Evolve: Cardiovascular, Perfusion EAQ, Cardiovascular EAQ

A client requiring surgery because of mitral valve incompetence is admitted to the hospital and states, "I need a new valve, with an oil change, too!" What is the nurse's most therapeutic response?

"I'm sure you have a great deal to ask about your surgery."

A client who is diagnosed as having a myocardial infarction is admitted to the coronary care unit with prescriptions for bed rest and medication for chest pain. Within an hour after admission, the nurse finds the client walking around the unit. What is the nurse's best initial response?

"You need to rest. You should get back into bed."

The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement? 1. "Red blood cells appear normal in size and color; however, there is a decreased amount produced." 2. "The red blood cells have an increased life span with a decrease in normal functioning." 3. "Administration of vitamins B 12 and folate will help to treat this type of long-term anemia." 4. "This is the mildest form of anemia and is easily corrected through administration of blood products."

1. "Red blood cells appear normal in size and color; however, there is a decreased amount produced."

Which pH value of the blood is usually fatal? 1. 7.91 2. 6.91 3. 7.36 4. 7.40

1. 7.91

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

1. Sodium

What is the average systolic blood pressure in a 15 year old? Record your answer using a whole number ______________________ mm Hg

119

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?

140 to 159 mm Hg

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client? 1. Renin causes a gradual decrease in arterial pressure. 2. Lipid plaque formation occurs within the arterial vessels. 3. Development of atheromas within the myocardium is characteristic. 4. Mobilization of free fatty acid from adipose tissue contributes to plaque formation.

2. Lipid plaque formation occurs within the arterial vessels.

A nurse is monitoring a child for toxicity precipitated by digoxin. For what sign of digoxin toxicity will the nurse assess the child? 1. Oliguria 2. Vomiting 3. Tachypnea 4. Splenomegaly

2. Vomiting

What does a nurse who is caring for a client experiencing anginal pain expect to observe about the pain? 1. Unchanged by rest 2. Precipitated by light activity 3. Described as a knifelike sharpness 4. Relieved by sublingual nitroglycerin

4. Relieved by sublingual nitroglycerin

nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg; the second sound is a swishing sound heard at 130 mm Hg; a tapping sound is heard at 100 mm Hg; a muffled sound is heard at 90 mm Hg; the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1 72 mm Hg 2 90 mm Hg 3 100 mm Hg 4 130 mm Hg

72

What is the average diastolic pressure recorded in a 16 year old? Record your answer using a whole number. ________________ mm Hg

75

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

Bradycardia Hypotension Bladder dysfunction

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

Dependent edema Swollen hands and fingers Right upper quadrant discomfort

A nurse is assessing a middle-aged female client for the presence of risk factors associated with coronary heart disease. Which risk factor carries a greater risk for women than for men?

Diabetes mellitus

A client receiving hemodialysis has an external shunt for circulatory access. With which life-threatening complication associated with external cannulas should the nurse be most concerned?

Hemorrhage

Before a femoral arteriogram is started, the nurse plans to teach the client that:

Local anesthesia will be used to lessen pain at the site

What is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?

Lower extremity color

What group of clients should the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas?

Older adults

The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse would look for potential causes such as: Select all that apply

Anxiety Caffeine Exercise Anemia

Metoprolol (Toprol-XL) is prescribed for a client with hypertension. For which side effect should the nurse monitor the client? 1. Hirsutism 2. Bradycardia 3. Restlessness 4. Hypertension

2. Bradycardia

When monitoring fluids and electrolytes, the nurse recalls that the major cation regulating intracellular osmolarity is what? 1. Sodium 2. Potassium 3. Calcium 4. Calcitonin

2. Potassium

A client experiences fatigue, chest pain, and dyspnea caused by low tissue perfusion after exercise. Which symptom might also occur in this client? 1. Edema 2. Syncope 3. Orthopnea 4. Increased body temperature

2. Syncope

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis? 1. Perform leg exercises 2. Sit with the knees flexed 3. Apply warm soaks to the legs daily 4. Put on elastic stockings before arising

4. Put on elastic stockings before arising

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? Select all that apply. 1. Decreased urine 2. Hypotension 3. Dyspnea 4. Dry mucous membranes 5. Pulmonary edema 6. Poor skin turgor

1. Decreased urine 2. Hypotension 4. Dry mucous membranes 6. Poor skin turgor

What is the priority nursing action when caring for a client with disseminated intravascular coagulation? 1. Monitor for Homan sign. 2. Avoid giving intramuscular injections. 3. Take temperatures via the rectal route. 4. Apply sequential compression stockings.

2. Avoid giving intramuscular injections.

Which client is most likely to report experiencing fatigue? 1. A client with peripheral edema 2. A client limiting vigorous activity 3. A client with increased oxygen demand 4. A client with increased body temperature

3. A client with increased oxygen demand

A client is admitted to the emergency department with a blood pressure of 240/150 mm Hg. The client complains of a severe headache, blurred vision, and swelling of the ankles. In response to the clinical manifestations, what should the nurse do? 1. Obtain a glucose blood sample 2. Collect urine and blood samples 3. Assess the client's pulse and respirations 4. Place the client on bed rest in the supine position

3. Assess the client's pulse and respirations

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect? 1. Decreased cardiac output 2. Decreased stroke volume of the heart 3. Increased contractile force of the myocardium 4. Increased electrical conduction through the atrioventricular (AV) node

3. Increased contractile force of the myocardium

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? 1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis 4 Intermittent claudication

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

Which significant risk factors for coronary heart disease carry a greater risk for women than for men? Select all that apply.

Diabetes mellitus Low levels of high-density lipoprotein (HDL) cholesterol

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? Select all that apply.

Avoid prolonged exposure to the sun. Schedule regular ophthalmic examinations. Contact your health care provider if skin becomes gray-bronze.

A client, receiving a potassium infusion via a peripheral intravenous (IV) site, complains of burning sensation above the IV site. What should the nurse do first?

Check the IV access for a blood return.

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

3 Decrease the workload on the heart and promote maximum coronary artery filling With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and therefore oxygen to reach cardiac muscle; this increases myocardial efficiency. Increasing left ventricular filling increases the workload of the heart. Oxygenation of vital organs must be maintained. Decreasing oxygen to vital organs of the body may interfere with their ability to function. Increasing venous return to the right atrium increases the workload of the heart.

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? 1. Causes mild perspiration 2. Occurs after moderate exercise 3. Continues after rest and nitroglycerin 4. Precipitates discomfort in the arms and jaw

3. Continues after rest and nitroglycerin

A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. What is an appropriate postoperative nursing intervention on the day after surgery?

Assist the client with walking.

A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order?

Check health care provider's prescription Obtain vital signs and history of transfusions Ascertain that intravenous catheter size is 18 or 20 gauge Change main line solution to normal saline Check client identification before hanging unit of blood

A nurse is caring for an infant with tetralogy of Fallot. What clinical finding should the nurse expect when assessing this child? 1 Slow respirations 2 Clubbing of the fingers 3 Subcutaneous hemorrhages 4 Decreased red blood cell count

Clubbing of the fingers The mixing of oxygenated and deoxygenated blood results in tissue hypoxia; clubbing occurs as a result of additional capillary development and tissue hypertrophy of the fingertips. The respirations are rapid, not slow. The child's problems are related to decreased oxygenation, not to a clotting defect. The body attempts to compensate for the hypoxemia associated with tetralogy of Fallot by increased erythropoiesis.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?

Feeling of heaviness in both legs.

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, the nurse recalls that the most accurate measurement of the client's left ventricular pressure is the:

Pulmonary capillary wedge pressure

An 85-year-old client with a history of congestive heart failure on daily weights has a 2-pound weight gain and pitting edema in lower extremities bilaterally, indicative of fluid retention. The most appropriate response is:

Perform a head-to-toe assessment, including vital signs

To ensure accuracy when assessing a client's blood pressure, how does the nurse avoid a parallax error?

Read the manometer at eye level.

Which foods rich in vitamin C act as dietary supplement for wound healing? Select all that apply. 1. Broccoli 2. Cabbage 3. Legumes 4. Red meat 5. Strawberries 6. Riboflavin-enriched cereals

1. Broccoli 2. Cabbage 5. Strawberries

A client is recovering from a myocardial infarction. Before developing the client's teaching plan, it is important for the nurse to do what? 1. Identify the learning needs of the client 2. Determine the nursing goals for the client 3. Evaluate the community resources available to the client 4. Explore the use of group teaching for the client

1. Identify the learning needs of the client

A primary healthcare provider prescribes atenolol 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to include in the discharge teaching plan for this client? 1. Drink alcoholic beverages in moderation. 2. Avoid abruptly discontinuing the medication. 3. Increase the medication if chest pain develops. 4. Report a pulse rate less than 70 beats per minute.

2. Avoid abruptly discontinuing the medication.

A client with stage III-B Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the health care provider to seek treatment for which response to chemotherapy? 1. Fever of 100°F 2. Sores in the mouth 3. Moderate diarrhea after treatment 4. Nausea for six hours after treatment

2. Sores in the mouth

A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. The nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when what happens? 1. Sublingual tingling is experienced. 2. The tablets are more than three months old. 3. The pain is unrelieved, but facial flushing is increased. 4. Onset of relief is delayed, but the duration of relief is unchanged.

2. The tablets are more than three months old.

The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. The teaching includes that the client will be what? 1. Ambulated shortly after being transferred to the inpatient room after the procedure. 2. Given a general anesthesia and therefore will be asleep during the procedure. 3. In the supine position with the affected leg extended for several hours postprocedure. 4. Given only clear liquids for the remainder of the procedure day.

3. In the supine position with the affected leg extended for several hours postprocedure.

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

3. Type A or O negative

A client with hypertension is to follow a 2-gram sodium diet. Which client statement provides evidence that the nurse's dietary instructions are understood? 1. "My fluid intake should be restricted." 2. "I should limit the number of daily food servings." 3. "Salt should not be used during cooking but can be used at the table." 4. "Labels on prepackaged food products should be evaluated before purchase."

4. "Labels on prepackaged food products should be evaluated before purchase."

A client with type 1 diabetes asks what causes the several brown spots that have been noted on the skin. What is the nurse's best response? 1. "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." 2. "The brown spots indicate a high glucose content in the skin, which may get infected if left untreated." 3. "The brown spots are the result of diseased small vessels in the shins and may spread if not treated soon." 4. "The brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

4. "The brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

A client with a tentative diagnosis of pernicious anemia is scheduled for a Schilling test. Which body process associated with vitamin B 12 is assessed with the Schilling test? 1. Storage 2. Digestion 3. Production 4. Absorption

4. Absorption

A nurse is caring for a client with the diagnosis of right ventricular failure. Which condition unrelated to cardiac disease is the major cause of right ventricular failure? 1. Renal disease 2. Hypovolemic shock 3. Severe systemic infection 4. Chronic obstructive pulmonary disease (COPD)

4. Chronic obstructive pulmonary disease (COPD)

Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? Select all that apply. 1. Increase the client's intravenous (IV) flow rate 2. Massage the client's extremities with lotion 3. Place the client's legs in pneumatic stockings 4. Instruct the client to avoid crossing the legs 5. Instruct the client to dorsiflex the feet routinely

4. Instruct the client to avoid crossing the legs 5. Instruct the client to dorsiflex the feet routinely

A client with chronic heart failure is taking a diuretic twice a day. The health care provider prescribes a diet that includes the intake of dietary potassium. What foods that have a higher amount of potassium should the nurse instruct the client to consume? Select all that apply.

Bananas Baked potatoes with skins

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

Begin chest compressions.

A client with Hodgkin disease enters a remission period and remains symptom free for six months when a relapse occurs. The client is diagnosed at stage IV. The therapy option the nurse expects to be implemented at this time is:

Combination chemotherapy

A client has been experiencing chest discomfort for several months, especially after eating, which the client attributed to a hiatal hernia. The client reports that after eating a meal today, the client coughed severely and then vomited profusely. The client stated that because the vomitus was bright red in color, medical care was sought. The nurse reviews the plan of care and determines that the priority is to:

Draw blood for typing and crossmatching

What clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply.

Edema Dyspnea

Which Korotkoff sound represents the diastolic blood pressure in an adolescent? 1 First 2 Third 3 Fifth 4 Fourth

Fifth In adolescents, the fifth Korotkoff sound corresponds to the diastolic pressure. The first Korotkoff sound, which is sharp, represents systolic blood pressure, which is heard in all individuals. The third Korotkoff sound is a crisper, more intense tapping. The fourth Korotkoff sound is muffled and low. This sound corresponds to diastolic pressure in the toddler.

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider the most likely reason for this change?

Increased intravascular volume

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? Select all that apply.

Reports of leg fatigue Tortuous veins in the legs Pain in lower extremities when standing

The nurse is caring for a client that experienced a myocardial infarction (MI). The nurse monitors for the most serious complication that occurs within 48 hours after an MI, which is:

Ventricular tachycardia

A 28-year-old woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the nurse's best response? 1. "Give me your name and address. I am sending an ambulance to your home. You need emergency care." 2. "It sounds as if your cast may be constricting the blood flow in your leg. You probably need a new cast." 3. "It sounds like you are having an allergic response to the medication. Can you drive yourself to the hospital?" 4. "You are experiencing a pulmonary embolism. You need to come to the emergency department now for care."

1. "Give me your name and address. I am sending an ambulance to your home. You need emergency care."

During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of large and painful varicose veins. In light of this information, what should the nurse's assessment include? 1 Monitoring daily clotting times 2 Assessing for peripheral pulses 3 Monitoring daily hemoglobin values 4 Assessing for signs of thrombophlebitis

Assessing for signs of thrombophlebitis Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites? 1 Impaired portal venous return 2 Impaired thoracic lymph channels 3 Excess production of serum albumin 4 Enhanced hepatic deactivation of aldosterone secretion

Impaired portal venous return The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.

Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply.

Gastrointestinal (GI) suction Diuretic therapy Continuous bladder irrigation

The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level?

Increased total iron-binding capacity (TIBC)

A client has a splenectomy after a motor vehicle collision. What is a postoperative nursing concern specifically related to this type of surgery?

Adequate lung aeration

When a client has a myocardial infarction, one of the major manifestations is a decrease in conductive energy provided to the heart. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart?

Strength of contractions

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? 1. Refer the client to a nutritionist after providing health teaching about a low-sodium diet. 2. Place the client in a recumbent position and call the paramedics for transport to the hospital. 3. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. 4. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

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

Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that the cause of the increase in the client's urinary output is:

An expected effect of the dye used with the procedure

A client has a pulse deficit. Which documentation by the nurse supports this finding? 1 Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. 2 Capillary refill greater than 3 seconds indicating pulse deficit. 3 Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. 4 Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.

Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.

A client with Hodgkin disease is to receive the cyclic antineoplastic vincristine (Oncovin) as part of a therapy protocol. The client asks how this medication works. The nurse explains in language that the client will understand that vincristine helps destroy the malignant cells by:

Arresting mitosis in metaphase

A client with a history of severe intermittent claudication has a femoropopliteal bypass graft. An appropriate postoperative intervention on the day after surgery is to:

Assist the client with ambulation

The nurse is assessing the pulse of a client with an on-demand pacemaker. What should the nurse identify when a client's on-demand pacemaker is functioning effectively?

At least at the demand rate

A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding?

Chemical irritation to the tissues

An 83-year-old client is diagnosed with left-sided congestive heart failure. Which assessment findings should the nurse expect to find on this client? Select all that apply.

Dyspnea Crackles Cool extremities

A client complains of foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. The nurse concludes that further teaching is needed when the client states, "I will:

Elevate my foot"

A client exhibits persistent pyrexia, abdominal pain, and symptoms of neuritis. A diagnosis of polyarteritis nodosa is suspected. Which adaptation should the nurse expect when assessing the client?

Elevation in blood pressure

A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse.

Ensure that the client signed a consent for the transfusion. Determine the client's vital signs. Compare the number on the blood product and laboratory record. Don a pair of clean gloves. Run the transfusion slowly.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? 1 Feeling of heaviness in both legs 2 Intermittent claudication of the legs 3 Calf pain on dorsiflexion of the foot 4 Hematomas of the lower extremities

Feeling of heaviness in both legs Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.

A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse concludes that the surgeon should be contacted immediately because the hypertension may indicate that the:

Graft is leaking

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? Select all that apply.

Malaise Swollen lymph glands

For which expected response should the nurse monitor a client after a cardiac catheterization?

Marked increase in the volume of urine output

A child returns to his room after left-side cardiac catheterization. What is involved in the postprocedure nursing care? 1 Encouraging early ambulation 2 Monitoring the insertion site for bleeding 3 Comparing blood pressures in the two extremities 4 Restricting fluids until the blood pressure has stabilized

Monitoring the insertion site for bleeding Postprocedure hemorrhage, a life-threatening complication after cardiac catheterization, is possible because arterial blood is under pressure and the catheter has entered an artery. Rest will be encouraged; flexion of the insertion site should be avoided to prevent disturbance of the clot. Comparing blood pressures in the two extremities is unnecessary; the pulse distal to the catheterization insertion site is monitored. The blood pressure will not be unstable unless a problem develops; fluid intake should be encouraged.

An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.

Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification.

Within the first 2½ hours after a radical neck dissection, 40 mL of medium red, bloody fluid is collected in the portable wound drainage system. What should the nurse do first?

Obtain the vital signs.

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? Select all that apply.

Stupor Paresthesia in affected body parts

A client is discharged with a prescription for sustained-release nitroglycerin. What should the nurse teach the client about sustained-release nitroglycerin?

Swallow the capsule whole

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle?

T wave

A client is receiving intravenous heparin for treatment for a deep vein thrombosis (DVT). While completing the client's morning assessment, the nurse notes that the intravenous (IV) insertion site is cool to touch and the skin appears blanched. The nurse also notes there is <1 inch edema around the site. Based on the infiltration scale, how should the nurse properly document the infiltration?

One (1)

A client had a femoral-popliteal bypass graft. Four hours after surgery the client's blood pressure (BP) increases to 200/110. The nurse concludes that the increase in blood pressure is a specific indicator of what postoperative complication?

Rupture of the graft

A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. The nurse should instruct the client to:

Select familiar settings for sexual activity

Which cardiovascular adverse effect is associated with the use of clomiphene? 1 Ischemia 2 Chest pain 3 Tachycardia 4 Hypertension

Tachycardia Clomiphene is used to induce ovulation. Tachycardia is reported with the use of clomiphene. Ischemia and hypertension are not associated with clomiphene. Chest pain may occur with the use of clomiphene as a rare adverse effect.

Which antihypertensive drug is contraindicated in lactating women? 1 Tenormin 2 Labetalol 3 Metoprolol 4 Propranolol

Tenormin Tenormin is contraindicated in lactating woman because it enters the breast milk and may cause adverse effects to the neonate. Labetalol and propranolol are safe to administer during lactation. Metoprolol is a safe drug to be taken during pregnancy.

What statement is true of ventricular dysrhythmias? Select all that apply.

The QRS complex appears widened and has a bizarre shape. The polarity of the T wave is opposite that of the QRS complex. Most ventricular dysrhythmias have no apparent P wave.

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization? 1 To obtain the pressures in the heart chambers 2 To determine the existence of congenital heart disease 3 To visualize the disease process in the coronary arteries 4 To measure the oxygen content of various heart chambers

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

nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next? 1 Count the pulse at another site. 2 Notify the primary healthcare provider. 3 Lower the legs to increase blood flow. 4 Verify the pulse by using a Doppler.

Verify the pulse by using a Doppler.

When determining whether or not an atrial rhythm is regular, the nurse determines the consistency of the space between the:

P waves.

A 78-year-old client comes to the health clinic complaining of fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL. Which is the most appropriate nursing intervention in response to these laboratory results?

Conduct a complete nutritional assessment of the client.

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? Select all that apply. 1. Anxiety 2. Chest pain 3. Irregular pulse 4. Fear of losing control 5. Feelings of depersonalization

1. Anxiety 2. Chest pain 3. Irregular pulse

A client with heart failure is digitalized and placed on a maintenance dose of digoxin (Lanoxin) 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved? 1. Diuresis and decreased pulse rate 2. Increased blood pressure and weight loss 3. Regular pulse rhythm and stable fluid balance 4. Corrected heart murmur and decreased pulse pressure

1. Diuresis and decreased pulse rate

What should the nurse suggest for a client with right ventricular failure? 1. "Take a hot bath before bedtime." 2. "Avoid emotionally stressful situations." 3. "Avoid sleeping in an air-conditioned room." 4. "Exercise daily until the pulse rate exceeds 100 beats per minute."

2. "Avoid emotionally stressful situations."

The client is receiving multiple blood transfusions after having extensive abdominal surgery. If the client develops fever, chills, and lower back pain, and seems very nervous, what will be the nurse's first action? 1. Notify the blood bank 2. Notify the health care provider 3. Reduce the rate of the blood transfusion 4. Stop the blood and infuse normal saline

4. Stop the blood and infuse normal saline

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? 1 A fever may lead to diaphoresis. 2 A fever increases the cardiac output. 3 An increased temperature indicates cerebral edema. 4 An increased temperature may be a sign of hemorrhage.

A fever increases the cardiac output. Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.

A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.

Avoid intramuscular injections. Examine the skin for ecchymotic areas.

A client reports a history of bilateral blanching and pain in the fingers on exposure to cold. When rewarmed, the fingers become bright red and "tingly" with a slow return to their usual color. The client smokes one to two packs of cigarettes per day. The nurse determines that the client has Raynaud's disease and not Raynaud's phenomenon because of the:

Bilateral involvement

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor and concludes that these complexes are a sign of:

Cardiac irritability

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? 1 Check for a pulse 2 Start cardiac compressions 3 Prepare to defibrillate the client 4 Administer oxygen via an ambu bag

Check for a pulse The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. Select all that apply.

Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats

The nurse is conducting a nutrition class for a group of clients with congestive heart failure (CHF). It would be most important for the nurse to explain the importance of:

Choosing fresh or frozen vegetables instead of canned ones.

A client is brought into the emergency department with complaints of chest pain. What are possible causes for the client's chest pain? Select all that apply.

Costochondritis Pneumonia Pleurisy Myocardial infarction

A client has arrived on the nursing unit scheduled for a cholecystectomy, and there is one registered nurse, a licensed practical nurse, and a certified nursing assistant. Institution policy is that all admissions must have the initial assessment completed by a registered nurse. The registered nurse currently is caring for a client with a transfusion reaction. Which is the best decision?

Have the practical nurse perform the initial assessment and the registered nurse verify all findings after the transfusion client is stable.

To help reduce a client's risk factors for heart disease, what should the nurse include in the client's teaching plan?

Increase the quantity of complex carbohydrates

The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply.

Shock Abdominal distention Pulmonary complications

The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse? 1 Strong 2 Bounding 3 Expected 4 Diminished

Strong A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)?

Deflate the balloon as soon as the PCWP is measured.

Halfway through the administration of a unit of blood, a client complains of lumbar pain. After stopping the transfusion and replacing the tubing, the nurse should:

Increase the flow of normal saline

A client comes to the outpatient clinic with a large leg ulcer. The clinical finding that supports the diagnosis of arterial ulcer is:

Pain at the ulcer site

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition? 1 "I have abnormal platelets." 2 "I have abnormal hemoglobin." 3 "I have abnormal hematocrit." 4 "I have abnormal white blood cells."

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

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.

Absence of hair on the toes Reports of pain associated with exercising

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?

Arteriolar constriction occurs.

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms most likely are to be associated with this disorder?

Burning pain after exposure to cold

What intervention should the nurse implement when caring for a client 24 hours postthyroidectomy? 1 Check the back and sides of the operative site. 2 Support the head during mild range-of-motion (ROM) exercises. 3 Encourage the client to ventilate feelings about the surgery. 4 Advise the client that regular activities can be resumed immediately.

Check the back and sides of the operative site. Bleeding may occur, and blood will pool in the back of the neck because the blood will flow via gravity. ROM exercises will increase pain and put tension on the suture line. Talking should be avoided in the immediate postoperative period, except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. Activity should be resumed gradually and frequent rest periods encouraged.

An older client exhibits typical clinical indicators of pulmonary edema. List the following clinical indicators of pulmonary edema in the order they typically appear.

Crackles Increased respirations Tachycardia Orthopnea Frothy, blood-tinged sputum

The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say that this daily information is important in determining? 1 Fluid retention 2 Kidney function 3 Nutritional status 4 Medication dosage

Fluid retention Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.

A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? 1 It should be elevated on a pillow. 2 It should be kept extended while on bed rest. 3 It will be positioned dependent to the level of the heart. 4 It will be put through range-of-motion exercises several times an hour.

It should be kept extended while on bed rest. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. Elevating the leg on a pillow will flex the hip, which may traumatize the catheter insertion site and impede healing. The leg is kept even with the level of the heart because the client usually is placed in the supine position with the leg extended. Range of motion will flex the hip, which may traumatize the catheter insertion site and impede healing.

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

Manages an abnormally slow heart rate."

Which oxytocic drug may help to control uterine bleeding post-delivery and promote milk ejection? 1 Oxytocin 2 Mifepristone 3 Dinoprostone 4 Ergot alkaloids

Oxytocin Oxytocin is used to induce labor, control uterine bleeding after delivery, and promote milk ejection during lactation. Mifepristone is generally used to induce abortion. Dinoprostone induces labor but has no effect on milk ejection or uterine bleeding. Although ergot alkaloids control uterine bleeding after delivery, they do not cause milk ejection during lactation.

A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client? 1 Peripherally inserted central catheter (PICC) line 2 #20 angiocatheter in either antecubital area 3 Large-gauge butterfly needle in hand 4 Femoral line

Peripherally inserted central catheter (PICC) line Dopamine hydrochloride is a vesicant, and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly needle are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.

A nurse is preparing to teach a client to apply a nitroglycerin patch as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? 1 Apply the patch on a distal extremity. 2 Remove a previous patch before applying the next one. 3 Massage the area gently after applying the patch to the skin. 4 Apply a warm compress to the site before attaching the patch.

Remove a previous patch before applying the next one Removing the previous patch before applying the next patch ensures that the client receives just the prescribed dose. Ideally, a patch should be removed after 12 to 14 hours to avoid the development of tolerance. The patch should be rotated among hair-free and scar-free sites; acceptable sites include chest, upper abdomen, proximal anterior thigh, or upper arm. The patch should be gently pressed against the skin to ensure adherence; it should not be massaged. Applying a warm compress to the site before attaching the patch is unnecessary and can result in an excessive absorption of the medication.

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? 1 Trimming toenails so that they are short and rounded 2 Checking bathwater temperature by putting the toes in first 3 Using alcohol to rub hands, feet, legs, and arms at least two times a day 4 Seeking professional treatment for any minor injuries to the extremities

Seeking professional treatment for any minor injuries to the extremities Because diminished circulation leads to inadequate healing, early treatment of injuries is essential. Toenails should not be too short and should be trimmed straight across. Bathwater should be checked with a bath thermometer; toes of persons with peripheral artery disease (PAD) may be less sensitive to temperature change, and a burn may occur. These clients develop trophic skin changes; the drying action of alcohol will contribute to dryness and skin breakdown.

A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? 1 The client's heart may be beating faster temporarily. 2 The nurse may not know how to take an accurate pulse. 3 The radial pulse site may be surrounded by too much subcutaneous fat. 4 The client may have atrial fibrillation.

The client may have atrial fibrillation.

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings? 1 The stockings should reach the middle of the knee. 2 The stockings should be applied before getting out of bed. 3 The stockings should be applied at the first sign of discomfort. 4 The stockings may be substituted with loose elastic bandages.

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

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply. 1 Age 2 Height 3 Weight 4 Smoking 5 Family history

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