Chapter 38. Circulation and Perfusion My Nursing Test Banks

Chapter 38. Circulation and Perfusion

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient?

1)

BP will be lower than 135/85 mm Hg on all occasions.

2)

BP will be normal after 2 to 3 weeks on medication.

3)

Patient will not experience dizziness on rising.

4)

Urine output will increase to at least 50 mL/hr

ANS: 1

Goals must be clearly stated so that it is easy to evaluate if they have been met. BP . . . lower than 135/85 mm Hg . . . is clearly stated and easily evaluated. In contrast, BP will be normal . . . does not clearly state the desired endpoint. Freedom from dizziness on rising is probably not achievable because ACE inhibitors are vasodilating agents, which may cause vessel dilation and hypotension, especially when the patient arises from a seated or lying position. Patients should be warned of this effect. The expected/desired effect of the ACE inhibitor is to lower the blood pressure; the urine output is minimally relevant in determining that outcome, if at all.

PTS: 1 DIF: Difficult REF: pp. 1372-1373

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

____ 2. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate?

1)

Decreased Cardiac Output

2)

Impaired Tissue Perfusion

3)

Impaired Cardiac Contractility

4)

Impaired Activity Tolerance

ANS: 1

The patients symptoms reflect altered cardiac preload, a component of cardiac output. Acute myocardial infarction is often associated with decreased cardiac output as a result of altered cardiac pumping ability. Although the other nursing diagnoses might be associated with Decreased Cardiac Output, these diagnoses cannot be determined from the symptoms presented. Additionally, Impaired Cardiac Contractility is not a NANDA-I nursing diagnosis.

PTS: 1 DIF: Difficult REF: p. 1372

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

____ 3. You are to connect a patient to a cardiac monitor. Which of the following actions should you take to ensure an accurate electrocardiogram tracing?

1)

Select electrode placement sites over bony prominences.

2)

Apply the electrodes immediately after cleansing the skin, before the alcohol evaporates.

3)

Before applying the electrodes, rub the placement sites with gauze until the skin reddens.

4)

Ensure that the gel on the back of the electrodes is dry.

ANS: 3

Electrodes should be placed over soft tissues or close to bone in order to obtain accurate waveforms. Sites over bony prominences, thick muscles, and skinfolds can produce artifact; therefore, they should not be used. Alcohol removes skin oils that may prevent the electrodes from adhering. However, the alcohol should be allowed to dry before the electrodes are placed. Rubbing the skin with gauze or a washcloth removes dead skin cells and promotes better electrical contact. A dry electrode will not conduct electrical activity; gel should not be dry.

PTS: 1 DIF: Moderate REF: p. 1377

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

____ 4. Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

1)

Histamine

2)

Catecholamines

3)

Cortisol

4)

Protease

ANS: 2

The stress response stimulates release of catecholamines from the sympathetic nervous system. This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot. Cortisol is also released in the stress response, but it is more indirectly related to development of cardiovascular disease through altered glucose, fat, and protein metabolism.

PTS: 1 DIF: Moderate REF: p. 1365

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

____ 5. The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement:

1)

I may need to drink more fluids in order to make more oxygen.

2)

I may need to take an iron supplement so that I am not anemic.

3)

I will need a multivitamin supplement for several months.

4)

I will need to eat more fruits and vegetables.

ANS: 2

During pregnancy, oxygen demand increases dramatically. To compensate, the mothers blood volume increases by 30%. The woman requires additional iron to produce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother.

PTS: 1 DIF: Moderate REF: p. 1365-1366

KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application

____ 6.  Which part of the ECG tracing represents ventricular repolarization?

1)

P wave

2)

QRS complex

3)

T wave

4)

U wave

ANS: 2

The QRS complex represents ventricular depolarization and leads to ventricular contraction. The P wave represents the firing of the SA node and conduction of the impulse through the atria. In the healthy heart, this leads to atrial contraction. The T wave represents the return of the ventricles to an electrical resting state so they can be stimulated again (ventricular repolarization). The atria also repolarize, but they do so during the time of ventricular depolarization; thus, they are obscured by the QRS complex and cannot be seen on the ECG complex. The U wave is not always seen on the ECG but may be detected with electrolyte imbalance, such as hypokalemia or hypercalcemia. U waves sometimes occur in response to certain medication (e.g., digitalis, epinephrine). Inverted U wave may occur with ischemia to the cardiac muscle.

  1. 1)

PTS: 1 DIF: Moderate REF: pp. 1371-1372

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

____ 7. Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication?

1)

Deep vein thrombosis

2)

Dehiscence of the wound

3)

Internal bleeding

4)

Infection at the incisional site

ANS: 1

Deep vein thrombosis (DVT) is a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratts sign (squeezing calf to trigger pain) have not been found to be reliable in diagnosing DVT. Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia. Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature).

PTS: 1 DIF: Moderate REF: pp. 1367-1368

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. Nursing interventions to reduce the risk of clot formation in the legs include which of the following activities? Choose all that apply.

1)

Keep the patients hips and knees flexed while the patient is in bed.

2)

Apply compression devices (e.g., sequential compression devices).

3)

Turn the patient frequently or encourage frequent position changes.

4)

Promote adequate hydration by encouraging oral intake.

ANS: 2, 3, 4

A

Antiembolism stockings and SCDs are frequently used in perioperative patients to promote venous return and prevent clot formation. Turn patients frequently; teach patients to change positions frequently. This prevents vessel injury from prolonged pressure in one position. Promote adequate hydration to keep the blood from becoming viscous (thick). Viscous blood clots more readily.

PTS: 1 DIF: Difficult REF: p. 1373

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

____ 2. Which of the following medications would you expect to be included in the treatment of a patient with congestive heart failure? Choose all that apply.

1)

Nitrates

2)

Beta-adrenergic agents

3)

Diuretics

4)

Anticoagulants

ANS: 2, 3

Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood vessels and decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility. Diuretics increase removal of sodium and water from the body through increased urine output. Diuretics reduce the volume of circulating blood and prevent accumulation of fluid in the pulmonary circulation.

PTS: 1 DIF: Moderate REF: pp. 1373-1374

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

____ 3. As the nurse caring for a patient who has suffered a myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Choose all that apply.

1)

Decreased heart rate

2)

Increased heart rate

3)

Decreased cardiac output

4)

Decreased strength of ventricular contractions

ANS: 1, 3

Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to 100 beats per minute. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. Cardiac output will decrease as a result of the decrease in heart rate. Damage to the SA node interferes with the electrical activity of the heart but does not directly affect the pumping action of the heart.

PTS: 1 DIF: Difficult REF: pp. 1362-1363

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

____ 4.  Which outcome statement is related to Decreased Cardiac Output? Choose all that apply.

1)

No dyspnea or shortness of breath with exertion

2)

Normal skin color

3)

Respiratory rate less than 16 breaths/min

4)

Brisk capillary refill

ANS: 1, 2, 4

Individualized goals/outcome statements depend on nursing diagnoses you identify for the patient. However, for a patient with compromised cardiac output, you might plan goals, such as no shortness of breath with exertion, brisk capillary refill in nailbeds, and normal skin color with no pallor. Respiratory rate of less than 16 breaths/min is hypoventilation and can lead to poor oxygenation and tissue acidosis. (See Chapter 39 for more information about acidbase balance.)

PTS: 1 DIF: Moderate REF: p. 1367

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

____ 5.  Your client is a healthy, older adult who has come to the health clinic because she reports not feeling like herself. When you are gathering data in your clients health history, she tells you that she is feeling more fatigue when walking up stairs and doing her normal household activities. What  normal physiologic changes in the cardiovascular system occur with aging?  Choose all that apply.

1)

Cardiac contractile strength is reduced.

2)

Heart valves become more rigid.

3)

Peripheral vessels lose elasticity.

4)

Heart responds to increased oxygen demands.

ANS: 1, 2, 3

Cardiac efficiency gradually declines as the heart muscle loses contractile strength and heart valves become thicker and more rigid. The peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. As a result of these changes, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding.

PTS: 1 DIF: Moderate REF: p. 1365

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

True or False

Complete each statement.

1.Nicotine increases the risk for thrombus (blood clot) formation.

ANS: T

Nicotine increases the risk for thrombus formation because of its constricting effects on blood vessel walls.

PTS: 1 DIF: Easy REF: p. 1373

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

2.A troponin level is a laboratory test performed to determine how well the cells, tissues, and organs are supplied with oxygen.

ANS: F

Troponin is a serum evaluation used to detect myocardial infarction (MI). Levels of these contractile proteins remain elevated for up to 7 days after MI. Organ function indirectly evaluates the extent to which oxygen demands have been met in the cells, organs, and tissues.

PTS: 1 DIF: Difficult REF: p. 1370

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

3. Heat causes vasodilation, which decreases cardiac output and oxygenation.

ANS: F

Heat causes vasodilation, which increases cardiac output and oxygenation.

PTS: 1 DIF: Easy REF: p. 1365

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

Leave a Reply