The client who has a fever can also lose fluid via : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler). Physically, she has no shortness of breath or to Client Problem Health Promotion and Disease Prevention Risk Factors Expected Findings Laboratory Tests Diagnostic Procedures Complications Therapeutic Procedures Interprofessional Care Nursing Care Medications Client Education. Some of the signs and symptoms of atrial fibrillation include chest tightness, palpitations, shortness of breath, dyspnea, fluttering in the chest, dizziness, confusion, fainting, and fatigue. A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Treatments for this heart block can include intravenous atropine, supplemental oxygen, and, in some cases, a temporary or permanent pacemaker, as indicated. Assess incison and dressing, Do not strain, do heavy lifting or hard exercise that All phases must be. fluid volume deficit. ALTERATION IN HEALTH- HEMODYNAMIC SHOCK-HYPOVOLEMIC SHOCK) Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery or increased oxygen consumption or inadequate oxygen utilization.This is most commonly occurs when View the full answer Transcribed image text: NT System Disorder Previous question Next question Which of the following findings C. Document the CVP and continue to monitor. C. Loop diuretic therapy Atrial flutter, which is a relatively frequently occurring tachyarrhymia, is characterized with a rapid atrial rate of 250 to 400 beats per minute, a variable ventricular rate, a regular atrial rhythm, a possibly irregular ventricular rhythm. oxygen concumption significantly. B. As a result of this failure, these cardiac arrhythmias have no atrial activity or P wave and they also have an unusual and wider QRS complex that is more than the normal 0.12 seconds. A. cm H2O, BP 90/50 mm Hg, skin cold and pale, and urinary output 55 mL over the last 2 hr. 1. Rationale: Platelets are administered to clients who have thrombocytopenia. There are Inspect the blood for discoloration, Prior to transfusion, two RNs must identify the correct blood product and client, by looking at the hospital identification number (noted on the blood product) and the, number identified on the client's identification band to make sure the numbers, The nurse completing the blood product verification must be one of the nurses, Prime the blood administration set with 0.9% sodium chloride only. Cross), Give Me Liberty! Vitamin K prolongs bleeding time. It is used to assess cardiovascular function in critically ill or unstable clients. The five types of sinus rhythms are: Normal sinus rhythms have a rate of 60 to 100 beats per minute, the atrial and the ventricular rhythms are regular, the P wave occurs prior to each and every QRS complex, the P waves are uniform in shape, the length of the PR interval is form 0.12 to 0.20 seconds, the QRS complexes are uniform and the length of these QRS complexes are from 0.06 to 0.12 seconds. The atrial and ventricular cardiac rates are from 150 to 250 beats per minute, the cardiac rhythm is regular, the p wave may not be visible because it is behind the QRS complex, the PR interval is not discernable, the QRS complexes look alike, and the length of the QRS complexes ranges from 0.06 to 0.12 seconds. C. Oliguria new staff nurse has been effective when the nurse Educate the client on the procedure Rationale: The heart rate of a client with hypovolemia will be increased. A. Administer IV diuretic medications. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following should C. Unconsciousness D. increasing preload. Aspiration should not be the treatment of choice. Verify prescription for blood product. Y-tubing with a filter is used to transfuse blood. low pressures. Hypovalemic shock priorities; Hypopituitarism - ATI templates and testing material. following is the priority intervention? PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________, Melyn Cruz formation and platelet counts. manifestations, such as angina. Reposition the client in bed at least every 2 hr and every 1 hr in a chair. that pulmonary hypertension was improving. 7 mkg/kg/min, Reduction of myocardial oxygen consumption is best achieved through which of the following changes? taking the airway, breathing, circulation (ABC) approach to client care. degrees, Obtain informed consent A reading Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. The basic three types of pacemakers are the single chamber pacemaker, the dual chamber pacemaker and the biventricular pacemaker. The classical features of torsades de pointes are a long QT interval in addition to a downward and upward deflection of the QRS complexes that are seen on the cardiac strip. medications should the nurse administer first? C. Reinforce teaching regarding gargling with warm saline several times daily. A. Rationale: Petechiae characterize the progressive stage of shock. After the implantation of a pacemaker, the nurse must be fully aware of the possible complications associated with pacemakers which include bleeding, inadvertent punctures of major vessels, infection, and mechanical failures, including battery failures, of the pacemaker. between hypovolemic shock and cardiac tamponade. C. Pulmonary vascular resistance (PVR) Some of the signs and symptoms of sinus tachycardia include: Some of the treatments for sinus tachycardia include the treatment of an underlying disorder or a problematic medication and no treatments when the client is asymptomatic. A. Fluid volume deficit D. Metabolic acidosis (ABC) approach to client care. C. ensures that the patient is supine with the head of the bed flat for all readings. Rationale: The nurse should understand DIC is not a genetic disorder involving vitamin K deficiency. D. Muscle cramps How many micrograms per kilogram per A trifascicular block is a right bundle branch block in combination with a left posterior fascicular block or a left anterior fascicular block in addition to first degree heart block. . (PAP) 30/16; PAWP 13; CVP 16; Cardiac Output 4; Cardiac index 2. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. Rationale: Cryoprecipitates are administered to clients with hemophilia or von Willebrands factor. The treatment for premature atrial contractions ranges from no treatments other than perhaps avoiding stimulants because most of these clients affected with this arrhythmia are asymptomatic and without complications to treatments including the correction and treatment of the underlying cause and the administration of medications such as calcium channel blockers and beta blockers. Rationale: Fatigue is an expected finding with a client who has anemia due to surgical blood loss. Low RA pressure A. Assessing the Client for Decreased Cardiac Output, Identifying Cardiac Rhythm Strip Abnormalities, Applying a Knowledge of Pathophysiology to Interventions in Response to Client Abnormal Hemodynamics, Providing the Client with Strategies to Manage Decreased Cardiac Output, Intervening to Improve the Client's Cardiovascular Status, Monitoring and Maintaining Arterial Lines, Managing the Care of a Client on Telemetry, Managing the Care of a Client Receiving Hemodialysis, Managing the Care of a Client With an Alteration in Hemodynamics, Tissue Perfusion and Hemostasis, Adult Gerontology Nurse Practitioner Programs (AGNP), Womens Health Nurse Practitioner Programs, Advanced Practice Registered Nurse (APRN), Performing and Managing the Care of the Client Receiving Dialysis, Identifying the Client with Increased Risk for Insufficient Vascular Perfusion, Physiological AdaptationPractice Test Questions, RN Licensure: Get a Nursing License in Your State, Assess client for decreased cardiac output (e.g., diminished peripheral pulses, hypotension), Identify cardiac rhythm strip abnormalities (e.g., sinus bradycardia, premature ventricular contractions [PVCs], ventricular tachycardia, fibrillation), Apply knowledge of pathophysiology to interventions in response to client abnormal hemodynamics, Provide client with strategies to manage decreased cardiac output (e.g., frequent rest periods, limit activities), Intervene to improve client cardiovascular status (e.g., initiate protocol to manage cardiac arrhythmias, monitor pacemaker functions), Manage the care of a client with a pacing device (e.g., pacemaker), Manage the care of a client receiving hemodialysis, Manage the care of a client with alteration in hemodynamics, tissue perfusion and hemostasis (e.g., cerebral, cardiac, peripheral), Make a conclusion about the cardiac rhythm on the rhythm strip, The normal sinus rhythm which has a cardiac rate of 60 to 100 beats per minute, Sinus bradycardia which has a cardiac rate of less than 60 beats per minute, Sinus tachycardia which has a cardiac rate of more than 100 beats per minute, A sinus arrhythmia which is an irregular heart rate that can range from 60 to 100 beats per minute, An idioventricular rhythm, also referred to as a ventricular escape rhythm, has a rate of less than 20 to 40 beats per minute, An accelerated idioventricular rhythm with more than 40 beats per minute, An agonal rhythm with less than 20 beats per minute, Ventricular tachycardia with more than 150 beats per minute, Second-Degree Atrioventricular Block, Type I, Second-Degree Atrioventricular Block, Type II. all of the antibiotics have been completed. Poor nutrition, Client education A. Hypotension A. Cardiac output is nonexistent and death is highly likely without immediate treatment. Systemic vascular resistance (SVR) Rationale: Decreased level of consciousness is a sign of shock, but it is not the earliest indicator. Normal renal tubular function is reestablished during this phase. 10 L/min, SVR 4802 dynes/sec/cm5, and WBC 28,000. SEE Physiological AdaptationPractice Test Questions. 3 mm Hg Antipyretics may be taken as directed for the treatment of fever. Which of the following changes indicates to the nurse that the Reoccurence of bladder neck obstruction---> Urethral trauma, urinary retention, bleeding, and infection *Monitor the client and intervene for bleeding This increasing prolongation leads to the progressive lengthening of the PR interval until is leads to a non conducted P wave and the absence of a QRS complex. The treatment of atrial fibrillation includes the control of the cardiac rate with medications such as beta blockers, calcium channel blockers, or digoxin, intravenous verapamil when rapid cardiac rate reduction is necessary, cardioversion, supplemental oxygen, and antithrombolytic medications to prevent clot formation and pulmonary emboli. A. because of the decreased ability of the body to carry oxygen to vital tissues and organs. of infection, such as localized redness, swelling, drainage, fever. The complications can include ventricular fibrillation which can lead to cardiac arrest. B. 40 Comments Please sign inor registerto post comments. When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to Some of the signs and symptoms of sinus bradycardia include: Some of the treatments for sinus bradycardia include the treatment of an underlying disorder or a problematic medication and no treatments when the client is asymptomatic. when taking the airway, breathing, circulation (ABC) approach to client care. D. Pulmonary artery wedge pressure (PAWP). A nurse in the emergency department is caring for a client who has anaphylaxis following a bee sting. Loss of central venous pressure waveform and inability to aspirate blood from the line. B. Purpura A. Fluids to keep the CVP elevated. Hemodynamic Parameters Heart rate Arterial blood . Sunburns - ATI templates and testing material. D. Instruct the client to take antipyretics as directed for elevated temperature. A nurse is caring for a client who has hypovolemic shock. The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a The cardiac rates for the atria and the ventricles are different and the QRS complexes are wide and prolonged. This is, Tachypnea is more likely than respiratory depression in a client who has anemia due to blood. of 15 mm Hg is elevated. Rationale: This is not the correct analysis of the ABGs. rupture and impending MODS. The normal parameters for hemodynamic monitoring values, as shown below. Initial- No visible changes in client parameters; only changes on the cellular level 2. Elevated PAWP measurements may Ventricular tachycardia occurs when no impulses come from the atria; this life threatening arrhythmia will progress to ventricular fibrillation and then cardiac arrest and cardiac asystole unless emergency medical care is immediately rendered. D. Atelectasis Keep the head of the bed at or below a 30 angle (or flat), unless contraindicated, to relieve pressure on the sacrum, buttocks, and heels. A nurse is caring for a client who is at risk for shock. The rate is slow and less than 20 beats per minute, the rhythm is typically regular, the P wave is absent, the PR interval is not measurable, and the QRS interval is abnormally wide and more than 0.12 seconds with an abnormal T wave deflection. B. diuretics to reduce the CVP. A. Some of the diseases and disorders associated with this cardiac arrhythmia include hypertension, heart failure, impaired sinus node functioning, hypoxia, a mitral valve defect, pericarditis, rheumatic heart disease, coronary artery disease, hyperthyroidism, the aging process and the presence of a pulmonary embolus. The other parameters also may be monitored but B. Lethargy and V2. Specific language should not be used to present the reasons for bad news when a, Early recognition of fetuses with incompatible blood types is now possible by, Interactive outputs which involve the user is communicating directly with the, What are the Differences What are the Differences What are the Differences What, FIN340+7-1+Final+Project+Matthew+Williams.docx, Copy of "The Struggle for Human Rights" by Eleanor Roosevelt.docx, Algorithm for Calculating the Inverse of a Matrix There is a more practical way, When used as a microbial control method filtration is the passage of air or a, The vector c i s j is perpendicular to the string and thus F r bead, This cushion traps some of the exhausting air near the end of the stroke before, This is Mrs Browns first pregnancy The obstetrician orders amniocentesis to. Rationale: A decreased PAWP is seen with hypovolemia or afterload reduction. D. Decreased level of consciousness B. positions the zero-reference stopcock line level with the phlebostatic axis. Rationale: The PAWP is a mean pressure that is expected to range between 4 and 12 mm Hg. infection. B. B. BUN and serum creatinine levels begin to decrease. Rationale: ANS: 2A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Arterial lines, which can be surgically placed in a number of arteries including the femoral, brachial, radial, ulnar, axillary, posterior tibial, and dorsalis pedis arteries, are used for the continuous monitoring of the client's blood pressure and other hemodynamic measurements in addition to drawing frequent blood samples, such as drawing frequent arterial blood gases which could lead to repeated trauma, hematomas and scar tissue formation. Sinus bradycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the number of beats per minute. A. 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