The nurse performs a rapid assessment on a client who states, "I feel really sick and my heart is beating so fast." What signs and symptoms would indicate to the nurse that the client's cardiac output is inadequate?
Select All That Apply
1. CVP 5 mm Hg.
2. Moist skin.
3. Urinary output 150 mL o...
Cardiac Content Post Test- HURST
The nurse performs a rapid assessment on a client who states, "I feel really sick and my heart is beating so fast." What signs and symptoms would indicate to the nurse that the client's cardiac output is inadequate?
Select All That Apply
1. CVP 5 mm Hg.
2. Moist skin.
3. Urinary output 150 mL over 4 hours.
4. Weak radial pulses.
5. BP 90/50, HR 200, RR 22.
6. Mild chest discomfort. - correct answer 2, 4, 5, 6
Rationale
2, 4, 5, & 6. Correct: When cardiac output is inadequate, the vital organs are not being perfused properly. Skin will be cool and clammy (moist) because the skin is not being perfused. Radial pulses will be weak and thready, because less blood is pumping through the arteries. Less volume means less pressure, so BP is low. The heart rate is too fast, so blood does not have time to get in the ventricles before it is contracting again which decreases cardiac output. Less blood is being pumped to the body. Chest pain means oxygenated blood is not reaching the heart muscle.
1. Incorrect: Normal CVP is 2-6 mmHg, so this is a normal finding.
3. Incorrect: Normal urinary output (UOP) should be at least 30 mL per hour. This client's UOP was 150 mL over 4 hours (50 mL per hour). So no concern here.
The nurse is caring for a client post cardiac catheterization that was performed via the right femoral artery. What assessment finding in the right lower extremity would be of concern to the nurse?
Choose One
1. Right pedal pulse 2+/4+.
2. Capillary refill 2 seconds.
3. Erythema. 4. Slight oozing of blood. - correct answer 4
Rationale
4. Correct: The number 1 complication is bleeding. So slight oozing of blood is a problem. Assume the Worse! This is bleeding and you must do something.
1. Incorrect: 2+/4+ is a normal pulse amplitude. We worry about 1+.
2. Incorrect: This is a normal capillary refill. Remember, we want color to return within 2 seconds.
3. Incorrect: Erythema is redness of the skin or mucous membranes, caused by an increased blood flow in superficial capillaries. We are worried about decreased blood flow which would be evidenced by pallor.
A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac
rhythm displayed on the telemetry monitor. What actions should the nurse take? - correct answer 2, 3
Rationale
2. & 3. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low, indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds.
1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall or the condition could deteriorate while ambulating.
4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs.
5. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100% per nonrebreather mask. Start with the least amount of oxygen that could relieve symptoms.
The nurse has informed a client diagnosed with heart failure about the treatment plan, including prescriptions for an ACE inhibitor and a 2 gm sodium diet. Which statement by the client would indicate to the nurse that the client understands the treatment plan?
Select All That Apply
1. "I plan to elevate the head of my bed on concrete blocks so I can sleep better."
2. Instead of using salt, I should use a salt substitute to season my food."
3. "It is important that I weigh myself weekly to monitor for weight gain."
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