Which of the following clients is at greatest risk for fluid volume Some of the conditions and disorders that can lead to complete heart blood include rheumatic fever, coronary ischemia, an inferior wall myocardial infarction, the presence of an atrial septal defect, and some medications including digoxin and beta blockers, for example. A. balances and calibrates the monitoring equipment every 2 hours. Rationale: The nurse should expect to find a decrease, not increase, in platelet count because of the Some of contraindications for the use of an arterial line include severe burns near the desired site, impaired circulation to the site, pulselessness, Buergers disease, and Raynaud syndrome; and arterial lines are cautiously implanted and used when the client is affected with atherosclerosis, a clotting disorder, impaired circulation, scar tissue near the desired site, and the presence of a synthetic graft. Pulmonary Artery Systolic Pressure: 15 to 26 mm Hg, Pulmonary Artery Diastolic Pressure: 5 to 15 mm Hg, Pulmonary Artery Wedge Pressure: 4 to 12 mm Hg, Pulmonary Artery End Diastolic: 4 to 14 mm Hg, Pulmonary Artery Occlusion Mean: 2 to 12 mm Hg, Pulmonary Artery Peak Systolic: 15 to 30 mm Hg, Right Ventricle Peak Systolic: 15 to 30 mm Hg, Right Ventricle End Diastolic: 0 to 8 mm Hg, Left Ventricle Peak Systolic: 90 to 140 mm Hg, Left Ventricle End Diastolic: 5 to 12 mm Hg, Brachial Artery Peak Systolic: 90 to 140 mm Hg, Brachial Artery End Diastolic: 60 to 90 mm Hg, Mixed Venous Oxygen Saturation: 60% to 80%, Pulmonary artery catheters and their distal lumen, their proximal lumen, their balloon inflation port, Diminished peripheral pulses and poor perfusion tissue and organ perfusion, Changes in terms of mental status and level of consciousness. Most episodes of transient first degree heart block are benign and asymptomatic, but at times, it can lead to atrial fibrillation and other cardiac irregularities of varying severity according to the length of the PR interval prolongation. Assess for a history of blood-transfusion reactions. A. Rationale: Dobutamine does not reverse the most severe manifestations of anaphylactic shock; therefore, Hemodynamic studies reveal the following: BP 102/72 mm Hg; pulse 105; pulmonary arterial pressure Rationale: Dyspnea is characteristic of respiratory conditions, but is not usually associated with because of the decreased ability of the body to carry oxygen to vital tissues and organs. A similar ratio designation is used for second degree atrioventricular block Type II, as you will learn in the next section. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can Skip to document. Torsades de pointes can occur as the result of an over dosage of a tricyclic antidepressant drug of phenothiazine, hypomagnesemia and hypokalemia. B. infection. Rationale: Respiratory alkalosis is present in the compensatory stage of shock. A client with a BMI of 60 kg/mm is admitted to the intensive care unit 3 weeks after gastric bypass with gastric Rationale: This CVP is within the expected reference range. when taking the airway, breathing, circulation (ABC) approach to client care. might the nurse expect this finding to indicate? Cardiac output as the function of the volume of pumped blood by the heart and the factors and forces that alter normal cardiac output. There are Temporary and permanent pacemakers are indicated for clients affected with a number of different cardiac conditions and arrhythmias. There are 400 mg of dopamine hydrochloride in 250 ml D5W, B. Regrowth of prostate tissue 2. When discharged eat a mechanical soft diet, swallowing may be more difficult after surgery for the, first 2 to 4 weeks due to swelling in your throat, Sleep with your head and upper body elevated 30, The diverticulum pouch is removed and the, Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Psychology (David G. Myers; C. Nathan DeWall), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Course Hero is not sponsored or endorsed by any college or university. of obtaining the blood product to reduce the risk of bacterial growth. Bleeding, The diverticulum pouch is removed and the Progressive increase in platelet production. Intussusception - ATI templates and testing material. The goals of treatment in terms of the management of care for a client with an alteration in terms of their hemodynamics, tissue perfusion and hemostasis include the correction and treatment of any treatable underlying causes, and the promotion of improved tissue perfusion. 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. 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. Clients affected with bundle branch block may be symptomatic and asymptomatic. The steps for identifying cardiac rhythms are as follows: Sinus cardiac rhythms begin in the sintoatrial (SA) node of the heart. B. positions the zero-reference stopcock line level with the phlebostatic axis. diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for Immediate CPR and ACLS protocols, cardioversion, the placement of an internal pacemaker, amiodarone, lidocaine and antiarrhythmic medications may be used for the treatment of ventricular fibrillation according to the client's condition and their choices. A. Administer IV diuretic medications. 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. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. A nurse is assessing a client who is postoperative and has anemia due to excess blood loss during surgery. Mean arterial pressure (MAP) 1. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01. 3 mm Hg procedure to evaluate the repair, Esophageal perforation Rationale: Platelets are administered to clients who have thrombocytopenia. septic shock. degrees, Obtain informed consent reevaluated if there is no improvement within 3 days, or if manifestations are still present after A. Vitamin K prolongs bleeding time. Y-tubing with a filter is used to transfuse blood. Which of the following changes indicates to the nurse that the involves the upper body for 2 weeks B. 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. D. Atelectasis Home and Safety - ATI templates and testing material. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. two most common complications: Infection, Clotting (CAB) (occlusion), priority action: ABC, given antibiotics or anticoagulants to treat problem, if infection spreads to body, remove, Hemodialysis and Peritoneal Dialysis: Assessment of Arteriovenous Fistula, compare Pt's pre- and post-procedure weight as a way to estimate the amount, assess for indications of bleeding, and/or infection at the access site, avoid invasive procedures for 4 to 6 hr. Rationale: Anemia from blood loss is unlikely to cause muscle cramps, although it can cause other painful This abnormal sinus rhythm can occur secondary to hyperthyroidism, some medications, hypertension, hyperpyrexia, extreme stress and anxiety, the presence of pain, some electrolyte imbalances, preexisting heart disease and the intake of illicit substances like cocaine and the excessive intake of nicotine, alcohol and caffeine. The risk factors associated with ventricular fibrillation include non treated ventricular tachycardia, illicit drug overdoses, a myocardial infarction, severe trauma, some electrolyte imbalances, and severe hypothermia. The esophagus is about 25cm long. Mechanical ventilation D. Fluid output is greater than 1000 ml per 24 hours. Which of the following is an expected finding? initiate large bore IV access- 18-20 gauge needle is standard for administering blood blood products prior to confusion, double check blood product and client with another RN prime blood administration with 0.9% sodium chloride stay with client first 15-30 min during infusion; assess vital signs B. Purpura As discussed in the previous section entitled "Evaluating Invasive Monitoring Data", intracranial pressure has an impact on the perfusion of the brain. Which of the following is This is, Tachypnea is more likely than respiratory depression in a client who has anemia due to blood. Which of the following nursing statements indicates an understanding of the condition? after dialysis (risk of bleeding from, Heart Failure and Pulmonary Edema: Contraindication for Receiving Furosemide, Loop diuretics: such as furosemide and bumetanide, Thiazide diuretics: such as hydrochlorothiazide, Potassium-sparing diuretics: such as spironolactone, administer furosemide IV no faster than 20mg/min, loop and thiazide diuretics can cause hypokalemia, and potassium supplementation can be, Client education: teach clients taking loop or thiazide diuretics to ingest foods and drinks, that are high in potassium to counter the effects of hypokalemia, Blood and Blood Product Transfusions: Preparing to Administer a Blood, Remain w/client during the first 15 to 30, Assess laboratory values (e.g., platelet count less than 20,000 and hemoglobin, Obtain blood samples for compatibility determination, such as type and cross-. Educate the client about the manifestations of dehydration, including thirst, decreased urine output, and dizziness, Educate the client about wearing seat belts and helmets, and the, use of caution with dangerous equipment, machinery, or, Advise the client to obtain early medical attention with evidence. treated with the diuretics. Rationale: Decreaseing the amount of stretch in cardiac muscle just before contraction decreases the This is B. Hemodynamic status is assessed with several parameters -Central venous pressure (CVP) -Pulmonary artery pressure (PAP) -Pulmonary artery wedge pressure (PAWP) -Cardiac Output (CO) -Intra-arterial pressure Mixed venous oxygen saturation (SvO2) indicates the balance between oxygen supply and demand. Left bundle branch block is categorized as either a left posterior fascicular block or a left anterior fascicular block; and other categories of bundle branch block include a trifascicular block and a bifascicular block. A reading C. Bradycardia The interpretation of these rhythm strips is done according to the details provided above for many cardiac arrhythmias in the previous section entitled "Identifying Cardiac Rhythm Strip Abnormalities", such as the rate, the P wave, the PR interval and the QRS complexes. Rationale: The client who has end-stage renal failure is likely to have fluid volume excess that is being Increase the IV fluid infusion per protocol. types of shock cardiac ATI practice questions hypovolemic shock CVP Glasgow Coma A CVP below 2 mm Hg indicates reduced right ventricular preload, typically from hypovolemia. The nurse asks a colleage to The nurse will then apply their knowledge of pathophysiology, their critical thinking skills and their professional judgment skills in terms of their interpretation of the rhythm strip, they will perform a simple system specific assessment of the client, and then they will initiate and document the appropriate interventions based on their assessment of the client and their interpretation of the abnormal rhythm strip. The definition of hemodynamics as the flow of blood as ejected from the heart to circulate throughout the body in order to effectively oxygenate the tissues of the body. The North American Nursing Diagnosis Association (NANDA) defines altered and ineffective tissue perfusion as "a decrease in oxygen resulting in a failure to nourish tissues at the capillary level." Monitoring hypoxia - ATI templates and testing material. Supraventricular tachycardia, simply defined is all tachyarrhythmias with a heart rate of more than 150 beats per minute. 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