Critical Alterations in Perfusion Questions

A nurse is providing care for a client during a cardiac arrest. Following the first shock for a client with ventricular fibrillation (VF), which of the following actions should the nurse be prepared to take?

Perform CPR for 2 min.

Provide an additional shock.

Administer oxygen.

Administer 1 mg Epinephrine IV push.

Perform CPR for 2 min.

The nurse should perform CPR for 2 minutes following the first shock for ventricular fibrillation.

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The nurse should not administer oxygen as oxygen should already have been provided at the start of the cardiac arrest.

The nurse should not administer 1 mg epinephrine IV push as epinephrine should be administered after the second shock for a shockable rhythm.

The nurse is planning care for a client with multiple organ dysfunction syndrome (MODS). What should the nurse include on the care plan? (Select all that apply)

Monitor client for hemodynamic stability.

Maintain the client on bedrest for at least 48 hours.

Reposition client every 2 hours.

Administer fresh frozen plasma.

Discuss assessment findings with the team.

Monitor client for hemodynamic stability is correct. Hemodynamic instability leads to immobility, reducing the immune response. 

Discuss assessment findings with the team is correct. Discussing assessment findings with the team should be included on the care plan

Reposition client every 2 hours is correct. Repositioning the client every 2 hours should be included on the care plan in order to prevent pressure injuries.

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Administer fresh frozen plasma is incorrect. Administer fresh frozen plasma should not be included on the care plan as it is not indicated. 

Maintain the client on bedrest for at least 48 hours is incorrect. Providing rest periods are important; however, maintaining the client on bedrest for at least 48 hours should not be included on the care plan because mobilizing clients is an important goal. 

A nurse is reviewing a client’s chart to identify risk factors for sudden cardiac arrest (SCA). The nurse should state that septic shock is the leading risk of cardiac arrest in the hospital. (Select all that apply.)

Decreased C-reactive protein levels

Active lifestyle

74-year old male

History of gout

History of dyslipidemia

Obesity

74-year old male

History of dyslipidemia

Obesity

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C-reactive protein levels may be increased due to inflammation, but the lab value is not a risk factor.

A nurse is discharging a client who is at high risk for abdominal aortic aneurysm (AAA). Which of the following information should the nurse include in the teaching plan for this client? (Select all that apply.)

The client should be instructed to stop smoking.

The client should resume a regular diet.

The client should be taught to monitor blood pressure.

The client should manage anxiety to reduce stress.

The client should be taught to implement a walking program.

The client should be instructed to stop smoking.

The client should be taught to monitor blood pressure.

The client should manage anxiety to reduce stress.

The client should be taught to implement a walking program.

A nurse is completing a postoperative assessment of a client after surgical repair of an abdominal aortic aneurysm (AAA). What are the most important components for the nurse to include as part of the focused data collection? (Select all that apply.)

Pedal pulses

Ecchymosis to abdomen

Urine output

Radial pulses

Serum sodium

Pedal pulses is correct. The nurse should include femoral pulses as part of the focused assessment following an AAA repair because the location of the repair is above the common iliac and renal arteries.

Ecchymosis to abdomen is correct. The nurse should include assessing for abdominal ecchymosis as part of the focused assessment following an AAA repair, as this manifestation suggests rupture of the aneurysm and requires emergency intervention. 

Urine output is correct. The nurse should include urine output as part of the focused assessment following an AAA repair because the location of the repair is above the common iliac and renal arteries.

A nurse is providing education to clients at a community health fair regarding cardiovascular health and risk factors. Which of the following statements should the nurse include?

"Sudden cardiac arrest occurs infrequently and is considered a minor public health burden."

"Coronary artery disease is the greatest risk factor for cardiac arrest."

"Anaphylactic shock is the leading risk factor for cardiac arrest in the hospital."

"Younger age and being female increases the risk for cardiac arrest."

"Coronary artery disease is the greatest risk factor for cardiac arrest."

The nurse should state that more than 70 to 75% of clients who have experienced cardiac arrest have a history of coronary artery disease.

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The nurse should state that septic shock is the leading risk of cardiac arrest in the hospital.

The nurse should state that sudden cardiac arrest accounts for 15 to 20% of all natural deaths in adults in the USA and Western Europe.

A nurse is teaching a student nurse about the coronary artery bypass graft (CABG) procedure. Which of the following information should the nurse include in the teaching? (Select all that apply.)

CABG is a procedure that restores blood flow to the heart muscle.

Blood vessels are taken from an artery in the leg and grafted onto a section of the aorta.

Regional anesthesia is used when a CABG procedure is performed.

During CABG surgery, chemicals and hypothermia are used to stop the heart.

To access the heart, the surgeon cuts through the rib cage over the left chest wall.

CABG is a procedure that restores blood flow to the heart muscle is correct. The nurse should explain that CABG is a procedure that restores blood flow to the heart muscle.

During CABG surgery, chemicals and hypothermia are used to stop the heart is correct. The nurse should explain that during CABG surgery, the heart is stopped using chemicals and hypothermia.

To access the heart, the surgeon cuts through the rib cage over the left chest wall is incorrect. The nurse should explain that the surgeon cuts through the sternum to access the heart.

Blood vessels are taken from an artery in the leg and grafted onto a section of the aorta is incorrect. The nurse should explain that a vein in the leg (saphenous vein) or an artery in the chest (internal mammary artery) or arm (radial artery) is grafted onto a section of the aorta.

Regional anesthesia is used when a CABG procedure is performed is incorrect. The nurse should explain that general anesthesia is used when CABG procedure is performed.

A nurse is providing care for a client who has systemic inflammatory response syndrome (SIRS). Which of the following is a risk factor that could have contributed to the development of SIRS?

Injecting illicit drugs

Hypoglycemia

Increased pain

Acute stress

Injecting illicit drugs

A nurse is providing care for a client with cardiac tamponade (CT). Which of the following manifestations should the nurse anticipate? (Select all that apply.)

Jugular venous distention (JVD)

Hypertension

Muffled heart sounds

Tachypnea

Pulsus alternans

Jugular venous distention (JVD) is correct. JVD is a manifestation of CT due to the heart's inability to pump the blood forward. This results in muffled heart sounds.

Muffled heart sounds is correct. Muffled heart sounds are a manifestation of CT due to the heart's inability to pump. This results in heart sounds that are difficult to hear.

Tachypnea is correct. Tachypnea is a manifestation of CT due to the diminished supply of blood to the lungs. This results in hypoxemia.

Pulsus alternans is incorrect. Pulsus alternans is not a manifestation of CT.

Hypertension is incorrect. Hypotension, rather than hypertension, is a manifestation of CT. 

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Pulsus alternan weak and strong arterial pulse beats

• Left ventricular failure

• Cardiomyopathy

• Severe CAD

A nurse is providing care for a client during a cardiac arrest. The Code Leader is preparing the first dose of amiodarone. What dosage of amiodarone should the nurse anticipate the Code Leader to prepare for the first dose?

150 mg

200 mg

250 mg

300 mg

300 mg

A nurse is assessing a client admitted for an abdominal aortic aneurysm (AAA) 2 days ago. Which of the following psychosocial manifestations might the client display?

Reporting sleeping soundly for 8 hours per night

Reporting abdominal fullness

Expressing a sense of powerlessness

Bruit over the carotid artery

Expressing a sense of powerlessness

Expressing a sense of powerlessness is attributed to the possibility of the AAA rupturing.

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As the AAA enlarges, it can compress surrounding viscera resulting in gastrointestinal (GI) or renal manifestations but not psychosocial

Clients who are aware they have a AAA may experience anxiety, loss of sleep and fear, which is attributed to the possibility of the AAA rupturing.

A nurse is providing care for several clients. Which of the following clients is at greatest risk for cardiac tamponade?

A client being treated for Grave's disease with radioiodine therapy

A client with diabetes and is receiving intravenous insulin therapy

A client undergoing central line insertion for parental nutrition

A client who has a severe head injury and is undergoing intracranial pressure monitoring

A client undergoing central line insertion for parental nutrition

A nurse is providing care for a client who is 1 day postoperative following a coronary artery bypass graft (CABG) surgery. Why does the nurse need to monitor for physiological and psychological health impairment?

Pain is expected and does not affect physiological health.

Psychological health influences positive outcome after CABG more than physiological needs.

Wound infections occur because of a decreased psychological recovery from the surgery.

Psychological distress can cause hyperactivation of the sympathetic pathway, worsening physiological outcomes.

Psychological distress can cause hyperactivation of the sympathetic pathway, worsening physiological outcomes.

A nurse is planning care for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory tests should the nurse expect the provider to prescribe? (Select all that apply.)

Red blood cell (RBC) count

D-dimer

Prothrombin time (PT)

Partial thromboplastin time (PTT)

Troponin

Fibrinogen

D-dimer

Prothrombin time (PT)

Partial thromboplastin time (PTT)

Fibrinogen

A nurse is providing care for several clients on a cardiac floor. Which of the following is a comorbidity that increases the client's risk for abdominal aortic aneurysm (AAA)?

Chronic asthma

Osteoarthritis

Renal insufficiency

Addison's disease

Renal insufficiency

A nurse is providing care to a client who is unresponsive, without a pulse, and not breathing. Which of the following actions are the nurse's priority as a first responder? (Select all that apply.)

Instruct a team member to get the crash cart.

Begin CPR.

Get the automatic external defibrillator (AED).

Call for help.

Identify staff roles in the emergency response.

Assess for and establish venous IV access.

Instruct a team member to get the crash cart.

Begin CPR.

Call for help.

A nurse is teaching a new graduate nurse about the Sequential Organ Failure Assessment (SOFA) scoring system. Which of the following does a SOFA score assess?

The SOFA score distinguishes between acute and chronic organ dysfunction.

A SOFA score assesses the risk of mortality in relation to cardiac dysrhythmias.

The SOFA score is used to identify the correct antibiotic to treat sepsis.

A SOFA score assesses the risk of mortality in relation to multiple organ dysfunction syndrome (MODS).

A SOFA score assesses the risk of mortality in relation to multiple organ dysfunction syndrome (MODS).

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Blood cultures are used to identify the correct antibiotic to treat sepsis

Assesses cardiovascular function, but it does not assess the mortality of dysrhythmias.

A nurse is caring for a client following a cardiac arrest that was successfully treated with external defibrillation. Which of the following rhythms is the most likely cause of the client's cardiac arrest?

Pulseless electrical activity (PEA)

Ventricular fibrillation

Atrial flutter

Sinus bradycardia

Ventricular fibrillation

Ventricular fibrillation is one of the shockable rhythms and is the most common cause of cardiopulmonary arrest; therefore, this rhythm is most likely the cause of the client's cardiac arrest.

A nurse is planning care for a client who has been admitted for evaluation of their heart valves. The nurse should anticipate the client will undergo which of the following tests?

Echocardiogram

Electrocardiogram (EKG)

Chest x-ray

Stress test

Echocardiogram

A nurse is teaching a group of nursing students about septic shock. Which of the following information should the nurse include in the teaching?

Septic shock occurs when intravascular volume decreases due to poor cardiac output.
Septic shock occurs due to a severe hypersensitivity mediated by immunoglobulin E.
Septic shock occurs due to autonomic dysregulation followed by a spinal cord injury.
Septic shock is a result of the release of inflammatory cytokines.

Septic shock occurs due to the release of inflammatory cytokines in the presence of sepsis. The cytokines initiate clotting mechanisms that produce microemboli.

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Neurogenic shock occurs due to autonomic dysregulation caused by a spinal cord injury.

Anaphylactic shock occurs due to a severe hypersensitivity mediated by immunoglobulin E.

Hypovolemic shock occurs when intravascular volume is decreased due to poor cardiac output.

A nurse is providing care for a client who has multiple organ dysfunction syndrome (MODS) following severe pneumonia. Which of the following is the possible physiological impact of MODS on a client's health?

The number of organ systems affected during MODS only slightly increases the chance of death.

Decreased urine output and kidney injury can occur due to decreased renal perfusion.

Clients receive via mask as a precaution during MODS.

The liver is often the last organ to be affected by MODS.

Decreased urine output and kidney injury can occur due to decreased renal perfusion.

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The liver can start to fail as quickly as other organs, putting the client at risk of eliminating toxins.

A nurse is providing discharge instructions to a client who has survived cardiac tamponade (CT). The client's family asks the nurse what complications can occur after cardiac tamponade. Which of the following information should the nurse include? (Select all that apply.)

The client may have anxiety, restlessness, confusion and difficulty breathing.  

The client may develop heart failure as a complication.

The client may have new cardiac dysrhythmias that require a defibrillator.

The client may require long-term parenteral nutrition.

The client may have increased mortality risk if the cause is from malignancy.

The client may have anxiety, restlessness, confusion and difficulty breathing is correct. CT triggers anxiety, restlessness, confusion, and difficulty breathing.

The client may develop heart failure as a complication is correct. Potential complications of CT include heart failure, pulmonary edema, bleeding, shock, and a recurrence of tamponade. 

The client may have increased mortality risk if the cause is from malignancy is correct. Malignancy as the cause of the CT increases the risk of mortality within 12 months, whereas any other cause has less mortality risk.

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The client may have new cardiac dysrhythmias that require a defibrillator is incorrect. Heart failure may occur as a complication, but not new dysrhythmias that require defibrillator placement. 

The client may require long-term parenteral nutrition is incorrect. There is no indication that the client needs long-term parenteral nutrition. 

A nurse is reviewing concepts related to shock with a newly graduated nurse. Which of the following information should the nurse include in the teaching?

Shock results in excess aerobic cellular metabolism.

Shock is the result of circulatory failure.

Shock causes increased systemic vascular resistance (SVR) resulting in the dilation of blood vessels.

Shock results in increased myocardial contractility.

Shock is the result of circulatory failure.

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Decreased SVR, not increased vascular resistance results in dilation of blood vessels.

Shock results in decreased myocardial contractility related to myocardial ischemia.

Shock results in excess anaerobic metabolism, not excess aerobic cellular metabolism.

A nurse is assessing a client who has disseminated intravascular coagulation (DIC) that occurred as a result of sepsis. Which of the following manifestations may be observed in a client experiencing DIC? (Select all that apply.)

Bradycardia

Ecchymosis

Bleeding around IV insertion site

Hematuria

Hypothermia

Dyspnea

Dyspnea is correct. Dyspnea is a manifestation of DIC related to pulmonary hemorrhage or pulmonary embolism.

Ecchymosis is correct. Ecchymosis is a manifestations of DIC.

Bleeding around IV insertion site is correct. Bleeding around IV insertion site is a manifestation of DIC.

Hematuria is correct. Hematuria is a manifestation of DIC related to bleeding from the mucous membrane lining of the bladder.

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Hypothermia is incorrect. Hypothermia is not a manifestation of DIC.

Bradycardia is incorrect. Tachycardia, not bradycardia, may be a manifestation of DIC.

A nurse is teaching a client about cardiac tamponade (CT). Which of the following information should the nurse include in the teaching?

Accumulation of fluid around the heart causes CT.

CT results in increased cardiac output.

CT causes a softening of the left ventricle, increasing cardiac output.

CT is a disorder related to atrial fibrillation.

Accumulation of fluid around the heart causes CT.

Less than 30 mL of fluid surrounds the heart of a healthy adult; CT occurs when 200 to 300 mL of fluid accumulates around the heart.

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CT causes an accumulation of fluid and prevents cardiac muscle relaxation, leading to decreased cardiac output.

The accumulated fluid in the pericardial space can harden the ventricles, preventing ventricular relaxation.

CT does not result from atrial fibrillation but from an accumulation of blood, fluid, clots, or gas in the pericardial space.

Intervention	Septic shock	Cardiogenic shock	Anaphylactic shock	Hypovolemic shock
Initiate central line access.
Administer 0.9% sodium chloride IV.
Initiate antibiotic therapy.
Administer packed red blood cells.
Administer IM epinephrine.
Prepare for insertion of Intra-aortic balloon pump.
Administer IV antihistamines.

anaphylactic shock

• plan for administration epinephrine, antihistamines, corticosteroids, and nebulized albuterol

cardiogenic shock

• intra-aortic balloon pump, vasopressors, and IV fluids.

hypovolemic shock

• administration of blood products but not vasopressors.

most shocks

• central line access and IV crystalloid fluids