Medical-Surgical Cardiovascular and Hematology
A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? a. Avoid IM injections b. Assess the client for ecchymosis once per shift c. Do not allow the client to have visitors d. Encourage daily flossing between teeth
A. Avoid IM injections. This client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding. Incorrect: B. The nurse should assess the client for indications of bleeding, including ecchymosis, T LEAST EVERY 4 HOURS. C. The nurse should LIMIT but not disallow VISITORS for a client who has neutropenia. D. The nurse should promote safe oral hygiene but should instruct the client to AVOID FLOSSING due to RISK OF BLEEDING.
A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? a. Eggs b. Squash c. Kale d. Tofu
A. Eggs. The nurse should encourage the client to increase consumption of foods rich in VITAMIN B12, such as DAIRY PRODUCTS, ANIMAL PROTEIN, POULTRY, SHELLFISH, and EGGS. Incorrect: B. C. D. Squash, kale, and tofu do not contain vitamin B12.
A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? a. Lentils b. Avocados c. Cabbage d. Broccoli
A. Lentils. The nurse should encourage the client to increase her consumption of iron-rich foods, including MEAT, FISH, POULTRY, and DRIED BEANS AND PEAS. A 1-cup serving of lentils contains 3.6 mg of iron. Lentils, like beans, are legumes. They're high-protein, edible pulses that grow in pods.
A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? a. Turkey on whole-wheat bread b. Hamburger and french fries c. Frankfurter on a white roll d. Macaroni and cheese
A. Turkey on whole-wheat bread The primary diet alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole-wheat bread has a relatively low sodium content. Incorrect: B. C. D. The relatively high sodium content of a hamburger with french fires, frankfurters, or macaroni and cheese makes this meal a poor choice for a client who has heart failure.
A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? a. Flattened T waves b. Prolonged QT intervals c. Shortened QT intervals d. Widened QRS complexes
B. Prolonged QT intervals. Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasms. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea. Incorrect: A. Hypokalemia causes flattened T waves and cardiac dysrhythmias. B. Hypercalcemia shortens QT intervals. C. Hyperkalemia widens QRS complexes.
A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? a. Beef liver b. Oranges c. Turnips d. Whole milk
A. Beef liver. The nurse should encourage the client to increase her consumption of iron-rich foods, including MEAT, FISH, and POULTRY. A 3 oz serving of beef liver contains 4.17 mg of iron. Incorrect: B. Oranges are not a good source of iron. A 1-cup serving of orange slices contains only 0.l8 mg of iron. C. Turnips are not a good source of iron. A 1-cup serving of cubed turnips contains only 0.39 mg of iron. Instead, the client should eat more ASPARAGUS and BROCCOLI. D. Whole milk does not contain iron.
A nurse is caring for a client who is having a possible myocardial infarction. Which of the following findings should the nurse identify as an associated manifestation of an MI? a. Headache b. Hemoptysis c. Nausea d. Diarrhea
C. Nausea. Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen. Associated manifestations of MI can include anxiety, dizziness, dyspnea, dysrhythmias, fatigue, and palpitations.
A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? a. Warm the unit of blood to room temperature before administering it b. Administer acetaminophen prior to the blood transfusion c. Give an antihistamine prior to the transfusion d. Use a transfusion pump to regulate and maintain the transfusion at a slower rate
D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate. These are manifestations of a hypervolemic reaction due to circulatory overload, which likely occurs when the blood transfusion is too rapid for the client's size or status. To prevent this problem with future transfusions, the nurse should use a transfusion pump to regulate the transfusion at a slower rate. Incorrect: A. This intervention helps prevent chills and hypothermia; however, the client's manifestations are not related to the temperature of the blood. B. This medication can prevent a febrile reaction; however, the client's manifestations do not indicate a febrile reaction. C. If a client is allergy-prone, an antihistamine prior to the blood transfusion can help prevent a reaction; however, the client's manifestations do not indicate an allergic transfusion reaction.
A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? a. Elevated ST segments b. Absent P waves c. Depressed ST segments d. Varying PP intervals
A. Elevated ST segments. Elevated ST segments can indicate hyperkalemia and pericarditis. Incorrect: B. Absent P waves can indicate A-Fib and sustained V-tach. C. Depressed ST segments can indicate HYPOkalemia and ventricular hypertrophy. D. Varying PP intervals indicate an irregular atrial rate and rhythm.
While participating in a community health fair, a nurse is providing information to a client who has a BP of 150/90 mmHg during screening. Which of the following actions should the nurse take? a. Give the client a written record of his BP to bring to his provider b. Encourage the client to go to the nearest emergency department c. Instruct the client to follow-up with a provider within 6 months d. Explain to the client that he is not at risk unless he has manifestations of HTN
A. Give the client a written record of his BP to bring to his provider. Since this client has an elevated BP reading from a HTN screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider. Incorrect: B. A client who has a BP of 150/90 mmHg does not require emergency services unless manifestations of a stroke or MI are present. C. The nurse should instruct the client to follow-up with a provider for another BP measurement within 2 months. D. HTN is often asymptomatic. Even w/o symptoms like severe HA or neurological deficits, HTN can cause fatal strokes and MI's.
A nurse is providing information to a client who is scheduled for an exercise electrocardiography (stress) test. Which of the following client statements indicates an understanding of the teaching? a. "I will not drink coffee 4 hr prior to my test." b. "I can eat a light meal 1 hr prior to the test." c. "I can have a cigarette up to 30 min prior to the test." d. "I will take my heart medication on the day of the test."
A. I will not drink coffee 4 hr prior to my test." The client should AVOID COFFEE, ALCOHOL, and CAFFIENE on the DAY OF the test. These can affect the client's heart rate and blood pressure during the test. Incorrect: B. The nurse should instruct the client to HAVE A LIGHT MEAL 2 HOURS PRIOR to the test. C. The nurse should instruct the client to AVOID SMOKING the DAY OF the test. Smoking is a stimulant and can affect the client's heart rate and blood pressure during the test. D. The nurse should instruct the client to speak with the provider about taking heart medication on the day of the test. Beta blockers or calcium channel blockers are typically withheld on the day of the test to allow the heart rate to increase during the stress portion.
A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? a. Potassium 2.8 mEq/L b. Digoxin level 0.7 ng/L c. Hemoglobin 9.8 g/dL d. Calcium 8.0 mg
A. Potassium 2.8 mEq/L. A flattened T wave or the development of U waves is indicative of a low potassium level. Incorrect: B. This client has a digoxin level within the therapeutic range of 0.5 to 0.8 ng/mL. Atrioventricular block, ventricular fibrillation, and ventricular tachycardia are a few of the dysrhythmias occurring with toxic digoxin levels. C. A client who has a low hemoglobin will manifest tachycardia on the ECG rhythm because of the compensatory mechanism that provides oxygen to vital organs. D. A client who has hypocalcemia can have a prolonged S-T interval and a prolonged Q-T interval, not a flattened T wave.
A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit
A. Prothrombin time. The nurse should review the client's prothrombin time after the administration of FFP, which is plasma-rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time. Incorrect: B. The nurse should review the client's WBC count if there is a possible infection. C. The nurse should review the client's platelet count following the administration of platelets. D. The nurse should review the client's hematocrit following the administration of packed red blood cells (PRBC).
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of information should the nurse include in the teaching? a. Hospitalization is required when administering each treatment. b. The maximum effect of the medication will occur in 6 months. c. Hypertension is a common adverse effect of this medication. d. Blood transfusions are needed with each treatment.
C. Hypertension is a common adverse effect of this medication. A common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level. Incorrect: A. Epoetin alfa can be self-administered at home. B. The maximum effect of epoetin alfa will occur in 2-3 months. D. Epoetin alfa is administered to decrease the need for periodic blood transfusions.
A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? a. Dyspnea b. Pain in the shoulder and left arm c. Substernal chest pain d. Palpitations
C. Substernal chest pain. Evidence-based practice indicates that the MOST COMMON manifestation of acute MI is SUBSTERNAL CHEST PAIN THAT DOES NOT SUBSIDE WITH REST OR NITROGLYCERIN. Therefore, nurses should make pain management with MORPHINE a priority to reduce myocardial oxygen demand and increase oxygenation. Incorrect: A. Evidence-based practice indicates that dyspnea is a common manifestation of acute MI, but it is not the most common. Other findings include diaphoresis and nausea. B. Evidence-based practice indicates that pain in the shoulder and left arm is a common manifestation of acute MI, but it is not the most common. Other findings include dizziness and anxiety. D. Evidence-based practice indicates that palpitations are a common manifestation of acute MI, but they are not the most common. Other findings include epigastric distress and disorientation.
A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? a. Sudden hemoptysis b. Acute diarrhea c. Frontal headache d. Acute confusion
D. Acute confusion. Acute confusion is a manifestation of myocardial infarction in clients AGE 65 OR OLDER. Other manifestations can include N/V, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue. Incorrect: A. Hemoptysis is a manifestation of gastrointestinal bleeding. B. Acute diarrhea is a manifestation of gastroenteritis. C. A frontal headache is a manifestation of fluid overload.
A nurse is showing a client who has right-sided heart failure an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium? a. Right coronary artery b. Left carotid artery c. Aorta d. Superior vena cava
D. Superior vena cava. The nurse should identify that the superior and inferior vena cava carry deoxygenated blood to the right atrium. Incorrect: A. This blood vessel supplies oxygenated blood to the heart. B. This blood vessel supplies oxygenated blood to the heart and neck. C. This blood vessel carries oxygenated blood away from the left side of the heart.
A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? a. "I should remove the skin from poultry before eating it." b. "I will eat seafood once per week." c. "I should use margarine when preparing meals." d. "I can use whole milk in my oatmeal."
A. "I should remove the skin from poultry before eating it." The nurse should identify the client understands the teaching when he states he will remove the skin from poultry before eating, as the skin contains the greatest amount of fat. Incorrect: B. A client who has heart disease and is on a low-cholesterol diet should eat seafood AT LEAST TWICE per week because it is high in omega-3 fatty acids. C. A client who has heart disease and is on a low-cholesterol diet should use LIQUID OILS such as CANOLA OIL instead of margarine, which is a solid fat. D. A client who has heart disease and is on a low-cholesterol diet should use NONFAT or LOW-FAT MILK instead of whole milk in oatmeal or cereal.
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? SATA. a. Use a 5 mL syringe to flush the line b. Cleanse the insertion site with half-strength hydrogen peroxide c. Flush the line with sterile 0.9% sodium chloride before and after medication administration d. Access the PICC for blood sampling e. Perform a heparin flush of the line at least daily when not in use
C. Flush the line with sterile 0.9% sodium chloride before and after medication administration. D. Access the PICC for blood sampling. E. Perform a heparin flush of the line at least daily when not in use. The nurse should flush the line with 10 mL of sterile 0.9% sodium chloride solution before and after administering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger. PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line. Incorrect: A. A 5 mL syringe generates too much pressure and could rupture the line. The nurse should use a 10 mL syringe instead. B. The nurse should use chlorhexidine for cleansing the insertion site. Chlorhexidine is effective in reducing the incidence of bloodstream infections.
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates LOUD, BUBBLY sounds ON INSPIRATION. Which of the following adventitious breath sounds should the nurse document? a. Coarse crackles b. Wheezes c. Rhonchi d. Friction rub
A. Coarse crackles. A client who has recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing. Incorrect: B. A client who wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway. C. A client who has rhonchi will manifest coarse, loud, low-pitched sounds during inspiration or expiration. COUGHING often CLEARS THE AIRWAY and stops the sound. D. A client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration.
A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? a. Decreased albumin b. Elevated hemoglobin c. Elevated lymphocytes d. Decreased cortisol
A. Decreased albumin. A decrease in the albumin level can be an indication of long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function. Incorrect: B. Protein-calorie malnutrition can negatively impact the production of RBCs, resulting in a decrease in hemoglobin. C. Nutritional deficiencies such as protein-calorie malnutrition can result in low lymphocyte levels, which increases the client's risk of infection. D. Cortisol is a glucocorticoid that plays a role in the metabolism of proteins, fats, and carbohydrates. Low levels are associated with Addison's disease. However, cortisol is not reflective of protein-calorie malnutrition.
A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? a. Hyperkalemia b. Hyponatremia c. Hypercalcemia d. Hypomagnesemia
A. Hyperkalemia. The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid. Incorrect: B. A low sodium level is not a manifestation of respiratory acidosis. Causes of hyponatremia include diuretics, kidney disease, vomiting, and burn injuries. C. A high calcium level is not a manifestation of respiratory acidosis. Cause of hypercalcemia include kidney failure and hyperparathyroidism. D. A low magnesium level is not a manifestation of respiratory acidosis. Causes of hypomagnesemia include malnutrition, alcohol use disorder, and diarrhea.
A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? a. Necrosis b. Hypokalemia c. Hypomagnesemia d. Insufficiency
A. Necrosis. ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery. Incorrect: B. U waves indicate hypokalemia. C. Although P waves can reflect other dysrhythmias, they are common with sustained ventricular tachycardia, which hypomagnesemia can cause. D. Ventricular tachycardia often reflections coronary insufficiency, which results in poor oxygenation of the heart.
A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? a. Omega-3 fatty acids b. Antioxidants c. Vitamins A, D, and C d. Beta-carotene
A. Omega-3 fatty acids. Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels. Incorrect: B. Antioxidants are substances that occur naturally in many fruits and vegetables, as well as in nuts, grains, and even some meat, poultry, and fish. Beta-carotene; vitamins A, C, and E; and selenium are some of the most commonly known antioxidants. Studies have suggested that antioxidants can slow or even prevent the development of cancer; however, they are not found in fish oil. C. Vitamins A, D, and C are not found in fish oil. D. Beta-carotene is a precursor to vitamin A. Beta-carotene functions as a fat-soluble antioxidant, which can help protect the body from deleterious free-radical reactions. It is not found in fish oil.
A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? a. Position the client supine with his legs elevated when in bed. b. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr. c. Tell the client to sit with his legs dependent after ambulating. d. Instruct the client to wear knee-length socks for 2 weeks after surgery.
A. Position the client supine with his legs ELEVATED when in bed. The nurse should elevate the client's legs above his heart to PROMOTE VENOUS RETURN by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart. Incorrect: B. The nurse should encourage the client to ambulate for 5 to 10 min every hour while awake to prevent venous stasis. C. The nurse should discourage the client from sitting or standing for any duration to prevent venous stasis. The feet should be elevated above the heart to prevent venous stasis. D. The nurse should instruct the client to wear graduated compression stockings for up to 1 week after surgery to promote venous return.
A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? a. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes b. Premature ventricular complexes at 12/min c. Telemetry monitoring showing pacing spikes with no QRS complexes d. Hiccups
A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min because the client's intrinsic rate overrides the set rate of the pacemaker. Incorrect: B. The nurse should report frequent premature ventricular complexes because this complication can indicate a lead wire is displaced in the ventricle. C. The nurse should report pacer spikes w/o QRS complexes because this complication can indicate a non-capture of the pacemaker. D. The nurse should report hiccups because this complication can indicate a lead wire is displaced and is stimulating the diaphragm.
A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? a. A client who is postmenopausal b. A client who is a vegetarian c. A middle adult male client d. A client who is pregnant e. A toddler who is overweight
B. A client who is a vegetarian. D. A client who is pregnant. E. A toddler who is overweight. A client who is a vegetarian might require additional iron because the availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for iron-deficiency anemia. Incorrect: A. Iron requirements are increased for women who have excessive blood loss due to menstruation. Generally, postmenopausal women do not require additional iron. C. Most adult males consume adequate iron in their diet and do not require supplementation.
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? a. Increased cardiac output b. Increased pulmonary congestion c. Decreased left atrial pressure d. Decreased pulmonary artery pressure
B. Increased pulmonary congestion. Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, pulmonary artery pressure increases, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure. Incorrect: A. Cardiac output is DECREASED in a client who has heart failure related to mitral stenosis because the left ventricle is receiving insufficient blood volume to pump into the systemic circulation. C. As the mitral valve opening narrows, blood flow from the atria to the ventricle falls, causing a backup and increased pressure in the left atria. D. Pulmonary artery pressure is increased as a result of backup pressure from the narrowing (stenosis) of the mitral valve that affects the flow of blood from the left atrium to the left ventricle.
A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions? a. "I need to stay active to prevent blood clots in my legs." b. "If I have a bad headache, I can take aspirin to get rid of it." c. "I should eliminate uncooked foods from my diet for now." d. "I should eat more iron-fortified cereal to strengthen my blood."
C. "I should eliminate uncooked foods from my diet for now." Aplastic anemia is a condition that occurs when your body stops producing enough new blood cells. The condition leaves you fatigued and more PRONE TO INFECTIONS and UNCONTROLLED BLEEDING. The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, egg, meat, and fish can harbor microorganisms that cooking destroys, so the client should AVOID RAW FOODS. Incorrect: A. Although staying active is always a good strategy, clients who have aplastic anemia are not at a particular risk for deep-vein thrombosis because a common manifestation of this disorder is a LOW PLATELET COUNT. B. Clients with aplastic anemia should not take aspirin because it can increase bleeding tendencies. C. Although iron-fortified cereal is a component of a healthy diet, it is a specific recommendation for clients who have iron-deficiency anemia, not aplastic anemia.
A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? a. "Request a provider's prescription when traveling to alert airport security." b. "Stand at least 3 feet away while using a microwave." c. "Keep your cell phone 6 inches away from your pacemaker when making a call." d. "Avoid showering for the first 2 weeks following surgery."
C. "Keep your cell phone 6 inches away from your pacemaker when making a call." The nurse should instruct this to avoid interfering with the function of the generator inside the client's pacemaker. Incorrect: A. The client does not need a provider's prescription to alert airport security while traveling. A card should be given to the client after surgery stating that he has a pacemaker and listing the type and model. The nurse should instruct the client to carry this card at all times and show it to airport security when he travels. B. The client does not need to stand 3 feet away while using a microwave. Proper shielding is part of microwave manufacturing, so this safety measure does not need to be taken. D. The client can take a bath or shower as long as he gives careful attention to the pacemaker site. The client should not stand directly under the shower or submerge himself in a tub of water, as this would allow the pacemaker to get extremely wet.
A nurse is caring for a client who reports CALF PAIN. What is the FIRST action the nurse should take? a. Notify the provider b. Elevate the affected extremity c. Check the affected extremity for warmth and redness d. Prepare to administer unfractionated heparin
C. Check the extremity for warmth and redness. The first action the nurse should take using the nursing process is to assess the client's calf for SWELLING, REDNESS, and WARMTH. These findings indicate a deep vein thrombophlebitis (DVT). Incorrect: A. The nurse should notify the provider to report a change in the client's condition; however, there is another action the nurse should take first. B. The nurse should elevate the client's extremity to decrease swelling and relieve pain; however, there is another action the nurse should take first. D. The nurse should prepare to administer an anticoagulant (e.g. unfractionated heparin) to the client if prescribed to decrease the risk for further clot formation; however, there is another action the nurse should take first.
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? a. Administer ferrous sulfate supplementation b. Increase dietary intake of folic acid c. Initiate weekly injections of vitamin B12 d. Initiate a blood transfusion
C. Initiate weekly injections of VITAMIN B12. The nurse should initiate weekly injections of vitamin B12 for a client who has PERNICIOUS ANEMIA and then decrease the injections to a monthly schedule. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract. Incorrect: A. The nurse should administer FERROUS SULFATE to a client who has IRON-DEFICIENCY ANEMIA, which is a decrease in red blood cells caused by inadequate intake of dietary iron. B. The nurse should increase the intake of food containing FOLIC ACID for a client who has MEGALOBASTIC ANEMIA, which is a decrease in red blood cells caused by folate deficiency. C. The nurse should initiate a BLOOD TRANSFUSION for a client who has APLASTIC ANEMIA when bleeding is life-threatening from a LOW PLATELET COUNT or if a client has blood loss from TRAUMA or SURGERY.
A nurse is caring for a client following a stroke. Which of the following actions should the nurse take FIRST? a. Obtain coagulation laboratory studies from the client b. Apply pneumatic compression boots to the client c. Request a referral for a speech-language pathologist d. Keep the client NPO
D. Keep the client NPO. The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experienced a cerebrovascular accident is at risk for dysphagia, which increases the chance of life-threatening aspiration. Incorrect: A. The nurse should obtain coagulation laboratory studies from the client to determine the risk of bleeding and to establish a baseline prior to starting anticoagulation therapy. However, there is another action the nurse should take first. B. The nurse should apply pneumatic compression boots to the client to prevent the formation of deep-vein thrombosis. However, there is another action the nurse should take first. C. The nurse should request a referral for a speech-language pathologist to determine the client's ability to swallow. However, there is another action the nurse should take first.
A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? a. Instruct the client about a long-term cardiac conditioning program b. Administer scheduled doses of acetaminophen c. Check for peak laboratory markers of myocardial damage d. Monitor for bleeding
D. Monitor for bleeding. Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis is assured. Incorrect: A. The nurse should provide teaching about cardiac rehabilitation prior to the client's discharge from the hospital. B. The nurse should plan to administer scheduled doses of ASPIRIN post-procedure. This maintains the patency of the client's coronary arteries following the PTCA by preventing platelet aggregation and thrombus formation around the newly placed stent. C. The nurse should monitor for peak laboratory markers of myocardial damage following a myocardial infarction and reperfusion with thrombolytic therapy.
A nurse is caring for a client who has pernicious anemia. Which of the following should the nurse identify with this condition? a. Iron deficiency b. Hemolytic blood loss c. Folic acid deficiency d. Vitamin B12 deficiency
D. Vitamin B12 deficiency. A client who has PERNICIOUS ANEMIA is deficient in VITAMIN B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12. Incorrect: A. Iron deficiency can be a result of blood loss, poor absorption of iron, or poor nutrition in the diet. This condition is called iron-deficiency anemia. B. Hemolytic blood loss is a result hemorrhage, not pernicious anemia. C. FOLIC ACID DEFICIENCY is caused by poor nutrition related to a LACK OF GREEN LEAFY VEGETABLES, CITRUS FRUITS, and NUTS in the diet. Folic acid is essential for the absorption of vitamin B12.
A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps?
Step 1: Palpate the blood pressure and inflate the cuff above the systolic pressure. [The nurse should auscultate the blood pressure to detect paradoxical blood pressure for a client with possible cardiac tamponade.] Step 2: Deflate the cuff slowly and listen for the first audible sounds. Step 3: Identify the first BP sounds audible on expiration and then on inspiration. Step 4: Substract the inspiratory pressure from the expiratory pressure. [This determines pulsus paradoxus. A difference of >10 mmHg can indicate cardiac tamponade.] Step 5: Inspect for jugular vein distention and notify the provider. [The nurse should inspect for JVD, muffled heart sounds, and decreased cardiac output and notify the provider of the results.]
A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? a. "I can snack on fresh fruit." b. "I can continue to eat lunchmeat sandwiches." c. "I can have cottage cheese with my meals." d. "Canned soup is a good lunch option."
A. "I can snack on fresh fruit." Incorrect: B. Lunchmeats are usually high in sodium and should be avoided. The nurse should recommend choosing lower-sodium options, such as FRESH FISH or POULTRY. C. Cottage cheese contains 390 mg per 113 g (1/2 c) of sodium. The nurse should recommend LOW-FAT YOGURT as a low-sodium snack. D. Canned soups contain high amounts of sodium. The nurse should instruct the client to AVOID CONVIENIENCE and FAST FOODS such as canned or dry-packaged soups.
A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? a. "I would never have believed I could get used to enjoying my food without salt." b. "My blood pressure device at home usually shows about 156 over 98 or so." c. "I make sure I take my blood pressure medicine when I have headaches." d. "My blood pressure pills are very expensive. Could I take a cheaper medication?"
A. "I would never have believed I could get used to enjoying my food without salt." This statement implies that the client has stopped adding salt to food. Sodium restriction is a single aspect of the treatment plan, but it does not indicate dietary adherence by the client. Incorrect: B. The best evidence that a client's blood pressure is under control is consistent measures below 140/90 mmHg. Above age 60, a client's blood pressure should be below 150/90 mmHg. This average reading suggests the need for further intervention. C. Although the client is taking the medication, the client may need more education about following the prescribed medication therapy. This statement suggests the client is using the medication to treat a symptom that high blood pressure may be causing. Some antihypertensive medications such as verapamil, lisinopril, and furosemide can actually cause headaches. D. From this statement, the nurse cannot conclude whether the client is taking the medication. Further assessment is needed.
A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? SATA. a. Assess and document the client's vital signs. b. Restart the IV with a 22-gauge needle. c. Verify with another nurse the blood type and Rh of the packed RBC's. d. Hang a bag of lactated Ringer's IV solution. e. Change IV tubing to a set that has a filter.
A. Assess and document the client's vital signs. C. Verify with another nurse the blood type and Rh of the packed RBC's. E. Change IV tubing to a set that has a filter. The nurse should administer packed RBCs through IV tubing that has a FILTER to prevent the administration of aggregates and possible contaminants. B. The nurse should ensure the client has a 20-gauge or larger needle for administration of packed RBCs to prevent the formation of blood clots during the transfusion. D. The nurse should hang a bag of 0.9% sodium chloride IV solution for administration with the packed RBCs. Lactated Ringer's solution is not used because it causes clotting and hemolysis of the blood cells.
A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? a. Elevate the affected leg b. Place the client on bed rest c. Massage the affected leg d. Administer aspirin for discomfort
A. Elevate the affected leg. The nurse should elevate the affected leg when the client is in bed to reduce inflammation. Incorrect: B. The nurse should not place the client on bed rest because AMBULATION can PROMOTE VENOUS RETURN and does not increase the risk of pulmonary embolus. C. The nurse SHOULD NOT MASSAGE the affected leg, as this increases the risk of dislodging the clot and causing a pulmonary embolus. D. The nurse should not administer aspirin to the client because aspirin can increase the anticoagulant effect of enoxaparin by inhibiting platelet aggregation, increasing the risk of bleeding.
A nurse is assessing a client who has deep-vein thrombosis (DVT) in her left calf. Which of the following manifestations should the nurse expect to find? SATA. a. Hardening along the blood vessel b. Absence of a peripheral pulse c. Tenderness in the calf d. Cool skin on the leg e. Increased leg circumference
A. Hardening along the blood vessel. C. Tenderness in the calf. E. Increased leg circumference. DVT can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling. B. Arterial problems, not venous problems, affect peripheral pulsation. D. The calf usually has warm skin; however, the skin might be cool if the client has an arterial problem.
A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? a. Weight gain of 1 kg (2.2 lb) in 1 day b. Pitting edema c. Client report of a nocturnal cough d. B-type natriuretic peptide (BNP) level of 100 pg/mL
A. Weight gain of 1 kg (2.2. lb) in 1 day. A weight gain of 1 kg (2.2. lb) in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's heart failure is worsening. Incorrect: B. Pitting edema (a visible finger indentation after application of pressure) alerts the nurse that the client has retained fluid and indicates fluid in the client's tissues. Pitting edema is rated on a scale of mild (+1) to severe (+3). Pitting edema of +3 suggests the client has developed fluid volume overload and worsening heart failure. C. A client who is in the EARLY stages of heart failure might report a cough that is irritating, occurs at night, and is nonproductive. D. BNP levels increase as a result of the ventricular hypertrophy in heart failure. A BNP level ABOVE 100 pg/mL is indicative of heart failure. Levels continue to increase with severity of the condition.
A nurse is caring for a client who has a platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 5 min C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol
B. Apply pressure to the catheter removal site for 5 min. A platelet count below 100,000/mm^3 indicates thrombocytopenia, which puts the client at an increased risk for bleeding. By applying pressure to the site for at least 5 minutes, the nurse promotes coagulation and prevents additional blood loss. Incorrect: A. The application of heat INCREASES BLOOD FLOW to the area, which increases the client's risk of bleeding. C. ELEVATING the arm is recommended to decrease blood flow to the area, which decreases the client's risk of bleeding. D. Cleaning the site with alcohol is recommended prior to insertion to prevent infection at the insertion site. After discontinuation, the nurse should apply a sterile dressing.
A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? SATA. a. Bradycardia b. Bleeding at the venipuncture site c. Petechiae on the chest and arms d. Flushed, dry skin e. Abdominal distention
B. Bleeding at the venipuncture site. C. Petechiae on the chest and arms. E. Abdominal distention. The formation of large amounts of micro-emboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest arms, and bleeding in the abdominal cavity resulting in abdominal distention due to internal bleeding. Incorrect. A. D. Bradycardia and flushed, dry skin are not consistent with DIC. DIC is a complex malfunction involving the body's ability to clot. Tachycardia and pallor are manifestations of hemorrhaging.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Pitting peripheral edema b. Crackles in the lung bases c. Jugular vein distention d. Hepatomegaly
B. Crackles in the lung bases. Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs. Incorrect: A. C. D. Peripheral edema, JVD, and hepatomegaly are manifestations of right-sided heart failure.
A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? a. "Exertion often brings on pain." b. "Variant angina occurs randomly at various times." c. "Variant angina can cause changes on your electrocardiogram." d. "Reducing your cholesterol can help you experience less pain."
C. "Variant angina can cause changes on your electrocardiogram." Variant angina causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium. Incorrect: A. Variant angina typically occurs with rest. B. Variant angina pain tends to occur at the same time of day. D. Vasospasm, not atherosclerosis, causes variant angina. If the client's cholesterol level is above the expected reference range, attempts should be made to lower it; however, this measure is unlikely to affect variant angina.
A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? a. Severe hypertension b. Low body temperature c. Sudden oliguria d. Decreased respirations
C. Sudden oliguria. The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs. Incorrect: A. Hypotension due to circulatory shock is an indication of an intravascular hemolytic reaction. B. A fever is an indication of an intravascular hemolytic reaction. D. Tachypnea as a compensatory mechanism due to circulatory shock is an indication of an intravascular hemolytic reaction.
A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D
C. Vitamin C. Vitamin C deficiency produces symptoms of scurvy such as delayed wound healing and capillary fragility. Incorrect: A. A deficiency in vitamin A produces manifestations of night blindness and immunodeficiency. It is not associated with scurvy. B. A deficiency in vitamin B3 produces manifestations of pellagra, which include a scaly rash on sun-exposed skin, confusion, paranoia, and diarrhea. D. A deficiency in vitamin D produces manifestations of rickets and osteomalacia, which include bowed legs, fractures, and malformed teeth.
