EAQ_Content Area_Med-Surg_Cardio,Hema,&Lymph
Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? A. Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. B. Arrange for a supply of heparin for the client to take to the rehab center. C. Explain to the client that anticoagulant therapy will no longer be needed. D. Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.
ANSWER: A RATIONALE: Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the healthcare provider.
A client comes to the emergency department with chest pressure and shortness of breath. The client is admitted for observation after receiving a tentative diagnosis of a myocardial infarction. For which assessment finding should the nurse expect to monitor in a client with this diagnosis? A. Vomiting B. Bradycardia C. Severe headache D. Pain radiating to the abdomen
ANSWER: A RATIONALE: Nausea and vomiting are clinical manifestations associated with an inferior wall myocardial infarction. The heart rate will increase, not decrease, in an attempt to meet oxygen demands of the body. Headaches are not directly related to the infarction. Headaches are typically a result of an elevated blood pressure or side effect of nitroglycerin administered for the pain. Chest pain associated with a myocardial infarction may radiate to the jaw, back, or left shoulder and arm, but not the abdomen.
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? A. Arteriolar constriction occurs. B. The cardiac workload decreases. C. Contractility of the heart decreases. D. The parasympathetic nervous system is triggered.
ANSWER: A RATIONALE: The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.
An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply. A. Dyspnea B. Crackles C. Hacking Cough D. Peripheral Edema E. Jugular Distention
ANSWER: A,B,C RATIONALE: The left ventricle pumps oxygen-rich blood to the rest of the body. Left-sided heart failure occurs when the left ventricle doesn't pump efficiently. This prevents the body from getting enough oxygen-rich blood. The blood backs up into the lungs instead, which causes a buildup of fluid. Common symptoms may include: dyspnea, shallow respirations, crackles, dry, hacking cough, and frothy, pink-tinged sputum. Right-sided heart failure occurs when the right side of the heart can't perform its job effectively. Common symptoms of right-sided heart failure include peripheral edema, weight gain, and jugular distention.
A client who recently had a myocardial infarction is admitted to the cardiac care unit. How can the nurse best determine the effectiveness of the client's ventricular contractions? a. Observing anxiety levels b. Monitoring urinary output hourly c. Evaluating cardiac enzyme results d. Assessing breath sounds frequently
ANSWER: B RATIONALE: A decreased urinary output reflects a decreased cardiac output; immediate action is indicated if urinary output decreases. Although anxiety may occur, the priority is to monitor urinary output, which reflects cardiac effectiveness. Cardiac enzyme results do not reflect effectiveness of cardiac contractions; they reflect tissue damage. Although the presence of crackles (rales) will indicate pulmonary edema, it will not determine the effectiveness of ventricular contractions.
What is the most essential nursing care for a client who just had a cardiac catheterization? a. Maintain the semi-Fowler position. b. Monitor the apical pulse and blood pressure. c. Take the temperature hourly until it stabilizes d. Encourage frequent coughing and deep breathing.
ANSWER: B RATIONALE: An apical pulse is taken to detect dysrhythmias related to cardiac irritability; blood pressure is monitored to detect hypotension, which may indicate bleeding or shock. Maintaining the semi-Fowler position is contraindicated; flexion of the groin may compromise the clot at the femoral insertion site. A fever may indicate a bacterial invasion, but this will not be evident during the first few hours after catheterization. Encouraging frequent coughing and deep breathing is not necessary; the client did not have general anesthesia and will soon be ambulatory.
After teaching a client about a low-fat diet, what is most important for the nurse to document? A. Client's weight loss goals B. Client's ability to plan a low-fat meal C. Client's receptiveness to the education D. Education of family members/significant others as well as the client
ANSWER: B RATIONALE: Documenting the client's ability to plan a low-fat meal demonstrates the client's ability to apply the education to lifestyle. Not all clients on a low-fat diet need to lose weight. Clients can be receptive to education but not understand it. It helps to include family members or significant others in the education. However, it is most effective if the clients themselves take ownership of their healthcare plan.
A nurse teaches a client with varicose veins about prevention of a thromboembolus. Which statement regarding preventive measures indicates the client requires further teaching? A. "I must increase my fluid intake." B. "I will massage my legs twice a day." C. "Elastic stockings should be worn every day." D. "Involving my upper and lower extremities in all exercises is important."
ANSWER: B RATIONALE: Massaging the legs twice a day is unsafe if a thrombus is present because it may dislodge and cause an embolus. Fluids decrease blood viscosity, reducing the risk for thrombus formation. Elastic stockings physically compress veins, preventing venous stasis and lowering the risk for thrombus formation. Range-of-motion exercises prevent venous stasis and promote muscle tone; they propel venous blood toward the heart, facilitated by venous one-way valves.
A nurse is working with an unlicensed assistive personnel (UAP) in caring for a group of clients. Which statement by the UAP indicates a correct understanding of the UAP's role? A. "I will turn off clients' IVs that have infiltrated." B. "I will take clients' vital signs after their procedures are over." C. "I will use unit written materials to teach clients before surgery." D. "I will help by giving medications to clients who are slow in taking pills."
ANSWER: B RATIONALE: Monitoring vital signs after procedures is within the scope of a UAP's role. Registered professional nurses or licensed practical nurses, not UAPs, should perform turning off clients' intravenous (IV) infusions that have infiltrated. Using unit written materials to teach clients before surgery should be performed by registered professional nurses or licensed practical nurses, not UAPs. Helping by giving medications to clients who are slow in taking pills should be performed by registered professional nurses or licensed practical nurses, not UAPs.
The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? a. Defibrillate b. Assess the client's pulse c. Initiate advanced cardiac life support d. Check another lead to confirm asystole
ANSWER: B RATIONALE: Pulse should be immediately assessed because a lead or electrode coming off may mimic this dysrhythmia. Asystole is characterized by complete cessation of electrical activity. A flat baseline is seen, without any evidence of P, QRS, or T waveforms. A pulse is absent, and there is no cardiac output; cardiac arrest has occurred. Once confirmed, Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) protocols are initiated for asystole. Defibrillation is part of the ACLS protocol for ventricular fibrillation.
A nurse is caring for a client who was admitted to the hospital with the diagnosis of tertiary syphilis. Which system of the body should the nurse assess most closely in this stage of the disease? A. Reproductive B. Cardiovascular C. Lower Respiratory D. Lower GI
ANSWER: B RATIONALE: Tertiary syphilis is the last stage, affecting several body systems: skin, cardiovascular, and neurological. Aortic valvular disease and aortic aneurysms can occur. Although lesions occur on the genitalia during primary and secondary syphilis, the reproductive system is not the major body system affected in tertiary syphilis. Structures of the lower respiratory tract and gastrointestinal are not the major structures involved in tertiary syphilis.
A nurse is assessing a group of clients. Which client is considered at the highest risk for a dissecting aneurysm? A. 70-year-old male with peripheral vascular disease B. 65-year-old male with uncontrolled hypertension C. 40-year-old female with controlled hypertension D. 42-year-old female with peripheral vascular disease
ANSWER: B RATIONALE: The highest incidence of dissecting aneurysm is in people in their sixth and seventh decades of life; it is seen 2 to 5 times more frequently in men than in women. It occurs most often in older clients with hypertension. The 40-year-old female is not at as great a risk as a male. The 70-year-old male with peripheral vascular disease and the 42-year-old female with peripheral vascular disease are not at as high a risk as a male with uncontrolled hypertension.
A client who is to have sclerotherapy asks the nurse, "How did I get varicose veins?" Which etiology should the nurse take into consideration when formulating a response? A. Short episodes of standing B. Defective valves within the veins C. Compression of leg muscles on the veins D. Formation of thrombophlebitis in the veins
ANSWER: B RATIONALE: Varicose veins are dilated veins that occur as a result of incompetent valves. Varicosities may result from heredity factors, prolonged standing (which puts strain on the valves), and abdominal pressure on the large veins of the lower abdomen as occurs during pregnancy. Prolonged standing increases pressure on the valves within the veins. Compression of leg muscles on the veins limits venous pooling. Varicose veins increase the risk for thrombophlebitis; thrombophlebitis does not cause varicose veins.
A child in sickle cell crisis is admitted to the pediatric unit. Which actions will the nurse take? Select all that apply. a. Place on strict isolation b. Administer hydroxyurea c. Administer acetylsalicylic acid d. Apply oxygen via nasal cannula e. Offer age-appropriate activities f. Administer intravenous (IV) hydration
ANSWER: B,D,E,F RATIONALE: Hydroxyurea can reduce the number of sickling and pain episodes by stimulating fetal hemoglobin production. Providing oxygen via nasal cannula provides additional oxygen, which is necessary because of decreased hemoglobin, which carries oxygen. Age-appropriate activities can help alleviate boredom as the child begins to feel better. Providing intravenous hydration until the child is able to tolerate adequate by mouth fluids reduces sickle cell clotting. Strict isolation is not necessary. Aspirin should not be given to children because of risk of Reye syndrome.
A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? A. Hematocrit 46% B. Hemoglobin 14.1 g/dL (141 mmol/L) C. Potassium 3.0 mEq/L (3.0 mmol/L) D. White blood cell 9200/mm3 (9.2 × 109/L)
ANSWER: C RATIONALE: A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm3is within the normal range of 4000 to 11,000 cells/mm3 (4 to 11 × 109/L).
The nurse observes a client collapse while walking down the hallway and establishes unresponsiveness. What should the nurse do first? A. Do a blind finger sweep B. Begin chest compressions C. Check for a carotid pulse D. Perform the abdominal thrust maneuver
ANSWER: C RATIONALE: According to the American Heart Association guidelines (Canada: Heart and Stroke Foundation), assessing for a carotid pulse is the first step in CPR. A blind finger sweep is not performed. Chest compressions are done only after it is determined that the carotid pulse is absent. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.
When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress? a. Getting up from bed in the morning b. Walking to visit the next-door neighbor c. Climbing a flight of stairs to the bedroom d. Leaving the table immediately after a meal
ANSWER: C RATIONALE: Stair climbing increases oxygen consumption and therefore increases the workload of the heart; this results in dyspnea and fatigue. Getting up from bed in the morning may cause orthostatic hypotension; the oxygen demands of the body are not significantly increased when sitting up. Walking short distances on level surfaces will not place as much strain on the cardiovascular system as does climbing stairs against gravity. Although moving from a sitting to a standing position during digestion increases the demand on the heart, it is not as demanding or sustained an activity as is climbing stairs.
A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action should the nurse take to prepare for the arrival of the client? a. Reserve an operating room. b. Organize equipment for a tracheotomy. c. Prepare equipment for chest tube insertion. d. Arrange for a portable chest x-ray examination.
ANSWER: C RATIONALE: The priority is to reinflate the lungs and stabilize the client's respiratory status. Reserving an operating room may be necessary later but is premature at this time. Organizing equipment for a tracheotomy is unnecessary; an endotracheal tube should be used for maintenance of the airway if necessary. Arranging for a portable chest x-ray examination is not the priority at this time; this may be done later.
A client is admitted with a higher than expected red blood cell (RBC) count. What physiologic alteration does the nurse expect will result from this clinical finding? a. Increased serum pH b. Decreased hematocrit c. Increased blood viscosity d. Decreased immune response
ANSWER: C RATIONALE: Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. The number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity.
A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? a. Diuresis, irritability, and fever b. Lethargy, cold skin, and hypertension c. Thirst, cool skin, and orthostatic hypotension d. Bounding pulse, restlessness, and slurred speech
ANSWER: C RATIONALE: With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.
A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client? A. Acute pain B. Impaired mobility C. Impaired swallowing D. Hematoma formation
ANSWER: D RATIONALE:
A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? a. Fever and chest pain b. Positive Homans sign c. Loss of sensation in the operative leg d. Tachycardia and petechiae over the chest
ANSWER: D RATIONALE: Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurologic dysfunction; it is not an indication of a fat embolism.
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client? A. 5% Dextrose and lactated Ringer solution B. 0.9% normal saline solution C. Total parenteral nutrition D. Whole blood products
ANSWER: D RATIONALE: The client has experienced acute blood loss from the long bone and pelvic fractures and is tachycardic and hypotensive. Therefore the most appropriate parenteral fluid is whole blood.
An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its antioxidant effects on the structure of cell walls. I wonder whether it is wise to take it." Which vitamin does the nurse conclude the client is describing? A. K B. B1 C. C D. E
ANSWER: D RATIONALE: Vitamin E has antioxidant properties. Vitamin K assists in synthesizing blood clotting factors. Vitamin B1 is necessary for protein and fat metabolism and for functioning of the nervous system. Vitamin C is used for formation of collagen, which is important for maintaining capillary strength, promoting wound healing, and resisting infection.
A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. A. Weight loss B. Unusual fatigue C. Dependent Edema D. Nocturnal dyspnea E. Increased unrinary output.
ANSWERS: B, C, D RATIONALE: Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia; women more commonly report unusual fatigue than men. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure. Orthopnea, a compensatory mechanism, limits venous return, which decreases pulmonary congestion and promotes ventilation, easing the dyspnea. Weight gain, not loss, occurs because of fluid retention. Urinary output decreases, not increases, with heart failure because the sympathetic nervous system and the renin-angiotensin-aldosterone system stimulate the retention of sodium and water in the kidneys.
Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor? a. "The only times the monitor should be taken off are for showering and sleep." b. "The monitor will record my activities and symptoms if an abnormal rhythm occurs." c. "The results from the monitor will be used to determine the size and shape of my heart." d. "The monitor will record any abnormal heart rhythms while I go about my usual activities."
Answer: D Rationale: The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.