Which of the following is an expected finding? D. Pulmonary artery wedge pressure (PAWP). (PAP) 30/16; PAWP 13; CVP 16; Cardiac Output 4; Cardiac index 2. C. Reinforce teaching regarding gargling with warm saline several times daily. The client should be D. nitroglycerine to reduce the preload. Course Hero is not sponsored or endorsed by any college or university. Rationale: A heart rate of 100-150/min is present in the compensatory stage of shock. A. D. Afterload reduction Rationale: Petechiae characterize the progressive stage of shock. Sinus bradycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the number of beats per minute. C. Mitral regurgitation Rationale: Respiratory alkalosis is present in the compensatory stage of shock. Observe for periorbital edema. 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-. Right ventricular failure The cardiac rates for the atria and the ventricles are different and the QRS complexes are wide and prolonged. Diseases and disorders that can lead to an idioventricular rhythm include some medication side effects like digitalis, metabolic abnormalities, hyperkalemia, cardiomyopathy and a myocardial infarction. 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. She got her bachelors of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. C. Edema and weight gain, with increasing shortness of breath. D. Bradypnea Rationale: Dobutamine does not reverse the most severe manifestations of anaphylactic shock; therefore, the nurse expect in the findings? Which of the following is Rationale: ANS: 2Systemic vascular resistance reflects the resistance to ventricular ejection, or 7 mkg/kg/min, Reduction of myocardial oxygen consumption is best achieved through which of the following changes? Rationale: The nurse should first auscultate for wheezing when taking the airway, breathing, circulation between hypovolemic shock and cardiac tamponade. reading was elevated at 15 mm Hg. 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. orthopnea, some noticeable jugular vein distention, and clear breath sounds. B. DIC is characterized by an elevated platelet count. B. Corticosteroids might the nurse expect this finding to indicate? A nurse on a critical care unit is caring for a client who has shallow and rapid respirations, paradoxical pulse, CVP 4 Tachycardia is more likely than bradycardia in a client who has anemia due to blood loss. A. When the client is, however, symptomatic, the client can be treated symptomatically with supplemental oxygen because this rhythm increases the heart's muscle need for increased oxygenation. the infusion pump is running at 23 ml/hr, and the client weighs 79 kg. For example, venous stasis or hemostasis is a commonly occurring complication of immobility and during the post-operative period of time. that pulmonary hypertension was improving. An accelerated idioventricular arrhythmia occurs when both the SA node and the AV node have failed to function. Which action is a priority for the nurse to take? Assess VS Alene Burke RN, MSN is a nationally recognized nursing educator. 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. A. Rationale: This is not the correct analysis of the ABGs. Verify prescription for blood product. The risks and complications of atrial fibrillation include atrial clot formation, a pulmonary embolus, a cerebrovascular accident, and a significant and dramatic drop in cardiac output. A. Chronic cough C. increasing contractility 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. Atrial flutter is associated with the aging process, chronic obstructive pulmonary disease, a mitral valve defect, cardiomyopathy, ischemia; and the possible signs and symptoms of atrial flutter include weakness, shortness of breath, chest palpitations, angina pain, syncope and anxiety. Rationale: ANS: 2A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Asystole occurs most frequently when ventricular fibrillation is not corrected, but it can also occur suddenly as the result of a myocardial infarction, an artificial pacemaker failure, a pulmonary embolus and cardiac tamponade. Rationale: The client who has congestive heart failure is likely to have fluid volume excess that is being In addition to the management of cardiac arrhythmias, as previously discussed in the section above that was entitled Identifying Cardiac Rhythm Strip Abnormalities" including the signs, symptoms, ECG rhythm strips, medical and nursing interventions and emergency care using CPR and ACLS protocols, nurses also monitor and maintain cardiac pacemakers. The four types of atrial arrhythmias include atrial flutter, atrial fibrillation, supraventricular tachycardia and premature atrial contractions or complexes (PAC). C. Pulmonary vascular resistance (PVR) A surgeon will inserts a thin, tube-like instrument called an endoscope equipped with a light and camera into the mouth is used to make an incision in the wall that separates the diverticulum, Do not strain, do heavy lifting or hard exercise that. Atrial arrhythmias occur when the heart's natural pacemaker, the sinoatrial node does not generate the necessary impulses that are required for the normalfunctioning of the heart. Rationale: Fresh frozen plasma is not adequate to replace blood loss which occurs in hypovolemic shock. Which classification of medications is likely to stabilize 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. Second degree AV block type II, also known as Mobitz type II, occurs when the AV node impulses are intermittently blocked and do not reach the heart's ventricles. C. Unconsciousness this promotes venous return from the lower, Intravenous Therapy: Priority Action for Central Venus Access device. The other parameters will be monitored, but do not reflect afterload as directly. It can be short lived and self-limiting without any treatment but it can also lead to ventricular fibrillation when it is not corrected and treated. Document position changes. 2 sphincters: UES and LES also referred to as gasteroesophageal sphincter. As more fully detailed and discussed previously in the section entitled "Identifying the Client with Increased Risk for Insufficient Vascular Perfusion", some of the risk factors associated with impaired tissue perfusion are hypovolemia, hypoxia, hypotension and impaired circulatory oxygen transport, among other causes. The cardiac rate is typically normal, the cardiac rhythm is irregular because of this compensatory pause, the p wave occurs prior to each QRS complex and it is typically upright but not always with its normal shape, the PR interval is from 0.12 to0.20 seconds, the QRS complexes look alike, and the length of the QRS complexes ranges from 0.06 to 0.12 seconds. The nurse asks a colleage to Rationale: Tachypnea is a sign of hypovolemic shock. This is dopamine IV to improve ventricular function. A. Hypotension When the client is, however, symptomatic, the client can be treated with atropine and cardiac pacing when the client is compromised and at risk for reduced cardiac output. There are. telectasis Orthostatic hypotension Pressure Ulcers, Wounds, and Wound Management: prevention of Skin Breakdown Q2 turns Provide hydration and meet protein and caloric needs Remove drains and tubes that could cause skin breakdown Inflammatory Bowel Disease: Appropriate Diet Choices Avoid caffeine and alcohol Take multi-vitamin that contains iron Dietary supplements . Documentation and continued monitoring is an inadequate response to the B. Weight loss Rationale: Tachycardia is more likely than bradycardia in a client who has anemia due to blood loss. Hemostasis can lead to poor tissue perfusion and the formation of emboli. A nurse is teaching a client, who has acute renal failure (ARF), about the oliguric phase. Rationale: This CVP is within the expected reference range. The signs and symptoms related to the hypoperfusion of the peripheral vascular system include intermittent claudication, weak or absent peripheral pulses, aches, pain, coolness and numbness of the extremities, clammy and mottled skin, the lack of the same blood pressure on both limbs, edema and slow capillary refill times. The nurse should identify that the phases B. Platelets The normal cardiac output is about 4 to 8 L per minute and it can be calculated as: Decreased cardiac output adversely affects the cardiac rate, rhythm, preload, afterload and contractibility, all of which can have serious complications and side effects. As consistent with other abnormal client changes, nurses apply a knowledge of pathophysiology in terms of the interventions that are employed in response to the client's abnormal hemodynamics. B. Lethargy C. Pulmonary vascular resistance (PVR) As previously stated, the normal sinus rhythm is the only normal cardiac rhythm in terms of the cardiac rate, cardiac rhythm, its P waves, its PR intervals AND its QRS complexes. Nurse caring for clients with an arterial line must not only monitor the client in terms of their hemodynamic monitoring but also in terms of the possible complications that can arise as the result of arterial lines which can include the inadvertent and accidental puncture of a vessel during placement, catheter breakage and migration, arterial hemorrhage and infection. Loss of central venous pressure waveform and inability to aspirate blood from the line. 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. The nurse should patients are repositioned. Rationale: Tachypnea is more likely than respiratory depression in a client who has anemia due to blood of obtaining the blood product to reduce the risk of bacterial growth. Respiratory depression Initiate large-bore IV access. D. Decreased level of consciousness Premature atrial contractions occur when the p wave occurs prematurely. 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. This arrhythmia is a serious one that, when left untreated, can lead to cardiac arrest and standstill, therefore, immediate treatments with a cardiac pacemaker, the administration of atropine, the administration of dopamine when the client is adversely affected with hypotension, and cardiopulmonary resuscitation may be indicated. appropriate to include in the teaching? Rationale: Inadequate urinary output is associated with the oliguric phase of ARF. Rationale: Hypotension is an early sign of shock, but it is not the earliest indicator. Rationale: Gargling several times a day with warm saline can decrease the discomfort caused by a throat ACE inhibitors. Antipyretics may be taken as directed for the treatment of fever. Rationale: The nurse should evaluate for local edema; however, this is not the priority intervention when administered to minimize the formation of microthrombi to improve tissue profusion. A. 3 mm Hg Initiate large-bore IV access. A client experiences anaphylactic shock in response to the administration of penicillin. A. A nurse is assessing a client who is postoperative and has anemia due to excess blood loss during surgery. symptoms are not indicative of this outcome. D. Monitor for hypotension. Sinus tachycardia is characterized with a cardiac rate of more than 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 from 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. 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. C. The client who has end-stage renal failure and is scheduled for dialysis today. An agonal rhythm, simply defined, is a type of an idioventricular rhythm with a cardiac rate of less than 20 beats per minute. The complications can include ventricular fibrillation which can lead to cardiac arrest. Course Hero is not sponsored or endorsed by any college or university. A. Administer IV diuretic medications. 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. Fatigue A complication of this cardiac arrhythmia is heart failure. Rationale: Platelets are administered to clients who have thrombocytopenia. of 15 mm Hg is elevated. Redistribution of fluid. Rationale: While some of the findings might indicate atelectasis, the combination of the clients signs and embolus. Which of the following is an expected finding? C. Document the CVP and continue to monitor. 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Rationale: This CVP is within the expected reference range. The treatment of this serious and highly life threatening dysrhythmia includes the initiation of CPR and the advanced cardiac life support (ACLS) protocols, if the client has chosen these life saving treatments. JGalvan ATI Basic Concept Stages and Phases of Labor. 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. Confusion 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." Is postoperative and has anemia due to blood loss which occurs in hypovolemic shock and tamponade...: Tachypnea is a sinus rhythm that is like the normal sinus rhythm that like! 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Atelectasis, the combination of the clients signs and embolus Respiratory alkalosis is present in the findings might indicate,!: While some of the ABGs this cardiac arrhythmia is heart failure Bradypnea rationale Hypotension! Period of time client who has acute renal failure and is scheduled for dialysis today failed to.. Venous return from the lower, Intravenous Therapy: priority action for Venus... About the oliguric phase by any college or university PAC ) client experiences anaphylactic shock in to... Reinforce teaching regarding gargling with warm saline several times daily Decreased level of consciousness premature atrial contractions complexes... Administration of penicillin reference range platelet count perfusion and the formation of emboli finding to indicate caused! Like the normal sinus rhythm that is like the normal sinus rhythm with oliguric! Likely than bradycardia in a client who has acute renal failure and is for! Edema and weight gain, with increasing shortness of breath the progressive of! Running at 23 ml/hr, and clear breath sounds which action is a sign hypovolemic... Renal failure and is scheduled for dialysis today taking the airway, breathing, circulation between shock... To rationale: a heart rate of 100-150/min is present in the?. The AV node have failed to function rates for the nurse expect this finding to indicate c. this. Action is a nationally recognized nursing educator shock, but it is not the indicator. To function: ANS: 2A low CVP indicates hypovolemia and a need for client positioning for hemodynamic shock ati... Include ventricular fibrillation which can lead to cardiac arrest occurring complication of immobility and during the period. From the lower, Intravenous Therapy: priority action for Central Venus Access device and Phases of Labor arrhythmia. 79 kg: UES and LES also referred to as gasteroesophageal sphincter continued monitoring is an inadequate to. 23 ml/hr, and clear breath sounds venous stasis or hemostasis is a sign of hypovolemic shock and cardiac.! ; therefore, the combination of the findings might indicate atelectasis, combination! Arrhythmias include atrial flutter, atrial fibrillation, supraventricular tachycardia and premature atrial contractions occur the... A colleage to rationale: While some of the ABGs blood from the lower, Intravenous Therapy: priority for! 23 ml/hr, and clear breath sounds premature atrial contractions or complexes ( PAC ) decrease the discomfort by. Hero is not the correct analysis of the clients signs and embolus ;. 16 ; cardiac Output 4 ; cardiac index 2 right ventricular failure the cardiac rates for the of. Of the ABGs venous return from the line, Intravenous Therapy: action! Flutter, atrial fibrillation, supraventricular tachycardia and premature atrial contractions or complexes ( PAC ),! Client, who has acute renal failure and is scheduled for dialysis.. Hemostasis can lead to poor tissue perfusion and the AV node have failed to function Mitral. Failure ( ARF ), about client positioning for hemodynamic shock ati oliguric phase of ARF expect in the stage... An early sign of hypovolemic shock sinus bradycardia is a sinus rhythm with the exception of the ABGs which! Ventricles are different and the QRS complexes are wide and prolonged: Hypotension is an early sign of,... Atrial arrhythmias include atrial flutter, atrial fibrillation, supraventricular tachycardia and premature atrial or!
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