Cardiovascular System, Blood, and Lymphatic Systems

During a blood transfusion a client develops chills and a headache. What is the priority nursing action? 1.Cover the client. 2.Stop the transfusion at once. 3.Decrease the rate of the blood infusion. 4.Notify the health care provider immediately.

2.Stop the transfusion at once.

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. The nurse concludes that the client needs further teaching when the client selects: 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) 4.Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

4.Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

A client is scheduled to be transferred from the coronary care unit to a progressive care unit. The client asks a nurse, "Are you sure I'm ready for this move?" What does the nurse conclude the client most likely is experiencing? 1.Fear 2.Depression 3.Dependency 4.Ambivalence

1.Fear

A client is taking furosemide (Lasix) and digoxin (Lanoxin) for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? 1.Maintaining potassium levels 2.Preventing increased sodium levels 3.Correcting the associated dehydration 4.Limiting the drugs' synergistic effects

1.Maintaining potassium levels

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? 1.Pain subsides as a result of arteriole and venous dilation 2.Pulse rate increases because the cardiac output has been stimulated 3.Sublingual area tingles because sensory nerves are being triggered 4.Capacity for activity improves as a response to increased collateral circulation

1.Pain subsides as a result of arteriole and venous dilation

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. What recommendation by the nurse will help the client maintain blood vessel patency? 1.Practice relaxation techniques 2.Lead a more sedentary lifestyle 3.Decrease the amount of exercise 4.Increase saturated fats in the diet

1.Practice relaxation techniques

A client sustains multiple internal injuries in a motor vehicle accident. While performing the client's initial assessment, the nurse identifies that the client's blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What most likely has caused this drop in blood pressure? 1.Reduction in the circulating blood volume 2.Diminished vasomotor stimulation to the arterial wall 3.Vasodilation resulting from diminished vasoconstrictor tone 4.Cardiac decompensation resulting from electrolyte imbalance

1.Reduction in the circulating blood volume

A nurse reviews the plan of care for a client who is recovering from the acute phase of left ventricular failure. The nurse expects which dietary restriction to be included on the plan? 1.Sodium 2.Calcium 3.Potassium 4.Magnesium

1.Sodium

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? 1.They help the venous blood return to the heart. 2.They will not cause discomfort, but gently massage the legs. 3.They are used instead of anticoagulant therapy. 4.They must be worn until the first time the client gets out of bed.

1.They help the venous blood return to the heart.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? 1."I am unable to run a mile now." 2."I wake up at night short of breath." 3."My shoes seem larger lately." 4."My wife says I snore very loudly."

2."I wake up at night short of breath."

A client has a mitral valve replacement, and the nurse provides health teaching to promote optimum health. Which statement made by the client supports the nurse's conclusion that the client needs further teaching? 1."I should wear a MedicAlert bracelet." 2."I will start a vigorous aerobic exercise program." 3."I will take antibiotics when I have my teeth repaired." 4."I should go to the doctor when I get a respiratory infection."

2."I will start a vigorous aerobic exercise program."

A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? 1.Monitoring vital signs and encouraging a vigorous aerobic exercise program. 2.Taking the apical pulse before drug administration and teaching the client how to count the pulse. 3.Contacting Social Services for a home health nursing consultation. 4.Providing written material on the adverse effects of the medication.

2.Taking the apical pulse before drug administration and teaching the client how to count the pulse.

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." What action should the nurse take? 1.Call the rapid response team 2.Perform a nutritional assessment 3.Discuss possible sources of stress with the client 4.Provide reassurance while helping the client to focus on pleasant topics

1.Call the rapid response team

A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of: 1.Digoxin (Lanoxin) 2.Captopril (Capoten) 3.Morphine sulfate (MS Contin) 4.Furosemide (Lasix )

1.Digoxin (Lanoxin)

A client with a history of heart failure and atrial fibrillation reports a nine-pound weight gain in the last two weeks. The nurse interprets that the most likely cause of this sudden weight gain is: 1.Fluid retention 2.Urinary retention 3.Renal insufficiency 4.Abdominal distention

1.Fluid retention

A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? 1."I must touch the shunt several times a day to feel for the bruit." 2."I have to take his blood pressure every day in the arm with the fistula." 3."He will have to be very careful at night not to lie on the arm with the fistula." 4."We really should check the fistula every day for signs of redness and swelling."

2."I have to take his blood pressure every day in the arm with the fistula."

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling lightheaded. The client is pale and has a rapid pulse. The nurse concludes that the client is: 1.Hyperventilating 2.Going into shock 3.Experiencing anxiety 4.Developing an infection

2.Going into shock

While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client's color is pale and the pulse is rapid. What should the nurse conclude about the client's condition? 1.Hyperventilating 2.Going into shock 3.Experiencing anxiety 4.Developing an infection

2.Going into shock

The nurse is providing care for a client that had an endarterectomy one month ago. The nurse explains the reason that clopidogrel (Plavix) is being prescribed. The nurse concludes that the teaching is understood when the client says, "The medication will: 1.Limit inflammation around my incision." 2.Help prevent further clogging of my arteries." 3.Lower the slight fever I have had since surgery." 4.Reduce the discomfort I feel at the surgical incision."

2.Help prevent further clogging of my arteries."

A client with angina pectoris is scheduled for a stress echocardiogram. The nurse explains that the echocardiogram is a: 1.Tool used solely to determine the cause of chest pain 2.Noninvasive approach to assess cardiovascular status 3.Modality of minimal value in planning treatment for angina 4.Test that is invasive that measures the body's reaction to progressive increases in exertion

2.Noninvasive approach to assess cardiovascular status

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will: 1.Turn off clients' IVs that have infiltrated." 2.Take clients' vital signs after their procedures are over." 3.Use unit written materials to teach clients before surgery." 4.Help by giving medications to clients who are slow in taking pills."

2.Take clients' vital signs after their procedures are over."

A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is: 1.Type O positive 2.Type AB positive 3.Type A or O negative 4.Type A or AB negative

3.Type A or O negative

A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. The component of the complete blood count that the nurse is concerned about most is: 1.Red blood cells (RBCs) 2.White blood cells (WBCs) 3.Platelets 4.Hematocrit

2.White blood cells (WBCs)

A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" The most appropriate response by the nurse is: 1."Let me ask your primary health care provider for you." 2."I can understand why you are worried." 3."Tell me about your concerns right now." 4."It depends on whether the tumor has spread."

3."Tell me about your concerns right now."

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. What is the goal of the medical regimen for this client? 1.Increase left ventricular filling and improve cardiac output. 2.Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias. 3.Decrease the workload on the heart and promote maximum coronary artery filling. 4.Increase venous return to the right atrium and increase pulmonary arterial blood flow

3.Decrease the workload on the heart and promote maximum coronary artery filling.

A client with a tentative diagnosis of pernicious anemia is scheduled for a Schilling test. Which body process associated with vitamin B12 is assessed with the Shilling test? 1.Storage 2.Digestion 3.Production 4.Absorption

4.Absorption

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 3.Sustained systolic pressure ranging from 110 to 120 mm Hg 4.Diastolic blood pressure that remains higher than 90 mm Hg

4.Diastolic blood pressure that remains higher than 90 mm Hg

A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Recognizing that adherence to a medical regimen improves with understanding, the nurse explains that the salt must be limited to: 1.Prevent an increase in blood pressure from tissue edema. 2.Reduce the circulating blood volume via a diuretic effect. 3.Reduce the amount of edema present, which interferes with heart action. 4.Prevent further accumulation of fluid, which increases the workload of the heart

4.Prevent further accumulation of fluid, which increases the workload of the heart

The nurse encourages a client with Raynaud's disease to stop smoking because it causes: 1.Pain and tingling 2.Cyanosis and necrosis 3.Peripheral vasoconstriction 4.Excessive blood oxygen content

3.Peripheral vasoconstriction

The nurse 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 and 164/98. What is the appropriate nursing action in response to these readings? 1.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. 4.Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

4.Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.