg.
Assessingbthebcirculatorybstatusbofbthebextremitybwillbdeterminebwhetherbthebdressingbisbtoobti
ght.bLooseningbthebdressingbslightlybmaybresultbinbbleedingbfrombthebcatheterbinsertionbsiteban
dbisbcontraindicated.bNotifyingbthebprimarybhealthcarebproviderbisbpremature;bthebprimarybhe
althcarebproviderbshouldbbebnotifiedbifbcirculationbtobtheblegbisbcompromised.bHavingbthebclien
tbflexbthebjointsbofbthebrightblegbmaybresultbinbbleedingbfrombthebcatheterbinsertionbsitebandbisbc
ontraindicated.bTheblegbshouldbremainbextendedbforbseveralbhours.
,Abclientbwhobisbconsideringbsclerotherapybasksbthebnursebtobexplainbwhatbcausesbvaricosebvei
ns.bWhichbresponsebbybthebnursebisbbest?
b b "Thebcausebisbabnormalbconfigurationsbof bthebveins."
"Thebcausebisbincompetentbvalvesbofbsuperficialbveins."
b b "Thebcausebisbdecreasedbpressurebwithinbthebdeepbveins."b
b "Thebcausebisbatheroscleroticbplaquebformationbinbthebveins."
Incompetentbvalvesbresultbinbretrogradebvenousbflowbandbsubsequentbdilationbofbveins.bAbnor
malbconfigurationsbofbthebveinsbarebconsideredbabresultbof,bratherbthanbabcausebof,bvaricosebve
ins.bPressurebwithinbthebdeepbveinsbisbincreased,bnotbdecreased.bPlaquebformationbisbconside
redbanbarterial,bratherbthanbabvenous,bproblembandbisbassociatedbwithbatherosclerosis.
Abnursebinbthebpostanesthesiabcarebunitbisbcaringbforbabclientbwhobreceivedbabgeneralban
esthetic.bWhichbfindingbshouldbthebnursebreportbtobthebprimarybhealthcarebprovider?b
b Clientbpushesbthebairwaybout.
bb Clientbhasbsnoringbrespirations.
b Client’sbrespirationsbareb16bbreathsbperbminutebandbunlabored.b
Client’sbsystolicbbloodbpressurebdropsbfromb130btob90bmmbHg.
Abdropbinbbloodbpressure;brapidbpulsebrate;bcold,bclammybskin;bandboliguriabarebsignsbofbdecre
asedbbloodbvolumebandbshock,bwhichbifbnotbtreatedbpromptlybcanbleadbtobdeath.bThebclientbpus
hingbthebairwayboutbisbanbexpectedbresponse;bthebclientbwillbpushboutbthebairwaybasbthebeffectsb
ofbanesthesiabsubside.bRespirationsbofb16bbreathsbperbminutebisbabcommonbresponsebpostop
eratively.bIfbthebclientbisbexperiencingbabdepressantbeffectbofbanesthesia,bthebnursebwillbassessb
shallowbandbslowbrespirations.
Abnursebobservesbabwindowbwasherbfallingb25bfeetb(7.6bm)btobthebground.bThebnursebrushesbt
obthebscenebandbdeterminesbthatbthebpersonbisbinbcardiopulmonarybarrest.bWhatbshouldbthebn
ursebdobfirst?
b b Feelbforbabpulse
Beginbchestbcompressionsb
b Leavebtobcallbforbassistance
bb Performbthebabdominalbthrustbmaneuver
AccordingbtobthebAmericanbHeartbAssociationbandbHeartbandbStrokebFoundationbofbCanadabfor
bCPR,bthebfirstbstepbisbtobfeelbforbabpulsebafterbunresponsivenessbisbestablished.bInbthisbcase,bit
bhasbbeenbestablishedbthebclientbhasbnobpulseb(cardiopulmonarybarrest);bthereforebchestbcom
pressionsbarebinitiated.bDobnotbleavebthebclientbtobcallbforbassistance.bThebabdominalbthrustb(H
eimlich)bmaneuverbisbusedbtobrelievebairwaybobstructionbandbisbnotbappropriatebinbthisbinstanc
e.
Abclientbisbadmittedbtobthebhospitalbforbanbemergencybcardiacbcatheterization.bWhatbadaptatio
nbisbthebclientbmostblikelybtobcomplainbofbafterbthisbprocedure?
, b Fearbofbdying
bb Skippedbheartbeatsb
Painbatbthebinsertionbsite
bb Anxietybinbresponsebtobintensivebmonitoring
Painbatbthebarterialbpuncturebsitebisbattributablebtobentrybandbcannulationbofbthebarterybandbisbabc
ommonbcomplaintbafterbabcardiacbcatheterization.bFearbofbdyingbmightboccurbduringbthebprecat
heterizationbperiod.bAlthoughbskippedbheartbeatsbmayboccurbduringbthebprocedurebbecausebof
btraumabtobthebconductionbsystem,busuallybitbdoesbnotbcontinuebafterbthebprocedure.bAlthoughb
somebclientsbmaybbebanxious,bmanybfeelbsafebwhenbreceivingbongoingbmonitoring.
Thebnursebatbabhealthbfairbhasbtakenbabclient'sbbloodbpressurebtwice,b10bminutesbapart,binbthebs
amebarmbwhilebthebclientbisbseated.bThebnursebrecordsbthebtwobbloodbpressuresbofb172/104bm
mbHgbandb164/98bmmbHg.bWhatbisbthebappropriatebnursingbactionbinbresponsebtobthesebreadin
gs?
b Referbthebclientbtobabnutritionistbafterbprovidingbhealthbteachingbaboutbablow-sodium bdiet.b
b Placebthebclientbinbabrecumbentbpositionbandbcallbthebparamedicsbforbtransportbtobthe
hospital.
b b Talkbwithbthebclientbtobassessbwhetherbtherebisbstressbinbthebclient'sblifebandbreferbtoba
counselingbservice.
Takebthebclient'sbbloodbpressurebinbthebotherbarmbandbthenbschedulebabhealthcarebpractitioner'
sbappointmentbforbasbsoonbasbpossible.
AccordingbtobthebUnitedbStatesbDepartmentbofbHealthbandbHumanbServicesb(Canada:bCanadi
anbHeartbandbLungbAssociation),bbothbofbthesebreadingsbindicatebhypertensionbandbthusbrequir
ebfurtherbevaluationbbybabhealthcarebprovider;bhavingbabbaselinebforbbothbarmsbcanbassistbthebh
ealthcarebproviderbwithbthebmedicalbdiagnosis.bTeachingbaboutbablow-
sodiumbdietbisbanbinadequatebintervention.bAnbappointmentbwithbabhealthcarebprovider,bnotbabn
utritionist,bshouldbbebscheduledbasbsoonbasbpossible.bTherebarebinsufficientbdatabtobsupportbthi
sbemergencybinterventionb(callingbthebparamedics).bThebclient'sbelevatedbbloodbpressurebnee
dsbtobbebevaluatedbbybabhealthcarebproviderbandbthenbmedicalbtherapybimplemented.
Althoughbemotionalbstressbcanbprecipitatebhypertension,bphysicalbcausesbshouldbbebruledboutbf
irst.
Whatbisbthebmostbimportantbnursingbactionbwhenbmeasuringbabclient’sbpulmonarybcapillarybwe
dgebpressureb(PCWP)?
DeflatebthebballoonbasbsoonbasbthebPCWPbisbmeasured.b
bb HavebthebclientbbearbdownbwhenbmeasuringbthebPCWP.
bb PlacebthebclientbinbabsupinebpositionbbeforebmeasuringbthebPCWP.
bb FlushbthebcatheterbwithbabheparinbsolutionbafterbthebPCWPbisbdetermined.
Althoughbthebballoonbmustbbebinflatedbtobmeasurebthebcapillarybwedgebpressure,bleavingbthebb
alloonbinflatedbwillbinterferebwithbbloodbflowbtobtheblung.bBearingbdownbwillbincrease
