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The nurse is caring for a client who has undergone cardiac catheterization. The client says to the nurse, "The doctor said my cardiac output was 5.5 L/min. What is normal cardiac output?" Which of the following is the nurse's best response?
CORRECT ANSWER IS C
A) "It is best to ask your doctor."
B) "Did the test make you feel upset?"
C) "The normal cardiac output for an adult is 4 to 6 L/min."
D) "Are you able to explain why are you asking this question?"
The client asked a direct question that the nurse should be able to answer. Normal cardiac output for an adult is 4 to 6 L/min. Questions regarding diagnosis and prognosis may be referred to physicians. There is no harm in answering this question. When using therapeutic communication, the nurse should never ask a client to justify his or her feelings by inquiring why a question was asked. There is no evidence that this client is upset
A person who starts smoking in adolescence and continues to smoke into middle age:
Has an increased risk for cardiopulmonary disease and lung cancer
The risk of lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Cigarette smoking worsens peripheral vascular and coronary artery disease. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels.
Carbon monoxide (CO) is a toxic inhalant that decreases the oxygen-carrying capacity of blood by:
Forming a strong bond with hemoglobin
CO is the most common toxic inhalant and decreases the oxygen-carrying capacity of blood. In CO toxicity, hemoglobin strongly binds with carbon monoxide, creating a functional anemia. Because of the strength of the bond, carbon monoxide does not easily dissociate from hemoglobin, which makes hemoglobin unavailable for oxygen transport.
Conditions such as shock and severe dehydration resulting from extracellular fluid loss cause:
Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume (hypovolemia).
Fever increases the tissues' need for oxygen, and as a result:
Carbon dioxide production increases
Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production increases. When fever persists, the metabolic rate remains high and the body begins to break down protein stores, which results in muscle wasting and decreased muscle mass.
Left-sided heart failure is characterized by:
Decreased functioning of the left ventricle
Left-sided heart failure is an abnormal condition characterized by decreased functioning of the left ventricle. If left ventricular failure is significant, the amount of blood ejected from the left ventricle drops greatly, which results in decreased cardiac output
Cyanosis, the blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is:
A late sign of hypoxia
Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status.
A simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion is:
Frequent change of position
Changing the client's position frequently is a simple and cost-effective method for reducing the risk of pneumonia associated with stasis of pulmonary secretions and decreased chest wall expansion. Oxygen humidification, chest physiotherapy, and use of antiinfectives are all helpful, but are not cost effective.
The nurse is concerned when a client's heart rate, which is normally 95 beats per minute, rises to 220 beats per minute, because a rate this high will:
Reduce coronary artery perfusion
Coronary arteries fill and perfuse the myocardium (heart muscle) during diastole. When the heart rate is elevated, more time is spent in systole and less in diastole; hence, the myocardium may not be perfused adequately. The client may be exhausted, but the primary concern is myocardial perfusion. Major organs will adjust to increased blood flow. This is usually not a problem. With a heart rate this high, metabolic rate will be increased, not decreased.
A client is admitted to the emergency department with a suspected cervical spine fracture at the C3 level. The nurse is most concerned about the client's ability to:
When suctioning secretions that are collecting in an endotracheal tube, the nurse does not apply suction for longer than:
Applying suction for too long can result in complications such as hypoxemia and cardiac dysrhythmias. Thus the nurse is always aware of the length of time that suctioning is applied to an airway. If the suctioning time is too short, the suction catheter may not remove the secretions. If the suctioning time is too long, hypoxemia and/or cardiac dysrhythmias could result.
The nurse is caring for a client with a chest tube in the right thorax. On first assessment the nurse notes that there is bubbling in the water-seal chamber. This client is scheduled to undergo a chest x-ray examination, and the transporters have arrived to take him by wheelchair to the radiology department. The nurse considers whether the chest tube should be clamped or not during the trip to the radiology department. The nurse makes the which correct decision?
Do not clamp the chest tube and disconnect it from the wall suction.
A bubbling chest tube (in the water-seal portion) should never be clamped because it provides the only exit for air accumulating in the pleural space. If the tube is clamped, tension pneumothorax could occur, which could be fatal. There is no advantage to clamping the chest tube but venting the system. Clamping of the chest tube prevents communication of the chest tube with the venting system or with the wall suction. There is no such thing as "temporary suction" for a chest tube system.
A client is receiving oxygen via a nonrebreathing mask. A crucial nursing assessment the nurse performs is to be sure that:
The bag attached to the mask is inflated at all times
If the bag attached to a nonrebreathing mask is deflated, the client is at risk for breathing in large amounts of exhaled carbon dioxide. The bag should be maximally inflated at all times
A client with known chronic obstructive pulmonary disease (COPD) is admitted to the emergency department with multiple minor injuries following an automobile accident. To ensure adequate ventilation the nurse applies a nasal cannula providing oxygen at what rate and for what reason?
2 L/min to prevent elevating the arterial oxygen tension (PaO2), which would suppress the hypoxic drive
A client asks why smoking is a major risk factor for heart disease. In formulating a response, the nurse incorporates the understanding that nicotine
Symptoms associated with anemia include which of the following? (Select all that apply.)
CORRECT ANSWERS ARE A & D
A) Increased breathlessness
B) Decreased breathlessness
C) Increased activity tolerance
D) Decreased activity tolerance
Clients with anemia have fatigue, decreased activity tolerance, and increased breathlessness, as well as pallor (especially seen in the conjunctiva of the eye) and an increased heart rate.
Which of the following assessment data indicate that the client's airway needs suctioning? (Select all that apply.)
CORRECT ANSWERS ARE A, C & E
Suctioning is necessary when the client is unable to clear respiratory secretions from the airways. Signs that a client's airway needs suctioning include a change in respiratory rate or adventitious sounds, nasal secretions, gurgling, drooling, restlessness, gastric secretions or vomitus in the mouth, and coughing without clearance of secretions from the airway.
The nurse suspects left-sided heart failure in a newly admitted client when the nurse notes which of the following symptoms? (Select all that apply.)
CORRECT ANSWERS ARE B & D
A) Distended neck veins
B) Bilateral crackles in the lungs
C) Weight gain of 2 lb in past 2 days
D) Shortness of breath, especially at night
Left-sided heart failure results in ineffective ejection of blood from the left ventricle. This causes a backup of blood into the lungs. Thus, symptoms of left-sided heart failure are usually related to the lungs.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and anxiety. The nurse helps the client to breathe better by doing which of the following? (Select all that apply.)
CORRECT ANSWERS ARE B & C
A) Implementing guided imagery
B) Instructing the client to perform pursed-lip breathing
C) Elevating the head of the bed to semi-Fowler's or Fowler's position
Elevating the head of the bed to Fowler's position (45-degree angle) or semi-Fowler's position (30- to 45-degree angle) causes the diaphragm to lower from gravity and thus increases the space for lung expansion. Pursed-lip breathing prolongs exhalation and maintains the alveoli open longer, thus extending the period of oxygen and carbon dioxide exchange. Too high an elevation of the head of the bed could force the diaphragm into the thorax and reduce lung expansion. Fluids could help liquify the pulmonary secretions in the future, but right now the client needs more acute care. Guided imagery may help in the future, but now is not the time to implement this intervention.
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