Chapter 6 Circulation Answers PDF

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NURSETHINK® FOR STUDENTS CONCEPTUAL CLINICAL CASES

Chapter 6: Circulation

Case 1: Impaired Coronary Perfusion and Chest Pain

Kandice Sheridan Age 49

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Go To Clinical Case 1 Answers 1. The nurse is beginning the initial assessment. In what priority order should these actions be performed? 1. Vital sign assessment. Measurement of perfusion. Mean arterial pressure (MAP) is the best indicator. A MAP helps measure if there is adequate perfusion to vital organs. Tissue ischemia will begin when the MAP is < 65. 2. PQRST pain assessment. Pain in a cardiac patient indicates ischemia of the heart muscle. Pain can be described in different ways including “achiness.” 3. Assessment of contributing symptoms. Additional symptoms may include nausea/vomiting, radiating pain, diaphoresis, shortness of breath, etc. 4. Health history and medication use. Determine if there is a family history of heart disease. 5. Place in a hospital gown. Last choice since it is not a priority. THIN Thinking: Top Three — Blood pressure/MAP, heart rate, pain assessment. Acute vs. Chronic. NCLEX®: Physiological adaptation. QSEN: Patient-centered Care; Evidence-based Practice. 2. NurseThink® Prioritization Power! Evaluate the information within the E.D. admission note and pick the Top 3 Priority assessment findings. 1. Arm heaviness — indicates myocardial ischemia. 2. Moist skin — indicates myocardial ischemia. 3.Significantfamilyhistoryofheartdisease—increases the risk of heart disease. Clinical Hint: Presenting symptoms that are atypical should not be ignored. Delaying treatment of a cardiac condition could be deadly. Always consider cardiac disease before attributing symptoms to another cause (gastrointestinal, anxiety, etc.). 3. After reviewing the orders, which action should the nurse take first? 1. Request serum lab draw. Cardiac enzymes are important, but not the highest priority. 2. Obtain 12-lead EKG. This can detect acute changes and help to determine if this a cardiac problem. 3. Place IV capped line. Important if there is an emergency and medications need to be given, but not the highest priority. 4. Apply O2 at 2 L/nasal cannula. Because symptoms are atypical, the 12-lead will help to determine if this is a cardiac problem. Sats are >95%, O2 not indicated.

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4. In preparation for the IV insertion, the nurse should place a gauge capped IV line. Answer: 20-gauge. There is no indication at this time that the client will require rapid fluid administration or blood products which would require an 18 gauge IV. If the client has especially small veins, a 22 gauge would also be appropriate. 5. Which observation(s) should the nurse make in the review of the 12-lead EKG? Select all that apply. 1. The client has tachycardia. The heart rate is around 75 beats per minute. 2. There is ST segment elevation in V leads. ST elevation in the V leads indicates coronary ischemia. 3. The client has PVCs. There are no PVCs present. 4. There is artifact on the tracing. There is no artifact present. 5. The tracing is normal. It is not normal because of the ST segment elevation. THIN Thinking: Nursing Process — Assessment and analysis of the rhythm is the priority. Actual versus Potential. NCLEX®: Reduction of Risk Potential. QSEN: Safety. 6. After reviewing the EKG, what should be the nurse’s next action? 1. Apply continuous EKG monitor. This is necessary but not the priority. This will not improve the situation. 2. Check to see if the serum lab report is back. This can be done later. The 12-lead shows there is a cardiac problem that needs action. 3. Notify the healthcare provider. Important, but the nurse can initiate some priority interventions, then contact the provider. 4. Apply the ordered oxygen. This will help decrease the ischemia. THIN Thinking: Help Quick — O2 application will decrease the ischemia to the coronary muscle. STEMI protocol should be considered. ABCs. NCLEX®: Reduction of Risk Potential. QSEN: Safety.

THIN Thinking: Top Three — 12-lead EKG, begin IV, draw labs. Acute vs. Chronic. NCLEX®: Physiological adaptation. QSEN: Patient-centered Care.

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Go To Clinical Case 1 Answers

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7. NurseThink® Prioritization Power! Evaluate the information on the lab report and pick the Top 3 Priority lab findings. 1. Elevated Troponin I & T — Elevated CPK — indicates myocardial damage that occurred 4 to 12 hours ago. The myoglobin is negative which means the onset has not been within the last 4 hours. 2. Hypokalemia — low potassium can lead to cardiac dysrhythmias. 3. Anemia — low RBCs can decrease the body’s ability to carry oxygen to the cells, which is essential when the heart muscle is experiencing ischemia. Clinical Hint: Although the cholesterol and triglyceride elevations are concerning, these labs indicate the risk of developing atherosclerosis and should be addressed as a concern for health maintenance and health promotion.

8. THIN Thinking Time! Reflect on the events that have occurred since Kandice Sheridan came to the emergency department and apply THIN Thinking. T – In analyzing the 12-lead EKG and serum blood reports, it appears that the client has coronary ischemia. The top 3 priorities include oxygen application at 2 L/NC and requesting the delivery of morphine, nitroglycerin, and aspirin. The nurse will need a physician’s order to deliver these if there is not a standing facility protocol. There is already an O2 order in the EHR. H–Oxygenapplicationisthefirstaction. I – Safety concerns include the potential for cardiac dysrhythmias due to the ischemia and low potassium level. Continuous EKG monitoring is important for consideration with potassium replacement. N – There is enough assessment information of the situation to proceed to the implementation phase of the nursing process. Continual evaluation of the interventions needs to take place. 9. The nurse gathers the lab report and begins to prepare an SBAR conversation for the HCP. Complete each section of the communication form. S – Hi Dr. Dixon, this is Nurse Margery contacting you about the EKG and lab changes that Ms. Sheridan has. B – She came to the ED this morning with atypical elbow “achiness” that has been increasing over the last few days. She has a strong family history of cardiac disease. Her father had an AMI at the age of 56 years. A - She is diaphoretic, with a blood pressure of 145/88 mmHg. Her other VS are normal. Her 12-lead EKG has ST elevation in the anterior leads and both the Troponin T and I are elevated, along with the CPK. Her potassium is 3.3 mEq/dL and I’ve placed her on 2L/NC. Her oxygen saturation is at 97%. R – I feel she should be started on STEMI protocol with consideration of taking her for a coronary angiogram. Could we also get some potassium for replacement started? NurseThink.com

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Clinical Hint: ST-Elevation Myocardial Infarction (STEMI) protocol might include: Aspirin, morphine, oxygen, nitroglycerin (SL or IV), anticoagulation, cardiac angiography, and/or thrombolytic therapy.

10. The nurse obtains several STAT verbal prescriptions from the HCP for a client experiencing an acute myocardial infarction. In what order should the nurse complete these actions? 1. Read back the verbal orders. To confirm that the orders were received correctly, the nurse must read them back to the HCP before taking action. 2. Obtain blood pressure and heart rate. This assessment is needed before the delivery of nitroglycerin or morphine. 3. Nitroglycerin (NTG) 0.4 mg SL x 3 PRN for pain. Vasodilates the vessels, will lower blood pressure. 4. Morphine 2-4 mg IV PRN for pain unrelieved by NTG. Ordered to come after the nitroglycerin. 5. Consult Dr. Nemus, Cardiologist. Treat the client first, then consult. THIN Thinking: Identify Risk to Safety — Verbal order read back prevents medication errors. Safe Practice. NCLEX®: Safety and Infection Control. QSEN: Patient-centered Care. 11. After administering 4 mg of morphine sulfate IV for chest pain, the nurse discovers that the consent for an emergent coronary angiogram was not signed. The assessment shows that the client is alert, oriented and pain-free. What should the nurse do next? 1. Obtain a signature before the morphine peaks in the bloodstream. Not an option. The consent cannot be signed after the medication has been administered. 2. Notify the cardiologist and cancel the procedure. The nurse should notify the cardiologist and team if there will be a delay but does not have the authority to cancel the procedure. 3. Determine if a power of attorney is available. The client cannot legally sign, the power of attorney is the best option. 4. Ask the client’s teenage son, who is at the bedside, to sign the consent. This is not legal. THIN Thinking: Top Three — The nurse must consider whether the client is of sound mind and understands what is being signed. Safe Practice. NCLEX®: Management of Care. QSEN: Safety. 12. The nurse teaches the client about expectations of the emergent coronary angiogram and reviews what the cardiologist told her about the possibility of open-heart surgery if the stent placement is unsuccessful. The client begins to cry saying that her father died after open-heart surgery. How should the nurse respond? 1.

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“I’m sure you are frightened, this is a scary thing to go through.” Therapeutic, demonstrates empathy.

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Go To Clinical Case 1 Answers 2. “Do you want me to get the cardiologist back in here to answer your questions?” Client did not demonstrate a lack of knowledge. 3. “It’s okay, your cardiologist is excellent; he’s one of the best.” Reassurance is comforting but does not allow expression of fear. 4. “Would you like it if I called the chaplain?” Spiritual comfort is not indicated. THIN Thinking: Top Three — Response should be empathetic, open ended, and encourage a continuation of the emotions being expressed. Maslow. NCLEX®: Psychosocial Integrity. QSEN: Patient-centered Care. 13. The client returns from a cardiac catheterization procedure with a right groin sheath in place. What should the nurse include in the priority assessment of this client? Select all that apply. 1.

Blood pressure. Indicates problems with perfusion or bleeding. 2. Temperature. Not a priority. 3. Right groin assessment. Monitor for hemorrhage. 4. Lung sounds. Not a priority. 5. Cardiac monitor. Detects cardiac irritability.

THIN Thinking: Top Three — Blood pressure, groin assessment, cardiac monitor and ABCs. NCLEX®: Physiological Integrity. QSEN: Patient-centered Care. 14. A client has 25,000 units of heparin in 500 mL NS infusing at 1,000 unit per hour via a 20 gauge IV in the left hand. At what rate should the pump be set? 1. 10 mL/hr. 2. 20 mL/hr. mL = 500 mL x 1,000 units = 500,000 = 20 mL/hr hr 25,000 units hr 25,000 3. 25 mL/hr. 4. 50 mL/hr. 15. The nurse obtains the first three sets of vital signs. What should the nurse do next?

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16. While administering the ordered medications, Kandice asks why each of these medications are needed. Describe how the nurse should instruct her for each of these medications. 1. Clopidogrel 75 mg, daily. An antiplatelet medication for prevention of clot formation. There may be increased bruising and monitor for dark stools. 2. Aspirin 81 mg, daily. Used for its antiplatelet effect. May be increased bruising and monitor for dark stools. 3. Metoprolol 50 mg twice a day. Protects the heart and decreases the workload. Slows the heart rate, monitor rate. 4. Atorvastatin 80 mg once a day. Lowers cholesterol to prevent the plaque buildup. Monitor liver enzymes. THIN Thinking: Identify Risk to Safety — Medication teaching needs to be focused on safety. Safe Practice. NCLEX®: Pharmacological and Parenteral Therapies. QSEN: Safety. 17. Kandice asks what she can do to help decrease the risk for having another heart attack in the future. What should the nurse instruct? Select all that apply. 1.

Eat a diet low in cholesterol and saturated fats. Helps to keep cholesterol levels lower. 2. Minimize carbohydrate intake. A diet low in carbohydrates can control glucose levels which lead to heart disease. 3. Walk 30 minutes 5 days a week. Exercise that is consistent strengthens the heart and keeps body weight within control. 4. Increase dietary intake of fruit. Fruit increase is not indicated for a cardiac diet. 5. Monitor your serum lipid levels. Regular review of serum lipid levels will help in controlling the risk of further heart disease. THIN Thinking: Identify Risk to Safety — Teaching needs to be focused on evidence-based goals. Safe Practice. NCLEX®: Reduction of Risk Potential. QSEN: Patientcentered Care.

1. Have the UAP complete the remaining sets of vital signs. The vital signs demonstrate a change in status, so it’s an inappropriate delegation. 2. Assess for bleeding at the sheath site. Vital signs indicate bleeding may be a concern, assessment of site is the priority. 3. Re-evaluate the vital signs in 15 minutes. Delaying additional assessment is dangerous. 4. Notify the health care provider of the client’s status. Further assessment is needed before notification. THIN Thinking: Nursing Process — The change of vital signs indicates there may be a bigger problem; additional assessment is needed. Acute vs. Chronic. NCLEX®: Physiological Integrity. QSEN: Patient-centered Care.

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Go To Clinical Case 1 Answers 18. As the nurse enters Kandice’s room on the morning of discharge, she finds her crying. When asked what is wrong, she states, “I’m so afraid I’ll pass my bad genes to my children, and they’ll have heart disease also.” How should the nurse respond?

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20. Kandice returns to the office two weeks later acting withdrawn and sad. The nurse asks how things are going and she states, “It’s such an adjustment, I don’t know if I can do it.” What suggestions should the nurse make to the client?

1. “I don’t think that will be an issue since your spouse has a good heart.” Heart disease is familial, and her children are at risk. 2. “I’m sure you are afraid for them, maybe they’ll be luckier than you.” Not reassuring and ends conversation. 3. “They can make some lifestyle changes now, so their chances of heart disease are less.” Heart disease risk is lessened with lifestyle changes. 4. “With proper medication, they will have less chances of heart disease.” Lifestyle changes are important for prevention.

1. Request an antidepressant from the cardiologist. The feelings verbalized are to be expected. Antidepressants are not indicated. 2. Participate in a cardiac support group. Talking with others in a similar situation can provide a feeling of empowerment. 3. Encourage her spouse to be more supportive. This might be helpful, but the spouse may not be able to relate to what she is going through. 4. Suggest she takes more time off of work. Time away will not improve her ability to cope.

THIN Thinking: Identify Risk to Safety — Teaching needs to be focused on evidence-based goals. Acute vs. Chronic. NCLEX®: Reduction of Risk Potential. QSEN: Patientcentered Care.

THIN Thinking: Identify Risk to Safety — Teaching needs to be focused on evidence-based goals. Maslow. NCLEX®: Psychosocial Integrity. QSEN: Patient-centered Care.

19. NurseThink® Prioritization Power! Evaluate the care of this client and pick the Top 3 Priority discharge needs. Possible answers include: • Discharge medication instructions

Next Gen Clinical Judgment: Visit the American Heart Association’s website at www.heart.org. Find 3 health topics that wouldbebeneficialforKandice.Record them here and teach them to a classmate.

• Risk factors for heart disease • S/S of heart attack • Dietary changes • Exercise planning (include when and how to start) • Groin site care • Reasons to notify the HCP • When to follow-up with the HCP • Stress reduction • Possible weight loss • When to return to work and other activity Clinical Hint: The discharge instructions cannot contain all of this information. The nurse should prioritize based on Risk to Safety and include material and resources that can be utilized after discharge. Assessing willingness to learn, minimization of distractions, and other teaching methods should be considered for success.

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Answer Guide

NURSETHINK® FOR STUDENTS CONCEPTUAL CLINICAL CASES

Chapter 6: Circulation

Case 2: Decreased Perfusion from Hypertension and Heart Failure

William Jones Age 69

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Go To Clinical Case 2 Answers 1.

The nurse performs an environmental assessment. Why would each observation listed be a potential concern and area for further assessment by the nurse? List the action that the nurse should take. Large build. A large build can lead to further health concerns. The nurse should assess height, weight and calculate the BMI. Walks with a limp. This indicates an increased risk for fall. Further assessment of the leg/foot to determine if there is an injury? The use or need of assistive devices should be evaluated. Mildly short of breath. Shortness of breath may indicate worsening of his pulmonary status. Assessment of the respiratory rate at rest, oxygen saturation reading, and breath sounds are important. Small dog. A small pet sets him at risk for fall, especially given his unstable gait. The pet dander could be an allergy. Smell of food. Smelling of food can lead the nurse to assess his dietary intake and the types of foods he prepares. Inquiry about his dietary restrictions would be appropriate.

2. NurseThink® Prioritization Power! Evaluate the information within the admission note and pick the Top 3 Priority assessment concerns. 1. Tachypnea, S3, crackles, low oxygen saturation. 2. High blood pressure. 3. Glucose — higher than it should be, medication is needed. High BMI. Clinical Hint: Prioritize with most concerning physiologicalneedsfirstthatwillcausethegreatest damage most rapidly. Identify ABCs and Acute versus Chronic as the Prioritizing Process. 3. After further inquiry, it is discovered that no morning medications have been taken. Which medications should the nurse suggest Mr. Jones take now? Select all that apply. 1.

Lisinopril An ACE inhibitor that will help to lower the blood pressure. 2. Atenolol A beta blocker that will help to lower blood pressure. 3. Metformin Biguanides that will lower the blood glucose of 178 mg/dL. 4. Tamsulosin Alpha-1 blocker for enlarged prostate gland. Not a priority at this time. 5. Celecoxib Non-steroidal anti-inflammatory that will help with knee pain. THIN Thinking: Identify Risk to Safety — The client is at risk of injury and complications since he is hypertensive, hyperglycemic, and in pain. Safe Practice. NCLEX®: Pharmacological and Parenteral Therapies. QSEN: Safety.

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1. Askhimtofindanewhomeforhisdog.This is not appropriate to ask. Although the dog is a risk for injury as a tripping hazard, it is also a close companion. 2. Request a physical therapy referral. This could provide strengthening and stability. 3....