***compiled Exam 2 sos please send help

Which changes in ADLS are most appropriate for the nurse to suggest to a client newly diagnosed anemia about conserving energy? Which instructions would the nurse give to the client? (Select all that apply.) "Cluster your care together to get through them more quickly." "Accept help from others when you feel especially tired." "Take a complete bath or shower daily to promote relaxation." "Stop activity when you feel short of breath or palpitations are present." "Try eating four to six small, easy-to-eat meals daily instead of three larger ones." "Sit instead of standing for some tasks such as cutting vegetables."

"Accept help from others when you feel especially tired." "Stop activity when you feel short of breath or palpitations are present." "Try eating four to six small, easy-to-eat meals daily instead of three larger ones." "Sit instead of standing for some tasks such as cutting vegetables."

The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education?

"After this therapy, I will not need to have any more." Induction therapy is not a cure for leukemia, it is a treatment; therefore, the client needs more education to understand this. Because of infection risk, clients with leukemia should avoid people with a cold or flu. Induction therapy will most likely cause the client with leukemia to lose his or her hair. The goal of induction therapy is to force leukemia into remission.

The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client?

"Allow others to perform your care during periods of extreme fatigue." "Drink small quantities of protein shakes and nutritional supplements daily." "Provide yourself with four to six small, easy-to-eat meals daily." "Stop activity when shortness of breath or palpitations are present."

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest?

"Ask her how she is feeling" "ask her if she needs anything" "talk to her as you normally would when you haven't seen her for a long time" Asking the client how she is feeling is a broad general opening and would be nonthreatening to the client. Asking if she needs anything is a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member should talk to her as she normally would when she hasn't seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option. Acting as if things are "different" because she has cancer takes the control of the situation from the client. Telling her to be brave and not to cry is callous and unfeeling; if the client is feeling vulnerable and depressed, telling her to "be brave" shuts off any opportunity for her to express her feelings. There is no need to inform the client about her disease, unless she asks about it. Opening the conversation with discussion about leukemia should be the client's prerogative.

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client?

"Avoid grapefruit juice." The nurse teaches the client who is taking verapamil to avoid grapefruit juice. Grapefruit juice must be avoided with calcium channel blockers, such as verapamil, because it can enhance the action of the drug.Foods high in potassium would be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. Bradycardia, not irregular pulse, is a typical side effect of verapamil. Muscle cramping may occur with statins, not with calcium channel blockers.

A hematology unit is staffed by RNs, LPN/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care?

"Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" Determination of the need for oxygen and administration of oxygen should be done by licensed nurses who have the education and scope of practice required to administer it. All other documentation entries reflect appropriate delegation and assignment of care.

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information?

"Do you feel more tired after you get up and go to the bathroom?" Asking about feeling tired after using the bathroom is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provide needed answers. Asking about cold feet or hands does not address the client's endurance. The hospitalized client typically does not get much exercise; this would be a difficult assessment for a client in long-term care facility to make. Asking the client about his or her endurance level is too vague; the client may not know how to answer this question.

The nurse is assessing a client for hematologic risks. Which health history question would the nurse ask to determine if the risk cannot be reduced or eliminated? "Where do you work?" "Tell me what you eat in a day." "Does anyone in your family bleed a lot?" "Do you seem to have excessive bleeding or bruising?"

"Does anyone in your family bleed a lot?" To determine if hematologic risks exist while obtaining a health history from a client, the nurse asks if anyone in the client's family bleeds a lot. An accurate family history is important because many disorders that affect blood and blood clotting are inherited. Genetics cannot be changed. Work habits can be a risk, such as working near radiation, but these are behaviors that can be changed. Diet can affect risk, but it is a health behavior that can be changed. Excessive bleeding or bruising is a symptom, not a risk.

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective?

"Eating foods like green beans won't interfere with my Coumadin therapy." Teaching about the precautions of warfarin has been effective when the client says "that eating foods like green beans won't interfere with my Coumadin therapy." Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.Warfarin "thins" the blood, so the risk for cutting oneself and bleeding is very high with the use of a regular razor. The client needs to use an electric razor. Clients must apply pressure to bleeding wounds and must seek medical assistance immediately. They do not need to discontinue warfarin therapy. Blood in the urine of a client taking warfarin therapy is not a side effect. The client must notify the primary health care provider immediately if this occurs.

The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction?

"Getting an annual 'flu shot' would be dangerous for me." The client with SCD should receive annual influenza and pneumonia vaccinations; this helps prevent the development of these infections, which could cause a sickle cell crisis. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection.

The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question would the nurse ask the client? "Can you prepare your own meals every day?" "How is your energy level compared with last year?" "Has your weight changed by 5 pounds (2.3 kg) or more this year?" "What medications do you take daily, weekly, and monthly?"

"How is your energy level compared with last year?" The question the nurse needs to ask the client about endurance in performing ADLs is "How is your energy level compared with last year"? Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance for ADLs. The client may never have been able to prepare his or her own meals, and the ability to prepare meals does not really address endurance. The question about weight change addresses nutrition and metabolic needs, rather than ADL performance. The question about how often the client takes medication addresses nutrition and metabolic needs and focuses on health maintenance through the use of drugs, not on the client's ability to perform ADLs.

Which assessment question is most relevant for the nurse to ask a client on warfarin therapy whose international normalized ratio (INR) is 0.6? "What types of dairy products do you consume on a regular basis? "Have you noticed any bleeding from you gums after brushing or flossing? "How many salads and raw vegetables do you eat per week? "Do you or any member of your family have frequent nose bleeds or bruising?

"How many salads and raw vegetables do you eat per week? The normal INR ranges between 0.8 and 1.1 times the normal control. Lower INRs are associated with an increased risk for clotting. Clients on warfarin therapy, which is a vitamin K antagonist, are expected to have INRs between 2.0 and 3.0 depending on why anticoagulation is needed. Increased vitamin K intake, which is found in raw, leafy green vegetables, reduces the effectiveness of this drug.

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? "I don't know how I am going to change my lifestyle." "I don't need to change. It hasn't killed me yet." "I don't think it is as bad as the doctors say." "I will have to change my diet and exercise more."

"I don't need to change. It hasn't killed me yet." **An example of maladaptive denial to a recent cardiovascular diagnosis is when the client says that change is not needed, because "it hasn't killed me yet." This type of denial is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care.Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicate a willingness to change.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement?

"I just started to feel a tearing pain in my belly." The nurse suspects dissection of an AAA when the client says that "I just started to feel a tearing pain in my belly." Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? "I need to avoid eating hamburgers." "I must cut out bacon and canned foods." "I won't put the salt shaker on the table anymore." "I need to avoid lunchmeats but may cook my own turkey."

"I need to avoid eating hamburgers." **Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content.Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

Which client statement indicates that stem cell transplantation that is scheduled to take place in his home is not a viable option?

"I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own. The client must be emotionally stable to be a candidate for this type of care. It is acceptable for the client's spouse to support the client undergoing this procedure. It is not unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the hospital, in case of emergency.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? "I will call the provider if I have a cough lasting 3 or more days." "I will report to the provider weight loss of 2 to 3 pounds (0.9 to 1.4 kg) in a day." "I will try walking for 1 hour each day." "I should expect occasional chest pain."

"I will call the provider if I have a cough lasting 3 or more days." **The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs.The client would call the provider for weight gain of 3 pounds (1.4 kg) in a week or 1-2 pounds (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 meters) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching?

"If I wear pantyhose, I won't have to wear the stockings the hospital gives me." Further teaching is needed about how to prevent venous thromboembolism when the client says that "If I wear pantyhose, I won't have to wear the stockings the hospital gives me." Wearing the graduated compression stockings is a type of prevention specific to the hospital setting. They are designed to prevent blood clots, unlike regular pantyhose.Discontinuation of birth control pills is a routine prevention for thromboembolism, but this prevention is not specific to the client's acute hospitalization. Drinking a lot of water, where the quantity is not specified, may not be indicated for this client. Exercise is a prevention that can be done outside the hospital.

A client on anticoagulant therapy is being discharged. Which statement by the client indicates an understanding of the anticoagulants drug action? "It will thin my blood." "It is used to dissolve blood clots." "It should prevent my blood from clotting." "It might cause me to get injured more often."

"It should prevent my blood from clotting." The statement that shows the client understands anticoagulant drug action is, "it will prevent my blood from clotting." Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots. Anticoagulants do not cause any change in the thickness or viscosity of the blood. Anticoagulants do not dissolve clots, fibrinolytics do. Anticoagulants do not cause more injuries but may cause more bleeding and bruising when the client is injured.

A cousin arrives to visit a client recently diagnosed with leukemia. Which responses will the nurse suggest when the cousin asks, "What should I say to her?" (Select all that apply.) Select all that apply. "Just talk about the things you usually talk about with her." "Remind her to be brave and to not cry." "Ask how she is feeling." "Explain what you know about leukemia." "Ask if you can get or do anything for her." "Express how sorry you are that this has happened to her."

"Just talk about the things you usually talk about with her." "Ask how she is feeling." "Ask if you can get or do anything for her."

A client who is to undergo cardiac catheterization must be taught which essential information by the nurse? "Monitor the pulses in your feet when you get home." "Keep your affected leg straight for 2 to 6 hours." "Do not take your blood pressure medications on the day of the procedure." "Take your oral hypoglycemic with a sip of water on the morning of the procedure."

"Keep your affected leg straight for 2 to 6 hours." **The client undergoing cardiac catheterization must be taught to keep the affected leg straight for 2 to 6 hours after the test. The client will remain in bed and the affected leg kept straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding.The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the primary health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure, so antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating. They are not taken when the client is NPO for procedures or surgery.

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care?

"My leg might turn very white after the surgery." A need for further postoperative teaching about arterial revascularization is needed when the client says that "my leg might turn very white after the surgery." Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis.The foot turning blue is a sign of poor perfusion. Fever or drainage would indicate an infection. Warmness, redness, and swelling indicate reperfusion, which is a good sign.

The nurse is teaching a client who is preparing for discharge after a bone marrow aspiration. The nurse provides which discharge instructions to the client? "Inspect the site for bleeding every 4 to 6 hours." "Place an ice pack over the site to reduce the bruising." "Avoid contact sports or activity that may traumatize the site for 24 hours." "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."

"Place an ice pack over the site to reduce the bruising." Discharge instructions after a bone marrow include placing an ice pack over the site to reduce bruising. Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure. The client must carefully monitor the site every 2 hours for the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. A mild analgesic is appropriate, but it needs to be aspirin-free. Acetaminophen (Tylenol) would be a good choice.

A client with a low platelet count asks the nurse, "Why are platelets important?" Which statement is the nurse's best response? "Platelets will make your blood clot." "Your platelets finish the clotting process." "Blood clotting is prevented by your platelets." "The clotting process begins with your platelets."

"The clotting process begins with your platelets." The nurse's best response to why platelets are important is that, "The clotting process begins with your platelets." Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis. Platelets do not clot blood but are a part of the clotting process or cascade of coagulation. Platelets do not prevent the blood from clotting. Rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it.

A client with leukemia is being discharged from the hospital. After hearing the nurse's instructions to keep regularly scheduled follow-up provider appointments, the client says, "I don't have transportation." How does the nurse respond?

"The local American Cancer Society may be able to help." Many local units of the American Cancer Society offer free transportation to clients with cancer, including those with leukemia. Suggesting a pharmaceutical company is not the best answer; drug companies typically do not provide this type of service. Although the nurse offering to take the client is compassionate, it is not appropriate for the nurse to offer the client transportation. Telling the client to take the bus is dismissive and does not take into consideration the client's situation (e.g., the client may live nowhere near a bus route).

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include?

"The sickle cell trait will be inherited by your children." The children of the client with sickle cell disease will inherit the sickle cell trait, but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "This may be caused by a genetic trait." "Just imagine how bad it would be if you weren't in good shape."

"This may be caused by a genetic trait." **The nurse's best response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait.Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? "This is a noninvasive test performed to assess your heart rhythm." "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." "This is a painless test that is done to assess the structure of your heart using sound waves." "This test evaluates you for potentially fatal cardiac rhythms."

"This test evaluates you for potentially fatal cardiac rhythms." **The most correct teaching about the purpose of EPS is when the nurse says that the test evaluates the potential for fatal cardiac rhythms. EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities.A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.

Which instruction is most appropriate for the nurse to teach a client with persistent thrombocytopenia who is being discharged? "Use a soft-bristled toothbrush." "Avoid large crowds." "Drink at least 2 L of fluid per day." "Elevate your lower legs when sitting."

"Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia. Avoiding large crowds reduces the risk for infection but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration but is not particularly relevant to the client with thrombocytopenia. Elevating the lower legs reduces the risk for dependent edema and clot formation but is not specific to the client with thrombocytopenia.

A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client?

"Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia. Avoiding large crowds reduces the risk for infection, but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration, but is not specific to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema, but is not specific to the client with thrombocytopenia.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)?

"Walk to the point of leg pain, then rest, resuming when pain stops." The teaching point the nurse include for a client with PAD is walk to the point of leg pain, rest, and then resume when pain stops. Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous occlusive disease. Application of heat must be avoided in clients with PAD due to a lack of sensation and possible burns to the legs.

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this client's problem?

"Would you like to try some relaxation techniques?" Because most clients with multiple myeloma have local or generalized bone pain, analgesics and alternative approaches for pain management, such as relaxation techniques, are used for pain relief. This also offers the client a choice. Before prescribing additional medication, other avenues should be explored to relieve this client's pain. Even if it is too soon to give additional medication, telling that to the client is not helpful because it dismisses the client's pain concerns. Although music therapy can be helpful, this response does not give the client a choice.

The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? "The doctor will place a small needle in your back and will withdraw some fluid." "You will be sedated during the procedure, so you will not be aware of anything." "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area."

"You may experience a crunching sound or a scraping sensation as the needle punctures your bone." When describing a bone marrow biopsy procedure to a client, it is accurate to describe a crunching sound or scraping sensation when the needle punctures the bone. Proper expectations minimize the client's fear during the procedure. A very large-bore needle is used for a bone marrow biopsy, not a small needle, and the puncture is made in the hip or in the sternum, not the back. A local anesthetic agent is injected into the skin around the site. The client may also receive a mild tranquilizer or a rapid-acting sedative (such as lorazepam [Ativan]) but will not be completely sedated. The nurse, or sometimes a family member, is available to the client for support during a bone marrow biopsy. The procedure is sterile at the site of the biopsy, but others can be present without contamination at the site

What is the nurse's best response when a client with anemia asks "Why am I feeling tired all the time?" "Your brain is not getting enough oxygen." "How many hours are you sleeping at night?" "You are probably dehydrated." "When you are sick, you need to rest more."

"Your brain is not getting enough oxygen." The nurse's best response to the client complaining about feeling tired all the time is "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.

A client with anemia asks the nurse, "Why am I feeling tired all the time?" What is the nurse's best response? "You are not getting enough iron." "When you are sick you need to rest more." "How many hours are you sleeping at night?" "Your cells are delivering less oxygen than you need."

"Your cells are delivering less oxygen than you need." The nurse's best response to the client complaining about feeling tired all the time is "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs. While it may be true that the client isn't getting enough iron, it does not relate to the client's fatigue. The statement about the client needing rest because of being sick is simply not true. Although assessment of sleep and rest is good, it does not address the cause related to the diagnosis.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic?

"Your concerns are valid; we can review some steps to limit disease progression." The most therapeutic response by the nurse to this client is "Your concerns are valid; we can review some steps to limit disease progression." It is important to validate the client's concern and offer needed information.Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern. Controlling diabetes may help prevent amputation, but the nurse cannot state this with certainty. Asking the client about what concerns him the most is not as open-ended a question as the others. In addition, the client has already stated his concern.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation?

70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic The client who just arrived in the ED and needs immediate medical evaluation of the 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic. This client's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.The 64-year-old is most stable and can be seen last. The 60-year-old and the 69-year-old would both be seen soon, but the 70-year-old client must be seen first.

Which client does the nurse assign as a roommate for the client with aplastic anemia?

A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia should be free from infection or infection risk. The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.

Which client is at greatest risk for having a hemolytic transfusion reaction?

A 34-year-old client with type O blood Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient. The client with allergies would be most susceptible to an allergic transfusion reaction. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease. The older adult client would be most susceptible to circulatory overload.

An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse?

A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion; therefore, he or she should be assigned to the client with sickle cell disease. Aplastic anemia, folic acid deficiency, and polycythemia vera are problems more commonly seen in adult clients who should be cared for by nurses who are more experienced in caring for adults.

After reviewing the laboratory test results, the nurse calls the primary care provider about which client? A 52-year-old who had a hemorrhage with a reticulocyte count of 0.8% A 49-year-old with hemophilia and a platelet count of 150,000/mm3 (150 × 109/L) A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) A 44-year-old prescribed warfarin (Coumadin) with an international normalized ratio (INR) of 3.0

A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) The nurse calls the PCP about a 46-year-old client with a fever and a WBC of 1500/mm3 (1.5 × 109/L). This client is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed.An elevated reticulocyte count in the 52-year-old is expected after hemorrhage. A platelet count of 150,000/mm3 (150 × 109/L) in the 49-year-old is normal. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level.

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) **The nurse would first assess the 46-year-old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

Which client will the nurse identify as having the greatest risk for development of acute leukemia? A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease. A 20 year old with cystic fibrosis who has been on continuous enzyme replacement therapy since infancy. A 55 year old with diabetes mellitus type 1 who has received insulin injections for 43 years. A 38 year old who has used combination oral contraceptives without a break for 15 years.

A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease. Cyclophosphamide is a cytotoxic agent that damages bone marrow and has been known to induce leukemia.Diabetes, long-term use of oral contraceptives, and enzyme replacement therapy for cystic fibrosis do not increase the risk for development of any type of leukemia.

Which client will the nurse monitor most closely for development of a febrile transfusion reaction? A 50 year old receiving multiple transfusions for severe hemorrhage A 60 year old receiving an intraoperative autologous transfusion A 40 year old receiving two units of fresh-frozen plasma A 70 year old receiving a rapid transfusion

A 50 year old receiving multiple transfusions for severe hemorrhage Febrile transfusion reactions, not related to infection or transfusion with contaminated blood, occur most often in the client with anti-WBC antibodies, which can develop when receiving multiple transfusions.The risk for febrile transfusion reactions is not age-related or related to the rate of transfusion delivery. Plasma transfusions do not have an increased risk for a febrile response. Febrile responses are nonexistent with autologous transfusions.

The nurse is starting the shift by making rounds. Which client would the nurse assess first? A 52-year-old who just had a bone marrow aspiration and is requesting pain medication A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism A 47-year-old who had a Rumpel-Leede test and asks the nurse to "look at the bruises on my arm" A 42-year-old with a diagnosis of anemia who reports shortness of breath when ambulating down the hallway

A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism After rounds, the nurse would first assess the 59-year-old client who has a nosebleed and is getting heparin to treat a pulmonary embolism. The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and must be assessed first for the severity of the situation. The client waiting for pain medication would be next on the nurse's "to do" list. Making clients wait for pain medication is not desirable, but in this scenario, the client who is bleeding is the higher priority. The client who had a Rumpel-Leede test and the client with anemia are more stable and can be assessed later. The Rumpel-Leede test is a tourniquet test used to determine the presence of vitamin C deficiency or thrombocytopenia.

The nurse is caring for a group of hospitalized clients. Which client is at highest risk for infection and sepsis? A client with hemolytic anemia A client with cirrhosis of the liver A client who had an emergency splenectomy A client with recently diagnosed sickle cell anemia

A client who had an emergency splenectomy The client who is at the highest risk for infection and sepsis is the client who had an emergency splenectomy. Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms and is at increased risk for infection. A low red blood cell count with hemolytic anemia can contribute to a client's risk for infection, but this client is more at risk for low oxygen levels and ensuing fatigue. The liver plays a role in blood coagulation, so this client is more at risk for coagulation problems than for infection. Sickle cell anemia causes pain and discomfort because of the changed cell morphology, so acute pain, especially at joints, is the greatest threat to this client.

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is most appropriate for the RN to assign to the LPN/LVN? A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging A client with acute coronary syndrome who has just been admitted and needs an admission assessment

A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index **The most appropriate client the RN assigns to the LPN/LVN is the client admitted with peripheral vascular disease who needs assessment of the ankle-brachial index. The scope of practice of the LPN/LVN includes taking blood pressure in the arm and lower extremity. This information will be given to the nurse for assessment.The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education. The LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care. The LPN/LVN may implement the plan.

Which client does the medical unit charge nurse assign to a licensed practical nurse (LPN)/licensed vocational nurse (LVN)? A client with chronic microcytic anemia associated with alcohol use A client scheduled for a bone marrow biopsy with conscious sedation A client with a history of a splenectomy and a temperature of 100.9°F (38.3°C) A client with atrial fibrillation and an international normalized ratio of 6.6

A client with chronic microcytic anemia associated with alcohol use The medical unit charge nurse assigns the LPN/LVN a client with chronic microcytic anemia related to alcohol use. Chronic microcytic anemia is not considered life-threatening and is within the skill level of an LPN/LVN. The client with a bone marrow biopsy with conscious sedation, a history of splenectomy and a temperature, and atrial fibrillation require more complex assessment or nursing care and would be assigned to RN staff members.

Which observation by the home care nurse when visiting a client who had a stem cell transplant 2 months ago requires immediate action? The spouse is preparing a lettuce salad for lunch. The client's platelet count remains below 100,000 cells/mm3 (100 × 109/L). A dog is the household pet. A grandchild is visiting after receiving a measles, mumps, and rubella vaccine.

A grandchild is visiting after receiving a measles, mumps, and rubella vaccine. Although the client is discharged to home when the white blood cell count, especially the neutrophil count, is high enough to prevent general infections. However, antibody-mediated immunity takes at least a year to redevelop. During that time, exposure to anyone who has received a recent live-virus vaccination increases the client's risk for developing the disease caused by the live virus.By the time the client is discharged to home, there are no dietary restrictions beyond those recommended for all people. Dogs are not considered an infectious health hazard. Platelets usually remain low for months after stem cell transplantation.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN?

Administer a clonidine patch for hypertension. The action the nurse delegates to the LPN/LVN caring for a client with dark-colored toe ulcers and a BP of 190/100 mmHg is to administer a clonidine patch for hypertension. Administering medication is within the scope of practice for the LPN/LVN.The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 32 year old with pernicious anemia who needs a vitamin B12 injection A 40 year old with iron deficiency anemia who needs an iron dextran infusion A 67 year old with acute myelocytic leukemia with petechiae on both legs An 81 year old with thrombocytopenia and an increase in abdominal girth

An 81 year old with thrombocytopenia and an increase in abdominal girth The nurse needs to first assess the 81-year-old client with thrombocytopenia and an increase in abdominal girth. An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage, and warrants further assessment immediately.The 32 year old with pernicious anemia, the 67 year old with acute myelocytic leukemia, and the 40 year old with iron deficiency anemia do not have indications of any acute complications and their assessments can be delayed.

The nurse assesses the client with which hematologic problem first?

An 81-year-old with thrombocytopenia and an increase in abdominal girth An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage; this warrants further assessment immediately. The 32-year-old with pernicious anemia, the 40-year-old with iron deficiency anemia, and the 67-year-old with acute myelocytic leukemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia.

Which statement about diagnostic cardiovascular testing is correct? Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. The left side of the heart is catheterized first and may be the only side examined.

An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. **The correct statement about diagnostic cardiovascular testing is that an alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Intravascular ultrasonography (IVUS) is performed when a flexible catheter with a miniature transducer is inserted at the distal tip to view the coronary arteries. The transducer emits sound waves, which reflect off the plaque and the arterial wall to create an image of the blood vessel. It is another option besides using the medium injection method of diagnostic cardiovascular testing.Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing and not just the left side of the heart.

The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? "The doctor will place a small needle in your back and will withdraw some fluid." "You will be sedated during the procedure, so you will not be aware of anything." "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area."

Apply pressure to the biopsy site The priority postprocedural action after a bone marrow biopsy would be to stop bleeding by applying pressure to the site. Inspecting for ecchymosis, sending specimens to the laboratory and teaching the client about activity levels will be done after hemostasis has been achieved.

Safe and effective care

Assess pts for allergy to iodine based contrast media before having invasive diagnostic tests requiring an iodine based contrast agent After invasive cardiovascular dx testing, like angiography and cardiac catheterization, monitor the insertion site for bleeding and hematoma formation

What is the appropriate action for the nurse to take when a client's leukocyte count is 8200/mm3 (8.2 × 109/L) 8 weeks after hematopoietic stem cell transplantation for leukemia? Notifying the hematologic health care provider immediately Reminding the client to avoid crowds and people who are ill Documenting the report as the only action Assessing the client for other symptoms of infection

Assessing the client for other symptoms of infection The leukocyte (white blood cell) count is now within the normal range (5000 to 10,000/mm3) [5 to 10 × 109/L) and is an indicator of successful engraftment. The client is not at any particular risk for infection at this time, nor is this cause to believe that an infection is present. (At any posttransplantation checkup, the client is assessed for infection.)

Which statement reflects correct cardiac physical assessment technique? Auscultate the aortic valve in the second intercostal space at the right sternal border. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. Palpate the apical pulse over the third intercostal space in the midclavicular line. Assess for carotid bruit by auscultating over the anterior neck.

Auscultate the aortic valve in the second intercostal space at the right sternal border. **The statement that shows correct cardiac physical assessment technique is to auscultate the aortic valve in the second intercostal space at the right sternal border.Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.

The home health nurse visits a client with heart failure who has gained 5 pounds (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Assess the client for peripheral edema. Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions.

Auscultate the client's posterior breath sounds. **The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

Which precaution is most important for the nurse to teach a patient with leukemia to prevent an infection by cross-contamination? Reporting any burning on urination immediately Taking antibiotics exactly as prescribed Avoiding crowds and people who are ill Performing mouth care three times daily

Avoiding crowds and people who are ill Infection by cross-contamination occurs when organisms from another person are transmitted to the client. This risk can be reduced for the neutropenic client by avoiding crowds and people who are ill (social distancing).Auto-contamination is the overgrowth of the client's own normal flora or the translocation of his or her normal flora from its normal location to a different one. Taking antibiotics does not prevent cross-contamination and neither does reporting symptoms of an infection. Performing mouth care frequently can reduce the number of normal flora organisms in the mouth and decrease the risk for developing an infection from auto-contamination but not cross-contamination

Which collaborative problem will the nurse consider to have the highest priority when caring for a client with multiple myeloma? Minimizing the side effects of chemotherapy Helping the client conserve energy Providing pain control Protecting the client from infection

Avoiding crowds and people who are ill Infection by cross-contamination occurs when organisms from another person are transmitted to the client. This risk can be reduced for the neutropenic client by avoiding crowds and people who are ill (social distancing).Auto-contamination is the overgrowth of the client's own normal flora or the translocation of his or her normal flora from its normal location to a different one. Taking antibiotics does not prevent cross-contamination and neither does reporting symptoms of an infection. Performing mouth care frequently can reduce the number of normal flora organisms in the mouth and decrease the risk for developing an infection from auto-contamination but not cross-contamination.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? Serum potassium level of 3.2 mEq/L (3.2 mmol/L) Ejection fraction of 60% B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) Chest x-ray report showing right middle lobe consolidation

B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) **A BNP of 760 pg/ml (760 ng/dL) is consistent with a diagnosis of heart failure. BNP is produced and released by the ventricles when the client has fluid overload as a result of HF. A normal BNP value is less than 0-99 picograms per milliliter (pg/mL) or 0-99 nanograms per liter (ng/L).Hypokalemia (serum potassium level of 3.2 mEq/L [3.2 mmol/L]) may occur in response to diuretic therapy for HF, but may also occur with other conditions. It is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture?

Blood pressure (BP) 192/102 mm Hg The problem that must be addressed immediately to prevent rupture in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.The nurse must consider the client's usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. Blurred vision Tachycardia Fatigue Serum digoxin level of 1.5 ng/ml (1.92 nmol/L) Anorexia

Blurred vision Fatigue Anorexia **The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur.Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

Which condition or event within the past 24 hours will the nurse identify as a possible cause of the current crisis episode in a client with sickle cell disease (SCD)? Participating in an archery tournament Spraining a wrist while stopping a fall Binge-drinking wine at a party Engaging in sexual intercourse

CORRECT Binge-drinking wine at a partyCommon conditions that cause sickling that may lead to crises include hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol consumption, high altitudes, low or high environmental or body temperatures, acidosis, strenuous exercise, emotional stress, tobacco use (especially cigarettes), and anesthesia. Therefore binge-drinking is a strong possible trigger for the client's current crisis.Although strenuous exercise can induce a crisis, archery is not a strenuous activity that causes hypoxemia or acidosis. Sustaining a sprained wrist or engaging in sexual intercourse does not commonly induce a crisis.

Which medication, when given in heart failure, may improve morbidity and mortality? Dobutamine (Dobutrex) Carvedilol (Coreg) Digoxin (Lanoxin) Bumetanide (Bumex)

Carvedilol (Coreg) **Carvedilol when given to clients in heart failure may improve morbidity and mortality. Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure. This category of pharmacologic agents improves morbidity, mortality, and quality of life.Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion, and does not improve morbidity and mortality.

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia (AML) is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. An infection develops. What knowledge does the nurse use to determine that the appropriate antibiotic has been prescribed for this client?

Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection is the best action to take. Drug therapy is the main defense against infections that develop in clients undergoing therapy for AML. Agents used depend on the client's sensitivity to various antibiotics for the organism causing the infection.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Select all that apply. Chest discomfort or pain Tachycardia Expectorating thick, yellow sputum Sleeping on back without a pillow Fatigue

Chest discomfort or pain Tachycardia Fatigue **When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

Which signs and symptoms are seen with suspected pericarditis? Select all that apply. Squeezing, vise-like chest pain Chest pain relieved by sitting upright Chest and abdominal pain relieved by antacids Sudden-onset chest pain relieved by anti-inflammatory agents Pain in the chest described as sharp or stabbing

Chest pain relieved by sitting upright Sudden-onset chest pain relieved by anti-inflammatory agents Pain in the chest described as sharp or stabbing **The chest pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing.Squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? Ejection fraction is 25%. Client states that she is able to sleep on one pillow. Client was hospitalized five times last year with pulmonary edema. Client reports that she experiences palpitations.

Client states that she is able to sleep on one pillow. **A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol.An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition?

Client stating that the year is 1967 The nurse becomes most concerned after a client receives t-PA for a large vein thrombus when the client states that the year is 1967. The most serious complication from thrombolytic therapy is intracerebral bleeding, manifested by changes in the level of consciousness.Thrombolytics such as t-PA dissolve clots. Even without this medication, a small amount of blood at the insertion site is not abnormal. Anticoagulants and thrombolytics may cause heavier-than-usual menstrual bleeding. Swelling is expected in the extremity with deep vein thrombosis.

Which client would the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain Client who has many questions about the electrophysiology studies (EPS) scheduled for today

Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes **The client returning from a coronary arteriogram who requires vital signs and checks of the insertion site every 15 minutes. This client is within the scope of practice of a newly licensed RN.An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable, so the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS. The newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently.

Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with heart failure who is receiving dobutamine (Dobutrex) Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea Client with pericarditis who has a paradoxical pulse and distended jugular veins Client with rheumatic fever who has a new systolic murmur

Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea **The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice.The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? Client with abdominal pain and belching Client with pressure in the mid-abdomen and profound diaphoresis Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows Client with claudication and fatigue

Client with pressure in the mid-abdomen and profound diaphoresis **The client with pain most consistent with an MI is the client with pressure in the mid-abdomen and profound diaphoresis. Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety.Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms?

Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action would be taken by he nurse? No intervention is needed; this is a normal reading. Collaborate with the primary health care provider to administer a positive inotropic agent. Administer a STAT dose of metoprolol (Lopressor). Ask the client to perform the Valsalva maneuver.

Collaborate with the primary health care provider to administer a positive inotropic agent. **A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min.No intervention is needed because this is a normal reading. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility, so cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.

Which body area on a client with darker skin is most appropriate for the nurse to examine for indications of pallor and cyanosis? Earlobes and bridge of the nose Palms and soles Conjunctiva of the eyes Tongue

Conjunctiva of the eyes Pallor and cyanosis are more easily detected in adults with darker skin by examining the oral mucous membranes and the conjunctiva of the eye, not the palms of the hands or soles of the feet (although petechiae may be more apparent there). The tongue is a poor indicator of pallor or cyanosis although changes in texture and color may indicate other hematology problems.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? Calls the family to lift the client's spirits Considers further assessment for depression Sedates the client to decrease myocardial oxygen demand Tells the client that things will get better

Considers further assessment for depression **The nurse's best response to the client when he/she says it isn't worth it anymore and I want it all to end is to consider further assessment for depression. This client is at risk for depression because of the diagnosis of heart failure, and further assessment must be done.Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels?

Consume melons and baked potatoes. Melons and baked potatoes are foods high in potassium.Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron. Oatmeal contains fiber but not potassium.

Which task does the nurse delegate to unlicensed assistive personnel (UAP) who is assisting with the care of a female client with anemia? Monitor the oral mucosa for pallor, bleeding, or ulceration Ask about the amount of blood loss with each menstrual period Check for sternal tenderness while applying fingertip pressure Count the respiratory rate before and after ambulating 20 feet (6 m)

Count the respiratory rate before and after ambulating 20 feet (6 m) Counting the respiratory rate before and after ambulation is within the scope of practice for a UAP. The UAP will report this information to the RN. Monitoring oral mucosa requires skilled assessment techniques and knowledge of normal parameters, asking the client about the amount of blood loss with each menstrual period, and checking for sternal tenderness would be done by the RN.

early S&S of pulmonary edema

Crackles in lung bases, dyspnea at rest, disorientation, confusion

A client with heart failure reports a 7.6-pound (3.4 kg) weight gain in the past week. What intervention does the nurse anticipate from the primary health care provider? Dietary consult Sodium restriction Daily weight monitoring Restricted activity

Daily weight monitoring **The nurse expects that the primary health care provider will want the client's daily weights monitored. A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg), or 4 to 7 L of fluid to occur before excess fluid accumulation (edema) is apparent.The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

Which assessment finding will the nurse associate as a complication of a client having three episodes of sickle cell crisis in the past 3 months? Deeply yellowed sclera Worsening hypertension Several episodes of priapism Increased deep tendon reflexes

Deeply yellowed sclera Many red blood cells are lysed and destroyed during crises, which can greatly increase the bilirubin concentration in the blood. After three crises close together, the elevated bilirubin levels result in jaundice, which may manifest as deeply yellowed sclera.Clients with sickle cell disease are more likely to be hypotensive because of the anemia, not hypertensive. Priapism is a random event not associated with a crisis. When crises cause brain infarctions or strokes, deep tendon reflexes are reduced.

How will the nurse interpret a client's laboratory finding of an increased total iron-binding capacity (TIBC)? Increased risk for clot formation Deficient circulating and stored iron levels Iron excess Decreased bone marrow function

Deficient circulating and stored iron levels TIBC measures how much iron could be bound to transferrin. When this value increases, a client is deficient in serum iron and stored iron levels and less is bound to the transferrin.Changes in TIBC do not reflect actual bone marrow function. Clot formation does not increase with higher TIBC.

Which drugs does the nurse anticipate giving as premedication to client who is to receive a pooled platelet transfusion and has had a previous transfusion reaction? Vitamin K and a diuretic Diphenhydramine and acetaminophen Aspirin and hydroxyurea Hydrocortisone and antihypertensives

Diphenhydramine and acetaminophen A client who has had a transfusion reaction in the past may be given diphenhydramine and acetaminophen before the transfusion to reduce the fever and severe chills (rigors) that often occur during platelet transfusions.

What is the nurse's interpretation of when the blood laboratory values a client who has chronic myelogenous leukemia (CML) shows a high percentage of blast cells and promyelocytes? Infection risk is decreasing. Disease is progressing. Leukemia type is now lymphocytic. Drug therapy is effective.

Disease is progressing. The leukemia is progressing and drug therapy is no longer effective. CML has three phases: The chronic phase is often a slowly progressing (indolent) course with fewer than 10% blast cells at this time. The accelerated phase has progressive symptoms with 10% to 30% blast cells and poor response to therapy. The blast phase indicates transformation to a very aggressive acute leukemia with more than 30% blast cells that commonly spread to other tissues and organs. The leukemia becomes more like acute leukemia than chronic leukemia but does not change from myelogenous to lymphocytic. With so many blast cells that are immature and do not function properly, the client is now at greatly increased risk for infection.

Which new-onset symptom in a client with sickle cell disease (SCD) will the nurse report immediately to the health care provider to prevent harm? Distention of neck veins in the sitting position Itching of the extremities Priapism lasting 30 minutes Increased urinary output

Distention of neck veins in the sitting position Clients with SCD are at risk for heart failure. One of the major symptoms of heart failure, which can be a life-threatening complication, is distention of the neck veins when the client is in the upright position. The nurse will report this change immediately so that proper management of heart failure can begin to prevent multiple organ system dysfunction and death.Although prolonged priapism is a condition requiring urgent intervention, 30 minutes is not considered prolonged. An increased urinary output may indicate decreased concentrating function of the kidney, but is not an emergent change. Most clients with SCD have skin dryness on the extremities as a result of reduced perfusion. This could also be related to increased bilirubin in the skin resulting from red blood cell lysis; however, it does not require urgent management.

What action will the nurse take when a client's laboratory results indicate the platelet count is 180,000/mm3 (180 × 109/L)? Apply oxygen to improve gas exchange. Document the result as the only action. Instruct assistive personnel (AP) to handle client gently. Immediately inform the health care provider because of possible spontaneous bleeding.

Document the result as the only action. The client's platelet count is within the normal limits and requires no action beyond ensuring documentation. This value is at the lower end of the normal range but does not increase the client's risk for excessive bleeding or bruising even after trauma.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client would the nurse question?

Dopamine (Intropin) The nurse would question the prescription for dopamine. Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure, and would not be used in hypertensive emergency.Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies. Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies. Labetalol, an intravenous calcium channel blocker, is used in hypertensive emergencies when oral therapy is not feasible.

Which action will the nurse perform first when caring for a client with neutropenia who has a suspected infection? Administering prescribed antibiotics Administering IV normal saline for hydration Placing the client on Contact Precautions Drawing blood for cultures

Drawing blood for cultures The priority action for the nurse to take is to draw blood cultures for cultures to identify the infectious agent. This must be done before administering prescribed antibiotics.Placing the client on Contact Precautions is unnecessary because the neutropenic client is not contagious to others. Hydration is important but not the first priority.

Which of these factors contribute to the risk for cardiovascular disease? Select all that apply. Consuming a diet rich in fiber Elevated C-reactive protein levels Low blood pressure Elevated high-density lipoprotein (HDL) cholesterol level Smoking

Elevated C-reactive protein levels Smoking **Factors that contribute to the risk for cardiovascular disease include elevated C-reactive protein levels and smoking. Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation must also be emphasized. Smoking is a major modifiable risk factor for cardiovascular disease.A diet rich in fiber is not a risk factor for cardiovascular disease, but rather a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis. Elevated HDL cholesterol is desirable and may be cardioprotective.

Which intervention most effectively protects a client with thrombocytopenia?

Encouraging the use of an electric shaver The client with thrombocytopenia should be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. To prevent rectal trauma, rectal thermometers should not be used. Oral or tympanic temperatures should be taken. Ice (not heat) should be applied to areas of trauma.

Reduce risk for heart disease with modifiable factors

Exercise, smoking cessation, diet modification,

A client who is suffering from dyspnea on exertion and congestive heart failure (CHF) will most likely report which symptom during the health history? Fatigue Swelling of one leg Slow heart rate Brown discoloration of lower extremities

Fatigue **The CHF client with dyspnea on exertion will most likely report fatigue during the health history. Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle.Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.

Monitor HF pt on beta blockers

For hypotension and bradycardia

The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client?

Frequent and thorough handwashing Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance. Drug therapy is a major defense against infections that develop in the client with sickle cell disease, but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention. Taking vital signs every 4 hours will help with early detection of infection, but is not prevention.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, with pink, frothy sputum, and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings Diagnostic Findings Provider Prescriptions Crackles in all fieldsS3 presentOliguriaEjection fraction 30%BNP 560Sodium 130 mEq/L (130 mmol/L)Diagnosis: heart failureEnalapril 10 mg orally dailyHeparin 5000 units subcutaneously every 12 hoursFurosemide 40 mg IV dailyStrict I & O Enalapril Heparin Furosemide Intake and output (I & O)

Furosemide **While caring for a client with acute heart failure, the ED nurse Administers Furosemide first. The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion. A diuretic will promote fluid loss.Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis secondary to immobility, but will not reduce fluid excess. Although all clients with congestive heart failure need to have daily weights and I & O monitored, this is not a priority. Removing fluid volume and treating dyspnea are matters of priority.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective?

Has maintained a low-sodium, no-add-salt diet Has lost 3 pounds (1.4kg) since last seen in the clinic Has cut down on the caffeine

The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? Uses a prepared list and finds out the client's food preferences Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) Has the client write down everything he or she has eaten for the past week Determines who prepares the client's meals and plans an interview with him or her

Has the client write down everything he or she has eaten for the past week The best way for the nurse to assess an anemic client's diet is to have the client write down everything he/she has eaten in the last week. Having the client provide a list of items eaten in the past week is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as protein, vitamin, and mineral intake. Determining food preferences from a prepared list provides information about what the client enjoys eating, not necessarily what the client has been eating. For instance, the client may like steak but may be unable to afford it. Rating scales are good for subjective data collection about some conditions such as pain, but the subjectivity of a response such as this does not provide the nurse with specific data needed to assess a diet. Interviewing the food preparer is time-consuming and poses several problems, such as whether a number of people are preparing meals, or if the client goes "out" for meals.

A newly admitted client has an elevated reticulocyte count. Which condition does the nurse suspect in this client? Leukemia Aplastic anemia Hemolytic anemia Infectious process

Hemolytic anemia The nurse suspects that the client has hemolytic anemia. An elevated reticulocyte count in an anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying RBCs. Therefore, more immature RBCs are in circulation. A low white blood cell count is expected in clients with leukemia. Aplastic anemia is associated with a low reticulocyte count. A high white blood cell count is expected in clients with infection.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8°F (37.7°C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action does the nurse take? Give the digoxin; reassess the heart rate in 30 minutes. Give the digoxin; document assessment findings in the medical record. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement.

Hold the digoxin, and obtain a prescription for a potassium supplement. **The nurse needs to hold the digoxin and get a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

A 32-year-old client is recovering from a sickle cell crisis. His discomfort is controlled with pain medications and he is to be discharged. What medication does the nurse expect to be prescribed for him before his discharge?

Hydroxyurea (Droxia) Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD). Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out?

Hyperkalemia During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products. High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.

Which electrolyte imbalance will the nurse expect to find in a client with polycythemia vera (PV)? Hyperkalemia Hypokalemia Hyponatremia Hypernatremia

Hyperkalemia The actual number of circulating red blood cells is greatly increased in PV, but the cells are not normal and have shorter cell life spans. This problem leads to rapid cell turnover and excessive release of intracellular substances, including potassium. The increased potassium level is hyperkalemia, not hypokalemia. Blood sodium levels are unaffected by high turnover of red blood cells.

risk for cardiovascular disease

Hyperlipidemia, hypertension, excess weight, physical inactivity, smoking, psychological stress, family history, and diabetes

Which signs and symptoms in an older client receiving a blood transfusion indicate to the nurse that the client is experiencing transfusion-associated circulatory overload (TACO)? Urticaria, itching, and bronchospasm Hypertension, bounding pulse, and distended neck veins Headache, chest pain, and hemoglobinuria Fever, chills, and tachycardia

Hypertension, bounding pulse, and distended neck veins Older clients are much more at risk for TACO than younger clients. Common symptoms include hypertension, bounding pulse, distended jugular veins, dyspnea, restlessness, and confusion.Headache, chest pain, and hemoglobinuria are symptoms of a hemolytic transfusion reaction. Urticaria, itching, and bronchospasm are symptoms of allergic transfusion reactions. Fever, chills, and tachycardia are symptoms of bacterial transfusion reactions.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? Ibuprofen (Motrin) Hydrochlorothiazide (HydroDIURIL) NPH insulin Levothyroxine (Synthroid)

Ibuprofen (Motrin) **The nurse questions an 82-year-old client with exacerbation of heart failure if the client is taking ibuprofen. Long-term use of nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF.A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism. It does not cause HF.

Which lab values would the nurse expect to see for a client with sickle cell disease? (Select all that apply.) Select all that apply. Decreased total bilirubin Increased hematocrit Decreased iron levels Increased reticulocyte count Elevated total white blood cell count 80% hemoglobin S

Increased reticulocyte count The hemoglobin S levels in a client with SCD are always elevated because it is the basis of the disease. The reticulocyte is elevated because anemia of long duration stimulates the bone marrow to produce more red blood cells (RBCs) and release them at the less mature stage. The WBC count is usually high in clients with SCD related to chronic inflammation caused by tissue hypoxia and ischemia.Iron levels and bilirubin levels are increased in SCD because they are released from the damaged RBCs. The hematocrit is lower because of RBC loss. Elevated total white blood cell count The hemoglobin S levels in a client with SCD are always elevated because it is the basis of the disease. The reticulocyte is elevated because anemia of long duration stimulates the bone marrow to produce more red blood cells (RBCs) and release them at the less mature stage. The WBC count is usually high in clients with SCD related to chronic inflammation caused by tissue hypoxia and ischemia.Iron levels and bilirubin levels are increased in SCD because they are released from the damaged RBCs. The hematocrit is lower because of RBC loss. 80% hemoglobin S The hemoglobin S levels in a client with SCD are always elevated because it is the basis of the disease. The reticulocyte is elevated because anemia of long duration stimulates the bone marrow to produce more red blood cells (RBCs) and release them at the less mature stage. The WBC count is usually high in clients with SCD related to chronic inflammation caused by tissue hypoxia and ischemia.Iron levels and bilirubin levels are increased in SCD because they are released from the damaged RBCs. The hematocrit is lower because of RBC loss.

Which laboratory trend indicates to the nurse that drug therapy with hydroxyurea is effective in the client who has sickle cell (SCD)? Increasing hemoglobin-F levels Decreasing blood osmolarity Increasing platelet levels Increasing blood iron levels

Increasing hemoglobin-F levels Hydroxyurea has been successfully used to reduce the number of sickling and pain episodes. Hydroxyurea works by stimulating fetal hemoglobin (HbF) production. HbF is present during fetal development, but production of hemoglobin F is turned off before birth. Increasing the level of HbF reduces sickling of red blood cells in persons with sickle cell disease.Hydroxyurea does not reduce blood osmolarity or increase platelet numbers. Clients with SCD are not iron-deficient and do not need therapy to increase blood iron levels.

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan?

Infection The main objective in caring for a newly diagnosed client with leukemia is protection from infection. Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow?

Infuse the transfusion over a 15- to 30-minute period. The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period. Administering steroids is not standard practice in administering platelets. Platelets must be administered immediately after they are received; they are considered to be quite fragile. A special transfusion set with a smaller filter and shorter tubing is used to get the platelets into the client quickly and efficiently.

Which actions are priorities for the nurse to perform to prevent harm after a client has a bone marrow biopsy performed? (Select all that apply.) Sending the specimen to the laboratory Measuring temperature Advising the client to not drive for 24 hours Inspecting the site for ecchymosis Applying pressure to the biopsy site Instructing the client to avoid vigorous activity

Inspecting the site for ecchymosis Prevention of harm after a bone marrow biopsy is to minimize postprocedure bleeding. The nurse applies pressure for 10 minutes to the site and evaluates for ecchymosis around the site. The client is instructed to avoid activities that could cause trauma to the procedure site.Measuring temperature does not prevent bleeding and is not a priority after bone marrow biopsy. Sending specimens to the laboratory is important but does not prevent harm. Unless the client had a sedative or anesthesia for the procedure, driving is not restricted. CORRECT Applying pressure to the biopsy site Prevention of harm after a bone marrow biopsy is to minimize postprocedure bleeding. The nurse applies pressure for 10 minutes to the site and evaluates for ecchymosis around the site. The client is instructed to avoid activities that could cause trauma to the procedure site.Measuring temperature does not prevent bleeding and is not a priority after bone marrow biopsy. Sending specimens to the laboratory is important but does not prevent harm. Unless the client had a sedative or anesthesia for the procedure, driving is not restricted. CORRECT Instructing the client to avoid vigorous activity Prevention of harm after a bone marrow biopsy is to minimize postprocedure bleeding. The nurse applies pressure for 10 minutes to the site and evaluates for ecchymosis around the site. The client is instructed to avoid activities that could cause trauma to the procedure site.Measuring temperature does not prevent bleeding and is not a priority after bone marrow biopsy. Sending specimens to the laboratory is important but does not prevent harm. Unless the client had a sedative or anesthesia for the procedure, driving is not restricted.

Which medication will the nurse prepare to administer to a client who is in sickle cell crisis and requests "something for pain"? Intramuscular (IM) meperidine Intravenous (IV) hydromorphone Oral ibuprofen Oral morphine sulfate

Intravenous (IV) hydromorphone The client with sickle cell crisis needs immediate pain relief, usually an opioid, which is most effective when administered intravenously. NSAIDs may be used for clients with SCD for pain relief once their pain is under control, but not during a crisis. Meperidine is no longer a first-line drug for pain management.

A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer?

Intravenous (IV) hydromorphone (Dilaudid) The client needs IV pain relief, and it should be administered on a routine schedule (i.e., before the client has to request it). Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin. Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control; however, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis; IV analgesics should be used until his or her condition stabilizes.

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the primary health care provider? Saline infusion Morphine sulfate No treatment, continue monitoring Intravenous furosemide

Intravenous furosemide **The nurse expects that the primary health care provider will request intravenous furosemide be given to the client with a right atrial pressure of 8 mm Hg. Normal right atrial pressure is 0 to 5 mm Hg. The primary health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure.Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse must collaborate with the provider to decrease the right atrial pressure.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension?

Kidney disease The client who is most at risk for secondary hypertension is the client with kidney disease. Kidney disease is one of the most common causes of secondary hypertension.Psychiatric disturbance can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.

Which are risk factors that are known to contribute to atherosclerosis-related diseases?

Low-density lipoprotein cholesterol of 160mg/dL Smoking Type 2 diabetes

Which client has the highest risk for cardiovascular disease? Man who smokes and whose father died at 49 of myocardial infarction (MI) Woman with abdominal obesity who exercises three times per week Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL (1.94 mmol/L) Man who is sedentary and reports four episodes of strep throat

Man who smokes and whose father died at 49 of myocardial infarction (MI) **The client who has the highest risk for cardiovascular disease is the man who smokes and whose father died at 49 years of age of MI. Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death.Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI, but an HDL cholesterol of 75 mg/dL (1.94 mmol/L) is in the optimal range of greater than 55 mg/dL (1.42 mmol/L). Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation?

Marfan syndrome Marfan syndrome is a risk factor for cardiovascular disorders such as AAA. Marfan syndrome is a genetic connective tissue disorder. It occurs in middle-aged and older people, peaking in adults in their 50s and 60s. Men are more commonly affected than women.Peptic ulcer disease is not a risk factor for AAA formation. AAA is an arterial problem, so DVT is not a related risk. Osteoarthritis is related to overuse of joints, and does not present a risk for AAA.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? Right atrial pressure is 4 mm Hg. Mean arterial pressure (MAP) is 58 mm Hg. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. PO2 is reported as 78 mm Hg.

Mean arterial pressure (MAP) is 58 mm Hg. **To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. An MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain.An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.

Valvular dysfunction, cardiac infection, and cardiomyopathy teaching

Necessity of taking preventative antibiotic therapy before any invasive dental procedure

Which assessment finding of a newly admitted client with thrombocytopenia requires immediate action by the nurse? Elevated temperature Pain rating of 8 on a 0 to 10 scale Nosebleed Decreased urine output

Nosebleed The assessment finding on a newly admitted client with thrombocytopenia that needs immediate action by the nurse is bleeding from the nose. The client with thrombocytopenia has a high risk for hemorrhage with any bleeding. The client's report of pain, decreased urine output, and temperature elevation are not the highest priority.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? Assess preprocedure medications the client took that day. Have the client sign the consent form before the procedure is performed. Educate the client about the need to remain on bedrest after the procedure. Obtain client vital signs and a resting electrocardiogram (ECG).

Obtain client vital signs and a resting electrocardiogram (ECG). **Checking vital signs and performing a 12-lead ECG can be delegated to the UAP.The primary health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching must be done by the RN.

Which nursing action may be delegated to an unlicensed assistive personnel (UAP) working on the medical unit? Determine the usual alcohol intake for a client with cardiomyopathy. Monitor the pain level for a client with acute pericarditis. Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis.

Obtain daily weights for several clients with class IV heart failure. **The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does the nurse implement first?

Obtain requested cultures. Obtaining cultures to identify the infectious agent correctly is the priority for this client. Hydrating the client is not the priority. Administering antibiotics is important, but antibiotics should always be started after cultures are obtained. Placing the client on Bleeding Precautions is unnecessary.

Which would be an appropriate task to delegate to unlicensed assistive personnel (UAP) working on a medical-surgical unit?

Obtaining vital signs on a client receiving a blood transfusion Obtaining vital signs on a client is within the scope of practice for UAP. Administering medication, assessing clients, and assisting with prescribed diet choices are complex actions that should be done by licensed nurses.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure?

Pedal pulses After a client with PAD has had a PTA, it is essential for the nurse to assess for pedal pulses. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring distal pulses to ensure adequate perfusion. Pulse checks must be assessed post procedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).Ankle-brachial index is a diagnostic study used to detect the presence of PAD. This is not necessary after PTA, which is an intervention to treat PAD. It is imperative to assess for dye allergy before performing PTA. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy). The femoral artery is generally the access site for PTA.

A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request?

Penicillin V (Pen-V K) Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease. Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? Maintains NPO (nothing by mouth) until this resolves Calls in another nurse for a second opinion Performs a complete neurologic assessment and notifies the primary care provider Explains to the client and family that this is expected after sedation

Performs a complete neurologic assessment and notifies the primary care provider **The first action the nurse must do when a client recovering from a cardiac angiography develops slurred speech is to perform a complete neurologic assessment and notify the primary health care provider. Based on the assessment finding, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness must be reported immediately for prompt intervention.Keeping the client NPO and waiting for symptoms to resolve are not appropriate. This assessment does not warrant a second opinion. Slurred speech is not expected after a cardiac angiography and sedation.

Why does an abnormally low erythrocyte count reduce gas exchange? Pulmonary ventilation is reduced. Circulation to the peripheral tissues is reduced. Blood flow is obstructed from increased clot formation. Peripheral oxygen transport is reduced.

Peripheral oxygen transport is reduced. The major component of erythrocytes is hemoglobin, which is responsible for transporting oxygen through the blood to the tissues for tissue gas exchange. Fewer erythrocytes result in decreased oxygen transport although circulation to the peripheral tissues is unaffected.Clot formation is not increased, and pulmonary ventilation (movement of atmospheric air into and out from the lungs) is not affected.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Monitor pulse oximetry and cardiac rate and rhythm. Reassure the client that his distress can be relieved with proper intervention. Place the client in high-Fowler's position with the legs down. Ask a family member to remain with the client.

Place the client in high-Fowler's position with the legs down. **The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler's position with the legs down. High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased laboratory value would be of greatest concern to the nurse because it is not age-related? Hemoglobin level Red blood cell (RBC) count Platelet (thrombocyte) count White blood cell (WBC) response

Platelet (thrombocyte) count The decreased laboratory value of the greatest concern to the nurse is the 76-year-old client's platelet count. Platelet counts do not generally change with age. Hemoglobin levels in men and women fall after middle age. Iron-deficient diets may play a role in this reduction. Total RBC and WBC counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)?

Platelets 32,000/mm3 (32 × 109/L) When caring for a client receiving UFH, the nurse notifies the PCP of a platelet level of 32,000/mm3 (32 × 109/L). UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm3 (100 to 120 × 109/L). Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm3 (150 × 109/L).A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? Determines the client's physical limitations Encourages alternate rest and activity periods Monitors and documents heart rate, rhythm, and pulses Positions the client to alleviate dyspnea

Positions the client to alleviate dyspnea **The ICU nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

A client's medical record shows these data:Physical Assessment FindingsDiagnostic Findings Provider PrescriptionsCrackles at basesPTT 55 secondsLovenox 40 mg twice dailyRight leg swellingPOSITIVE, D-dimerElevate right legRight calf painhCG negativeDoppler study right leg

Positive D-dimer (>0.5mg/L) The above finding that confirms the presence of thromboembolism is positive D-dimer (>0.5mg/L). A D-dimer test is a global marker of coagulation activation, and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is often used for the diagnosis of deep vein thrombosis when the client has few clinical signs, and stratifies clients into a high-risk category for reoccurrence.A negative hCG indicates that the client is not pregnant, removing risk for thromboembolism. This test does not confirm thromboembolism. Crackles may be present in a variety of conditions, including pneumonia, heart failure, and pulmonary embolism. Leg swelling may be related to injury and thromboembolism.

Which serum electrolyte will the nurse monitor most closely in a client who receiving four units of packed red blood cells (PRBCs) over the next 12 hours? Chloride Sodium Calcium Potassium

Potassium The electrolyte imbalance the nurse needs to monitor in a client after transfusing four units of PRBCs is hyperkalemia. During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the primary health care provider by the nurse for further instructions? Calcium 8.5 mEq/L (4.25 mmol/L) Potassium 3.0 mEq/L (3.0 mmol/L) Magnesium 2.1 mEq/L (1 mmol/L) International normalized ratio (INR) of 1.0

Potassium 3.0 mEq/L (3.0 mmol/L) **The nurse needs to contact the primary health care provider when a potassium level of 3.0 mEq/L (3.0 mmol/L) is noticed on a client admitted with heart failure. Normal potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Hypokalemia may predispose to the client to dysrhythmia, especially if the client is taking digitalis preparations.A normal calcium level is 8.5 to 10.5 mEq/L (4.25 to 5 mmol/L). A normal magnesium level is 1.7 to 2.4 mEq/L (0.85 to 1.2 mmol/L). INR of 1.0 reflects a normal value.

The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first?

Provide pain medications as needed. Analgesics are needed to treat sickle cell pain. Warm soaks or compresses can help reduce pain perception. Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.

Which action will the nurse to perform first when caring for a female client who is in sickle cell crisis? Asking the client about possible triggers Teaching the client about barrier forms of contraception Ensuring adequate oral and IV fluid intake Providing pain medication

Providing pain medication The action the nurse would perform first for a client in sickle cell crisis is to provide pain medications as needed because the pain is often severe. Although ensuring adequate fluid intake is important, pain is managed first. Assessing for possible triggers and teaching about contraception are not priorities at this time.

Assess s&s of worsening HF

Rapid weight gain (3lb in a week), a decrease in exercise tolerance lasting 2-3 days, cold symptoms (cough) lasting more than 3-5 days, nocturia, development of dyspnea or angina at rest, or unstable angina

Which laboratory blood test results for a client undergoing hematologic assessment does the nurse report immediately to the prescriber? Platelets 185,000/mm3 INR 1.2 Red blood cell count 1.2 million/mm3 Hematocrit 36%

Red blood cell count 1.2 million/mm3 All of these test results are in the low to low-normal range. However, the parameter most abnormal is the red blood cell count. The normal range is 4.2 to 6.1 × 106/micL (4.2 to 6.1 × 1012cells/L. This client's value is dangerously below normal.

Which foods will the nurse help the client with vitamin B12 deficiency to increase in the diet? Grains Unsaturated fats Red meat Starchy vegetables

Red meat The nurse encourages the client to increase foods such as animal proteins, fish, eggs, nuts, dairy products, dried beans, citrus fruit, and leafy green vegetables, as sources of vitamin B12.The other food items listed contain little, if any vitamin B12.

With which member of the interprofessional team will the nurse collaborate when providing instructions for a client who has anemia cause by vitamin B12 acid deficiency? Registered dietitian nutritionist Mental health professional Physical therapist Wound care specialty nurse

Registered dietitian nutritionist The most common type of vitamin B12 acid deficiency anemia is caused by poor nutrition. This anemia is primarily managed is managed by teaching the client to increase his or her intake of foods rich in vitamin B12, although additional vitamin supplementation may be needed initially. A physical therapist is needed only in severe cases in which permanent nerve damage is present that interferes with mobility.

Which task does the nurse delegate to unlicensed assistive personnel (UAP)? Refer a client with a daily alcohol consumption of 12 beers for counseling Obtain a partial thromboplastin time from a saline lock on a client with a pulmonary embolism Report any bleeding noted when catheter care is given to a client with a history of hemophilia Perform a capillary fragility test to check vascular hemostatic function on a client with liver failure

Report any bleeding noted when catheter care is given to a client with a history of hemophilia The task the nurse delegates to the UAP is to report any bleeding when catheter care is given to a client with a history of hemophilia. Reporting findings during routine care is expected and required of unlicensed staff members. Referring a client for alcohol counseling, drawing a partial thromboplastin time, and performing a capillary fragility test are more complex and would be done by licensed nursing staff.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess?

Reproducible leg pain with exercise The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.

The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action?

Respiratory rate of 36 breaths/min in a client receiving red blood cells An increased respiratory rate indicates a possible hemolytic transfusion reaction; the nurse should quickly stop the transfusion and assess the client further. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response. Sleepiness is expected when Benadryl is administered. Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever.

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification?

Reviews all information with another registered nurse With another registered nurse, verify the client by name and number, check blood compatibility, and note expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses. Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate.

Which client laboratory trend indicates to the nurse that the prescribed erythropoietin therapy is effective? Rising reticulocyte count Rising platelet count Decreasing albumin levels Decreasing white blood cell count

Rising reticulocyte count Erythropoietin stimulates the bone marrow to produce more new red blood cells. A rising reticulocyte count reflects bone marrow release of new and less mature erythrocytes.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L (135 mmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L) Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) Serum magnesium level of 1.9 mEq/L (0.95 mmol/L)

Serum potassium level of 2.8 mEq/L (2.8 mmol/L) **The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and must be communicated immediately to the primary health care provider? White blood cell count Low-density lipoproteins Serum troponin I level C-reactive protein

Serum troponin I level **Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications.The white blood cell count does not reflect ACS. A mild leukocytosis (increase in white blood cells) may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

Which symptom reported by a client suggests to the nurse that anemia is a possibility? Chronic headaches Shortness of breath Cold hands and feet Difficulty sleeping

Shortness of breath Shortness of breath is very common with anemia because the blood is not efficient at providing enough oxygen. Thus, to maintain adequate oxygenation to tissues, the person has to increase his or her respiratory rate. Although cold hands/feet and headaches are associated with anemia, these symptoms are not specific enough to suggest anemia.

Which symptom reported by a client who has had a total hip replacement requires emergency action?

Shortness of breath and chest pain Emergency action is needed when the postoperative total hip replacement client reports shortness of breath and cheat pain. Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE.Although localized swelling is a symptom of DVT, it is not emergent. Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of clients with DVT, and false-positive findings are common, so assessing for Homans' sign is not advised. Tenderness and redness at the IV site indicate phlebitis and are not emergent, but must be attended to after the emergency.

Which vascular assessment by the student nurse requires intervention by the supervising nurse?

Simultaneously palpating the bilateral carotids The vascular assessment by the student that needs intervention by the supervisor nurse is simultaneously palpating the bilateral carotids. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. Many clients with vascular disease have poor blood flow. Pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in both arms.

What is the most important environmental risk for developing leukemia?

Smoking cigarettes According to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette smoking. Leukemia is not contagious. Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS, living near high-voltage power lines is not a proven risk factor for leukemia.

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? Friction rub auscultated at the left lower sternal border Pain aggravated by breathing, coughing, and swallowing Splinter hemorrhages Thickening of the endocardium

Splinter hemorrhages **Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed.Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next?

Stop the transfusion. The client may be experiencing a transfusion reaction; the nurse should stop the transfusion immediately. Calling the Rapid Response Team or obtaining vital signs is not the first thing that should be done. The nurse should not slow the infusion rate, but should stop it altogether.

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the primary health care provider (PCP) immediately?

Swelling and tenseness in the affected area The finding the nurse immediately reports to the PCP when caring for a postoperative embolectomy client who had an acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis is swelling and tenseness in the affected arm. Compartment syndrome may develop after an embolectomy, with swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb.Incisional pain is expected. Pink fingers and mobility are normal physical assessment findings. Heparin may be prescribed to maintain patency of the vessel after clot removal.

All of these client assignments have been made by the charge nurse. Which assignment is questionable?

The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure (BP) is 210/150 mm Hg The questionable assignment made by the charge nurse is assigning the LPN/LVN with 20 years' experience to care for a client with a headache whose BP is 210/150 mm Hg. The client with a headache and high blood pressure has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. This client must be assigned to an experienced RN, who can assess for end-organ damage and administer IV medications.A better assignment would be to assign the client with a headache to an RN and the client with PAD to the LPN/LVN. The RN with 3 years of experience has sufficient experience to provide care for a client with PE. The LPN/LVN can provide care for the client with leg ulcers, including dressing changes, if needed. The RN with 8 years of experience has sufficient knowledge to provide care for the client with PAD.

Which sign/symptom is essential for the nurse to report to the primary health care provider (PCP) when caring for a client with Raynaud's phenomenon?

The affected extremity becomes purple and cold. When caring for a client with Reynaud's phenomenon, it is essential for the nurse to report to the PCP an affected extremity that becomes purple and cold. Reynaud's phenomenon is described as painful vasospasms of arteries and arterioles in extremities, especially digits. This causes red-white-blue skin color changes on exposure to cold or stress. The cause is unknown, occurs more in women, and may be autoimmune because it is associated with many rheumatic diseases like systemic lupus erythematosus.Vasodilating drugs are administered as treatment and may lower the blood pressure, but this is not a significant drop. In severe cases, the attack lasts longer, and gangrene of the digits can occur. Pain, numbness, and cold are typical findings in Raynaud's phenomenon.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the primary care provider before the procedure begins? The client has had intermittent substernal chest pain for 6 months. The client develops wheezes and dyspnea after eating crab or lobster. The client reports that a previous arteriogram was negative for coronary artery disease. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

The client develops wheezes and dyspnea after eating crab or lobster. **The most important information the nurse needs to report to the primary health care provider before a coronary arteriogram is that the client develops wheezes and dyspnea after eating crab or lobster. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based. The client with a shellfish allergy is likely to have an allergic reaction to the contrast and must be medicated with an antihistamine or a steroid before the procedure.The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain. The intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time. It is appropriate to know that, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure. The pulses can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.

The nurse is assigned to all of these clients. Which client would be assessed first?

The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago The client who would be assessed first is the client who had a PTA of the right femoral artery 30 minutes ago. This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment and can be assessed after the PTA client is seen.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min. The client's weight decreases by 2.5 kg.

The client's weight decreases by 2.5 kg. **The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 pounds (2.5 kg) in one day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

After a cardiac catheterization, the client needs to increase his or her fluid intake for which reason? NPO status will cause the client to be thirsty. The dye causes an osmotic diuresis. The dye contains a heavy sodium load. The pedal pulses will be more easily palpable.

The dye causes an osmotic diuresis. **After a cardiac catheterization, the client needs to increase fluid intake because the dye used causes osmotic diuresis. The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment.Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodinated and does not contain a heavy sodium load. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids.

A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" Which is the nurse's best response to the client? "Yes, they do." "No, they don't." "The number varies with gender, age, and general health." "You have fewer red blood cells because you have anemia."

The number varies with gender, age, and general health." The nurse's best response to the client with anemia about most people having the same number of blood cells is, "The number varies with gender, age, and general health." This statement is the most educational and reasonable response to the client's question. Responding "yes, they do." and "no, they don't." are not educational statements. Although telling the client that people do not have the same number of RBCs is true, it is not informative, and there is a better answer. While it may be true that the client has fewer red blood cells because of anemia, it does not answer the client's general question.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The client ambulates around the nursing unit with a walker. The nurse monitors the client's pulse and blood pressure frequently. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when the client becomes tachycardic.

The nurse obtains a bedside commode before administering furosemide. **The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The risk for hypotension The potential for bradycardia Liver function tests

The risk for hypotension **At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

Which statement best reflects correct client education for a client with a blood pressure (BP) of 136/86 mm Hg? This blood pressure is good because it is a normal reading. This blood pressure indicates that the client has hypertension or high blood pressure. This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle. This blood pressure seems a little low; the client must be further assessed for orthostatic hypotension.

This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle. **The statement that best reflects correct client education about a BP of 136/86 mm Hg is that this blood pressure increases the workload of the heart so I need to consider modifying my lifestyle.Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg.

Which laboratory finding is consistent with acute coronary syndrome (ACS)? Troponin 3.2 ng/mL (3.2 mcg/L) C-reactive protein 13 mg/dL (130 mg/L) Triglycerides 400 mg/dL (4.52 mmol/L) Lipoprotein-a 18 mg/dL (0.64 mcmol/L)

Troponin 3.2 ng/mL (3.2 mcg/L) **Normal troponin would be less than 0.03 ng/mL (0.03 mcg/L).Normal C-reactive protein would be less than 1 mg/dL (10 mg/L). This tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides would be 35-135 mg/dL (0.40-1.50 mmol/L) for females and 40-160 mg/dL (0.45-1.81 mmol/L) for males. This tests for risk for CAD, not ACS. Normal lipoprotein-a is less than 30 mg/dL (1.07 mcmol/L). This also tests for risk for CAD, not ACS.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction (MI)? C-reactive protein of 1 mg/dL (10 mg/L) Homocysteine level of 13 mcmol/L Creatine kinase (CK) of 125 units/L Troponin of 5.2 ng/mL (5.2 mcg/L)

Troponin of 5.2 ng/mL (5.2 mcg/L) **The test results that best confirm that this client sustained a MI is a troponin of 5.2 ng/mL (5.2 mcg/L). The presence of elevated troponin indicates myocardial damage. Normal troponin would be less than 0.03 ng/mL (0.03 mcg/L).A C-reactive protein level lower than 1 mg/dL (10 mg/L) is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mcmol/L is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding?

Urine output of 20 mL over 2 hours The nurse caring for a client who had an AAA repair would be most alarmed with the client's urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria.Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output (think ABCs). +3 pedal pulses is a normal physical assessment finding.

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet?

Use canola oil rather than palm oil. The nurse teaches the client who has had MI to use canola oil rather than palm oil. Palm oil is higher in saturated fats and needs to be avoided. Nontropical vegetable oils would be encouraged, e.g., canola.Less than 30% of daily calories need to come from fats. Clients would be encouraged to consume 30 g of dietary fiber daily. A higher HDL cholesterol level (good cholesterol) is more desirable. Clients need to strive to reduce low-density lipoprotein cholesterol (bad cholesterol) when elevated.

Gender differences in CVD with women

Vague symptoms: fatigue, indigestion, SOB

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? Auscultate the client's precordium for murmurs. Teach the client about the reason for the TEE. Reassure the client that the test is painless. Validate that the client has remained NPO.

Validate that the client has remained NPO. **The essential nursing action the nurse must take is to validate that the client scheduled for a TEE has remained NPO. Owing to the risk for aspiration, the client must be NPO before the procedure.It is anticipated that the client with mitral stenosis may have an audible murmur, so auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable.

A client is scheduled for a bone marrow aspiration. What is the priority nursing action before this procedure is performed? Hold the client's hand and ask about concerns. Review the client's platelet (thrombocyte) count. Verify that the client has given informed consent. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine).

Verify that the client has given informed consent. The priority nursing action before a scheduled bone marrow aspiration is done is for the nurse to verify that the client has been given informed consent. A signed permit must be on the client's chart. Cleaning the biopsy site is done before the procedure, but this is not done until consent is verified. Cleaning the site will be done just before the procedure is performed. Holding the client's hand and offering verbal support may be done during the procedure, but the procedure cannot be completed until the consent is signed. Reviewing the client's platelet count is not imperative.

The nurse is mentoring a recent graduate RN about administering blood and blood products. What does the nurse include in the data?

Verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities in administering blood and blood products. Initial VS should be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen. A 20-gauge needle (or a central line catheter) is used; the 22-gauge needle is too small.

The nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do?

Wait until the transfusion has been completed to administer furosemide. Completing the transfusion before administering furosemide is the best course of action in this scenario. Drugs are not to be administered with infusing blood products; they can interact with the blood, causing risks for the client. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision. Changing the admission route is not a nursing decision.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? Auscultation of crackles Pedal edema Weight loss of 6 pounds (2.7 kg) since the last visit Reports sucking on ice chips all day for dry mouth

Weight loss of 6 pounds (2.7 kg) since the last visit **The clinic nurse recognizes that the client has been compliant with fluid restrictions when the client has a weight loss of 6 pounds (2.7 kg) since the last visit. Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions. Alternative methods of treating dry mouth need to be explored.

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that an infection is present or should be ruled out?

Wheezes or crackles Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs. Coughing and deep breathing are not indications of infection, but can help prevent it. The client with leukopenia, not neutropenia, may have a severe infection without pus or with only a low-grade fever.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information would be included? Men do not tend to report chest pain. Men are more likely than women to die after MI. Men more than women tend to deny the importance of symptoms. Women may experience extreme fatigue and dizziness as sole symptoms.

Women may experience extreme fatigue and dizziness as sole symptoms. **The differences in symptoms of MI in men versus women are that women may experience extreme fatigue and dizziness as sole symptoms. Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like.Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.

What are the risk factors for the development of leukemia?

bone marrow hypoplasia chemical exposure down syndrome ionizing radiaiton Reduced production of blood cells in the bone marrow is one of the risk factors for developing leukemia. Exposure to chemicals through medical need or by environmental events can also contribute. Certain genetic factors contribute to the development of leukemia; Down syndrome is one such condition. Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, also contributes. There is no indication that multiple blood transfusions are connected to clients who have leukemia. Although some genetic factors may influence the incidence of leukemia, prematurity at birth is not one of them.

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What is the major side effect of this therapy?

bone marrow suppression Intravenous cytosine arabinoside and daunorubicin are a commonly prescribed course of aggressive chemotherapy, and bone marrow suppression is a major side effect. The client is even more at risk for infection than before treatment began. Liver toxicity, nausea, and stomatitis are not the major problems with this therapy.

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat?

dairy products Dairy products such as milk, cheese, and eggs will provide the vitamin B12 that the client needs. Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.

What are the typical clinical manifestations of anemia?

dyspnea on exertion fatigue pallor tachycardia

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client?

hypertension hypotension rapid, bounding pulse In an older adult receiving a transfusion, hypertension is a sign of overload, low blood pressure is a sign of a transfusion reaction, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem. Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions.

What are serious side effects of antiviral agents prescribed for a client with acute myelogenous leukemia?

nephrotoxicity ototoxicity Antiviral agents, although helpful in combating severe infection, have serious side effects, especially nephrotoxicity and ototoxicity. Cardiomyopathy and stroke are not serious side effects of antiviral agents. Diarrhea is a mild side effect associated with antibiotic therapy.

The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention?

nosebleed The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to immediately. The client's report of pain, decreased urine output, and increased temperature are not the highest priority.