Cardiovascular, Hematologic and Lymphatic Systems

splenomegaly

abnormal enlargement of the spleen

Hypernatremia

caused by excessive sodium loss in water which leads to increased sodium concentration in the body

atrial fibrillation

rapid, random, ineffective contractions of the atrium

vagal stimulation

which slows the heart rate, occurs during straining while defecating, taking rectal temperatures, enemas, and digital removal of impacted stool.

A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first? 1. check the IV access for a blood return 2. apply warm compresses to the affected extremity 3. slow the IV infusion until the burning sensation is gone 4. request an oral supplement from the primary healthcare provider

1, Because potassium infusions can be caustic to the vein, a nurse should check for continued blood return. That finding determines the nurse's next intervention(s)

When assessing for hemorrhage on a client who has a total hip replacement, what is the most important nursing action to implement? 1. measure the girth of the thigh 2. examine the bedding under the client 3. check the vital signs every 4 hours 4. observe for eccymosis at the operative site

2, Because of the recumbent position, drainage may flow by gravity under the client and not be noticed unless the bedding is examined

A nurse is performing an assessment on a client with probable acute lymphocytic leukemia (ALL). Which clinical manifestation will the nurse expect to be present? 1. Alopecia 2. Insomnia 3. Ecchymosis 4. Hypertension

3, Bleeding tendencies occur because of bone marrow suppression and rapidly proliferating leukocytes

acute lymphocytic leukemia (ALL)

a form of leukemia characterized by the overproduction of immature lymphocytes lymphocytes are a type of white blood cell important for immunity)

PR interval

delay of AV node to allow filling of ventricles, 0.12 to 0.20 seconds

hypovolemic shock

shock resulting from blood or fluid loss AEB elevated pulse, respirations, and low blood pressure treat with IV fluids

After surgery, a client's fever does not respond to antipyretics. The primary healthcare provider prescribes that the client be placed on a hypothermia blanket. What response to hypothermia therapy must the nurse prevent? 1. Shivering 2. Vomiting 3. Dehydration 4. Hypotension

1, Shivering should be prevented; peripheral vasoconstriction increases the temperature, the circulatory rate, and oxygen consumption

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). Which goal is priority during the acute phase of recovery? 1. promote pain relief 2. increase activity tolerance 3. prevent cardiac dysrhythmias 4 maintain potassium and sodium intake

1, The major goal is to manage pain. Pain relief helps increase the oxygen supply and decrease myocardial oxygen demand, decreasing the workload of the heart

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. 1. discolored toenails 2. reports of leg fatigue 3. localized heat in a calf 4. reddened areas on a leg 5. tortuous veins in the legs 6. pain in lower extremities when standing

2, 4, 5 Leg fatigue is a common clinical manifestation caused by venous stasis and inadequate tissue oxygenation. Vein walls weaken and dilate resulting in distended, protruding veins that appear tortuous and darkened. As vein walls weaken and dilate, venous pressure increases and the valves become incompetent; venous stasis and inadequate oxygenation result in leg pain

Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first? 1. Auscultate the chest for diminished breath sounds 2. Encourage coughing and deep breathing every hour 3. Record the temperature reading and continue to monitor it 4. Suspect an infection and notify the healthcare provider immediately

3, Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days

A client with a history of heart failure on daily weights has a 2-pound (0.9 kilogram) weight gain and pitting edema in lower extremities bilaterally. Which action should the nurse take next? 1. Check the record to ascertain the code status 2. Encourage increased intake of favorite drink 3. Perform a head-to-toe assessment, including vital signs 4. Continue to monitor daily weights and edema and to document findings

3, Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary issues (crackles) associated with left-sided heart failure

The medical-surgical nurse called the code team for a client who is unresponsive and not breathing. Cardiopulmonary resuscitation and an ambu bag have been initiated. What is the next most appropriate action for the nurse to take? 1. contact the client's primary healthcare provider 2. move any other clients or visitors out of the room 3. get the client's record and have it available in the room 4. contact religious ministry

3, The client's nurse must be in the room to give information on the client's condition, history, and medical data to the arriving code team