ATI Cardiovascular and Hematology Dynamic Quizzes

A nurse in a clinic is collecting data from a client who has a history of peripheral ARTERIAL disease. Which of the following findings on the client's lower extremities should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation ✔C. Cool, pale skin with minimal body hair D. Sunburned appearance with desquamation

Correct Answer: C. Cool, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses. Incorrect Answers: A. A client who has VENOUS insufficiency can display pitting edema because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. This also can be a manifestation of congestive heart failure due to coronary artery disease. B. A client who has VENOUS insufficiency can display areas of reddish-brown pigmentation because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. D. Desquamation, which is the loss of bits of outer skin by peeling or shedding, is associated with sunburn, Kawasaki disease, and various other skin lesions.

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? ✔A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your bloodstream." D. "Treatment with heparin will dissolve the clot and keep other clots from forming."

Correct Answer: A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." Fibrinolysis is a process that breaks a clot down over time in the body. It is a treatment option for clots that are not immediately life-threatening. Incorrect Answers: B. There is no physiological mechanism that stabilizes a clot, although the desired outcome is stabilization and eventual resolution. C. Mobile clots (emboli) are pathological and not an expected resolution of an existing clot. D. Heparin does not dissolve clots. It prevents enlargement of the existing clots and prevents future clot formation. Thrombolytic therapy, not anticoagulant therapy, dissolves clots.

A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? (Click on "Exhibit NCLEX 3" under Resources on the right-hand side for additional information about the client) ✔A. BNP of 200 pg/mL B. Bradycardia C. Fluid restriction of 3 L per day D. 4 g sodium diet

Correct Answer: A. BNP of 200 pg/mL The nurse should identify that a client who has heart failure will have an elevated human B-type natriuretic peptide (BNP) level of >100 pg/mL. Endogenous BNP is released into the client's bloodstream due to decreased cardiac output, a process called natriuresis. Incorrect Answers: B. A client who has heart failure can have a history of tachycardia. C. A client who has heart failure should be on a fluid restriction of 2 L per day. D. A client who has heart failure should be on a 3 g sodium diet.

A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? ✔A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

Correct Answer: A. Decreased albumin A decreased albumin level can be an indication of long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function. Incorrect Answers: B. Protein-calorie malnutrition can negatively impact the production of RBCs, resulting in a decrease in hemoglobin. C. Nutritional deficiencies such as protein-calorie malnutrition can result in low lymphocyte levels, which increases the client's risk of infection. D. Cortisol is a glucocorticoid that plays a role in the metabolism of proteins, fats, and carbohydrates. Low levels are associated with Addison's disease. However, cortisol does not indicate protein-calorie malnutrition.

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? ✔A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals

Correct Answer: A. Elevated ST segments Elevated ST segments can indicate hyperkalemia and pericarditis. Incorrect Answers: B. Absent P waves can indicate atrial fibrillation and sustained ventricular tachycardia. C. Depressed ST segments can indicate hypokalemia and ventricular hypertrophy. D. Varying PP intervals indicate an irregular atrial rate and rhythm.

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? ✔A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

Correct Answer: A. Hyperkalemia The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid. Incorrect Answers: B. A low sodium level is not a manifestation of respiratory acidosis. Causes of hyponatremia include diuretics, kidney disease, vomiting, and burn injuries. C. A high calcium level is not a manifestation of respiratory acidosis. Causes of hypercalcemia include kidney failure and hyperparathyroidism. D. A low magnesium level is not a manifestation of respiratory acidosis. Causes of hypomagnesemia include malnutrition, alcohol use disorder, and diarrhea.

A nurse is collecting data from a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. This client has manifestations of which of the following electrolyte imbalances? ✔A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

Correct Answer: A. Hypokalemia The nurse should identify that furosemide can cause a loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats. Incorrect Answers: B. The nurse should identify that manifestations of hypophosphatemia can include muscle weakness and bradycardia. C. The nurse should identify that manifestations of hypercalcemia can include tachycardia, hypertension, and muscle weakness. D. The nurse should identify that manifestations of hypermagnesemia can include bradycardia, hypotension, and decreased deep tendon reflexes.

A nurse is collecting data from a client who has isotonic dehydration. Which of the following findings should the nurse expect? ✔A. Increased hematocrit B. Bradycardia C. Distended neck veins D. Decreased urine specific gravity

Correct Answer: A. Increased hematocrit The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume. Incorrect Answers: B. The nurse should expect the client to have tachycardia to compensate for a decrease in blood pressure, which occurs as a result of reduced plasma fluid volume. C. The nurse should expect the client to have flat neck veins as a result of reduced plasma fluid volume. D. The nurse should expect the client to have an increased urine specific gravity due to concentrated urine as a result of reduced plasma fluid volume.

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? ✔A. Necrosis B. Hypokalemia (U wave: PotassiumUwave-gross) C. Hypomagnesemia (P wave) D. Insufficiency (v.tacycardia)

Correct Answer: A. Necrosis ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery. Incorrect Answers: B. U waves indicate hypokalemia. C. Although absent P waves can reflect other dysrhythmias, they are common with sustained ventricular tachycardia, which hypomagnesemia can cause. D. Ventricular tachycardia often reflects coronary insufficiency, which results in poor oxygenation of the heart.

A nurse is contributing to the plan of care for a client who has thrombophlebitis. Which of the following actions should the nurse recommend for the plan of care? ✔A. Place compression stockings on the lower extremities B. Apply cold compresses to the affected extremity C. Gently massage the area every 4 hours D. Inform the client that heparin is prescribed to dissolve the thrombus

Correct Answer: A. Place compression stockings on the lower extremities The nurse should apply compression stockings on the client's lower extremities to promote blood return and decrease venous stasis. Incorrect Answers: B. The nurse should apply warmth to the affected extremity for the treatment of thrombophlebitis. C. The nurse should avoid rubbing or massaging the affected area to prevent dislodging the thrombus. D. While thrombolytic medications can dissolve a thrombus, heparin does not. The nurse should inform the client that heparin prevents enlargement of the thrombus and further clot formation.

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?

Correct Answer: A. Position the client supine with his legs elevated when in bed The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart. Incorrect Answers: B. The nurse should encourage the client to ambulate for 5 to 10 minutes every hour while awake to prevent venous stasis. C. The nurse should discourage the client from sitting or standing for any duration to prevent venous stasis. Also, the feet should be elevated above the heart to prevent venous stasis. D. The nurse should recommend wearing graduated compression stockings for up to 1 week after surgery to promote venous return.

A nurse is caring for a client who has heart failure and is lethargic with muscle weakness. The client's telemetry reading displays dysrhythmias. Which of the following laboratory results should the nurse anticipate? ✔A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 11.5 g/dL D. Calcium 8.0 mg

Correct Answer: A. Potassium 2.8 mEq/L Manifestations of hypokalemia include muscle weakness and cramps, confusion, and drowsiness. Hypokalemia can also result in life-threatening dysrhythmias. Incorrect Answers: B. The client has a digoxin level within the therapeutic range of 0.5 to 0.8 ng/mL. C. The manifestations of mild anemia include headaches, palpitations, and shortness of breath with exertion. D. Manifestations of hypocalcemia include numbness and tingling in the hands and feet, abdominal cramping, and tetany. Severe hypocalcemia can cause hypotension and ECG changes.

A nurse is assisting with data collection from a client who has a history of unstable angina. Which of the following findings should the nurse expect?

Correct Answer: A. The client reports chest pain when at rest. A client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina, caused by an artery spasm. Incorrect Answers: B. C. A client who has unstable angina will report chest pain or discomfort with exertion and have minimal, if any, relief of chest pain from nitroglycerin. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction. D. A client who has unstable angina will have chest pain that lasts longer than 15 minutes. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? ✔A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

Correct Answer: A. Ventricular dysrhythmias The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery. Incorrect Answers: B. The appearance of Q waves indicates infarction, not reperfusion. C. The elevated ST segments indicate infarction, not reperfusion. D. The recurrence of chest pain can indicate an extension of acute MI. With reperfusion, chest pain should subside.

A nurse is caring for a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? ✔A. Weight gain of 1 kg (2.2 lb) in 1 day B. Pitting edema +1 C. Report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

Correct Answer: A. Weight gain of 1 kg (2.2 lb) in 1 day A weight gain of 1 kg in 1 day alerts the nurse that the client might be retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening. Incorrect Answers: B. Pitting edema (a visible finger indentation after application of pressure) indicates the client has retained fluid in the tissues. Pitting edema is rated on a scale of mild (+1) to severe (+3). Pitting edema of +3 is an indication that the client has developed fluid volume overload and heart failure is worsening. C. A client who is in the early stages of heart failure might report a cough that is irritating, occurs at night, and is nonproductive. D. Serum BNP levels increase as a result of the ventricular hypertrophy that occurs in heart failure. A BNP level above 100 pg/mL is indicative of heart failure. Levels continue to increase with the severity of heart failure.

A nurse is reinforcing dietary teaching with a client who has heart failure and is on a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? "I should use salt sparingly while cooking." Correct answer B. "I can have yogurt as a dessert." "I should use baking soda when I bake." D. "I should use canned vegetables instead of frozen."

Correct Answer: B. "I can have yogurt as a dessert." Incorrect Answers: A. Salt should be eliminated from the client's diet. Spices or vinegar can be used to season the client's food. C. Baking soda is high in sodium and should be eliminated from the client's diet. D. Canned vegetables are high in sodium and should be eliminated from the client's diet. Frozen or fresh vegetables, which are low in sodium, should be incorporated into the client's diet.

A nurse is collecting data from a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses ✔B. Ankle swelling C. Hair loss D. Skin atrophy

Correct Answer: B. Ankle swelling The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis. Incorrect Answers: A. The nurse should identify that absent pedal pulses are a manifestation of peripheral arterial disease rather than venous insufficiency. C. The nurse should identify that hair loss on the affected extremity is a manifestation of peripheral arterial disease rather than venous insufficiency. D. The nurse should identify that thin, dry, atrophied skin is a manifestation of peripheral arterial disease, rather than venous insufficiency.

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? A. Wheezes ✔B. Coarse crackles C. Rhonchi D. Friction rub

Correct Answer: B. Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by the movement of air through airways partially or intermittently occluded with fluid. These sounds are associated with heart failure and frothy sputum, are heard at the end of inspiration, and are not cleared by coughing. Incorrect Answers: A. A client who has wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway. C. A client who has rhonchi will manifest coarse, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airway and stops the sound. D. A client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration.

A nurse is assisting with the preparation of an in-service presentation about the management of myocardial infarction (MI). The nurse should identify that death following MI is most often a result of which of the following complications? A. Cardiogenic shock ✔B. Dysrhythmias C. Heart failure D. Pulmonary edema

Correct Answer: B. Dysrhythmias According to evidence-based practice, the nurse should identify that dysrhythmias, specifically ventricular fibrillation, are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately. Incorrect Answers: A. Evidence-based practice indicates that cardiogenic shock is a complication of MI, but it is not the most common cause of death following MI. Other complications include emboli and pericarditis. C. Evidence-based practice indicates that heart failure is a complication of MI, but it is not the most common cause of death following MI. Other complications include postinfarction angina and reinfarction. D. Evidence-based practice indicates that pulmonary edema is a complication of MI, but it is not the most common cause of death following MI. Other complications include ventricular septal defect and left ventricular septum rupture.

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? A. Vertigo ✔B. Epistaxis C. Exophthalmos D. Spondylolisthesis

Correct Answer: B. Epistaxis Epistaxis is a manifestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches, dizziness, facial flushing, and fainting. Incorrect Answers: A. Vertigo is a manifestation of several other disorders, including Ménière's disease. C. Exophthalmos (a protrusion of the eyes) is caused by a thyroid disorder, not hypertension. D. Spondylolisthesis is a condition in which a vertebra slips, causing pressure on the nerve root that results in pain in the back and over the buttocks. This condition is not related to hypertension.

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower QRS complexes ✔B. Greater amplitude QRS complexes C. Same polarity QRS complexes D. Immediate resumption of the usual rhythm

Correct Answer: B. Greater amplitude QRS complexes The QRS complexes are of unusually great amplitude in height and depth for clients who have PVCs. Incorrect Answers: A. The QRS complexes are much wider than usual for clients who have PVCs. C. The QRS complexes are usually of the opposite polarity compared to the client's usual QRS complexes. D. With PVCs, a compensatory pause follows the PVC before the usual rhythm resumes, unless more PVCs follow in immediate succession.

A nurse is assisting with planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care?

Correct Answer: B. Measure the client's abdominal girth daily The nurse should plan to measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk for bleeding due to delayed clotting. Incorrect Answers: A. The nurse should not plan to restrict fluids for a client who has thrombocytopenia. Most clients require 2,000 mL to 2,400 mL of fluids per day to reduce the risk of dehydration and promote regular bowel function. C. The nurse should plan to check the client's IV sites every 2 hours for bleeding. D. The nurse should not plan to administer an enema to a client who has thrombocytopenia.

A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take? A. Weigh the client weekly ✔B. Monitor the client for ototoxicity C. Place the client on a 24-hour urine collection analysis D. Monitor for hypoglycemia

Correct Answer: B. Monitor the client for ototoxicity The nurse should monitor the client for ototoxicity, and the client should report any manifestations of hearing impairment while on the loop diuretic. The nurse should use caution when a loop diuretic is used in conjunction with other ototoxic medications such as aminoglycoside antibiotics. Incorrect Answers: A. The nurse should weigh the client daily to determine the amount of fluid excreted after the administration of the loop diuretic. C. The nurse should monitor the client's intake and output to determine the effectiveness of the loop diuretic. A 24-hour urine collection is completed for a study of kidney function. D. The nurse should monitor the client for hyperglycemia because a loop diuretic can inhibit insulin release.

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? A. Obtain blood samples to test platelet function ✔B. Prepare for replacement of the missing clotting factor C. Administer aspirin for the client's pain D. Place the bleeding joint in the dependent position

Correct Answer: B. Prepare for replacement of the missing clotting factor Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range-of-motion in repeatedly affected joints. Incorrect Answers: A. Coagulation tests that measure platelet function such as bleeding time are used to diagnose, not treat, hemophilia. C. Medications that interfere with clotting function such as aspirin, NSAIDs, and some herbal supplements should be avoided. D. The affected joint should be elevated to allow blood to drain away from the joint.

A nurse is evaluating a client's repeat laboratory results 4 hours after administering fresh frozen plasma (FFP). Which of the following laboratory values should the nurse review? A. WBC count ✔ B. Prothrombin time C. Platelet count D. Hematocrit

Correct Answer: B. Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time. Incorrect Answers: A. The nurse should review the client's WBC count if there is a possible infection. C. The nurse should review the client's platelet count following administration of platelets. D. The nurse should review the client's hematocrit following the administration of packed RBCs.

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection." B. "Platelets help break down clots in the body." ✔C. "Platelets plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen."

Correct Answer: C. "Platelets plug breaks in blood vessels." Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When a blood vessel is injured, platelets collect at the edge of the break and, by adhering to each other, plug the injured area and limit blood loss. Incorrect Answers: A. Leukocytes, not platelets, help the body fight infection. B. Plasmin is among the many substances that help break down blood clots in the body. Platelets do not perform this function. D. Red blood cells, not platelets, produce hemoglobin molecules, which transport oxygen throughout the body.

A client who has just learned that he has variant (Prinzmetal's) angina asks the nurse how this condition compares to stable angina. Which of the following replies should the nurse make? A. "Exertion often brings on pain." B. "Variant angina occurs randomly at various times." ✔C. "Variant angina can cause changes on your electrocardiogram." D. "Reducing your cholesterol can help you experience less pain."

Correct Answer: C. "Variant angina can cause changes on your electrocardiogram." Variant or Prinzmetal's angina causes ECG changes that reflect coronary artery spasms, resulting in less oxygen supplying the myocardium. Incorrect Answers: A. Variant angina typically occurs with rest. B. Variant angina pain tends to occur at the same time of day. D. Vasospasm, not atherosclerosis, causes variant angina. If the client's cholesterol level is above the expected reference range, attempts should be made to lower it; however, it is unlikely to affect variant angina.

A nurse is assisting with preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in the preoperative instructions?

Correct Answer: C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow." The nurse should prepare the client to expect a painful, pulling sensation when the provider aspirates the marrow and some discomfort from the rotation of the needle into the bone. Incorrect Answers: A. During a bone-marrow biopsy, the client will receive local anesthesia and mild sedation and will be awake during the procedure. B. When the iliac crest is the extraction site, the client should be side-lying or prone. D. A bone-marrow biopsy typically takes 5 to 15 minutes.

A nurse is collecting data about the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? A. Pallor B. Jaundice ✔Absence of hair on the legs D. Poor nailbed capillary refill

Correct Answer: C. Absence of hair on the legs Progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider. Incorrect Answers: A. Although pallor can indicate a hematologic disorder such as anemia, pigment loss is common with aging. Pallor is an unreliable indicator of anemia for an older adult. B. Although jaundice can indicate a hematologic disorder such as hyperbilirubinemia, yellowing of the skin is common with aging. Jaundice is an unreliable indicator of hyperbilirubinemia for an older adult. D. Although poor nailbed capillary refill can indicate a hematologic disorder such as arterial insufficiency, thickening and discoloration of the nails are common with aging, which can make this an unreliable indicator of arterial insufficiency for an older adult client.

A nurse is caring for a client who reports calf pain. Which of the following is the first action the nurse should take?

Correct Answer: C. Check the affected extremity for warmth and redness The first action the nurse should take using the nursing process is to collect data about the client's calf to check for swelling, redness, and warmth that can indicate deep-vein thrombophlebitis. Incorrect Answers: A. The nurse should notify the provider to report a change in the client's condition; however, there is another action the nurse should take first. B. The nurse should elevate the client's extremity to decrease swelling and relieve pain; however, there is another action the nurse should take first. D. The nurse should prepare to administer an anticoagulant such as unfractionated heparin to the client if prescribed to decrease the risk of further clot formation; however, there is another action the nurse should take first.

A nurse is collecting data from a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia B. Relief of chest pain with deep inspiration ✔C. Dyspnea D. Chest pain that increases when sitting upright

Correct Answer: C. Dyspnea The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade. Incorrect Answers: A. A client who has pericarditis will have tachycardia because of decreased cardiac output and oxygen perfusion. B. Chest pain associated with pericarditis will increase with deep inspiration due to increased pressure on the pericardial sac. D. Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac.

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid and electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia ✔C. Elevated Hct D. Decreased Hgb

Correct Answer: C. Elevated Hct The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration. Incorrect Answers: A. The nurse should expect a client who is experiencing third spacing resulting from a major burn to have hyperkalemia as a result of potassium being leaked from cellular injury. B. The nurse should expect a client who is experiencing third spacing resulting from a major burn to have hyponatremia as sodium leaks into the interstitial space, causing decreased levels in the blood. D. The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an increased hemoglobin level as blood volume is reduced by vascular dehydration.

A nurse is caring for a male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? A. Cholesterol level 195 mg/dL B. Elevated HDL levels ✔C. Elevated LDL levels D. Triglyceride level 135 mg

Correct Answer: C. Elevated LDL levels An elevated LDL level increases a client's risk for atherosclerosis. The client's desirable LDL level is below 130 mg/dL. Incorrect Answers: A. Total cholesterol levels <200 mg/dL are recommended to help reduce the incidence of developing atherosclerosis. B. The nurse should expect a decreased HDL level in a client who is at risk for atherosclerosis. Elevated HDLs have a protective effect against the development of atherosclerosis. The client's desirable HDL level is 35 to 65 mg/dL. D. Triglyceride levels <150 mg/dL are recommended to help reduce the incidence of atherosclerosis.

A nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of information should the nurse include in the teaching? A. Hospitalization is required when administering each treatment. B. The maximum effect of the medication will occur in 6 months. ✔C. Hypertension is a common adverse effect of this medication. D. Blood transfusions are needed with each treatment.

Correct Answer: C. Hypertension is a common adverse effect of this medication. A common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level. Incorrect Answers: A. The nurse should reinforce that epoetin alfa can be self-administered at home. B. The nurse should reinforce that the maximum effect of epoetin alfa will occur in 2 to 3 months. D. The nurse should reinforce that epoetin alfa is administered to decrease the need for periodic blood transfusions.

A nurse is contributing to the plan of care for a client who has pernicious anemia. Which of the following interventions should the nurse recommend? A. Administer ferrous sulfate supplementation B. Increase dietary intake of folic acid ✔C. Initiate weekly injections of vitamin B12 D. Initiate a blood transfusion

Correct Answer: C. Initiate weekly injections of vitamin B12 Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract. The nurse should recommend weekly injections of vitamin B12 for a client who has pernicious anemia. These may be decreased to monthly. Incorrect Answers: A. The nurse should recommend the administration of ferrous sulfate to a client who has iron-deficiency anemia, which is a decrease in the red blood cells caused by inadequate intake of dietary iron. B. The nurse should recommend an increase in the intake of food containing folic acid for a client who has megaloblastic anemia, which is a decrease in red blood cells that is caused by folate deficiency. D. The nurse should recommend a blood transfusion for a client who has aplastic anemia when bleeding is life-threatening from low platelet count or if a client has blood loss from trauma or surgery.

A nurse is collecting data from a client who has pernicious anemia. Which of the following findings should the nurse expect? A. Thick, white coating on the tongue B. Decreased pulse rate ✔C. Paresthesias in the hands and feet D. Joint pain in extremities

Correct Answer: C. Paresthesias in the hands and feet The nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected finding of pernicious anemia. Other manifestations include weight loss and fatigue. Incorrect Answers: A. A thick, white coating on the tongue is a manifestation of oral candidiasis rather than pernicious anemia. The nurse should expect the client to have glossitis (a beefy-red discoloration of the tongue). B. Tachycardia, not bradycardia, is an expected finding of pernicious anemia. D. Joint pain is a manifestation of sickle cell disease rather than pernicious anemia.

A nurse is collecting data from a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular-vein distention and peripheral edema ✔C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

Correct Answer: C. Report of sudden, severe back pain An aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden, increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots. Incorrect Answer: A. If the client develops a rupturing AAA, the nurse should expect indications of shock such as a decreased BP and increased pulse rate. B. Jugular-vein distention and peripheral edema are manifestations of right-sided heart failure, not of an extending AAA. D. Chest pain radiating to the left arm is a manifestation of a myocardial infarction, not AAA.

A nurse is assisting in monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hours? A. Infective endocarditis B. Pericarditis ✔C. Ventricular dysrhythmias D. Pulmonary emboli

Correct Answer: C. Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system. Incorrect Answers: A. Infective endocarditis occurs when bacteria invade the endothelial surface of the heart. Infective endocarditis is usually seen in clients who have prosthetic heart valves or pacemakers. B. Pericarditis can occur 1 to 12 weeks following a myocardial infarction. Pericarditis is an inflammation of the pericardial sac that surrounds the heart and is usually a result of infection, connective tissue disorders, or trauma. D. Pulmonary emboli occur if a client develops heart failure following a myocardial infarction. Pulmonary emboli are found more commonly with valvular disorders, with a atrial fibrillation, or from a deep-vein thrombosis.

A nurse is reinforcing teaching about measures to increase comfort and promote circulation with a client who has been admitted to the hospital with a deep-vein thrombosis (DVT) of the left leg. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer: D. "I will keep my legs elevated when I'm in bed." The client should keep the legs elevated while in bed to promote venous return to the heart and prevent venous pooling. Incorrect Answers: A. Wearing compression stockings on both legs to promote venous return to the heart is indicated for a client who has a DVT. The client should wear these stockings for extended periods of time, not just when walking. B. The client can apply moist heat to the leg that has a DVT to decrease pain and swelling. C. The client should avoid massaging an extremity that has a DVT, as this can cause the thrombosis to dislodge, resulting in an embolus.

A nurse is contributing to the plan of care for a client during a sickle cell crisis. Which of the following interventions should the nurse recommend? A. Ambulate the client every hour B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved ✔D. Administer oxygen via nasal cannula

Correct Answer: D. Administer oxygen via nasal cannula The nurse should administer oxygen to the client during a sickle cell crisis. Hypoxia increases sickling and client discomfort. Incorrect Answers: A. The nurse should promote client rest because increased activity aggravates sickling and client discomfort. B.T he nurse should keep the room warm during a sickle cell crisis and apply warm, moist compresses to painful joints. The application of cold compresses causes vasoconstriction, which increases sickling. C. The nurse should ensure the client receives opioids, including morphine and hydromorphone, on a routine schedule during a crisis to manage the client's pain.

A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first? A. Press the analyze button on the machine (3rd) B. Stop CPR and move away from the client (2nd) C. Push the charge button to prepare to shock (4th) ✔Correct answer D D. Apply the defibrillator pads to the client's chest (1st)

Correct Answer: D. Apply the defibrillator pads to the client's chest After obtaining the AED, the nurse should apply 2 large adhesive defibrillator pads on the client's anterior chest wall to enable the machine to analyze the rhythm and deliver the shock appropriately if indicated. One pad should be applied to the upper right chest area above the client's nipple and to the right of the sternum, and the second pad should be applied to the left lower chest area below the client's nipple and pectoral muscle. The pads should be applied without interrupting CPR. Incorrect Answers: A. This is the third step the nurse should perform. After the rescuers momentarily stop CPR and move away from the client, the nurse should press the analyze button. After rhythm analysis, which can take up to 30 seconds, the machine advises whether a shock is necessary. B. This is the second step the nurse should perform. The nurse using the AED on the client should instruct rescuers to stop CPR and move away from the client after the defibrillator pads are applied. This action eliminates motion artifact when the machine analyzes the rhythm. C. This is the last step the nurse should perform before administering an advised shock. If a shock is indicated, the nurse will issue a command to clear all contact with the client and press the charge button. Once the AED is charged, the shock button will be pressed, and the shock will be delivered. Shocks are recommended for ventricular fibrillation or pulseless ventricular tachycardia only.

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Dizziness ✔D. Dependent edema

Correct Answer: D. Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema. Incorrect Answers: A. Decreased capillary refill occurs in clients who have decreased cardiac output resulting from left-sided heart failure. B. When the left side of the heart fails, blood return from the lungs via the pulmonary vein is slowed, causing fluid buildup in the lungs that results in shortness of breath. C. Dizziness occurs in clients who have decreased cardiac output resulting from left-sided heart failure.

A nurse is collecting data from a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? A. Bradycardia B. Paresthesia C. Hypertension ✔D. Low back pain

Correct Answer: D. Low back pain The nurse should identify that low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include headaches, chest pain, tachypnea, tachycardia, and dark urine. Incorrect Answers: A. Tachycardia, rather than bradycardia, is a manifestation of a hemolytic transfusion reaction. B. Certain medications such as clonidine can cause paresthesia; however, paresthesia is not a manifestation of a hemolytic transfusion reaction. C. Hypotension, rather than hypertension, is a manifestation of a hemolytic transfusion reaction.

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities ✔D. Lower back discomfort

Correct Answer: D. Lower back discomfort Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain. Incorrect Answers: A. A client who has an abdominal aortic aneurysm will have back and abdominal pain. Midsternal chest pain is a manifestation of a myocardial infarction. B. The nurse should auscultate for a bruit heard over the location of the mass. C. Pitting edema is a manifestation of heart failure. This is not a finding with an abdominal aortic aneurysm.

A nurse is assisting with preparing an in-service presentation about the basics of hematology. The nurse should suggest explaining that which of the following factors provides a stimulus for the production of RBCs? A. Venous stasis B. Thrombocytopenia C. Inflammation ✔D. Tissue hypoxia

Correct Answer: D. Tissue hypoxia In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes (RBCs) in the bone marrow. Incorrect Answers: A. Venous stasis activates platelets and stimulates blood clotting. It does not affect the production of RBCs. B. Platelets are essential for blood clotting. Platelet deficiency does not affect the production of RBCs. C. Inflammation and infection trigger the production of white blood cells.

A nurse is caring for an older adult client who has had an acute myocardial infarction (MI). When collecting data from this client, the nurse should identify that older adults are prone to complications of MI in tissue perfusion because of which of the following age-related factors?

Correct Answer: A. Peripheral vascular resistance increases. Older adult clients are more prone to complications from poor tissue perfusion following acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels. Incorrect Answers: B. The sensitivity of blood-pressure-regulating baroreceptors decreases with aging, causing postural and postprandial hypertension, which can affect perfusion. C. Older adults are more prone to bleeding complications, particularly hemorrhage. Anticoagulation therapy requires constant and careful monitoring of clotting times. D. Older adults are more likely to develop toxicity from cardiac medications, especially severe adverse effects from thrombolytic therapy.

A nurse is reinforcing discharge teaching with a client who has aplastic anemia. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Correct Answer: C. "I should eliminate uncooked foods from my diet for now." The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorganisms that cooking would destroy, so the client should avoid raw foods. Incorrect Answers: A. Although staying active is always a good strategy, clients who have aplastic anemia are not at particular risk for deep-vein thrombosis because a common manifestation of this disorder is a low platelet count. B. Clients with aplastic anemia should not take aspirin because it can increase bleeding tendencies. D. Although iron-fortified cereal is a component of a healthy diet, it is a specific recommendation for clients who have iron-deficiency anemia, not aplastic anemia.

A nurse is checking a client who has pericarditis for cardiac tamponade. Which of the following actions should the nurse take? A. Check for hypertension B. Auscultate for loud, bounding heart sounds ✔C. Auscultate blood pressure for pulsus paradoxus D. Check for a pulse deficit

Correct Answer: C. Auscultate blood pressure for pulsus paradoxus The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. Incorrect Answers: A. A client who has cardiac tamponade will have hypotension because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. B. A client who has cardiac tamponade will have muffled heart sounds on auscultation because of the fluid compressing the atria and ventricles. D. The nurse will not detect cardiac tamponade by checking for a pulse deficit. This is performed by checking the apical and radial pulses simultaneously to determine if the rate is the same. If the rate is different, the findings indicate a cardiac dysrhythmia.

A nurse is assisting with the preparation of an in-service presentation about collecting data from clients who are having acute myocardial infarction (MI). The nurse should identify that the most common finding of acute MI is which of the following?

Correct Answer: C. Substernal chest pain Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or with nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation. Incorrect Answers: A. Evidence-based practice indicates that dyspnea is a common manifestation of acute MI, but it is not the most common. Other findings include diaphoresis and nausea. B. Evidence-based practice indicates that pain in the shoulder and left arm is a common manifestation of acute MI, but it is not the most common. Other findings include dizziness and anxiety. D. Evidence-based practice indicates that palpitations are a common manifestation of acute MI, but they are not the most common. Other findings include epigastric distress and disorientation.

A nurse is checking laboratory values for an adult client who has sickle cell anemia and is in crisis. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia ✔D. Elevated bilirubin

Correct Answer: D Elevated bilirubin The client who has sickle cell anemia and is in crisis will have an elevated bilirubin because hemolysis of the abnormal red blood cells occurs. Incorrect Answers: A. The client is at risk for hyperkalemia if blood transfusions are received during a crisis. Stored blood releases increased amounts of potassium due to red blood cell hemolysis. B. A client who has sickle cell anemia and has received numerous blood transfusions is not at risk for lead poisoning because lead is not found in blood. C. The client is at risk for having hypocalcemia if blood transfusions are received during a crisis. The citrate in the transfused blood bonds with calcium, causing calcium to be excreted.

A nurse is assisting in the plan of care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postoperative plan of care?

Correct Answer: D. Initiate an aspirin regimen The nurse should plan to initiate an aspirin regimen or another antiplatelet agent. The antiplatelet medication maintains the patency of the stent by reducing platelet aggregation. Incorrect Answers: A. The nurse should reinforce teaching about cardiac rehabilitation prior to the client's discharge from the facility. B. The nurse should plan to administer scheduled doses of aspirin after the procedure. This maintains the patency of the client's coronary arteries following the PTCA by preventing platelet aggregation and thrombus formation around the newly placed stent. C. The nurse should monitor for peak laboratory markers of myocardial damage following a myocardial infarction and reperfusion with thrombolytic therapy.

A nurse is collecting data from a client who has manifestations of aplastic anemia. Which of the following findings should the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice with an enlarged liver ✔D. Petechiae and ecchymosis

Correct Answer: D. Petechiae and ecchymosis The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually. Incorrect Answers: A. A client who has polycythemia vera will have a plethoric (dark, flushed) manifestation of the facial skin and mucous membranes. B. A client who has pernicious anemia will have manifestations of glossitis (smooth, beefy-red tongue) and weight loss. C. A client who has sickle cell anemia will have manifestations of jaundice with an enlarged liver and spleen.

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse reinforce with the client before the procedure? (Select all that apply.)

Correct Answers: A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure." Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure. Incorrect Answers: C. The client will feel a sensation similar to a hot flash when the dye enters the heart. E. Adequate hydration, both IV and oral, is crucial for excreting the contrast medium and reducing the risk of renal toxicity from retaining the dye.

A nurse is assisting with the care of a client who is scheduled to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply.)

Correct Answers: A. Check and document the client's vital signs C. Make sure the blood type and Rh of the packed RBCs are checked by 2 nurses E. Provide the RN with IV tubing that has a filter The nurse should check and document the client's vital signs prior to a blood transfusion to obtain a baseline for comparison. Monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and identify if the client is tolerating the volume of the prescribed blood product. Additionally, 2 nurses should check the blood type and Rh of the packed RBCs and compare these items with the client's information for compatibility. This action decreases the risk of an ABO incompatibility reaction. Finally, the nurse should provide the RN with IV tubing that has a filter to prevent the administration of aggregates and possible contaminants. Incorrect Answers: B. The nurse should ensure the client has a 20-gauge or larger needle for administration of packed RBCs to prevent the formation of blood clots during the transfusion. D. The nurse should obtain a bag of 0.9% sodium chloride IV solution for administration with the packed RBCs. Lactated Ringer's solution is not used because it causes clotting and hemolysis of the blood cells.

A nurse is collecting data from a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Hardening along the blood vessel B. Absence of a peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumference

Correct Answers: A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins. Additionally, deep-vein thrombosis causes pain or tenderness in the calf and an increased circumference of the leg due to swelling. Incorrect Answers: B. Arterial problems, not venous problems, affect peripheral pulsation. D. The calf usually has warm skin; however, the skin might be cool if the client has an arterial problem.

A nurse is collecting data from a client who has fluid volume overload resulting from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Jugular vein distension B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

Correct Answers: A. Jugular vein distension B. Moist crackles D. Increased heart rate The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment that results in an increased heart rate and bounding pulses. Incorrect Answers: C. Fluid volume excess results in hypertension and tachycardia. E. A fever is common in clients who are experiencing dehydration, not fluid volume excess.

A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and a myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of an MI? (Select all that apply.) A. Nausea and vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea

Correct Answers: A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom Nausea, vomiting, and epigastric distress are common manifestations of MI, as well as diaphoresis (sweating), dizziness, fatigue, and anxiety and feelings of doom and fear, DIMINSHED OR ABSENT PULSE, TACHYPNEA Incorrect Answer: C. Chest and left arm pain that subsides with rest is a manifestation of angina, not MI. E. A diminished or absent pulse is a manifestation of an MI due to decreased cardiac output. Tachypnea is an indication of an MI due to anxiety and pain.

A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and a myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of an MI? (Select all that apply.)

Correct Answers: A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom Nausea, vomiting, and epigastric distress are common manifestations of MI, as well as diaphoresis (sweating), dizziness, fatigue, and anxiety and feelings of doom and fear. Incorrect Answer: C. Chest and left arm pain that subsides with rest is a manifestation of angina, not MI. E. A diminished or absent pulse is a manifestation of an MI due to decreased cardiac output. Tachypnea is an indication of an MI due to anxiety and pain.

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on chest and arms D. Flushed, dry skin E. Abdominal distension

Correct Answers: B. Bleeding at the venipuncture site C. Petechiae on chest and arms E. Abdominal distension The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur as manifested by bleeding at the venipuncture site, petechiae on the arms and chest, and abdominal distension due to internal bleeding. Incorrect Answers: A. D. Bradycardia and flushed, dry skin are not consistent with DIC. Tachycardia and pallor are cardiac responses of a client who is hemorrhaging.

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply.) A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6-hour period D. Seek verification from 2 RNs to compare the packed RBCs label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride

Correct Answers: B. Check to determine the packed RBCs are less than 1 week old D. Seek verification from 2 RNs to compare the packed RBCs label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the bloodstream. Additionally, the nurse should seek verification from 2 RNs before the packed RBCs are hung by an RN. Verification involves comparing the packed RBCs label against the medical record, against the client's complete name and identification number, and against the blood group name and number. If there is any discrepancy, the nurse should not infuse the blood and should notify the blood bank. Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs. Incorrect Answers: A. The nurse should use an 18- to 20-gauge angiocatheter to allow the packed RBCs to flow easily and to prevent occlusion of the catheter. A 23-gauge angiocatheter is too narrow and can result in a prolonged infusion time and an increased risk of catheter occlusion. C. The nurse should infuse the packed RBCs slowly over a 2- to 4-hour period to decrease the risk of bacterial contamination.

A nurse is collecting data from a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

Correct Answers: B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking The nurse should identify that a client who has hypertension, diabetes mellitus, or hyperlipidemia is at risk of coronary artery disease (CAD). Hypertension can be controlled by diet and exercise, along with medication if needed. Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage. Diabetes mellitus can be managed by monitoring glucose levels and implementing diet and exercise. Hyperlipidemia can be controlled with diet and exercise, along with medication if needed. Cholesterol levels (total, HDL, and LDL) should be monitored, as elevated total serum cholesterol levels increase the risk of myocardial infarction. Smoking accelerates the rate of the narrowing of the coronary arteries and increases the risk of clot formation. Smoking cessation classes or other forms of treatment can be offered to help the client quit smoking. Incorrect Answer: A. Hypothyroidism is NOT a risk factor for CAD.

A nurse is checking for paradoxical blood pressure in a client who has a possible cardiac tamponade. In what sequence should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Palpate the blood pressure and inflate the cuff above the systolic pressure Deflate the cuff slowly and listen for the first audible sounds Identify the first BP sounds audible on expiration and then on inspiration Subtract the inspiratory pressure from the expiratory pressure Inspect for jugular venous distention and notify the provider Step 1. The nurse should auscultate the blood pressure to detect paradoxical blood pressure in a client with possible cardiac tamponade by first palpating the blood pressure and inflating the cuff above the systolic pressure. Step 2. The nurse should deflate the cuff slowly and listen for the first audible sounds. Step 3. The nurse should listen for the BP sounds audible on expiration and on inspiration. Step 4. This action should be followed by subtracting the inspiratory pressure from the expiratory pressure to determine the pulsus paradoxus. A difference of greater than 10 mmHg can indicate cardiac tamponade. Step 5. The nurse should inspect for jugular venous distention, muffled heart sounds, and decreased cardiac output and notify the provider of the results and findings.

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of MI? A. Headache B. Hemoptysis ✔C. Nausea D. Diarrhea

The nurse should identify that nausea is an associated manifestation of an MI. Manifestations of an MI include chest pain and pain in the jaw, shoulder, or abdomen. Associated manifestations of MI can include anxiety, dizziness, dyspnea, dysrhythmias, fatigue, and palpitations. Incorrect Answers: A. A headache is not an expected finding of MI. Associated manifestations of MI can include anxiety, dizziness, dyspnea, dysrhythmias, fatigue, and palpitations. B. Hemoptysis (coughing up blood) is not an expected finding of MI. Associated manifestations of MI can include anxiety, dizziness, dyspnea, dysrhythmias, fatigue, and palpitations. D. Diarrhea is not an expected finding of MI. Associated manifestations of an MI can include anxiety, dizziness, dyspnea, dysrhythmias, fatigue, and palpitations.

A nurse is assisting with the care of a client who is receiving continuous cardiac monitoring. To determine if the client is in sinus rhythm, which of the following waveforms should the nurse observe? (Using the hot spots in the artwork, select only the area that corresponds to the answer.)

The nurse should observe the P wave, which represents atrial depolarization, to determine if the rhythm is originating from the sinoatrial (SA) node and is, therefore, a sinus rhythm. The P wave should be regular and accompany every QRS complex. Incorrect Answers: B. The R wave, which is part of the QRS complex, represents ventricular depolarization. Measuring from an R wave to the next is a method of determining the regularity of the rhythm and the ventricular rate. D. The S wave, which is part of the QRS complex, represents ventricular depolarization. It is also a part of the ST segment, which when elevated can indicate myocardial infarction or hyperkalemia. ST depression can indicate myocardial infarction or hypokalemia. C. The T wave represents ventricular repolarization. Abnormalities in the T wave can indicate myocardial infarction or ventricular hypertrophy.