Perfusion Questions (Ati and Saunders)
A client with atrial fibrillation is receiving a continuous heparin infusion at 1000
units/hr. The nurse would determine that the client is receiving the therapeutic
effect based on which of the following results?
1. Prothrombin time of 12.5 seconds
2. Activated partial thromboplastin time of 60 seconds
3. Activated partial thromboplastin time of 28 seconds
4. Activated partial thromboplastin time longer than 120 seconds - correct
answer-2. Activated partial thromboplastin time of 60 seconds
Common laboratory ranges for activated partial thromboplastin time (aPTT)
are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the
normal value, the client's aPTT would be considered therapeutic if it was 60
seconds. Prothrombin time assesses the response to warfarin therapy.
The nurse provides discharge instructions to a client who is taking warfarin
sodium,. Which statement, by the client, reflects the *need for further
teaching*?
1. "I will avoid alcohol consumption"
2. "I will take my pills every day at the same time"
3. "I have already called my family to pick up a MedicAlert bracelet."
4. I will take coated aspirin for my headaches because it will coat my
stomach." - correct answer-4. I will take coated aspirin for my headaches
because it will coat my stomach."
Aspirin-containing products need to avoided when a client is taking this
medication. Alcohol consumption should be avoided by a client taking warfarin
sodium. Taking the prescribed medication at the same time each day
increases client compliance. The MedicAlert bracelet provided health care
personnel with emergency information.
A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L
(3 mmol/L) and is complaining of anorexia. The HCP prescribes a serum
digoxin level to be done. The nurse checks the results and should expect to
note which level that is outside of the therapeutic range?
,1. 0.3 ng/ml
2. 0.5 ng/ml
3. 0.8 ng/ml
4. 1.0 ng/ml - correct answer-4. 1.0 ng/dl
The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/ml. If the client is
experiencing symptoms such as anorexia and is experiencing hypokalemia as
evidenced by a low potassium level, digoxin toxicity is a concern. Therefore,
option 4 is correct because it is outside of the therapeutic level and an
elevated level.
A client is being treated with procainamide for a cardiac dysrhythmia.
Following IV administration of the medication, the client complains of
dizziness. What interventions should the nurse take *first*?
1. Measure the heart rate on the rhythm strip.
2. Administer prescribed nitroglycerine tablets.
3. Obtain a 12-lead electrocardiogram immediately.
4. Auscultate the client's apical pulse and obtain a blood pressure. - correct
answer-4. Auscultate the client's apical pulse and obtain a blood pressure.
Signs of toxicity from procainamide include confusion, dizziness, drowsiness,
decreased urination, nausea, vomiting, and tachydysrhythmias. If the client
complains of dizziness, the nurse should assess the vital signs first. Although
measuring the heart rate on the rhythm strip and obtaining a 12-lead
electrocardiogram ay be interventions, these would be done after the vital
signs are taken. Nitroglycerin is a vasodilator and will lower the blood
pressure.
The nurse is monitoring a client who is taking propranolol (Inderal LA). Which
assessment data indicates a potential adverse complication associated with
this medication?
1. The development of complaints of insomnia.
2. The development of auditory expiratory wheezes.
3. a baseline blood pressure of 150/80 mm Hg followed by a blood pressure of
138/72 mmHg after two doses of the medication.
4. A baseline resting heart rate of 88 beats/minute followed by a resting heart
rate of 72 beats/minute after two doses of the medication. - correct answer-2.
The development of auditory expiratory wheezes.
,Audible expiratory wheezes may indicate a serious adverse reaction,
bronchospasm. Beta blockers may induce this reaction, particularly in clients
with chronic obstructive pulmonary disease or asthma. Normal decreases in
blood pressure and hear rate are expected. Insomnia is a frequent mild side
effect and should be monitored.
A client with a clot in the right atrium is receiving a heparin sodium infusion at
1000 units/hour and warfarin sodium 7.5 mg at 5:00 pm daily. The morning
laboratory results are as follows: activated partial thromboplastin time (aPTT),
32 seconds; international normalized ratio (INR), 1.3. The nurse should take
which action based on the clients laboratory results?
1. Collaborate with the HCP to discontinue the heparin infusion and administer
the warfarin sodium as prescribed.
2. Collaborate with the HCP tp obtain a prescription to increase the heparin
infusion and administer the warfarin sodium as prescribed.
3. Collaborate with the HCP to withhold the warfarin sodium since the client is
receiving a heparin infusion and the aPTT is within the therapeutic range.
4. Collaborate withe the HCP to continue the heparin infusion at the same rate
and to discuss the use of dabigatran etexilate in place of warfarin sodium -
correct answer-2. Collaborate with the HCP tp obtain a prescription to
increase the heparin infusion and administer the warfarin sodium as
prescribed.
When a client is receiving warfarin for clot prevention due to atrial fibrillation,
an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a
therapeutic range, the client should be maintained on a continuous heparin
infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the
nurse should collaborate withe the HCO to obtain a prescription to increase
the heparin infusion and to administer the warfarin as prescribed.
A client is diagnosed ST segment elevation myocardial infarction (STEMI) and
is receiving a tissue plasminogen activator, alteplase. Which action is a
*priority* nursing intervention?
1. Monitor for kidney failure.
2. Monitor psychosocial status.
3. Monitor for signs of bleeding.
,4. Have heparin sodium available. - correct answer-3. Monitor for signs of
bleeding.
Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication
of any type of thrombolytic medication. The client is monitored for bleeding.
Monitoring for renal failure and monitoring the client's psychosocial status are
important but are not the most critical interventions. Heparin may be
administered after thrombolytic therapy, but the question is not asking about
follow-up medications.
The nurse is planning to administer hydrochlorothiazide to a client. The nurse
should monitor for which adverse effects related to the administration of this
medication?
1. Hypouricemia, hyperkalemia
2. Increased risk of osteoporosis
3. Hypokalemia, hyperglycemia, sulfa allergy
4. Hyperkalemia, hypoglycemia, penicillin allergy - correct answer-3.
Hypokalemia, hyperglycemia, sulfa allergy
Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications,
and a client with a sulfa allergy is at risk for an allergic reaction. Aldo, clients
are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia,
and hyperuricemia.
The home health care nurse is visiting a client with elevated triglyceride levels
and a serum cholesterol level of 398 mg/dL. The client is taking
cholestyramine (Questran) and the nurse teaches the client about the
medication. Which statement, by the client, indicates the *need for further
teaching*?
1. "Constipation and bloating might be a problem."
2. "I'll continue to watch my diet and reduce my fats."
3. "Walking a mile each day will help the whole process."
4. "I'll continue my nicotinic acid from the health food store." - correct
answer-4. "I'll continue my nicotinic acid from the health food store."
Nicotinic acid, even an over-the-counter form, should be avoided because it
may lead to liver abnormalities. All lipid-lowering medications also can cause
liver abnormalities, so a combination of nicotinic acid and cholestyramine resin
,needs to be avoided. Constipation and bloating are the 2 most common
adverse effects. Walking and the reduction of fats in the diet are therapeutic
measures to reduce cholesterol and triglyceride levels.
The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse
effects. Which findings are characteristics of digoxin toxicity? *Select all that
apply.*
1. Tremmors
2. Diarrhea
3. Irritability
4. Blurred vision
5. Nausea and vomiting - correct answer-2, 4, 5
Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of
this medication. Toxicity can lead to life-threatening events and the nurse
needs to monitor the client closely for signs of toxicity. Early signs of toxicity
include gastrointestinal manifestations such as anorexia, nausea, vomiting,
and diarrhea. Subsequent manifestations include headache; visual
disturbances such as diplopia, blurred visions, yellow-green halos, and
photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm
abnormalities can also occur. The nurse also monitors the digoxin level. The
optimal therapeutic range for digoxin is 05. to 0.8 ng/mL
Prior to administering a client's daily dose of digoxin, the nurse reviews the
client's laboratory data and notes the following results: serum calcium, 9.8
mg/dL; serum magnesium, 1.0 mg/dL; serum potassium, 4.1 mEq/L; serum
creatinine, 0.9 mg/dL. Which result should alert the nurse that the client is at
risk for digoxin toxicity?
1. Serum calcium level
2. Serum potassium level
3. Serum creatinine level
4. Serum magnesium level - correct answer-4. Serum magnesium level
An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia,
hypomagnesemia, hypothyroidism, and impaired renal function. The calcium,
creatinine, and potassium levels are all within normal limits. The normal range
for magnesium, is 1.3 to 2.1 mEq/L and the results in the correct option are
reflective of hypomagnesemia.
, A client being treated for heart failure is administered intravenous bumetanide.
Which outcome indicates the medication has achieved the expected effect?
1. Cough becomes productive of frothy pink sputum
2. Urine output increases from 10 mL/hour to greater than 50 mL hourly
3. The serum potassium level changes from 3.8 to 3.1 mEq/L
4. B-type natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL -
correct answer-2. Urine output increases from 10 mL/hour to greater than 50
mL hourly
Bumetanide is a diuretic and expected outcomes include increased urine
output, decreased crackles, and decreased weight. Options 1, 3, and 4 are
incorrect.
Intravenous heparin therapy is prescribed for a client. While implementing this
prescription, the nurse ensures that which medication is available on the
nursing unit?
1. Vitamin K
2. Protamine sulfate
3. Potassium chloride
4. Aminocaproic acid - correct answer-2. Protamine sulfate
The antidote to heparin is protamine sulfate; it should be readily available for
use if excessive bleeding or hemorrhage should occur. Vitamin k is an antidote
for warfarin sodium. Potassium chloride is administered for a potassium
deficit. Aminocaproic acid is the antidote for thrombolytic therapy.
A client receiving thrombolytic therapy with a continuous infusion of alteplase
(Activase) suddenly becomes extremely anxious and complains of itching. The
nurse hears stridor and notes generalized urticaria and hypotension. Which
nursing action is the priority?
1. Administer oxygen and protamine sulfate.
2. Cut the infusion rate in half and sit the client up in bed.
3. Stop the infusion and call for the Rapid Response Team (RRT).
4. Administer dyphenhydramine and epinephrone and continue the infusion. -
correct answer-3. Stop the infusion and call for the Rapid Response Team
(RRT).
A client with atrial fibrillation is receiving a continuous heparin infusion at 1000
units/hr. The nurse would determine that the client is receiving the therapeutic
effect based on which of the following results?
1. Prothrombin time of 12.5 seconds
2. Activated partial thromboplastin time of 60 seconds
3. Activated partial thromboplastin time of 28 seconds
4. Activated partial thromboplastin time longer than 120 seconds - correct
answer-2. Activated partial thromboplastin time of 60 seconds
Common laboratory ranges for activated partial thromboplastin time (aPTT)
are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the
normal value, the client's aPTT would be considered therapeutic if it was 60
seconds. Prothrombin time assesses the response to warfarin therapy.
The nurse provides discharge instructions to a client who is taking warfarin
sodium,. Which statement, by the client, reflects the *need for further
teaching*?
1. "I will avoid alcohol consumption"
2. "I will take my pills every day at the same time"
3. "I have already called my family to pick up a MedicAlert bracelet."
4. I will take coated aspirin for my headaches because it will coat my
stomach." - correct answer-4. I will take coated aspirin for my headaches
because it will coat my stomach."
Aspirin-containing products need to avoided when a client is taking this
medication. Alcohol consumption should be avoided by a client taking warfarin
sodium. Taking the prescribed medication at the same time each day
increases client compliance. The MedicAlert bracelet provided health care
personnel with emergency information.
A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L
(3 mmol/L) and is complaining of anorexia. The HCP prescribes a serum
digoxin level to be done. The nurse checks the results and should expect to
note which level that is outside of the therapeutic range?
,1. 0.3 ng/ml
2. 0.5 ng/ml
3. 0.8 ng/ml
4. 1.0 ng/ml - correct answer-4. 1.0 ng/dl
The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/ml. If the client is
experiencing symptoms such as anorexia and is experiencing hypokalemia as
evidenced by a low potassium level, digoxin toxicity is a concern. Therefore,
option 4 is correct because it is outside of the therapeutic level and an
elevated level.
A client is being treated with procainamide for a cardiac dysrhythmia.
Following IV administration of the medication, the client complains of
dizziness. What interventions should the nurse take *first*?
1. Measure the heart rate on the rhythm strip.
2. Administer prescribed nitroglycerine tablets.
3. Obtain a 12-lead electrocardiogram immediately.
4. Auscultate the client's apical pulse and obtain a blood pressure. - correct
answer-4. Auscultate the client's apical pulse and obtain a blood pressure.
Signs of toxicity from procainamide include confusion, dizziness, drowsiness,
decreased urination, nausea, vomiting, and tachydysrhythmias. If the client
complains of dizziness, the nurse should assess the vital signs first. Although
measuring the heart rate on the rhythm strip and obtaining a 12-lead
electrocardiogram ay be interventions, these would be done after the vital
signs are taken. Nitroglycerin is a vasodilator and will lower the blood
pressure.
The nurse is monitoring a client who is taking propranolol (Inderal LA). Which
assessment data indicates a potential adverse complication associated with
this medication?
1. The development of complaints of insomnia.
2. The development of auditory expiratory wheezes.
3. a baseline blood pressure of 150/80 mm Hg followed by a blood pressure of
138/72 mmHg after two doses of the medication.
4. A baseline resting heart rate of 88 beats/minute followed by a resting heart
rate of 72 beats/minute after two doses of the medication. - correct answer-2.
The development of auditory expiratory wheezes.
,Audible expiratory wheezes may indicate a serious adverse reaction,
bronchospasm. Beta blockers may induce this reaction, particularly in clients
with chronic obstructive pulmonary disease or asthma. Normal decreases in
blood pressure and hear rate are expected. Insomnia is a frequent mild side
effect and should be monitored.
A client with a clot in the right atrium is receiving a heparin sodium infusion at
1000 units/hour and warfarin sodium 7.5 mg at 5:00 pm daily. The morning
laboratory results are as follows: activated partial thromboplastin time (aPTT),
32 seconds; international normalized ratio (INR), 1.3. The nurse should take
which action based on the clients laboratory results?
1. Collaborate with the HCP to discontinue the heparin infusion and administer
the warfarin sodium as prescribed.
2. Collaborate with the HCP tp obtain a prescription to increase the heparin
infusion and administer the warfarin sodium as prescribed.
3. Collaborate with the HCP to withhold the warfarin sodium since the client is
receiving a heparin infusion and the aPTT is within the therapeutic range.
4. Collaborate withe the HCP to continue the heparin infusion at the same rate
and to discuss the use of dabigatran etexilate in place of warfarin sodium -
correct answer-2. Collaborate with the HCP tp obtain a prescription to
increase the heparin infusion and administer the warfarin sodium as
prescribed.
When a client is receiving warfarin for clot prevention due to atrial fibrillation,
an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a
therapeutic range, the client should be maintained on a continuous heparin
infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the
nurse should collaborate withe the HCO to obtain a prescription to increase
the heparin infusion and to administer the warfarin as prescribed.
A client is diagnosed ST segment elevation myocardial infarction (STEMI) and
is receiving a tissue plasminogen activator, alteplase. Which action is a
*priority* nursing intervention?
1. Monitor for kidney failure.
2. Monitor psychosocial status.
3. Monitor for signs of bleeding.
,4. Have heparin sodium available. - correct answer-3. Monitor for signs of
bleeding.
Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication
of any type of thrombolytic medication. The client is monitored for bleeding.
Monitoring for renal failure and monitoring the client's psychosocial status are
important but are not the most critical interventions. Heparin may be
administered after thrombolytic therapy, but the question is not asking about
follow-up medications.
The nurse is planning to administer hydrochlorothiazide to a client. The nurse
should monitor for which adverse effects related to the administration of this
medication?
1. Hypouricemia, hyperkalemia
2. Increased risk of osteoporosis
3. Hypokalemia, hyperglycemia, sulfa allergy
4. Hyperkalemia, hypoglycemia, penicillin allergy - correct answer-3.
Hypokalemia, hyperglycemia, sulfa allergy
Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications,
and a client with a sulfa allergy is at risk for an allergic reaction. Aldo, clients
are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia,
and hyperuricemia.
The home health care nurse is visiting a client with elevated triglyceride levels
and a serum cholesterol level of 398 mg/dL. The client is taking
cholestyramine (Questran) and the nurse teaches the client about the
medication. Which statement, by the client, indicates the *need for further
teaching*?
1. "Constipation and bloating might be a problem."
2. "I'll continue to watch my diet and reduce my fats."
3. "Walking a mile each day will help the whole process."
4. "I'll continue my nicotinic acid from the health food store." - correct
answer-4. "I'll continue my nicotinic acid from the health food store."
Nicotinic acid, even an over-the-counter form, should be avoided because it
may lead to liver abnormalities. All lipid-lowering medications also can cause
liver abnormalities, so a combination of nicotinic acid and cholestyramine resin
,needs to be avoided. Constipation and bloating are the 2 most common
adverse effects. Walking and the reduction of fats in the diet are therapeutic
measures to reduce cholesterol and triglyceride levels.
The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse
effects. Which findings are characteristics of digoxin toxicity? *Select all that
apply.*
1. Tremmors
2. Diarrhea
3. Irritability
4. Blurred vision
5. Nausea and vomiting - correct answer-2, 4, 5
Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of
this medication. Toxicity can lead to life-threatening events and the nurse
needs to monitor the client closely for signs of toxicity. Early signs of toxicity
include gastrointestinal manifestations such as anorexia, nausea, vomiting,
and diarrhea. Subsequent manifestations include headache; visual
disturbances such as diplopia, blurred visions, yellow-green halos, and
photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm
abnormalities can also occur. The nurse also monitors the digoxin level. The
optimal therapeutic range for digoxin is 05. to 0.8 ng/mL
Prior to administering a client's daily dose of digoxin, the nurse reviews the
client's laboratory data and notes the following results: serum calcium, 9.8
mg/dL; serum magnesium, 1.0 mg/dL; serum potassium, 4.1 mEq/L; serum
creatinine, 0.9 mg/dL. Which result should alert the nurse that the client is at
risk for digoxin toxicity?
1. Serum calcium level
2. Serum potassium level
3. Serum creatinine level
4. Serum magnesium level - correct answer-4. Serum magnesium level
An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia,
hypomagnesemia, hypothyroidism, and impaired renal function. The calcium,
creatinine, and potassium levels are all within normal limits. The normal range
for magnesium, is 1.3 to 2.1 mEq/L and the results in the correct option are
reflective of hypomagnesemia.
, A client being treated for heart failure is administered intravenous bumetanide.
Which outcome indicates the medication has achieved the expected effect?
1. Cough becomes productive of frothy pink sputum
2. Urine output increases from 10 mL/hour to greater than 50 mL hourly
3. The serum potassium level changes from 3.8 to 3.1 mEq/L
4. B-type natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL -
correct answer-2. Urine output increases from 10 mL/hour to greater than 50
mL hourly
Bumetanide is a diuretic and expected outcomes include increased urine
output, decreased crackles, and decreased weight. Options 1, 3, and 4 are
incorrect.
Intravenous heparin therapy is prescribed for a client. While implementing this
prescription, the nurse ensures that which medication is available on the
nursing unit?
1. Vitamin K
2. Protamine sulfate
3. Potassium chloride
4. Aminocaproic acid - correct answer-2. Protamine sulfate
The antidote to heparin is protamine sulfate; it should be readily available for
use if excessive bleeding or hemorrhage should occur. Vitamin k is an antidote
for warfarin sodium. Potassium chloride is administered for a potassium
deficit. Aminocaproic acid is the antidote for thrombolytic therapy.
A client receiving thrombolytic therapy with a continuous infusion of alteplase
(Activase) suddenly becomes extremely anxious and complains of itching. The
nurse hears stridor and notes generalized urticaria and hypotension. Which
nursing action is the priority?
1. Administer oxygen and protamine sulfate.
2. Cut the infusion rate in half and sit the client up in bed.
3. Stop the infusion and call for the Rapid Response Team (RRT).
4. Administer dyphenhydramine and epinephrone and continue the infusion. -
correct answer-3. Stop the infusion and call for the Rapid Response Team
(RRT).
