Cardiovascular

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

Correct Answer: B. Crackles in the lung bases Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs. Incorrect Answers:A. Peripheral edema is a manifestation of right-sided heart failure. C. Jugular vein distention is a manifestation of right-sided heart failure. D. Hepatomegaly is a manifestation of right-sided heart failure.

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

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

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

Correct Answer: C. Sudden oliguria 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. Incorrect Answers: A. Hypotension due to circulatory shock is an indication of an intravascular hemolytic reaction. B. A fever is an indication of an intravascular hemolytic reaction. D. Tachypnea as a compensatory mechanism due to circulatory shock is an indication of an intravascular hemolytic reaction.

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? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D

Correct Answer: C. Vitamin C Vitamin C deficiency produces symptoms of scurvy such as delayed wound healing and capillary fragility. Incorrect Answers:A. A deficiency in vitamin A produces manifestations of night blindness and immunodeficiency. It is not associated with scurvy. B. A deficiency in vitamin B3 produces manifestations of pellagra, which include a scaly rash on sun-exposed skin, confusion, paranoia, and diarrhea. D. A deficiency in vitamin D produces manifestations of rickets and osteomalacia, which include bowed legs, fractures, and malformed teeth

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? A. "My diabetes will not increase my risk of heart failure." B. "My asthma makes it more likely for me to have heart failure." C. "My age does not increase my risk of heart failure." D. "My coronary artery disease is a risk factor for heart failure."

Correct Answer: D. "My coronary artery disease is a risk factor for heart failure." Coronary artery disease is a primary risk factor for the development of heart failure. Other risk factors include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism. Incorrect Answers:A. Diabetes mellitus predisposes an individual to heart disease, including heart failure. B. Asthma is not a risk factor for heart failure. C. The risk of heart failure increases with age.

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

Correct Answer: D. Petechiae and ecchymosis A client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all 3 major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually. Incorrect Answers:A. A client who has polycythemia vera will have a plethoric (i.e. dark and flushed) manifestation of the facial skin and mucous membranes. B. A client who has pernicious anemia will have glossitis (i.e. smooth, beefy-red tongue) and weight loss. C. A client who has sickle cell anemia will have manifestations of jaundice with an enlarged liver and spleen.

A nurse is 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? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

Correct Answer: D. Superior vena cava The nurse should identify that the superior and inferior vena cava carry deoxygenated blood to the right atrium. Incorrect Answers:A. This blood vessel supplies oxygenated blood to the heart. B. This blood vessel supplies oxygenated blood to the head and neck. C. This blood vessel carries oxygenated blood away from the left side of the heart.

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option."

Correct Answer: A. "I can snack on fresh fruit." The nurse should identify that fresh fruits contain little to no sodium and are a good snack for a client who has hypertension. Incorrect Answers:B. Lunchmeats are usually high in sodium and should be avoided. The nurse should recommend choosing lower-sodium options, such as fresh fish or poultry. C. Cottage cheese contains 390 mg per 113 g (1/2 c) of sodium. The nurse should recommend choosing low-fat yogurt as a low-sodium snack. D. Canned soups contain high amounts of sodium. The nurse should instruct the client to avoid convenience and fast foods such as canned or dry-packaged soups.

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? A. "I should check my heart rate at the same time each day." B. "I don't have to take my antihypertensive medications now that I have a pacemaker." C. "I should keep a pressure dressing over the generator until the incision is healed." D. "I cannot stand in front of our new microwave oven when it is on."

Correct Answer: A. "I should check my heart rate at the same time each day." 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. Incorrect Answers:B. A pacemaker maintains a regular heart rate but is not intended to lower blood pressure or control hypertension. C. The client should avoid applying pressure over the generator. D. New microwaves are equipped with shielding that protects a person who has a pacemaker from interference. Hence, standing in front of a new microwave oven is not contraindicated. The client should avoid being in close proximity to older microwaves that do not have this shielding.

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

Correct Answer: A. "I should remove the skin from poultry before eating it." 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. Incorrect Answers:B. A client who has heart disease and is on a low-cholesterol diet should eat seafood at least twice per week because it is high in omega-3 fatty acids. C. A client who has heart disease and is on a low-cholesterol diet should use liquid oils such as canola oil instead of margarine, which is a solid fat. D. A client who has heart disease and is on a low-cholesterol diet should use nonfat or low-fat milk instead of whole milk in oatmeal or cereal.

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

Correct Answer: A. "I would never have believed I could get used to enjoying my food without salt." 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. Incorrect Answers:B. The best evidence that a client's blood pressure is under control is consistent measurements below 140/90 mmHg. Above age 60, a client's blood pressure should be below 150/90 mmHg. This average reading suggests the need for further intervention. C. Although the client is taking the medication, the client may need more education about following the prescribed medication therapy. This statement suggests the client is using the medication to treat a symptom that high blood pressure might not be causing. Some antihypertensive medications such as verapamil, lisinopril, and furosemide can actually cause headaches. D. From this statement, the nurse cannot conclude whether the client is taking the medication. Further assessment is needed.

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? A. "I'll stick with soft foods for now." B. "My family will be bringing me fresh flowers today." C. "I'll use a new disposable razor each day." D. "I'll blow my nose more often to avoid nosebleeds."

Correct Answer: A. "I'll stick with soft foods for now." Thrombocytopenia (a low platelet count) 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. Incorrect Answers: B. Fresh flowers should not be brought to immunocompromised clients in protective isolation because they might contain potentially harmful microorganisms. C. To reduce the risk of injury and bleeding, the client should use an electric shaver rather than a razor. D. To avoid bleeding, the client should not blow his nose or insert objects into his nares.

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

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

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? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade

Correct Answer: A. Acidosis 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. Incorrect Answers: B. The client could develop an infection following CABG surgery, but this is not the result of rewarming. Infection can be a result of surgical incisions or invasive tubes and procedures. C. Hypothermia promotes vasoconstriction, which puts the client at risk of hypertension. Rewarming the client reduces this risk. D. Cardiac tamponade results from bleeding inside the pericardium or blood backing up in mediastinal tubes and compressing the heart. Rewarming does not contribute to cardiac tamponade.

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? A. Administer antihypertensive medication for blood pressure B. Monitor to ensure the client's urinary output is 20 mL/hr C. Withhold pain medication to prepare the client for surgery D. Take the client's vital signs every 2 hr

Correct Answer: A. Administer antihypertensive medication for blood pressure The nurse should administer antihypertensive medication for elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall. Incorrect Answers:B. The nurse should ensure the client has adequate kidney profusion, as determined by a urinary output of at least 30 mL/hr. Oliguria can indicate a rupture of the aneurysm. C. The nurse should administer pain medication because pain occurs due to pressure from the aneurysm on the lumbar nerves. Pain can also cause hypertension. D. The nurse should take the client's vital signs at least every 15 minutes to monitor for a sudden drop in blood pressure, which can indicate a rupture of the aneurysm.

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 interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

Correct Answer: A. Avoid IM injections 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. Incorrect Answers:B. The nurse should assess the client for indications of bleeding, including ecchymosis, at least every 4 hours. C. The nurse should limit but not disallow visitors for a client who has neutropenia. D. The nurse should promote safe oral hygiene but should instruct the client to avoid flossing due to the risk of bleeding.

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? A. Beef liver B. Oranges C. Turnips D. Whole milk

Correct Answer: A. Beef liver 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. Incorrect Answers:B. Oranges are not a good source of iron. A 1-cup serving of orange slices contains only 0.18 mg of iron. C. Turnips are not a good source of iron. A 1-cup serving of cubed turnips contains only 0.39 mg of iron. Instead, the client should eat more asparagus and broccoli. D. Whole milk does not contain iron.

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

Correct Answer: A. Chicken breast and corn on the cob 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. Incorrect Answers:B. Shrimp are high in cholesterol and should be eaten in moderation; therefore, this food selection does not indicate an understanding of a low-cholesterol diet. C. Eggs and cheese are high in cholesterol; therefore, this food selection does not indicate an understanding of a low-cholesterol diet. D. Liver and other organ meats are high in cholesterol; therefore, this food selection does not indicate an understanding of a low-cholesterol diet.

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? A. Eggs B. Squash C. Kale D. Tofu

Correct Answer: A. Eggs 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. Incorrect Answers:B. A client who has pernicious anemia needs vitamin B12-rich foods. Squash does not contain vitamin B12. C. Kale does not contain vitamin B12. D. Tofu does not contain vitamin B12.

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? A. Give the client a written record of his BP to bring to his provider B. Encourage the client to go to the nearest emergency department C. Instruct the client to follow-up with a provider within 6 months D. Explain to the client that he is not at risk unless he has manifestations of hypertension

Correct Answer: A. Give the client a written record of his BP to bring to his provider Since this client has an elevated BP reading from a hypertension 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. Incorrect Answers:B. A client who has a BP of 150/90 mmHg does not require emergency services unless manifestations of a stroke or myocardial infarction are present. C. The nurse should instruct the client to follow-up with a provider for another BP measurement within 2 months. D. Hypertension is often asymptomatic. Even without symptoms like severe headaches or neurological deficits, hypertension can cause fatal strokes and myocardial infarctions.

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

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

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

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

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

Correct Answer: A. Lentils 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 3.6 mg of iron. Incorrect Answers:B. Avocados are not a good source of iron. A 1-cup serving of cubed avocado contains only 0.82 mg of iron. C. Cabbage is not a good source of iron. A 1-cup serving of chopped cabbage contains only 0.42 mg of iron. D. Broccoli is not a good source of iron. A 1-cup serving of chopped broccoli contains only 0.66 mg of iron.

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

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

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

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

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? A. Turkey on whole-wheat bread B. Hamburger and french fries C. Frankfurter on a white roll D. Macaroni and cheese

Correct Answer: A. Turkey on whole-wheat bread 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. Incorrect Answers:B. The relatively high sodium content of a hamburger with french fries makes this meal a poor choice for a client who has heart failure. C. The relatively high sodium content of frankfurters makes this a poor choice for a client who has heart failure. D. The relatively high sodium content of macaroni and cheese makes this a poor choice for a client who has heart failure.

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

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

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this 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? A. Peripheral vascular resistance increases. B. The sensitivity of blood pressure-adjusting baroreceptors increases. C. Blood is hypercoagulable and clots more quickly. D. Cardiac medications are less effective.

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

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

Correct Answer: B. "Before taking my medication, I will count my radial pulse rate." A beta blocker will induce bradycardia. The client should take the pulse rate for 1 minute before self-administration. Incorrect Answers:A. The client should consume foods low in saturated fat to decrease further atherosclerotic plaque development in the arteries. C. The client should exercise at least 3 to 5 times per week for a minimum of 30 minutes each session. D. The client should not discontinue the prescribed medication because adherence to the regimen will help prevent complications following a myocardial infarction.

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? A. "I will ask my provider to change my contraception to an intrauterine device." B. "I will notify my doctor before I have dental procedures." C. "I will avoid using antiseptic mouthwash for oral care." D. "I will wear a mask when I go out in public."

Correct Answer: B. "I will notify my doctor before I have dental procedures." 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. Incorrect Answers:A. Intrauterine devices increase the risk of an infection, which can lead to recurrence of infective endocarditis. C. Good oral hygiene reduces the risk of recurrence of infective endocarditis. The client should use an antiseptic mouthwash for 30 seconds twice daily as part of personal oral care. D. The client does not need to wear a mask when going out in public since infective endocarditis does not result in immunosuppression. The client should, however, avoid contact with individuals who have a streptococcal infection.

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? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

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

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? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS pattern

Correct Answer: B. Atrial rate of 300/min with QRS complex of 80/min 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. Incorrect Answers:A. The nurse should interpret this finding as a normal sinus rhythm. C. The nurse should interpret this finding as ventricular ectopy, such as premature ventricular contractions. D. The nurse should interpret this finding as ventricular tachycardia.

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

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

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

Correct Answer: B. Increased pulmonary congestion Pulmonary congestion occurs due to thickening and narrowing of the mitral valve which can cause pulmonary hypertension and congestion. Elevated pressure in the left atrium causes increased pressure to the pulmonary artery which can result in right ventricular hypertrophy and right-sided heart failure Incorrect Answers:A. Cardiac output is decreased in a client who has heart failure related to mitral stenosis because the left ventricle is receiving insufficient blood volume to pump into the systemic circulation. C. As the mitral valve opening narrows, blood flow from the atria to the ventricle falls, causing a backup and increased pressure in the left atria. D. Pulmonary artery pressure is increased as a result of backup pressure from the narrowing (stenosis) of the mitral valve that affects the flow of blood from the left atrium to the left ventricle.

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

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

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

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

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

Correct Answer: B. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea. Incorrect Answers:A. Hypokalemia causes flattened T waves and cardiac dysrhythmias. C. Hypercalcemia shortens QT intervals. D. Hyperkalemia widens QRS complexes.

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? A. Continue to monitor for manifestations of a transfusion reaction B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution C. Continue the transfusion and repeat the type and crossmatch D. Prepare to administer a dose of diphenhydramine IV

Correct Answer: B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution 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. Incorrect Answers:A. ABO compatibility is required for the transfusion of fresh frozen plasma. A client whose blood type is O can only receive type O plasma. C. The nurse should not continue infusing plasma that is not compatible with the client. There is no indication that a repeat type and crossmatch of the client's blood is necessary. D. The nurse should administer diphenhydramine IV only if the client manifests an allergic transfusion reaction.

A nurse is administering a unit of packed red blood cells (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? A. Maintain IV access with 0.9% sodium chloride B. Stop the infusion of blood C. Send the blood container and tubing to the blood bank D. Obtain a urine sample

Correct Answer: B. Stop the infusion of blood 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. Incorrect Answers:A. Maintaining IV access by initiating an infusion of 0.9% sodium chloride solution using a new IV administration set is important. However, there is another action that is the nurse's priority. C. The nurse should send the blood container and tubing to the blood bank for a repeat typing and culture. However, there is another action that is the nurse's priority. D. The nurse should obtain a urine sample from the client to determine if hemoglobin is in the urine. However, there is another action that is the nurse's priority.

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? A. "I need to stay active to prevent blood clots in my legs." B. "If I have a bad headache, I can take aspirin to get rid of it." C. "I should eliminate uncooked foods from my diet for now." D. "I should eat more iron-fortified cereal to strengthen my blood."

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

A nurse is 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? A. "Request a provider's prescription when traveling to alert airport security." B. "Stand at least 3 feet away while using a microwave." C. "Keep your cell phone 6 inches away from your pacemaker when making a call." D. "Avoid showering for the first 2 weeks following surgery."

Correct Answer: C. "Keep your cell phone 6 inches away from your pacemaker when making a call." 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. Incorrect Answers:A. The client does not need a provider's prescription to alert airport security when traveling. A card should be given to the client after surgery stating that he has a pacemaker and listing the type and model. The nurse should instruct the client to carry this card at all times and show it to airport security when he travels. B. The client does not need to stand 3 feet away while using a microwave. Proper shielding is part of microwave manufacturing, so this safety measure does not need to be taken. D. The client can take a bath or shower as long as he gives careful attention to the pacemaker site. The client should not stand directly under the shower or submerge himself in a tub of water, as this would allow the pacemaker to get extremely wet.

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? A. "I should try to drink at least 2 liters of fluid per day." B. "I can still fly out to visit my sister in Colorado for a while." C. "Physical activity is good for me, but I need to avoid overexertion." D. "I can still go skiing during the cold winter months."

Correct Answer: C. "Physical activity is good for me, but I need to avoid overexertion." To help prevent a recurrence of sickle cell crisis, the client should avoid overexertion from especially strenuous activities. Incorrect Answers:A. To help prevent a recurrence of sickle cell crisis, the client should drink 3 to 4 L of fluid per day. B. To help prevent a recurrence of sickle cell crisis, the client should avoid traveling to high altitudes and in airplanes since passenger cabins are non-pressurized. D. To help prevent a recurrence of sickle cell crisis, the client should avoid recreational activities that require persistent exposure to cold weather.

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

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

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? A. "Exertion often brings on pain." B. "Variant angina occurs randomly at various times." C. "Variant angina can cause changes on your electrocardiogram." D. "Reducing your cholesterol can help you experience less pain."

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

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? A. "You'll receive heavy sedation, so you might even sleep during the procedure." B. "You'll have to lie on your back throughout the procedure." C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow." D. "Expect the procedure to take about an hour."

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

A nurse is 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? A. Pallor B. Jaundice C. Absence of hair on the legs D. Poor nailbed capillary refill

Correct Answer: C. Absence of hair on the legs 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. Incorrect Answers:A. Although pallor can indicate a hematologic disorder such as anemia, pigment loss is common with aging. Pallor is an unreliable indicator of anemia for an older adult. B. Although jaundice can indicate a hematologic disorder such as hyperbilirubinemia, yellowing of the skin is common with aging. Jaundice is an unreliable indicator of hyperbilirubinemia for an older adult. D. Although poor nailbed capillary refill can indicate a hematologic disorder such as arterial insufficiency, thickening and discoloration of the nails are common with aging and are not a reliable indicator of arterial insufficiency for an older adult client

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

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

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin

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

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? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. Sunburned appearance with desquamation

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

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

Correct Answer: C. Dyspnea with hiccups 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 tamponade. Incorrect Answers:A. Pericarditis is usually seen on an ECG as an ST-T spiking. This elevation represents ischemic changes caused by inflammation around the heart. A client who has pericarditis will have tachycardia because of decreased cardiac output and oxygen perfusion. B. Chest pain associated with pericarditis will increase with deep inspiration due to greater pressure on the pericardial sac. D. Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac.

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

Correct Answer: C. Elevated Hct The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration. Incorrect Answers:A. The nurse should expect the client to have hyperkalemia as a result of potassium being leaked from cellular injury. B. The nurse should expect the client to have hyponatremia once sodium leaks into the interstitial space, causing decreased levels in the blood. D. The nurse should expect the client to have an increased hemoglobin 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? A. Cholesterol level 195 mg/dL B. Elevated HDL levels C. Elevated LDL levels D. Triglyceride level 135 mg

Correct Answer: C. Elevated LDL levels An elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL. Incorrect Answers:A. Total cholesterol levels that are <200 mg/dL are recommended to help reduce the incidence of developing atherosclerosis. B. A decreased HDL level is expected in a client who is at risk for atherosclerosis. Elevated HDL has a protective effect against the development of atherosclerosis. The client's desirable HDL level is ≥40 mg/dL. D. A triglyceride level that is <150 mg/dL for male clients and <135 mg/dL for female clients are recommended to help reduce the incidence of atherosclerosis.

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? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes D. Chicken bouillon and crackers

Correct Answer: C. Grilled chicken salad with fresh tomatoes Sodium reduction helps control blood pressure. 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. Incorrect Answers:A. Commercially prepared soups, broths, and bouillons tend to be high in sodium. Onion soup often contains cheese and croutons, which are typically high in sodium. The vegetables in a salad are low in sodium, but commercially prepared salad dressings and salad additives (e.g. bacon bits, crumbled cheese) are typically high in sodium. B. Potato chips are usually high in sodium. D. Commercially prepared soups, broths, and bouillons tend to be high in sodium. Crackers that are not labeled low-sodium are also a poor choice for a sodium-restricted diet.

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? A. Hospitalization is required when administering each treatment. B. The maximum effect of the medication will occur in 6 months. C. Hypertension is a common adverse effect of this medication. D. Blood transfusions are needed with each treatment.

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

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

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

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

Correct Answer: C. Report of sudden, severe back pain An aortic aneurysm is a weak spot in the wall of the aorta (the primary artery that carries blood from the heart to the head and extremities) 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. Incorrect Answers:A. If the client develops a rupturing AAA, the nurse should expect indications of shock (e.g. decreased BP and increased pulse rate). B. Jugular-vein distention and peripheral edema are manifestations of right-sided heart failure, not an extending AAA. D. Chest pain radiating to the left arm is a manifestation of a myocardial infarction, not AAA.

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

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

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

Correct Answer: C. Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system. Incorrect Answers:A. Infective endocarditis occurs when bacteria invade the endothelial surface of the heart. Infective endocarditis is usually seen in clients who have prosthetic heart valves or pacemakers. B. Pericarditis can occur from 10 days to 2 months following a myocardial infarction. Pericarditis is an inflammation of the pericardial sac that surrounds the heart and is usually a result of infection, connective tissue disorders, or trauma. D. Pulmonary emboli occur if the client develops heart failure following a myocardial infarction. Pulmonary emboli are found more commonly with valvular disorders, atrial fibrillation, or deep-vein thrombosis.

A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Compare the client's identification number with the number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs

Correct Answer: C. Witness the informed consent document 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. Incorrect Answers:A. The nurse should hang an IV infusion of 0.9% sodium chloride with the blood to dilute the blood and maintain the IV infusion line. However, the nurse should perform a less-invasive intervention first. B. The nurse should check the client's identification number against the number on the blood to ensure the client receives the correct unit of blood. With another nurse, the nurse should check the provider prescription, the identity of the blood product, the client, and the compatibility (blood type and Rh factor) of the blood and the client. However, the nurse should perform a less-invasive intervention first. D. The nurse should obtain the client's pretransfusion vital signs prior to infusing the packed RBCs. However, the nurse should perform a less-invasive intervention first.

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

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

A 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. A dressing is not applied to the port site after use. B. A 22-gauge non-coring needle is used to access the port. C. Blood return is noted prior to administering the medication. D. A solution of 5 mL heparin 1,000 units/mL has been prepared.

Correct Answer: D. A solution of 5 mL heparin 1,000 units/mL has been prepared. 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. Incorrect Answers:A. An implanted access port is surgically placed in the subcutaneous tissue, usually in the upper chest or an upper extremity. These sites do not require a dressing to cover the port site. B. A special non-coring needle must be used to access implanted ports. These needles have a deflected tip that is specifically designed to penetrate the dense septum without coring small pieces of it. Implanted ports placed in the chest can usually tolerate about 2,000 punctures. The edges of the port should be carefully palpated to identify the septum prior to placement of the needle. It is appropriate for the nurse to use a 22-gauge non-coring needle to access the device. C. Prior to administering medication through an implanted port, the nurse should always check the site for blood return. If there is no blood return, the nurse should hold the medication until patency can be ensured. Serious extravasation can occur due to the formation of a fibrin sheath over the tip of the catheter causing retrograde subcutaneous leakage. The nurse should check for blood return prior to administering an IV medication.

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

Correct Answer: D. Acute confusion Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue. Incorrect Answers:A. Hemoptysis is a manifestation of gastrointestinal bleeding rather than myocardial infarction. B. Acute diarrhea is a manifestation of gastroenteritis rather than myocardial infarction. C. A frontal headache is a manifestation of fluid overload rather than myocardial infarction.

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? A. Flexion of the extremities B. Therapeutic hypothermia C. Upright positioning D. Ample hydration

Correct Answer: D. Ample hydration 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. Incorrect Answers:A. The nurse should encourage the client to extend the extremities to promote venous return. B. Therapeutic hypothermia is not an appropriate intervention for sickle cell crisis because exposure to cold can provoke sickle cell crisis. C. The nurse should elevate the head of the client's bed by no more than 30°.

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

Correct Answer: D. Apply lateral pressure to the client's nose for 10 min 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. Incorrect Answers:A. The nurse should instruct the client to refrain from blowing his nose for 24 hours after the epistaxis stops. The formation of clots will terminate the nosebleed. Having the client blow his nose will dislodge any clots that do form and cause the bleeding to continue. B. The nurse should place the client in a sitting position, leaning forward. If the client positions his head and neck backward, blood will drain into the stomach, causing nausea and vomiting. C. The nurse should apply an ice pack or cool compress to the client's nose and face to help control epistaxis.

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? A. Chest pain is relieved soon after resting. B. Nitroglycerin relieves chest pain. C. Physical exertion does not precipitate chest pain. D. Chest pain lasts for longer than 15 min.

Correct Answer: D. Chest pain lasts for longer than 15 min. 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. Incorrect Answers:A. A client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and a decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina and is caused by an arterial spasm. B. A client who has unstable angina will have minimal, if any, relief of chest pain with nitroglycerin. C. A client who has unstable angina will report chest pain or discomfort with exertion, which can limit the client's activity.

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependent edema Check Answer Question Feedback Close Explanation

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

A nurse is 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? A. Maintain the client's knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

Correct Answer: D. Encourage increased fluid intake 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. Incorrect Answers:A. The nurse should avoid flexion of the client's knees and hips during a sickle cell crisis to promote adequate perfusion to all areas of the client's body, which can decrease pain. B. The nurse should keep the room warm during a sickle cell crisis and apply warm, moist compresses to painful joints. The application of cold compresses causes vasoconstriction, which increases sickling. C. The nurse should administer opioids, including morphine and hydromorphone, on a routine schedule during a crisis to manage the client's pain.

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? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

Correct Answer: D. Iron toxicity 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. Incorrect Answers:A. A client who has received several blood transfusions is at risk of hyperkalemia. Stored blood releases increased amounts of potassium due to red blood cell hemolysis. B. A client who has received numerous blood transfusions is not at risk of lead poisoning because lead is not found in blood. C. A client who has received several blood transfusions is at risk of hypocalcemia. The citrate in the transfused blood bonds with calcium, causing calcium to be excreted.

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? A. Bradycardia B. Paresthesia C. Hypertension D. Low back pain

Correct Answer: D. 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. Incorrect Answers: A. Tachycardia, not bradycardia, is a manifestation of a hemolytic transfusion reaction. B. Certain medications such as clonidine can cause paresthesia; however, paresthesia is not a manifestation of a hemolytic transfusion reaction. C. Hypotension, not hypertension, is a manifestation of a hemolytic transfusion reaction.

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

Correct Answer: D. Lower back discomfort 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. Incorrect Answers:A. The nurse should assess for mid or lower abdominal pain to the left of the midline because of the enlarged artery mass. B. The nurse should auscultate for a bruit heard over the location of the mass. C. Pitting edema is a manifestation of heart failure. This is not an assessment expected with an abdominal aortic aneurysm.

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? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion

Correct Answer: D. Stop the medication infusion 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. Incorrect Answers:A. This client is at risk of anaphylactic shock, and elevating the client's lower extremities helps maintain an adequate blood pressure; however, there is another action the nurse should take first. B. This client is at risk of progression of allergic manifestations. Because of the potential progression to anaphylaxis, the provider might prescribe epinephrine; however, there is another action that the nurse should take first. C. The client is at risk of progression to anaphylaxis, and infusing isotonic IV fluids can help hydrate the client and maintain blood pressure; however, there is another action that the nurse should take first.

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? A. Venous stasis B. Thrombocytopenia C. Inflammation D. Tissue hypoxia

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

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

Correct Answer: D. Vitamin B12 deficiency 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. Incorrect Answers:A. Iron deficiency can be a result of blood loss, poor absorption of iron, or poor nutrition in the diet. This condition is called iron-deficiency anemia and is not related to pernicious anemia. B. Hemolytic blood loss is a result of hemorrhage, not pernicious anemia. C. Folic acid deficiency is caused by poor nutrition related to a lack of green leafy vegetables, citrus fruits, and nuts in the diet. Folic acid is essential for the absorption of vitamin B12.

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? (Select all that apply.) A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." C. "You'll feel a cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr."

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

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.) A. Assess and document the client's vital signs B. Restart the IV with a 22-gauge needle C. Verify with another nurse the blood type and Rh of the packed RBCs D. Hang a bag of lactated Ringer's IV solution E. Change IV tubing to a set that has a filter

Correct Answers: A. Assess and document the client's vital signs C. Verify with another nurse the blood type and Rh of the packed RBCs E. Change IV tubing to a set that has a filter The nurse should assess and document the client's vital signs prior to initiating a blood transfusion to obtain a baseline for comparison. Monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and 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. Incorrect Answers: B. The nurse should ensure the client has a 20-gauge or larger needle for administration of packed RBCs to prevent the formation of blood clots during the transfusion. D. The nurse should hang a bag of 0.9% sodium chloride IV solution for administration with the packed RBCs. Lactated Ringer's solution is not used because it causes clotting and hemolysis of the blood cells.

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

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

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

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

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

Correct Answers: B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the blood steam. 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 Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs. Incorrect Answers: A. The nurse should use an angiocatheter that is 18- to 20-gauge to allow the packed RBCs to flow easily and to prevent occlusion of the catheter. A 23-gauge angiocatheter is too narrow, which can result in a prolonged infusion time and risk for catheter occlusion. C. The nurse should infuse the packed RBCs slowly over a 2- to 4-hour period to decrease the risk of bacterial contamination.

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

Correct Answers: B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for coronary artery disease (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 myocardial infarction. 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. Incorrect Answer:A. Hypothyroidism is not a risk factor for CAD.

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (Select all that apply.) A. Use a 5 mL syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use

Correct Answers: C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use The nurse should flush the line with 10 mL of sterile 0.9% sodium chloride solution before and after administering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger. PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line. Incorrect Answers:A. A 5 mL syringe generates too much pressure and could rupture the line. The nurse should use a 10 mL syringe instead. B. The nurse should use chlorhexidine for cleansing the insertion site. Chlorhexidine is effective in reducing the incidence of bloodstream infections.

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

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

A nurse is preparing to transfuse 250 mL of packed red blood cells (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? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the volume the nurse should infuse? 250 mL Step 3: What is the total infusion time? 4 hr Step 4: Should the nurse convert the units of measurement? Yes (hr does not equal min) 1 hr/60 min = 4 hr/X min X = 240 min Step 5: Set up an equation and solve for X. Volume (mL)/Time (min) x drop factor (gtt/mL) = X gtt/min 250 mL/240 min x 10 gtt/mL = X gtt/min X = 10.4 gtt/min Step 6: Round if necessary. 10.4 gtt/min = 10 gtt/min Step 7: Reassess to determine whether the amount to administer makes sense. If the prescription is for packed RBCs (250 mL) X 10 gtt/mL infused over 240 min, the nurse should set the manual IV infusion to deliver packed cells (250 mL) to infuse at 10 gtt/min.