Cardiovascular, Hematologic, and Lymphatic Systems Level 1 & 2

Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed, and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test?

1 Complete blood count Correct2 Serum potassium level 3 X-ray film of long bones 4 Blood cultures times three Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood count, x-ray film of long bones, and blood cultures times three will have no significance in the diagnosis of a potassium deficit.

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings?

1 The furosemide is causing dehydration. Correct2 Cloudy urine may be indicative of infection. 3 The client has inadequate hourly urine output. 4 All of the indications are within normal findings. Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.

A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, "What can I do to help myself?" How should the nurse respond?

1 "Limit walking to as little as possible." 2 "Reduce fluid intake to 1 L of liquid a day." 3 "Apply moisturizing lotion on your legs several times a day." Correct4 "Put on compression hose before getting out of bed in the morning." As valves become incompetent, they allow blood to pool in the veins, which increases hydrostatic pressure and leads to further valve destruction. Compression hose provide external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. The legs are less congested after sleeping, and therefore the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Prolonged sitting, standing, or crossing the legs should be avoided because they reduce venous return. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin more supple, it will not treat enlarged and tortuous veins.

A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a client is hypertensive?

1 Tachycardia 2 Extended Korotkoff sound Incorrect3 Sustained systolic pressure ranging from 110 to 120 mm Hg Correct4 Diastolic blood pressure that remains higher than 90 mm Hg A sustained diastolic pressure that exceeds 90 mm Hg reflects pathology and indicates hypertension. Tachycardia reflects the heart rate, not the pressures within the arteries. Extended Korotkoff sound is heard when measuring blood pressure by auscultation; it is unrelated to hypertension. Sustained systolic pressure ranging from 110 to 120 mm Hg is an expected systolic blood pressure.

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man?

Correct1 "Do you have chest pain?" 2 "Are you feeling anxious?" 3 "Do you have any palpitations?" 4 "Are you feeling short of breath?" Females may present with atypical symptoms of myocardial infarction, such as absence of chest pain, overwhelming fatigue, and indigestion. Anxiety, palpitations, and shortness of breath are common clinical manifestations in both males and females who are experiencing a myocardial infarction.

While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every 2 hours. What does the nurse explain that these exercises will help to do?

Correct1 Prevent clot formation 2 Reduce leg discomfort 3 Maintain muscle strength 4 Limit venous inflammation Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. Active ROM exercises help prevent, not limit, venous inflammation.

A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60 mm Hg. What should the nurse assess in the client as an early sign of decreased arterial pressure?

Correct1 Weak radial pulses 2 Warm, flushed skin 3 Lethargy with confusion 4 Increased pulse pressure Hypovolemia occurs with decreased cardiac output; the resulting decreased arterial pressure is reflected in weak, thready peripheral pulses. The skin will be cool and pale because of vasoconstriction. Lethargy with confusion will occur later as a result of hypovolemic shock. The pulse pressure will be decreased, not increased, with decreased cardiac output associated with hypovolemic shock.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful?

1 Apples Correct2 Broccoli 3 Cherries 4 Cauliflower Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.

A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?

1 Arterial spasm Correct2 Heart muscle ischemia 3 Blocking of the coronary veins 4 Irritation of nerve endings in the cardiac plexus Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session?

1 Elevated blood pressure Correct2 Increased blood viscosity 3 Fragility of the blood cells 4 Immaturity of red blood cells Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation. Hypertension usually is related to narrowing or sclerosing of arteries, not to an increased number of blood cells. The fragility of blood cells does not affect the viscosity of the blood. Erythrocyte immaturity is not related to increased viscosity.

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness?

1 Hepatitis A Correct2 Rheumatic fever 3 Spinal meningitis 4 Rheumatoid arthritis Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the heart's valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of streptococcal infections have limited the occurrence of rheumatic heart disease. Hepatitis A, an inflammation of the liver, is caused by the hepatitis A virus (HAV), not by bacteria. The most common causes of meningitis, an infection of the membranes surrounding the brain and spinal cord, include Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Rheumatoid arthritis is believed to be an autoimmune disorder; it is not caused by microorganisms.

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

1 Obtain vital signs 2 Initiate a cardiac arrest code Correct3 Administer oxygen using a face mask 4 Encourage the use of an incentive spirometer The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted. The client is not experiencing a cardiac arrest, and therefore a code should not be initiated. After more definitive medical intervention, deep breathing and coughing or use of an incentive spirometer may be done to prevent or treat atelectasis.

A primary healthcare provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive?

1 Omeprazole Incorrect2 Acetaminophen 3 Docusate sodium Correct4 Pseudoephedrine Pseudoephedrine has a pressor effect that may counteract antihypertensive medications, causing an increase in blood pressure. Omeprazole does not interact with antihypertensives. However, it can increase the action of phenytoin, digoxin, clopidogrel, and cyclosporine. Acetaminophen does not have to be avoided when receiving an antihypertensive. Docusate sodium does not have to be avoided when receiving an antihypertensive.

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client?

1 Renin causes a gradual decrease in arterial pressure. Correct2 Lipid plaque formation occurs within the arterial vessels. 3 Development of atheromas within the myocardium is characteristic. Incorrect4 Mobilization of free fatty acid from adipose tissue contributes to plaque formation. The term atherosclerosis means a thickening of the arterial lining by lipid plaques, which become atheromas. Arterial pressure increases, not decreases, as a result of renin. Atheromas develop within the lining of the arteries, not within the cardiac muscle tissue. Mobilization of free fatty acids will produce an acid-base imbalance.

A client on a 2-gram sodium diet states, "I never add salt to my food when I cook. I just need help selecting low-sodium foods." After receiving dietary education, the client creates sample menus. Which meal selection will cause the nurse to intervene?

1 Soft-cooked egg, toast, jelly, skim milk 2 Baked chicken, boiled potatoes, broccoli, coffee 3 Fillet of sole, baked potato, fresh fruit cup (berries and melons) Correct4 Cottage cheese, crackers, relish dish (celery, olives, sweet pickles) Cottage cheese, crackers, and a relish dish (celery, olives, sweet pickles) have the highest sodium content. Meals consisting of soft-cooked egg, toast, jelly, and skim milk; baked chicken, boiled potatoes, broccoli, and coffee; and fillet of sole, baked potato, and fresh fruit cup (berries and melons) are low in sodium.

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain?

1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis Correct4 Intermittent claudication Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

1 The fat-forming ketoacids were broken down. 2 The irregular heartbeat produced oxygen deficit. Correct3 The decreased tissue perfusion caused lactic acid production. 4 The client received too much sodium bicarbonate during resuscitation efforts. Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Too much sodium bicarbonate causes alkalosis, not acidosis.

Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon?

1 The increased blood pressure can cause the graft to occlude. 2 The hypervolemia needs to be corrected immediately. 3 The client's cardiovascular status can precipitate a brain attack. Correct4 The client's intraarterial pressure may compromise the graft's viability. The client is hypertensive, and the intraarterial pressure is elevated; this increased pressure can cause the arterial suture line to rupture. Blood pressure causing the graft to occlude is unlikely because the blood pressure is elevated and the client is at risk for bleeding. Hypervolemia is an assumption; other causes, such as arterial constriction, can precipitate hypertension. Although cardiovascular status can precipitate a brain attack, the priority for this client is protecting the graft.

client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?

1 The signs and symptoms of pericarditis Correct2 The signs and symptoms of heart failure 3 That cardiac surgery will have to be done eventually for the other valves 4 That cardiac surgery will have to be done every six months to replace the valve The teaching plan for this client should focus on the possibility of heart failure. Clients with a failed valve are prone to heart failure; report any signs of dyspnea, syncope, dizziness, edema, and palpitations. Infective endocarditis, not pericarditis, may occur. Endocarditis is an infection of the endothelial surface of the heart and valves. Pericarditis is an inflammation of the pericardium, the membranous sac enveloping the heart. There is no evidence of pathology of other valves. There is no schedule that valves will be replaced every six months.

A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order.

Correct 1. Stop the transfusion. Correct 2. Change the intravenous (IV) administration set. Correct 3. Run 0.9% normal saline at a rapid rate. Correct 4. Notify the primary healthcare provider and blood bank. The priority is to stop the transfusion. Failure to do so will make the reaction worse. Changing the IV administration set will prevent infusing any blood product remaining in tubing. Running normal saline rapidly will help to decrease shock and hypotension. Notifying the primary healthcare provider and blood bank would be the last step because this would take longer than the first three choices.

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition?

Incorrect1 "I have abnormal platelets." Correct2 "I have abnormal hemoglobin." 3 "I have abnormal hematocrit." 4 "I have abnormal white blood cells." The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. While it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Incorrect1 Feel for a pulse Correct2 Begin chest compressions 3 Leave to call for assistance 4 Perform the abdominal thrust maneuver According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, it has been established the client has no pulse (cardiopulmonary arrest); therefore chest compressions are initiated. Do not leave the client to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop?

Incorrect1 Hypokalemia Correct2 Metabolic acidosis 3 Respiratory alkalosis 4 Decreased Pco2 levels Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco2 level will increase in profound shock.

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor?

Incorrect1 Metabolic alkalosis Correct2 Myocardial hypoxia 3 Decreased catecholamine secretion 4 Increased parasympathetic nervous system stimulation Dysrhythmias are common and result from decreased oxygen to the cells of the myocardium. Myocardial infarction with tissue necrosis results in metabolic acidosis, not metabolic alkalosis. When physical or emotional stress is experienced, such as in an MI, catecholamine secretion increases; this is part of the "fight or flight" mechanism. Increased sympathetic, not parasympathetic, nervous system stimulation may contribute to the development of dysrhythmias.

While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority?

1 Administer nitroglycerin and aspirin 2 Slow the rate and monitor the vital signs Correct3 Stop the transfusion and administer normal saline 4 Ask the client to further describe the feeling and rate the pain The chest tightness or pressure and impending doom indicate the presence of an acute hemolytic reaction; other signs and symptoms include low back pain, tachycardia, tachypnea, and anxiety. The transfusion must be stopped immediately. Administering nitroglycerin and aspirin is appropriate for a possible myocardial infarction but not for a hemolytic reaction. Slowing the rate and monitoring the vital signs will increase the severity of symptoms and may increase morbidity or mortality. Exploring feelings will delay appropriate action.

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication?

1 Fever and chest pain 2 Positive Homans sign 3 Loss of sensation in the operative leg 4 Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurologic dysfunction; it is not an indication of a fat embolism.

A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best response by the nurse?

1 "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." 2 "Those spots indicate a high glucose content in the skin that may get infected if left untreated." 3 "They are the result of diseased small vessels in the shins and may spread if not treated soon." Correct4 "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot." "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the definition of a xanthoma. A high glucose content in the skin that has become infected is not the cause of brown spots on the skin; increased glucose in the skin is not observable by inspection. Brown spots result from the deposition of hemosiderin. Blood vessels may become diseased with diabetes, but this does not cause brown spots.

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client?

Correct1 Deficient fluid volume 2 Impaired skin integrity 3 Inadequate nutritional intake 4 Decreased participation in activities The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.

The nurse is collecting data from a client with varicose veins who is to have sclerotherapy. Which assessment finding does the nurse expect the client to report?

Correct1 Feelings of heaviness in both legs 2 Intermittent claudication of the legs 3 Calf pain on dorsiflexion of the foot 4 Hematomas of the lower extremities Impaired venous return causes increased pressure, with subjective symptoms of fatigue and heaviness of the legs. Intermittent claudication, a symptom of cellular hypoxia, is related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot can be indicative of thrombophlebitis. Ecchymosis may occur in some individuals, but there is insufficient bleeding into tissue to cause hematomas.

A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain?

Correct1 Fluid retention 2 Urinary retention Incorrect3 Renal insufficiency 4 Abdominal distention With the client's history and the large weight gain, fluid retention is the most likely cause of the increase in weight. Urinary retention occurs in the bladder, not the tissues, and does not account for the large weight gain. Renal insufficiency can occur with heart failure, but it is not the primary etiological factor of the sudden weight gain. Abdominal distention usually is caused by gas in the intestine and should not contribute to this large a weight gain. If the abdomen is enlarged, assessment by ballottement should be done to determine whether enlargement is caused by fluid in the peritoneal cavity (ascites).

What is the nurse primarily attempting to prevent when caring for a client in the initial stages of chronic lymphocytic leukemia (CLL)?

Incorrect1 Injury 2 Fatigue Correct3 Infection 4 Cachexia Although lymphocytosis is always present, defects in humoral and cellular immunity increase the risk for infection. Injury becomes an issue later in the disease when thrombocytopenia may develop. Fatigue becomes an issue later in the disease when anemia may develop. Although excessive weight loss is a concern, it does not pose the same threat as infection for clients with CLL.

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings?

Incorrect1 Refer the client to a nutritionist after providing health teaching about a low-sodium diet. 2 Place the client in a recumbent position and call the paramedics for transport to the hospital. 3 Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. Correct4 Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible. According to the United States Department of Health and Human Services (Canada: Canadian Heart and Lung Association), both of these readings indicate hypertension and thus require further evaluation by a healthcare provider; having a baseline for both arms can assist the healthcare provider with the medical diagnosis. Teaching about a low-sodium diet is an inadequate intervention. An appointment with a healthcare provider, not a nutritionist, should be scheduled as soon as possible. There are insufficient data to support this emergency intervention (calling the paramedics). The client's elevated blood pressure needs to be evaluated by a healthcare provider and then medical therapy implemented. Although emotional stress can precipitate hypertension, physical causes should be ruled out first.

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization?

Incorrect1 To obtain the pressures in the heart chambers 2 To determine the existence of congenital heart disease Correct3 To visualize the disease process in the coronary arteries 4 To measure the oxygen content of various heart chambers Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

Incorrect1 Age 2 Height Correct3 Weight Correct4 Smoking Incorrect5 Family history Obesity is a modifiable risk factor that is associated with coronary artery disease (CAD); an increased fat intake contributes to an increased serum cholesterol and atherosclerosis. Smoking, which constricts the blood vessels, is a modifiable risk factor for CAD. The incidence of CAD does increase with age. However, age is not a modifiable risk factor. Height is unrelated to the incidence of CAD. Family history is not a modifiable risk factor for CAD because one cannot control heredity.

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider?

My Account Help CatalogMy Evolve Loading... Elsevier Adaptive Quizzing - Intergrated Practicum (W18) Cardiovascular, Hematologic, and Lymphatic Systems Level 1 123456789101112 5. A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? 1 Hematocrit 46% 2 Hemoglobin 14.1 g/dL (141 mmol/L) Correct3 Potassium 3.0 mEq/L (3.0 mmol/L) 4 White blood cell 9200/mm3 (9.2 × 109/L) A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm3is within the normal range of 4000 to 11,000 cells/mm3 (4 to 11 × 109/L).

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment?

1 Decreased breath sounds Correct2 Elevated serum troponin I 3 Decreased creatine kinase-MB (CK-MB) 4 Elevated brain natriuretic peptide (BNP) level Elevations of troponin I levels are indicative and specific for cardiac muscle damage. Decreased breath sounds would indicate a pulmonary problem. An increase in CK-MB would indicate MI. Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction.

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication?

1 Cataracts 2 Esophagitis Correct3 Kidney failure 4 Diabetes mellitus Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures, such as tubules, glomeruli, and nephrons, leading to kidney failure. Retinopathy, resulting in blurred vision, retinal hemorrhage, and blindness, occurs with a long history of hypertension because of increased intravascular pressure, not cataracts. Esophagitis is caused by esophageal reflux disease, not a long history of hypertension. Hypertension does not cause diabetes mellitus; however, chronic elevations of serum glucose accelerate atherosclerosis, resulting in the development of hypertension.

A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse?

1 "These pacing wires can be attached to a temporary pacemaker to shock the heart if it starts beating too fast." 2 "This type of pacemaker will automatically defibrillate the heart if the heart forgets to beat." Incorrect3 "The pacemaker will maintain a constant cardiac rhythm." Correct4 "In case to too slow of a heart rate, the epicardial leads are attached to a pacemaker to maintain a normal rate." Epicardial pacing involves attaching an atrial and ventricular pacing lead to the epicardium during heart surgery. The leads are passed through the chest wall and attached to the external power source. Epicardial pacing leads are placed prophylactically in case any bradydysrhythmias or tachydysrhythmias occur in the early postoperative period. Vagal stimulation during surgery may cause a severe bradycardia; in anticipation, pacemaker wires are inserted into the right atrium to be used to initiate impulses if the natural rate decreases below the preset rate of the pacemaker; this will ensure that the heart beats at the rate set for the pacemaker. This pacemaker initiates an impulse if the heart rate drops below a certain rate; the concept underlying this pacemaker is to speed up the heart, not to slow it down. There are no data to support the fact that this is a defibrillator pacemaker. The pacemaker wires are not used for defibrillation; defibrillator paddles are placed so that electricity affects the entire heart muscle. The rhythm can be irregular; however, if the pause between two beats is too long, the pacemaker will initiate an impulse.

The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would be the best reply by the nurse?

1 "Why do you want to be out of bed?" 2 "Bed rest plays a role in most therapy." Correct3 "Rest helps your body direct energy toward healing." 4 "Would you like me to ask your primary healthcare provider to change the prescription?" A client's knowledge about the treatment program enhances compliance and reduces stress. The response "Why do you want to be out of bed?" does not answer the client's question and might produce frustration. The response "Bed rest plays a role in most therapy" does answer the client's question, but does not explain specifically why. The response "Would you like me to ask your primary healthcare provider to change the prescription?" does not support the treatment regimen; the client needs education.

How can the nurse best describe heart failure to a client?

1 A cardiac condition caused by inadequate circulating blood volume 2 An acute state in which the pulmonary circulation pressure decreases Correct3 An inability of the heart to pump blood in proportion to metabolic needs 4 A chronic state in which the systolic blood pressure drops below 90 mm Hg As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop.

A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action?

1 Abdominal pain 2 Respiratory distress 3 Sudden hemorrhage Correct4 Postural hypotension After administration of certain antihypertensives or opioids, a client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when an upright position is assumed. Postural or orthostatic hypotension occurs, and blood supply to the brain is temporarily decreased. Abdominal pain, respiratory distress, and sudden hemorrhage will not be prevented by the intervention described.

Correct 1. Stop the transfusion. Correct 2. Change the intravenous (IV) administration set. Correct 3. Run 0.9% normal saline at a rapid rate. Correct 4. Notify the primary healthcare provider and blood bank. The priority is to stop the transfusion. Failure to do so will make the reaction worse. Changing the IV administration set will prevent infusing any blood product remaining in tubing. Running normal saline rapidly will help to decrease shock and hypotension. Notifying the primary healthcare provider and blood bank would be the last step because this would take longer than the first three choices.

1 Atrial fibrillation Correct2 Sinus tachycardia 3 Ventricular fibrillation 4 First-degree atrioventricular block The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

A primary healthcare provider decides to omit a treatment that was part of a course of chemotherapy for a client because the client demonstrates myelosuppression. What information would be appropriate for the nurse to give to the client regarding myelosuppression?

1 Calcium carbonate and vitamin D must be increased in the diet because of the effects of myelosuppression. Correct2 Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. 3 The development of myelosuppression explains why the client has nausea, vomiting, anorexia, and alopecia. 4 Frequent testing for restlessness, muscle control, and pupillary response is necessary because the meninges may be irritable. Myelosuppression involves a decreased number of red blood cells (anemia), resulting in a reduced oxygen-carrying capacity of the blood and fatigue. A decreased number of white blood cells (leukopenia) results in a potential for infection. A decreased number of platelets (thrombocytopenia) results in a potential for bleeding. Myelosuppression is not related directly to calcium carbonate and vitamin D; myelosuppression, a reduction in bone marrow activity, results in decreased numbers of red blood cells (RBCs), white blood cells (WBCs), and platelets. Myelosuppression is not related to nausea, vomiting, anorexia, or alopecia. Myelosuppression is related to bone marrow activity, not the nervous system.

A nurse is performing external cardiac compression. Which action should the nurse take?

1 Extend the fingers over the sternum and chest with the heels of each hand side by side. 2 Place the fingers of one hand on the sternum and the fingers of the other hand on top of them. Correct3 Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it. 4 Clench the hand into a fist and place the fleshy part of a clenched fist on the lower sternum. Interlocking the fingers with the heel of one hand on the sternum and the heel of the other on top of it provides the best leverage for depressing the sternum. Thus, the heart is adequately compressed, and blood is forced into the arteries. Grasping the fingers keeps them off the chest and concentrates the energy expended in the heel of the hand while minimizing the possibility of fracturing ribs. Pressure spread over two hands may inadequately compress the heart and fracture the ribs. Application of pressure by the fingers is less effective; this provides inadequate cardiac compression. Both hands must be used; pressure on the lower portion of the sternum may fracture the xiphoid process, which can injure vital underlying organs.

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement?

1 Fear 2 Depression 3 Dependency 4 Ambivalence Fear of a recurrent myocardial infarction or sudden death is common when the client's environment is to be changed to one that appears less vigilant. Depression is exhibited by withdrawal, crying, anorexia, and apathy, and it usually becomes more evident after discharge from the hospital. Dependency is exhibited by an unwillingness to increase exercise or perform tasks. Ambivalence is exhibited by contrasting emotions; the client's statement does not demonstrate this.

A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure?

1 Fear of dying 2 Skipped heartbeats Correct3 Pain at the insertion site Incorrect4 Anxiety in response to intensive monitoring Pain at the arterial puncture site is attributable to entry and cannulation of the artery and is a common complaint after a cardiac catheterization. Fear of dying might occur during the precatheterization period. Although skipped heartbeats may occur during the procedure because of trauma to the conduction system, usually it does not continue after the procedure. Although some clients may be anxious, many feel safe when receiving ongoing monitoring.

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication?

1 Fever and chest pain 2 Positive Homans sign 3 Loss of sensation in the operative leg Correct4 Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurologic dysfunction; it is not an indication of a fat embolism.

When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress?

1 Getting up from bed in the morning 2 Walking to visit the next-door neighbor Correct3 Climbing a flight of stairs to the bedroom 4 Leaving the table immediately after a meal Stair climbing increases oxygen consumption and therefore increases the workload of the heart; this results in dyspnea and fatigue. Getting up from bed in the morning may cause orthostatic hypotension; the oxygen demands of the body are not significantly increased when sitting up. Walking short distances on level surfaces will not place as much strain on the cardiovascular system as does climbing stairs against gravity. Although moving from a sitting to a standing position during digestion increases the demand on the heart, it is not as demanding or sustained an activity as is climbing stairs.

What is the nurse primarily attempting to prevent when caring for a client in the initial stages of chronic lymphocytic leukemia (CLL)?

1 Injury 2 Fatigue Correct3 Infection 4 Cachexia Although lymphocytosis is always present, defects in humoral and cellular immunity increase the risk for infection. Injury becomes an issue later in the disease when thrombocytopenia may develop. Fatigue becomes an issue later in the disease when anemia may develop. Although excessive weight loss is a concern, it does not pose the same threat as infection for clients with CLL.

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first?

1 Interview the client for a health history. Correct2 Assess the client's heart and lung sounds. 3 Monitor the client's pulse and temperature. 4 Obtain the client's blood specimen for electrolytes. With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest?

1 It prevents the further aggregation of platelets. 2 It enhances the peripheral circulation in the deep vessels. Correct3 It decreases the potential for further dislodgment of emboli. 4 It maximizes the amount of blood available to damaged tissues. Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation or the circulation of blood to damaged tissues.

What should the nurse do to prevent thrombus formation after most surgeries?

1 Keep the client's bed gatched to elevate the knees. 2 Have the client dangle the legs off the side of the bed. 3 Have the client use an incentive spirometer every hour. Correct4 Encourage the client to ambulate with assistance every few hours. Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client's bed gatched to elevate the knees or having the client dangle the legs off the side of the bed cause increased popliteal pressure and impair venous return. Having the client use an incentive spirometer every hour helps prevent atelectasis, not thrombi.

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor?

1 Metabolic alkalosis Correct2 Myocardial hypoxia 3 Decreased catecholamine secretion Incorrect4 Increased parasympathetic nervous system stimulation Dysrhythmias are common and result from decreased oxygen to the cells of the myocardium. Myocardial infarction with tissue necrosis results in metabolic acidosis, not metabolic alkalosis. When physical or emotional stress is experienced, such as in an MI, catecholamine secretion increases; this is part of the "fight or flight" mechanism. Increased sympathetic, not parasympathetic, nervous system stimulation may contribute to the development of dysrhythmias.

A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension?

1 Mild but persistent depression 2 Transient temporary memory loss Correct3 Occipital headache in the morning Incorrect4 Cardiac palpitation during periods of stress Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged. Mild but persistent depression is a nonspecific response; it is not physiologically related to increased arterial blood pressure. Transient temporary memory loss occurs with transient ischemic attacks, which may be a later consequence of prolonged hypertension. Cardiac palpitation during periods of stress is a common physiologic effect; it is not specific to hypertension.

What must the nurse do to determine a client's pulse pressure?

1 Multiply the heart rate by the stroke volume. Correct2 Subtract the diastolic from the systolic reading. 3 Determine the mean blood pressure by averaging the two. 4 Calculate the difference between the apical and radial rate. Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.

A client returns from a cardiac catheterization procedure and is to remain in the supine position for 4 hours with the affected leg straight. What are these measures intended to prevent?

1 Orthostatic hypotension 2 Headache with disorientation Correct3 Bleeding at the arterial puncture site Incorrect4 Infiltration of radiopaque dye into tissue Bed rest with immobilization of the leg promotes coagulation and healing at the puncture site of the femoral artery. In the absence of bleeding and the presence of adequate fluid replacement, a cardiac catheterization does not cause orthostatic hypotension. Headache with disorientation is not expected after a cardiac catheterization. A small amount of radiopaque dye is injected (via the catheter) directly into the heart, where the blood dilutes it; it does not create a problem at the puncture site.

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority?

1 Prepare for blood transfusions. Correct2 Notify the surgeon immediately. 3 Make the client nothing by mouth (NPO). Incorrect4 Administer the prescribed preoperative sedative. Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms of shock.

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client?

1 Renin causes a gradual decrease in arterial pressure. Correct2 Lipid plaque formation occurs within the arterial vessels. 3 Development of atheromas within the myocardium is characteristic. Incorrect4 Mobilization of free fatty acid from adipose tissue contributes to plaque formation. The term atherosclerosis means a thickening of the arterial lining by lipid plaques, which become atheromas. Arterial pressure increases, not decreases, as a result of renin. Atheromas develop within the lining of the arteries, not within the cardiac muscle tissue. Mobilization of free fatty acids will produce an acid-base imbalance

After multiple bee stings, a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what processes?

1 Respiratory depression and cardiac arrest Correct2 Bronchial constriction and decreased peripheral resistance Incorrect3 Decreased cardiac output and dilation of major blood vessels 4 Constriction of capillaries and decreased peripheral circulation Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs. Respiratory depression and cardiac arrest are the problems that result from bronchial constriction and vascular collapse. Dilation of arterioles occurs. Arterioles dilate, capillary permeability increases, and eventually vascular collapse occurs.

A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation?

1 Sickle cell anemia is a random condition with no known cause. 2 If one parent is a carrier and one is negative for the gene, the child will get the disease. 3 If both parents are carriers, all of their offspring will probably get this disease, and they should consider sterilization. Correct4 If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free. If both parents are carriers, the odds are one in four an offspring will get the disease, two in four will be carriers, and one in four will be disease free. It is an autosomal recessive inherited condition. Sickle cell anemia is not random; the gene must come from both parents. One parent being a carrier and the other not having the gene would not cause the disease. If both parents are carriers there is the possibility of 25% with each pregnancy that the child may inherit the disease, and 50% of being a carrier.

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding?

1 Sinus tachycardia 2 Normal sinus rhythm Correct3 Sinus rhythm with premature atrial contractions (PACs) 4 Sinus bradycardia with premature ventricular contractions (PVCs) A PAC is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.12 seconds. P and QRS waves are consistent in shape. Bradycardia is defined as a heart rate less than 60 beats per minute.

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do?

1 Slide slowly to the floor to prevent a fall and injury. Correct2 Sit on the edge of the bed while they hold the client upright. 3 Bend forward because this will increase blood flow to the brain. 4 Lie down quickly so the legs can be raised above the heart level. Sitting allows the nurses to support the client until orthostatic hypotension subsides. The client's stable pulse and color indicate that the situation does not warrant placing the client in the supine position. Sliding slowly to the floor to prevent a fall and injury, bending forward, or rapid movement will permit flexion of the vertebrae, which may traumatize the spinal cord. A light-headed feeling usually is transient until the body adapts to the upright position, so leg elevation is unnecessary.

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?

1 The stockings should reach the middle of the knee. Correct2 The stockings should be applied before getting out of bed. 3 The stockings should be applied at the first sign of discomfort. 4 The stockings may be substituted with loose elastic bandages. To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches (5 cm) below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. The stockings apply uniform pressure; loose elastic bandages may slip, creating uneven, ineffective pressure. Edema also may result.

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization?

1 To obtain the pressures in the heart chambers 2 To determine the existence of congenital heart disease Correct3 To visualize the disease process in the coronary arteries 4 To measure the oxygen content of various heart chambers Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.

A client is seen in the clinic with sickle cell anemia. The primary healthcare provider has prescribed an iron supplement to treat the client's anemia. What is the nurse's primary concern in regard to giving the supplement?

Correct1 Giving iron with this condition is contraindicated. 2 Finding a straw is necessary to prevent staining of teeth. 3 When giving iron, orange juice is needed to improve absorption. 4 Warning about stools changing to black will prevent undue stress. Giving iron is contraindicated as sickled cells do not incorporate the iron, so it will build up in the body, causing pain rather than being absorbed. Liquid iron should be administered with a straw to prevent staining teeth, but not with this condition. Giving iron with orange juice is correct, but not to a person with sickle cell anemia. Feces will turn dark with iron supplements; however, this client should not be receiving iron.

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes?

Correct1 Hypokalemia 2 Hypocalcemia 3 Hyponatremia Incorrect4 Hypomagnesemia Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.

A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic?

Correct1 International normalized ratio (INR) 2 Accelerated partial thromboplastin time (APTT) 3 Bleeding time 4 Sedimentation rate Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what?

Correct1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock.

A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm?

Correct1 Normal sinus rhythm 2 Sinus tachycardia 3 Sinus bradycardia 4 Sinus arrhythmia Normal sinus rhythm reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.

After flushing a client's left forearm saline lock (SL) with normal saline, the client begins to report a painful and burning sensation at the insertion site. Which is the most appropriate action for the nurse to take?

Correct1 Remove the angiocatheter and saline lock and restart the SL in another site. 2 Document the findings per protocol and reassess the site in eight hours. 3 Flush the angiocatheter and saline lock again with sterile water. 4 Change the dressing and apply a new clean dressing. The angiocatheter has slipped out of the vein and infiltrated into the tissue and needs to be removed and restarted in another site. The nurse then needs to document the actions and follow protocol for reassessment. Flushing the angiocatheter with sterile water would only increase the pain and aggravate the infiltration site. Changing the dressing will not help infiltration.

A client with a history of type 1 diabetes is experiencing progressive problems with venous stasis. The client tells the nurse, "I bumped my leg a week ago, and now it has an open draining area just above the ankle." Which information is most important for the nurse to explore when collecting the client's health history?

Correct1 The type of treatment and care the client is receiving Incorrect2 What dosage and type of insulin the client is taking and how often 3 The number of family members that are experiencing similar problems 4 How many times a day the client voids and the frequency of bowel movements Asking what type of treatment the client is receiving and how the client is managing care will elicit a variety of data such as medications, diet, and other aspects of care and even includes the care of the new wound. Although it is important to know about the client's insulin use, the information is too limited and does not include how the client is caring for the new wound or for the diabetes itself. Although information about a client's bowel and bladder habits is important, it is not the priority. Although information about the client's children is important, determining the number of family members the client has and whether they are having similar problems is not the priority.

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider?

Incorrect1 Client pushes the airway out. 2 Client has snoring respirations. 3 Client's respirations are 16 breaths per min and shallow. Correct4 Client's systolic blood pressure drops from 130 to 90 mm Hg. A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Shallow respirations of 16 breaths per min is a common response to depressant effects of anesthesia.

A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations?

Incorrect1 Long-term use of an irritant-type laxative 2 Emotional response resulting in physical symptoms 3 Inadequate dietary practices resulting in altered bowel function Correct4 Systemic responses of the body to a localized inflammatory process With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).