Cardiovascular, Hematologic, and Lymphatic Systems
A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of? 1 Atrial fibrillation 2 Cardiac irritability 3 Impending heart block 4 Ventricular tachycardia
Cardiac irritability is the cardinal reason for PVCs. Atrial fibrillation is a type of dysrhythmia, not the cause of PVCs; the source of atrial fibrillation is the atrium, not the ventricles. Impending heart block type of dysrhythmia is associated with interference with the conduction system. Ventricular tachycardia is a type of dysrhythmia, not the cause of PVCs
Urticaria
a rash of round, red welts on the skin that itch intensely, sometimes with dangerous swelling, caused by an allergic reaction, typically to specific foods.
A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data? 1 Loss of battery power 2 Functioning as expected 3 Failure to stimulate the heart 4 Ignoring the client's heartbeat
If pacemaker spikes are present, the pacemaker is firing appropriately, but the lack of resulting QRS complexes indicates that it is not stimulating or "capturing" the heart. Loss of battery power is indicated by a slowing or irregular heart rate. Each pacemaker spike should be followed by a QRS complex. A fixed or asynchronous pacemaker is designed to work independently of the client's intrinsic rhythm.
The nurse is completing an assessment on a couple seeking genetic counseling for sickle cell anemia. Both prospective parents carry sickle cell traits. The nurse recognizes that the couple has what chance of having a child who develops the disease? 1 25% 2 50% 3 75% 4 100%
Sickle cell is an autosomal recessive genetic disorder. If both individuals have sickle cell traits, there is a 25% chance they will produce a child with the disease. Other options, such as 50%, 75%, and 100%, are not plausible. However, the children do have a 50% chance of being carriers.
A client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a screening session at a health fair asks the nurse what to do in light of this result. How should the nurse respond? 1 "Your cholesterol is high, and you may need medication." 2 "This is within the acceptable range, and no action is required." 3 "Your level is low; you should eat more foods that contain cholesterol." 4 "Your cholesterol is elevated slightly. A diet low in saturated fats should be followed."
A level more than 200 mg/dL (5 mmol/L) is considered elevated, and foods high in cholesterol and saturated fats should be limited in the diet. A level of 240 mg/dL (6.2 mmol/L) or more is considered high. Levels between 140 and 200 mg/dL (2 mmol/L to 5 mmol/L) are considered desirable. A low level is less than 140 mg/dL (2.0 mmol/L). Medical attention should be sought, because low cholesterol levels are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and myeloproliferative disease.
Although the nurse is unable to identify any obvious signs or symptoms of bleeding, a client repeatedly has tested positive for occult blood in the stool. Which laboratory result is a concern considering this client's history? 1 Iron level 100 mcg/dL (22 mcmol/L) 2 Hemoglobin level 8.5 g/dL (85 mmol/L) 3 Platelet count 160,000/mm3 (160 × 109/L) 4 Transferrin level 300 mg/dL (3 g/L)
Intermittent or continuous loss of a small amount of blood over extended periods will lead to a decreased hemoglobin level; 8.5 g/dL (85 mmol/L) is below the expected hemoglobin range for men (14 to 18 g/dL; 140 to 180 mmol/L) and women (12 to 16 g/dL; 120 to 160 mmol/L). An iron level of 100 mcg/dL (22 mcmol/L) is within the expected range of 60 to 180 mcg/dL (14 to 32 mcmol/L). A decrease in the platelet count indicates reduced blood clotting capacity, not blood loss. This platelet count is within the expected range of 150,000 to 400,000/mm3 (150 to 400 × 109/L). Transferrin level 300 mg/dL (3 g/L) is within the expected range of 215 to 380 mg/dL (2.15 to 3.80 g/L).
The left foot of a client with a history of intermittent claudication becomes increasingly cyanotic and numb. Gangrene of the left foot is diagnosed, and because of the high level of arterial insufficiency, an above-the-knee amputation (AKA) is scheduled. Which response by the client best demonstrates emotional readiness for the surgery? 1 Explains the goals of the procedure 2 Displays few signs of anticipatory grief 3 Participates in learning perioperative care 4 Verbalizes acceptance of permanent dependency needs
Active participation in self-care indicates a readiness to learn; it demonstrates that the client is interested in future expectations. Explaining the goals of the procedure may indicate intellectual readiness but not necessarily emotional readiness. An expected change in body image precipitates the grieving process; a client may be in denial if no concerns are expressed. The client need not be dependent permanently; verbalizing acceptance of permanent dependency needs indicates the need for more teaching and emotional support.
A healthcare provider prescribes thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do? 1 Slightly slit the top of the stockings to relieve pressure. 2 Leave the antiembolism stockings off to prevent tissue damage. 3 Roll the top of the stockings to below the knees to limit popliteal pressure. 4 Ask the healthcare provider if an elastic bandage can be used in place of the stockings.
An elastic bandage can be adjusted to the varying proportions of the client's legs. Cutting the stockings to relieve pressure is inappropriate and will decrease the effectiveness of the stockings. Leaving the antiembolism stockings off to prevent tissue damage is unsafe; this permits venous stasis. Rolling the top of the stockings to below the knees to limit popliteal pressure will increase the pressure in the popliteal space, which increases venous stasis and the risk of thrombophlebitis.
A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? 1 Septic shock 2 Cardiogenic shock 3 Neurogenic shock 4 Anaphylactic shock
Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.
The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively? 1 Administering supplemental oxygen 2 Maintaining a reduced blood pressure 3 Keeping the client in a supine position 4 Monitoring the peripheral vascular status
Maintaining a low blood pressure reduces the risk of aortic rupture. Administering supplemental oxygen may or may not be necessary. Keeping the client in a supine position may or may not be necessary. Monitoring will help identify whether an aneurysm has ruptured, but it will not prevent rupture.
A nurse is obtaining a health history on a client admitted to the hospital with heart failure. Which assessment finding will the nurse expect the client to report? 1 Feeling bloated after eating 2 Tingling in the upper extremities 3 Needing to use three pillows at night to sleep 4 Swelling of the ankles that is more apparent in the morning
Heart failure causes a fluid volume excess that results in pulmonary edema and dyspnea in the supine position, requiring pillows to sleep. Feeling bloated after eating and tingling in the upper extremities are unrelated to the cardiopulmonary system. Dependent edema usually occurs after standing or walking; swelling of the ankles is more evident in the evening.
After several months of chemotherapy treatment, a client with the diagnosis of multiple myeloma comes to the emergency department because of confusion, muscle weakness, and diarrhea. The nurse reviews the client's electronic medical record. Which complication associated with chemotherapy does the nurse suspect that the client is experiencing? 1 Septic shock 2 Tumor lysis syndrome 3 Superior vena cava syndrome 4 Disseminated intravascular coagulation
Hyperkalemia occurs when large quantities of tumor cells are destroyed, releasing potassium and purines more rapidly than the body can manage them (tumor lysis syndrome). A serum potassium of 5.8 mEq/L (5.8 mmol/L) is more than the expected range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L), resulting in the abnormal ECG results. Hyperkalemia can cause a pulse in the lower range of that expected for an adult, numbness in the extremities, flaccid paresis, hyperactive bowel sounds, and diarrhea. There are no adaptations indicating septic shock. The white blood cell count (WBC) and vital signs are all within the expected range. A rapid, weak pulse, rapid respirations, increased temperature, hypotension, and warm flushed skin are associated with septic shock. Superior vena cava syndrome occurs when a tumor obstructs or compresses the superior vena cava, resulting in blockage of blood flow to the venous system of the head, neck, and upper trunk and in edema of the face (especially periorbital edema) and distention of veins of the head, neck, and chest. With disseminated intravascular coagulation (DIC) there is abnormal coagulation, resulting in bleeding from many sites, clot formation, and decreasing blood flow to major organs. Decreased circulation to organs causes pain, dyspnea, tachycardia, oliguria, bowel necrosis, and multiple organ failure.
A nurse is caring for a client with first degree atrioventricular (AV) block. Which information will the nurse consider when planning care? 1 Every P wave is conducted to the ventricles. 2 Some P waves are conducted to the ventricles. 3 There are no P waves visible on the rhythm strip. 4 None of the P waves are conducted to the ventricles.
In first degree AV block, a P wave precedes every QRS complex, which is followed by a T wave indicating complete conduction. P waves are visible, but the PR interval is prolonged. Second degree heart block refers to AV conduction that is intermittently blocked. Therefore, some P waves are conducted and some are not. Third degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles.
The nurse notices sudden bursts of fast rhythm that end abruptly. The heart rate is 220 beats per minute during these bursts, but the P waves are very difficult to see. The QRS interval is normal. The nurse notifies the primary healthcare provider. Which rhythm did the nurse share with the primary healthcare provider? 1 Sinus tachycardia 2 Atrial tachycardia 3 Ventricular tachycardia (VT) 4
Paroxysmal supraventricular tachycardia (PSVT) PSVT occurs above the ventricles, and it has an abrupt onset and cessation. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Onset is gradual rather than abrupt. PR interval is 0.12 to 0.20 seconds. P and QRS waves are consistent in shape. Atrial tachycardia is a rapid rhythm that arises from an ectopic focus in the atria. Because the P wave arises outside the sinus node, the shape is different from the sinus P wave. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The client may or may not have a pulse.
A 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 triage 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. Is there someone there who can drive you to the hospital?" 4 "You are experiencing an interaction between your pain and oral contraceptive medications. You need to come to the emergency department now for care."
The client's clinical manifestations, along with the history of a recent fracture, immobilization, and use of an oral contraceptive, suggest a pulmonary embolism. An ambulance will limit the woman's use of her leg, which may prevent further emboli. The client's clinical findings are not indicative of compression syndrome. Tingling, numbness, cool skin, and lack of capillary refill are signs and symptoms of compression syndrome. The clinical manifestations do not support an allergic reaction. An allergic response may cause shortness of breath, but it does not cause calf pain. The client may be experiencing a pulmonary embolism, not an interaction between the two medications.
Ventricular fibrillation
Ventricular fibrillation reflects a rapid, feeble twitching/quivering of the ventricles; it has an irregular sawtooth configuration with unidentifiable PR intervals and QRS complexes. Atrial flutter is characterized by an atrial rate of 200 to 350 beats per min and a ventricular rate of approximately 150 beats per min; flutter to ventricular responses usually are 2:1, 3:1, or 4:1. Atrial fibrillation is characterized by an atrial rate of 350 to 600 beats per min and a variable ventricular rate; the rhythm is grossly irregular. Ventricular tachycardia has a rate of 140 to 200 or even 250 beats per min; the rhythm is usually regular but may vary. P waves are unidentifiable. PR intervals are unmeasurable. QRS complexes are wide and bizarre.
The healthcare provider prescribes a progressive exercise program that includes walking for a client with a history of diminished arterial perfusion to the lower extremities. The nurse explains to the client what to do if leg cramps occur while walking. Which instruction did the nurse give the client? 1 Chew one aspirin twice a day. 2 Stop to rest until the pain resolves. 3 Walk more slowly while pain is present. 4 Take one nitroglycerin tablet sublingually.
During an exercise program, the client walks to the point of claudication, stops and rests, and then walks a little farther. Decreasing the demand for oxygen by resting will relieve the pain. Pain will not resolve as long as exercise, thus muscle hypoxia, is continued, regardless of whether aspirin is taken. Walking more slowly while pain is present is appropriate for venous insufficiency, not arterial insufficiency. Sublingual nitroglycerin is not indicated for leg cramps.
An older adult client comes to the emergency department reporting pink-tinged urine. An electrocardiogram (ECG) is performed, which is within acceptable limits, and blood specimens are sent to the laboratory for diagnostic tests. The nurse obtains a health history and the client's vital signs and reviews the laboratory test results. What nursing action is a priority when caring for this client? 1 Monitor the intake and output. 2 Provide oxygen via nasal cannula. 3 Institute measures to prevent physical injury. 4 Obtain a prescription for an antidysrhythmic.
The therapeutic international normalized ratio (INR) level usually is between 2 and 3; the expected range for platelets is 150,000 to 450,000/mm3 (150 × 109 /L to 400 × 109 /L). The platelet count is significantly decreased, and the INR level of 4.5 is high. The client is at risk for bleeding and must be protected from injury. Monitoring the intake and output is unnecessary. There are no clinical manifestations of a fluid imbalance. Although the pulse and respirations are slightly elevated, the respirations have a regular depth and rhythm, and the hematocrit is within the expected range. There is no evidence that the client needs supplemental oxygen. The ECG indicates no problems, and the pulse is 84 and regular. The client is not experiencing a dysrhythmia.
A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority? 1 Elective cardioversion 2 Immediate defibrillation 3 An intramuscular (IM) injection of digoxin 4 An intravenous (IV) line for emergency medications
When ventricular fibrillation is verified, the first intervention is defibrillation; it is the only measure that will terminate this lethal dysrhythmia. Elective cardioversion delivers a shock during the R wave; because there is no R wave in ventricular fibrillation, the dysrhythmia will continue and death will result. Digitalis preparations are not used to treat ventricular dysrhythmias. If not already in place, an IV line should be inserted after the client is defibrillated.
An emergency department nurse is admitting a client after an automobile collision. The primary healthcare provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit? 1 Urine output of 50 mL/hr 2 Blood pressure of 150/90 mm Hg 3 Apical heart rate of 142 beats/min 4 Respiratory rate of 16 breaths/min
In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood flow to body organs. Urine output would fall to less than 30 mL/hr, because a decreased blood volume causes a decreased glomerular filtration rate. The blood pressure is decreased because of the decreased blood volume. Respiratory rate of 16 breaths/min is within the accepted range of 12 to 20 breaths/min; the respiratory rate is rapid with hypovolemic shock.
The spouse of a patient who had emergency coronary artery bypass surgery asks why there is a dressing on the patient's left leg. How should the nurse explain the dressing? 1 "This is the access site for the heart-lung machine." 2 "A filter is inserted in the leg to prevent embolization." 3 "A vein in the leg was used to bypass the coronary artery." 4 "The arteries in the extremities are examined during surgery."
The response that a vein in the leg was used to bypass the coronary artery provides information and reduces anxiety. The nurse understands that the greater saphenous vein of the leg is used to bypass the diseased coronary artery, and one surgical team obtains the vein while another team performs the chest surgery; this shortens the surgical time and decreases the risks of surgery. The internal mammary arteries are the grafts of choice, but the surgery is usually longer because of the necessity of dissecting the arteries from the chest wall. In addition, the internal mammary arteries may have been used in a previous bypass surgery. Cardiopulmonary bypass (extracorporeal circulation) is accomplished by placement of a cannula in the right atrium, vena cava, or femoral vein to withdraw blood from the body; blood is returned to the body via a cannula in the aorta or the femoral artery. Off-pump surgery is used for minimally invasive surgical techniques. A filter is not inserted in the leg to prevent embolization during a coronary artery bypass graft (CABG). The arteries in the extremities are not examined during a CABG.
