ATI Med Surge: Cardio and Hematology

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? "Pitting peripheral edema" "Crackles in the lung bases" "Jugular vein distention" "Hepatomegaly"

"Crackles in the lung bases" Rationale: Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs.

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? "I should check my heart at the same time each day" "I don't have to take my antihypertensive medications now that I have a pacemaker" "I should keep a pressure dressing over the generator until the incision is healed" "I cannot stand in front of our new microwave oven when it is on"

"I should check my heart at the same time each day" Rationale: The nurse should instruct the client to check the heart rate at the same time each day and to document the rate in a log for reporting to the provider.

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions? "I should try to drink at least 2 liters of fluid per day" "I can still fly out to visit my sister in Colorado for a while" "Physical activity is good for me, but I need to avoid overexertion" "I can still go skiing during the cold winter months"

"Physical activity is good for me, but I need to avoid overexertion" Rationale: To help prevent a recurrence of sickle cell crisis, the client should avoid overexertion from especially strenuous activities.

A nurse is preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in preoperative teaching? "You'll receive heavy sedation, so you might even sleep during the procedure" You'll have to lie on your back throughout the procedure" "You'll feel a painful, pulling sensation when the doctor withdraws the marrow" "Expect the procedure to take about an hour"

"You'll feel a painful, pulling sensation when the doctor withdraws the marrow" Rationale: The nurse should prepare the client to expect a painful, pulling sensation when the provider aspirates the marrow as well as some discomfort from the rotation of the needle into the bone.

A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? Ferrous sulfate Epoetin sulfa Vitamin B12 Folic acid

Vitamin B12 Rationale: The nurse should expect the client's provider to prescribe vitamin B12 for pernicious anemia.

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? (SATA) "A client who is postmenopausal" "A client who is a vegetarian" "A middle adult male client" "A client who is pregnant" "A toddler who is overweight"

"A client who is a vegetarian" "A client who is pregnant" "A toddler who is overweight" Rationale: A client who is a vegetarian might require additional iron because the availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for iron-deficiency anemia.

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's VS are BP 160/98, HR 102, RR 22, and SpO2 95%. Which of the following actions should the nurse take? "Administer antihypertensive medication for blood pressure" "Monitor to ensure the client's urinary output is 20mL/hr" "Withhold pain medication to prepare the client for surgery" "Take the client's VS every 2 hr"

"Administer antihypertensive medication for blood pressure" Rationale: The nurse should administer antihypertensive medication for elevated BP because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.

A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? "Request a provider's prescription when traveling to alert airport security" "Stand at least 3 feet away while using a microwave" "Keep your cell phone 6 inches away from your pacemaker when making a call" "Avoid showering for the first 2 weeks following surgery"

"Keep your cell phone 6 inches away from your pacemaker when making a call" Rationale: The nurse should instruct the client to keep a cell phone 6 inches away from the pacemaker when making a call to avoid interfering with the function of the generator inside the client's pacemaker.

A nurse is teaching a 70-year-old client about risk factors for heart failure. The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? "My diabetes will not increase my risk of heart failure" "My asthma makes it more likely for me to have heart failure" "My age does not increase my risk of heart failure" "My coronary artery disease is a risk factor for heart failure"

"My coronary artery disease is a risk factor for heart failure" Rationale: CAD is a primary risk factor for the development of heart failure. Other risk factors include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism.

A nurse is caring for an older adult client who had an acute MI. When assessing the client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? "Peripheral vascular resistance increases" "The sensitivity of blood pressure-adjusting baroreceptors increases" "Blood is hypercoagulable and clots more quickly" "Cardiac medications are less effective"

"Peripheral vascular resistance increases" Rationale: Older adult clients are more prone to complications from poor tissue perfusion following an acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels.

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

"Platelets plug breaks in blood vessels" Rationale: Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When an injury occurs to a blood vessel, platelets collect at the edge of the break and adhere to each other to plug the injured area and limit blood loss.

A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A dressing is not applied to the port site after use A 22-gauge non-coring needle is used to access the port Blood return is noted prior to administering the medication A solution of 5 mL heparin 1,000 units/mL has been prepared

A solution of 5 mL heparin 1,000 units/mL has been prepared Rationale: Implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing." It is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action requires intervention by the charge nurse.

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? P waves occurring at 0.16 seconds before each QRS complex Atrial rate of 300/min with QRS complex of 80/min Ventricular rate of 82/min with an atrial rate of 80/min Irregular ventricular rate of 125/min with a wide QRS pattern

Atrial rate of 300/min with QRS complex of 80/min Rationale: The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? Decreased cap refill Dyspnea Orthopnea Dependent edema

Dependent edema Rationale: 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.

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods. Eggs Squash Kale Tofu

Eggs Rationale: The nurse should encourage the client to increase consumption of foods rich in vitamin B12, such as dairy products, animal protein, poultry, shellfish, and eggs.

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? "Lentils" "Avocados" "Cabbage" "Broccoli"

Lentils Rationale: The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, poultry, and dried beans and peas. A 1-cup serving of lentils contains 3.6mg of iron.

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

Ventricular dysrhythmias Rationale: After a MI, 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.

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

Ventricular dysrhythmias Rationale: The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.

A nurse is assessing 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? Bradycardia Paresthesia Hypertension Low back pain

Low back pain "Low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include a headache, chest pain, tachypnea, tachycardia, and dark urine."

A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? "BNP of 200 pg/mL" "Bradycardia" "Fluid restriction of 3 L per day" "4 g sodium diet"

"BNP of 200 pg/mL" Rationale: 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.

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? "Chest pain is relieved soon after resting" "Nitroglycerin relieves chest pain" Physical exertion does not precipitate chest pain" "Chest pain lasts for longer than 15 min"

"Chest pain lasts for longer than 15 min" Rationale: A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? "Obtain coagulation laboratory studies from the client" "Apply pneumatic compression boots to the client" "Request a referral for a speech-language pathologist" "Keep the client NPO"

"Keep the client NPO" Rationale: The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experienced a cerebrovascular accident is at risk for dysphagia, which increases the chance of life-threatening aspiration.

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? "Obtain blood samples to test platelet function" "Prepare for replacement of the missing clotting factor" "Administer aspirin for the client's pain" "Place the bleeding joint in the dependent position"

"Prepare for replacement of the missing clotting factor" Rationale: 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 placement is initiated to prevent hemarthrosis, which can result in a long-term loss of range of motion in repeatedly affected joints.

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? 0.45% sodium chloride Dextrose 5% in 0.9% sodium chloride Dextrose 10% in water 0.9% sodium chloride

0.9% sodium chloride Rationale: Solutions of 0.9% sodium chloride, as well as LR solution, are used for fluid volume replacement. Sodium chloride is a physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products.

A nurse is assessing 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? Absent pedal pulses Ankle swelling Hair loss Skin atrophy

Ankle swelling Rationale: 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.

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? Beef liver Oranges Turnips Whole milk

Beef liver Rationale: The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, and poultry. A 3 oz serving of beef liver contains 4.17 mg of iron.

A nurse is teaching about a low-cholesterol diet to a client who had a MI. Which of the following meal selections by the client indicates an understanding of the teaching? Chicken breast and corn on the cob Shrimp and rice Cheese omelet and turkey bacon Liver and onions

Chicken breast and corn on the cob Rationale: The nurse should identify that chicken breast is low in cholesterol, and all vegetables, including corn, are cholesterol-free; therefore, this food selection by the client indicates an understanding of the teaching.

A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications? Cardiogenic shock Dysrhythmias Heart failure Pulmonary edema

Dysrhythmias Rationale: According to evidence-based practice, 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.

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? Erythropoietin Erythromycin Filgrastim Calcitriol

Erythropoietin Rationale: Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? Hypokalemia Lead poisoning Hypercalcemia Iron toxicity

Iron toxicity Rationale: A client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as in sickle cell anemia.

A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? Omega-3 fatty acids Antioxidants Vitamins A, D, and C Beta-carotene

Omega-3 fatty acids Rationale: Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels.

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? Elevate the client's feet and legs Administer epinephrine Infuse 0.9% sodium chloride Stop the medication infusion

Stop the medication infusion Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.

A nurse is assessing a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? Severe hypertension Low body temperature Sudden oliguria Decreased respirations

Sudden oliguria Rationale: The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs.

A nurse is showing a client who has right-sided heart failure an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium? Right coronary artery Left carotid artery Aorta Superior vena cava

Super vena cava Rationale: The nurse should identify that the superior and inferior vena cava carry deoxygenated blood to the right atrium.

A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes Premature ventricular complexes at 12/min Telemetry monitoring showing pacing spikes with no QRS complexes Hiccups

Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes Rationale: The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min because the client's intrinsic rate overrides the set rate of the pacemaker.

A nurse is teaching a client about heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? "I should remove the skin from poultry before eating it" "I will eat seafood once per week" "I should use margarine when preparing meals" "I can use whole milk in my oatmeal"

"I should remove the skin from poultry before eating it" Rationale: The nurse should identify the client understands the teaching when he states he will remove the skin from poultry before eating, as the skin contains the greatest amount of fat.

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

"Variant angina can cause changes on your electrocardiogram" Rationale: Variant angina causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium.

A nurse is assessing 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? Pallor Jaundice Absence of hair on the legs Poor nail bed cap refill

Absence of hair on legs Rationale: A 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.

A nurse is assessing a client who had a coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take? Check for hypertension Auscultate for loud, bounding heart sounds Auscultate blood pressure for pulsus paradoxus Check for a pulse deficit

Auscultate blood pressure for pulsus paradoxus Rationale: The client who has cardiac tamponade will have pulsus paradoxus when the systolic BP 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.

A nurse is caring for a client who had a MI 5 days ago. The client has a sudden onset of SOB 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? Coarse crackles Wheezes Rhonci Friction rub

Coarse crackles Rationale: A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.

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? Hyperkalemia Hyponatremia Hypercalcemia Hypomagnesemia

Hyperkalemia Rationale: 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 called into the extracellular fluid.

A nurse is caring for a client who is having a possible MI. Which of the following findings should the nurse identify as an associated manifestation of an MI? Headache Hemoptysis Nausea Diarrhea

Nausea Rationale: Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

A nurse is preparing to transfuse 250 mL of packed RBCs to a client over 4 hr. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min?

10

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? Acidosis Infection Hypertension Cardiac tamponade

Acidosis Rationale: Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1*C (1.8*F) per hour.

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following intervention should the nurse include? Avoid IM injections Assess the client for ecchymosis once per shift Do not allow the client to have visitors Encourage daily flossing between teeth

Avoid IM injection Rationale: This client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding.

A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? Increased Hct level Bradycardia Distended neck veins Decreased urine specific gravity

Increased Hct level Rationale: The nurse should expect the client to have an increased Hct level due to hemoconcentration caused by reduced plasma fluid volume.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? Administer ferrous sulfate supplementation Increase dietary intake of folic acid Initiate weekly injections of vitamin B12 Initiate a blood transfusion

Initiate weekly injections of vitamin B12 Rationale: The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia and then decrease the injections to a monthly schedule. Pernicious anemia is caused by a lack of intrinsic factors needed to absorb vitamin B12 from the GI tract.

A nurse is checking paradoxical BP of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps?

Palpate the BP 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

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? Thick, white coating on the client's tongue Decreased pulse rate Paresthesias in the hands and feet Joint pain in the extremities

Paresthesias in the hands and feet Rationale: The nurse should identify that paresthesia in the hands and feet is an expected finding of pernicious anemia, Other manifestations include weight loss and fatigue.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? "Have the client gently blow clots from the nose every 5 min" Instruct the client to sit with his head hyperextended" "Apply ice compresses to the back of the client's neck" "Apply lateral pressure to the client's nose for 10 min"

"Apply lateral pressure to the client's nose for 10 min" Rationale: The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is providing teaching about lifestyle changes to a client who experienced a MI and has a new prescription for a beta-blocker. Which of the following client statements indicates an understanding of the teaching? "I should eat foods that are high in saturated fat" "Before taking my medication, I will count my radial pulse rate" "I will exercise once a week for an hour at the health club" "I will stop taking my medication when my BP is within a normal range"

"Before taking my medication, I will count my radial pulse rate" Rationale: A beta-blocker will induce bradycardia. The client should take the pulse rate for 1 minute before self-administration

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (SATA) "Insert a 23-gauge angiocatheter with an IV adaptor" "Check to determine the packed RBCs are less than 1 week old" "Administer the packed RBCs over a 6-hr period" "Ask another nurse to check the packed RBCs' label against the medical record" "Prime the transfusion tubing with 0.9% sodium chloride"

"Check to determine the packed RBCs are less than 1 week old" "Ask another nurse to check the packed RBCs' label against the medical record" "Prime the transfusion tubing with 0.9% sodium chloride" Rationale: 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. In addition, the nurse should ask another nurse to check the packed RBCs label against the medical record for safety verification. The nurse should ensure that the client's complete name and identification number match and that the blood group name and number are correct. If there is any type of 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 LR and dextrose in water can cause clotting or hemolysis of the packed RBCs

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? "Bradycardia with ST-segment depression" "Relief of chest pain with deep inspiration" "Dyspnea with hiccups" "Chest pain that increases when sitting upright"

"Dyspnea with hiccups" Rationale: A 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 rta

A nurse is completing dietary teaching with a client who has heart failure and is prescribed 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" "I can have yogurt as a dessert" "I should use baking soda when I bake" "I should use canned vegetables of frozen

"I can have yogurt as a dessert" Rationale: The client understands the teaching when he selects yogurt as a dessert. Yogurt is low in fat and sodium and is a good source of calcium and protein.

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions? "I need to stay active to prevent blood clots in my legs" "If I have a bad headache, I can take aspirin to get rid of it" "I should eliminate uncooked foods from my diet for now" "I should eat more iron-fortified cereal to strengthen my blood"

"I should eliminate uncooked foods from my diet for now" Rationale: The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorganisms that cooking destroys, so the client should avoid raw foods.

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching? "I will ask my provider to change my contraception to an IUD" "I will notify my doctor before I have dental procedures" "I will avoid using antiseptic mouthwash for oral care" "I will wear a mask when I go out in public"

"I will notify my doctor before I have dental procedures" Rationale: The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection.

A nurse is caring for a client who is undergoing treatment for HTN. Which of the following statements indicates that the client is adhering to the treatment plan? "I would never have believed I could get used to enjoying my food without salt" "My BP device at home usually shows about 156 over 98 or so" "I make sure I take my BP medicine when I have headaches" "My BP pills are very expensive. Could I take a cheaper medication?"

"I would never have believed I could get used to enjoying my food without salt" Rationale: This statement implies that the client has stopped adding salt to food. Sodium restriction is a single aspect of the treatment plan, but it does indicate dietary adherence by the client.

A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home? "I'll stick with soft foods for now" "My family will be bringing me fresh flowers today" "I'll use a new disposable razor each day" "I'll blow my nose more often to avoid nosebleeds"

"I'll stick with soft foods for now" Rationale: Thrombocytopenia is common after a bone marrow transplant. To prevent bleeding until the client's platelet count improves, the client should avoid hard foods that could cause mouth trauma.

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? "Position the client supine with his legs elevated when in bed" "Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr" "Tell the client to sit with his legs dependent after ambulating" "Instruct the client to wear knee-length socks for 2 weeks after surgery"

"Position the client supine with his legs elevated when in bed" Rationale: 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.

A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? "Warm the unit of blood to room temperature before administering it" "Administer acetaminophen prior to the blood transfusion" "Give an antihistamine prior to the transfusion" "Use a transfusion pump to regulate and maintain the transfusion at a slower rate"

"Use a transfusion pump to regulate and maintain the transfusion at a slower rate" Rationale: These are manifestations of a hypervolemic reaction due to circulatory overload, which likely occurs when blood transfusion is too rapid for the client's size or status. To prevent this problem with future transfusions, the nurse should use a transfusion pump to regulate the transfusion at a slower rate.

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (SATA) "You'll have to lie flat for several hours after the procedure" "You'll receive medication to relax you before the procedure" "You'll feel a cool sensation after the injection of the dye" "You'll have to keep your leg straight after the procedure" "You'll have to limit the amount of fluid you drink for the first 24 hr"

"You'll have to lie flat for several hours after the procedure" "You'll receive medication to relax you before the procedure" "You'll have to keep your leg straight after the procedure" Rationale: 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.

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? "Your body has a process called fibrinolysis that will eventually dissolve the lot" "Your body had a mechanism that will keep the clot stable in its present location" "The clot will break into tiny fragments and float harmlessly in your bloodstream" "Treatment with heparin will dissolve the clot and keep other clots from forming"

"Your body has a process called fibrinolysis that will eventually dissolve the lot" Rationale: Fibrinolysis is a process that breaks down a clot over time in the body. This process is a treatment option for clots that are not immediately life-threatening.

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

A decrease in the 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.

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of MI? Sudden hemoptysis Acute diarrhea Frontal headache Acute confusion

Acute confusion Rationale: Acute confusion is a manifestation of MI in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care? "Flexion of the extremities" "Therapeutic hypothermia" "Upright positioning" "Ample hydration"

Ample hydration Rationale: A client who is in sickle cell crisis needs ample hydration (either IV, oral, or both) to shorten the duration of painful episodes. The nurse should plan to offer the client water, juice, or a favorite beverage that does not contain caffeine.

A nurse is caring for a client who has a platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? Apply warm compresses Apply pressure to the catheter removal sire for 5 min Place the affected arm in a dependent position Clean the insertion site with alcohol

Apply pressure to the catheter removal sire for 5 min Rationale: A platelet count below 100,000/mm^3 indicates thrombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure to the site for at least 5 minutes, the nurse promotes coagulation and prevents additional blood loss.

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? Press the analyze button on the machine Stop CPR and move away from the client Push the charge button to prepare to shock Apply the defibrillator pads to the client's chest

Apply the defibrillator pads to the client's chest Rationale: After obtaining the AED, the nurse should first 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.

A nurse is caring for a client who has an upper GI bleed and a Hct of 24%. Prior to initiating a transfusion of packed RBCs, which of the following actions should the nurse take? (SATA) Assess and document the client's VS Restart the IV with a 22-gauge needle Verify with another nurse the blood type and Rh of the packed RBCs Hang a bag of LR IV solution Change IV tubing to a set that has a filter

Assess and document the client's VS Verify with another nurse the blood type and Rh of the packed RBCs solution Change IV tubing to a set that has a filter Rationale: The nurse should assess and document the client's VS prior to initiating a blood transfusion to obtain a baseline for comparison. Monitoring the client's VS helps the nurse identify adverse reactions to the packed RBCs and determine whether the client is tolerating the volume of the prescribed blood product. The nurse should verify the blood type and Rh of the packed RBCs with another RN and compare these data with the client's information for compatibility. This action decreases the risk of an ABO incompatibility reaction. The nurse should administer packed RBCs through IV tubing that has a filter to prevent the administration of aggregates and possible contaminants.

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? (SATA) Bradycardia Bleeding at the venipuncture site Petechiae on the chest and arms Flushed, dry skin Abdominal distension

Bleeding at the venipuncture site Petechiae on the chest and arms Abdominal distension Rationale: 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 chest and arms, and bleeding in the abdominal cavity resulting in abdominal distention due to internal bleeding.

A nurse is preparing to transfuse a unit of packed RBCs for a client who has anemia. Which of the following actions should the nurse take first? Hang an IV infusion of 0.9% sodium chloride with the blood Compare the client's ID number with the number on the blood Witness the informed consent document Obtain pretransfusion VS

Compare the client's ID number with the number on the blood Rationale: The nurse should apply the least invasive priority-setting framework, which assigns priority to nursing interventions that are the least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, since witnessing the informed consent is the least invasive action, it should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion for a client.

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? Pitting edema Areas of reddish-brown pigmentation Dry, pale skin with minimal body hair Sunburned appearance with desquamation

Dry, pale skin with minimal body hair Rationale: 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, cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? Elevate the affected leg Place the client on bed rest Massage the affected leg Administer aspirin for discomfort

Elevate the affected leg Rationale: The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.

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

Elevated Hct Rationale: The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated Hct level as blood volume is reduced by vascular dehydration.

A nurse is caring for an adult 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? Cholesterol level 195 mg/dL Elevated HDL levels Elevated LDL levels Triglyceride level 135 mg

Elevated LDL level Rationale: An elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? Maintain the client's knees and hips in a flexed position Apply cold compresses to painful joints Withhold opioids until the crisis is resolved Encourage increased fluid intake

Encourage increased fluid intake Rationale: The nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can aggravate sickling and client discomfort.

While participating in a community health fair, a nurse is providing information to a client who has a blood pressure of 150/90 mmHg during screening. Which of the following actions should the nurse take? Give the client a written record of his BP to bring to his provider Encourage the client to go to the nearest ER Instruct the client to follow up with a provider within 6 months Explain to the client that he is not at risk unless he has manifestations of HTN

Give the client a written record of his BP to bring to his provider Rationale: Since the client has an elevated BP reading from a HTN screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider.

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? Onion soup and salad Vegetarian wrap with potato chips Grilled chicken salad with fresh tomatoes Chicken bouillon and crackers

Grilled chicken salad with fresh tomatoes Rationale: Sodium reduction helps control BP. Grilled chicken salad and fresh tomatoes are free of preservatives and, therefore, are likely to be low in sodium. However, it is essential to make sure the food preparer has not added salt generously to the chicken and the salad.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (SATA) Hardening along the blood vessel Absence of a peripheral pulse Tenderness in the calf Cool skin on the leg Increased leg circumference

Hardening along the blood vessel Tenderness in the calf Increased leg circumference Rationale: Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? Magnesium 2.0 mEq/L Hgb 6.5 g/dL WBC count 9.6/mm3 Creatinine 0.8 mg/dL

Hgb 6.5 g/dL Rationale: The expected reference range of Hgb is 14-18 g/dL for men and 12-16 g/dL for women. Therefore, a client who has an Hgb level of 6.5 g/dL as anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallor, dizziness, and tachycardia.

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (SATA) Hypothyroidism Hypertension Diabetes mellitus Hyperlipidemia Tobacco smoking

Hypertension Diabetes mellitus Hyperlipidemia Tobacco smoking Rationale: A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for (CAD). Hypertension and hyperlipidemia 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 recommendations. Cholesterol levels, such as total HDL and LDL levels, should be monitored since elevated total serum cholesterol levels increase the risk of a MI. Finally, 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.

A nurse is providing teaching to 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? Hospitalization is required when administering each treatment The maximum effect of the medication will occur in 6 months Hypertension is a common adverse effect of this medication Blood transfusions are needed with each treatment

Hypertension is a common adverse effect of this medication Rationale: 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.

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? Hypokalemia Hypophosphatemia Hypercalcemia Hypermagnesemia

Hypokalemia Rationale: Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports SOB on exertion. Which of the following conditions should the nurse expect? Increased cardiac output Increased pulmonary congestion Decreased left atrial pressure Decreased pulmonary artery pressure

Increased pulmonary congestion Rationale: Pulmonary congestion is a manifestation of mitral valve stenosis. Because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilates. The increased pressure results in a backflow of blood from the left atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (SATA) Jugular vein distension Moist crackles Postural hypotension Increased heart rate Fever

Jugular vein distension Moist crackles Increased heart rate Rationale: The increased venous pressure due to excessive circulating blood volume results in neck vein distention. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses.

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

Lower back discomfort Rationale: An abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.

A nurse is planning 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 post-procedure plan of care? Instruct the client about a long-term cardiac conditioning program Administer scheduled doses of acetaminophen Check for peak laboratory markers of myocardial damage Monitor bleeding

Monitor bleeding Rationale: Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis is assured.

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? Narrower than usual QRS complex Much greater amplitude than the usual QRS complex Same polarity as the usual QRS complexes Immediate resumption of the usual rhythm

Much greater amplitude than the usual QRS complex Rationale: The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs.

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? Necrosis Hypokalemia Hypomagnesemia Insufficiency

Necrosis Rationale: 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.

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? Plethoric appearance of facial skin Glossitis and weight loss Jaundice with an enlarged liver Petechiae and ecchymosis

Petechiae and ecchymosis Rationale: A client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion can also be present. In aplastic anemia, all 3 major blood components (RBCs, WBCs, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? Potassium 2.8 mEq/L Digoxin level 0.7 ng/mL Hemoglobin 9.8 g/fL Calcium 8.0 mg

Potassium 2.8 mEq/L Rationale: A flattened T wave or the development of U waves is indicative of a low potassium level.

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? Flattened T waves Prolonged QT intervals Shortened QT intervals Widened QRS complexes

Prolonged QT intervals Rationale: Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.

A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take? Continue to monitor for manifestations of a transfusion reaction Remove the unit of plasma immediately and start an IV infusion of normal saline solution Continue the transfusion and repeat the type and crossmatch Prepare to administer a dose of diphenhydramine IV

Remove the unit of plasma immediately and start an IV infusion of normal saline solution Rationale: A client who receives FFP that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.

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

Report of sudden, severe back pain Rationale: An aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar-sacral nerve roots.

A nurse is adminstering a unit of packed RBCs to a client who is postoperative. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? Maintain IV access with 0.9% sodium chloride Stop the infusion of blood Send the blood container and tubing to the blood bank Obtain a urine sample

Stop the infusion of blood Rationale: Using the urgent vs. non-urgent priority-setting framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.

A nurse is preparing an in-service presentation about assessing clients who are having an acute MI. What is the most common assessment finding with acute MI? Dyspnea Pain in the shoulder and left arm Substernal chest pain Palpitations

Substernal chest pain Rationale: Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? The percentage of blood the ventricles pump during each beat The amount of blood the left ventricle pumps during each beat The amount of blood in the left ventricle at the end of diastole The heart rate times the stroke volume

The heart rate times the stroke volume Rationale: Cardiac output is the product of the client's heart rate and stroke volume. In systolic heart failure, the heart cannot pump enough oxygenated blood into the circulation, causing cardiac output to decrease.

A nurse is preparing an in-service presentation about the basics of hematology. Which of the following factors provides a stimulus for the production of RBCs? Venous stasis Thrombocytopenia Inflammation Tissue hypoxia

Tissue Hypoxia Rationale: In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes (RBCs) in the bone marrow.

A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? Turkey on whole-wheat bread Hamburger and french fries Frankfurter on white roll Macaroni and cheese

Turkey on whole-wheat bread Rationale: The primary dietary alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole-wheat bread has a relatively low sodium content.

A nurse is caring for a client who has pernicious anemia. Which of the following factors should the nurse identify with this condition? Iron deficiency Hemolytic blood loss Folic acid deficiency Vitamin B12 deficiency

Vitamin B12 deficiency Rationale: A client who has pernicious anemia is deficient in vitamin B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12.

A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease? Vitamin A Vitamin B3 Vitamin C Vitamin D

Vitamin C Rationale: Vitamin C deficiency produced symptoms of scurvy such as delayed wound healing and capillary fragility.