Cardiovascular System. Blood, and Lymphatic Systems (HESI)

A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. The behavior that demonstrates an increase in client autonomy is when the client:

Actively participates in providing self-care. (Rationale: Planning self-care demonstrates decision making by the client; participating in care enhances feelings of self-worth and autonomy.)

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?

Call the rapid response team.

The nurse observes a client collapse while walking down the hallway. The nurse rushes to the client and determines that the client is in cardiopulmonary arrest. What will the nurse do first?

Check for a carotid pulse. (Rationale: According to the 2010 American Heart Association guidelines, assessing for a carotid pulse is the first step in CPR.)

For the first several hours after a cardiac catheterization, it is most essential for the nurse to:

Monitor the clients apical pulse and blood pressure .

A client is admitted to the post anesthesia care unit after surgery and electronic blood pressure monitoring is to be performed. The nurse should assess the client's blood pressure every:

10-15 minutes (Rationale: During the first two postoperative hours the blood pressure is monitored every 10 to 15 minutes to detect unstable vital signs that might indicate shock.)

A health care provider prescribes 0.2 mg of cyanocobalamin (vitamin B12) intramuscularly for a client with pernicious anemia. A vial of the drug labeled 100 mcg = 1 mL is available. How much solution should the nurse administer? Record your answer using a whole number. __________mL

2ml

The client is receiving multiple blood transfusions after having extensive abdominal surgery. If the client develops fever, chills, and lower back pain, and seems very nervous, what will be the nurse's first action?

Stop the blood and infuse normal saline. (Rationale: Fever, chills, and lower back pain, along with apprehension, headache, tachycardia, and hypotension, indicate an acute hemolytic reaction, which is potentially life threatening.)

What should the nurse expect the health care provider to prescribe if a client exhibits clinical indicators of warfarin (Coumadin) overdose?

Vitamin K (Rationale: Warfarin depresses prothrombin activity and inhibits formation of several clotting factors by the liver. Its antagonist is vitamin K, which is involved in prothrombin formation. )

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?

Going into shock. (Rationale: When the spleen ruptures, internal loss of blood may be profound, resulting in shock. )

A client who had a right total hip replacement three days ago reports extreme tenderness in the right calf. On examination the nurse identifies a warm area occurring on the back of the leg, extending into the popliteal space. The physical therapist has just arrived to assist the client with ambulation and exercise. What should the nurse do to best meet this client's needs?

Notify the health care provider regarding the client's status. (Rationale:These findings indicate deep vein thrombosis. Ambulation and exercise are contraindicated; the health care provider should be notified so that appropriate tests and treatments can be implemented. Ambulation and exercise may precipitate an embolism, which is life threatening. )

Enoxaparin (Lovenox) 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given to:

Provide prophylaxis against postoperative thrombus formation. (Rationale: Enoxaparin (Lovenox), a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III.)

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

Sit on the edge of the bed while they hold the client upright. (Rationale: Sitting allows the nurses to support the client until orthostatic hypotension subsides.)