Med Serge: cardiovascular, hematologic, and lymphatic system

When encouraging a client to seek testing and treatment for streptococcal pharyngitis, which complication will the nurse discuss? a. Rheumatic fever b. Reye syndrome

a. Rheumatic fever

A client with chronic venous insufficiency has ankle edema. Which action would the nurse take? a. elevate the legs b. apply a Unna boot

a. elevate the legs

When caring for a client admitted with massive vomiting of blood, which finding would be of most concern to the nurse? a. cool hands and feet b. heart rate 124 beats/minute

b. heart rate 124 beats/minute

Abdominal cramps occur with a. hypokalemia b. hyperkalemia

hypokalemia

Muscle weakness occurs with (hypokalemia or hyperkalemia) and may progress to paralysis.

hypokalemia

Rheumatic fever is caused by an abnormal (immunological response or RASS system) to group A beta-hemolytic streptococcus, which may cause permanent scarring and damage to the heart valves (rheumatic heart disease).

immunological response

Assessment of bowel sounds in the immediate postoperative period is a priority. y/n

no

The symptoms of Raynaud disease are caused by sudden arterial (vasoconstriction or vasodilation) and tobacco use also causes arterial vasoconstriction, which will worsen symptoms.

vasoconstriction

Lung sounds are monitored frequently because postoperative atelectasis is a common complication after abdominal surgery. Y/N

yes

Which actions by the nurse are priorities in the immediate postoperative period after splenectomy? Select all that apply. One, some, or all responses may be correct. a. monitor heart rate b. take blood pressure c. Listen to bowel sounds d. check urine output e. auscultate lung sounds f. look for abdominal distension

a. monitor heart rate b. take blood pressure d. check urine output e. auscultate lung sounds f. look for abdominal distension

Blood glucose levels higher than (140 mg/dL or 180mg/dL) might indicate sepsis or SIRS in a nondiabetic client, but would not be unusual in a client with diabetes.

140 mg/dL

Which finding for a client who has a potassium level of 2.8 mEq/L (2.8 mmol/L) would be of most concern to the nurse? a. irregular heart rate b. abdominal cramps

a. irregular heart rate The most serious complications of hypokalemia are due to changes in cardiac function, including potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation.

The client with clinical manifestations of superior vena cava syndrome show a. venous congestion and edema of the face and upper trunk and in distention of veins of the head, neck, and chest. b. arterial congestion and edema of the face and upper trunk and in distention of veins of the head, neck, and chest.

a. venous congestion and edema of the face and upper trunk and in distention of veins of the head, neck, and chest.

When performing cardiac compression on an adult client, how far would the nurse depress the lower sternum? a. 1 to 1.4 inches (2.5 - 3.6 cm) b. 2 to 2.3 inches (5-6 cm)

b. 2 to 2.3 inches (5-6 cm)

Monitoring the extremity distal to the insertion site for changes in (temperature and color or tenderness and color) should indicate the presence or absence of a clot; comparing pedal pulses of both extremities may reveal clot formation that disrupts circulation

temperature and color

Hypokalemia causes a. Decreased reflexes b. Increased reflexes but are not fatal.

a. Decreased reflexes

A 68-year-old client has multiple risk factors for peripheral arterial disease, including client age, siblings with diabetes, a sedentary lifestyle, and family history of heart disease. Which risk factor is the highest priority for client teaching? a. Low activity level b. Blood glucose control

a. Low activity level The client's low activity level is a modifiable risk factor and would be the focus of client teaching. Blood glucose control may be a concern in the future for this client, but it is not currently a risk factor.

A child with a congenital heart defect has a cardiac catheterization. Which is an essential element of nursing care after this procedure? a. encouraging early ambulation b. monitoring the extremity distal to the insertion site

b. monitoring the extremity distal to the insertion site

With tumore lysis syndrome in response to chemotherapy, large quantitis of tumor cells are destrouyed, leading to a. hypernatremia b. hypercalcemia c. hyperkalemia

c. hyperkalemia Hyperkalemia would cause the electrocardiogram (ECG) changes and symptoms of numbness in the extremities, flaccid paresis, hyperactive bowel sounds, and diarrhea. There are no findings indicating septic shock, because white blood cells are in the normal range and the blood pressure is normal.

When a client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?", which is the nurse's best response? a. "Tell me about what concerns you right now." b. "It depends on how extensive the disease is."

a. "Tell me about what concerns you right now."

Which laboratory test is most important for the nurse to monitor when a client is admitted with acute coronary syndrome? a. Troponin b. Creatine kinase (CK)

a. Troponin

Because of its large blood supply and general fragility, the spleen may hemorrhage, causing a. hypotension, tachycardia and abdominal distension. b. hypotension, bradycardia and abdominal distension

a. hypotension, tachycardia and abdominal distension.

The heart rate increases (tachycardia) to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased (catecholamines or serotonine) and activation of the renin-angiotensin-aldosterone system or (increase or decrease) fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.

catecholamines, increase

CK levels, especially the creatine phosphokinase (MB) subunit, increase with myocardial necrosis within (3 to 6 hours or 1 to 2 hours) but are not as sensitive as troponin testing for acute myocardial necrosis.

3 to 6 hours

Hypotonic bowel sounds may indicate a. sepsis or SIRS b. cardiac shock

a. sepsis or SIRS

CPR may be initiated in pulseless Ventricular Tachycardia if a defibrillator is not immediately available. Y/N

yes

Cool hands and feet are expected with a client who is admitted with gastrointestinal bleeding because of vasoconstriction that occurs to shunt blood to the major organs and as part of the stress response. Y/N

yes

DIC results in decreased circulation to organs which causes a. pain, dyspnea, tachycardia, oliguria, bowel necrosis, and multiple organ failure b. pain, tachypnea, tachycardia, oliguria, bowel necrosis, and multiple organ failure

a. pain, dyspnea, tachycardia, oliguria, bowel necrosis, and multiple organ failure

When a client in the coronary care unit develops ventricular tachycardia, which action will the nurse take first? a. initiate immediate defibrillation b. assess client pulse and blood pressure

b. assess client pulse and blood pressure Because ventricular tachycardia (VT) can be stable or unstable, the nurse's first action will be to assess the client, including pulse and blood pressure.

Disseminated intravascular coagulation (DIC) would cause abnormal (coagulation or petechiae), resulting in (bleeding from many sites, clot formation, and decreasing blood flow to major organs.

coagulation

Catecholamines are hormones made by your adrenal glands, two small glands located above your kidneys. These hormones are released into the body in response to physical or emotional stress. The main types of catecholamines are: a. dopamine b. norepinephrine c. epinephrine/adrenaline d. serotonin e. acetylcholine

dopamine norepinephrine epinephrine/adrenaline

Coolness or pallor of the feet might be seen in arterial disease; the nurse would teach this client to self-monitor for unusual warmth or redness of the feet. y/n

yes

Myoglobin is one of the first cardiac markers to increase after an MI, it lacks cardiac specificity. Y/N

yes

Stools that are positive for occult blood would be expected in a client with known gastrointestinal bleeding. Y/N

yes

Tachycardia is a cardiovascular compensatory mechanism for hypovolemia and the increased heart rate indicates possible ongoing bleeding and a need for further assessment of the client and communication with the health care provider. Y/N

yes

When the nurse is caring for a client who has cardiogenic shock, which clinical manifestations will be expected? Select all that apply. One, some, or all responses may be correct. a. rapid pulse b. decreased urinary output c. warm, flushed skin increased blood pressure

a. rapid pulse b. decreased urinary output

After the nurse has completed discharge teaching for a client who has had a myocardial infarction, which client statement indicates that more teaching is needed? a. I will avoid physical activity b. I will try to lose the extra weight I am carrying.

a. I will avoid physical activity

Which information would the nurse include in the preprocedure teaching for a client who requires emergency cardiac catheterization? a. Mild sedation is maintained during the procedure. b.The procedure will take approximately 15 minutes to complete.

A mild sedative is used because the client must be alert enough during the procedure to follow directions. A cardiac catheterization takes approximately 2 hours, not 15 minutes. The client remains on bed rest with the legs extended for 4 to 6 hours after the femoral method of entry. Blockages can be visualized during the procedure and are generally discussed with the client during or immediately after the procedure.

Which nursing action would be included in the plan of care after herniorrhaphy in a client with a history of lower extremity thrombophlebitis and varicose veins? a. assist the client to ambulate multiple times during the day b. teach the client to self-monitor for coolness or pallor of the feet

a. assist the client to ambulate multiple times during the day Because of the client's history and the site of the surgery, venous thromboembolism is a possible complication and ambulation will prevent blood stasis.

Which foods will the nurse include when suggesting dietary sources of iron to a client with anemia? Select all that apply. One, some, or all responses may be correct. a. boiled spinach and dried prunes or b. Brussel sprouts and asparagus spears

a. boiled spinach and dried prunes

When a client who has had a myocardial infarction suddenly develops a heart rate of 120 beats/minute, which action would the nurse take first? a. check blood pressure b. call for and electrocardiogram (ECG)

a. check blood pressure With a sudden change in heart rate, the nurse's first action would be to determine whether the client was perfusing adequately by checking blood pressure. Reassurance may be needed if the client's high rate is due to anxiety, but more information about the client is needed before meaningful reassurance is offered.

Which clinical manifestations are more likely to occur in women with coronary artery disease compared with men? Select all that apply. One, some, or all responses may be correct. a. severe fatigue b. sense of unease c. shortness of breath d. substernal chest e. pain radiating down the left arm

a. severe fatigue b. sense of unease c. shortness of breath

When a client with intermittent claudication asks what causes the associated symptoms, which response would the nurse make? a. "Edema occurs because the legs are dependent." b. "Inadequate circulation to the legs causes pain when walking."

b. "Inadequate circulation to the legs causes pain when walking." Intermittent claudication is the pain that occurs during exercise because of a lack of arterial blood flow and decreased oxygen delivery to muscles in the involved extremities. It is exercise-induced ischemia, not the lack of exercise, that causes muscle weakness.

When the spouse of a client with chest pain repeatedly expresses concern about the client's pallor, which response by the nurse is best? a. "We will be drawing blood to check your spouse for anemia." b. "Tell me why you are concerned about your spouse's paleness."

b. "Tell me why you are concerned about your spouse's paleness."

Which clinical parameter will be most important for the nurse to assess when administering warmed intravenous fluids to a client with hypothermia? a. hematocrit b. cardiac rhythm

c. cardiac rhythm Because dysrhythmias can occur during rewarming and may need treatment, ongoing cardiac monitoring is essential. Hematocrit may increase with hypothermia and would be expected to improve with administration of warm fluids, but changes in hematocrit during rewarming are expected.

How would anxiety affect outcomes for a client with heart failure? a. Increases the cardiac workload b. Interferes with usual respirations

a. Increases the cardiac workload Anxiety increases sympathetic nervous system activity, leading to increases in heart rate, vasoconstriction, and increased metabolic rate, which increase cardiac workload and worsen outcomes in clients with heart failure. Anxiety does not directly interfere with respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen needed for body functions.

When caring for a client with peripheral arterial insufficiency, how would the nurse position the client's feet and legs? a. Place them slightly lower than the head and chest. b. Use pillow to support the heels above the matress

a. Place them slightly lower than the head and chest.

The nurse would immediately activate the rapid response team and anticipate collaborative actions such as further diagnostic testing, massive fluid infusion, and administration of vasoconstrictive medications when a. Systolic blood pressure persistently 85 to 90 mm Hg b. Systolic blood pressure persistently 185 to 190 mm Hg

a. Systolic blood pressure persistently 85 to 90 mm Hg

Which finding in a client who had coronary artery bypass graft (CABG) surgery 1 day previously is most important for the nurse to communicate to the health care provider? a. Temperature of 102°F (38.9°C) b. Sinus rhythm with PR interval of 0.22 seconds

a. Temperature of 102°F (38.9°C) Although mild temperature elevations are common after surgery due to the inflammatory response, a high temperature may indicate wound infection and a need for actions such as blood cultures and antibiotic administration.

A client is prone to hyponatremia. Which factors would the nurse identify that can precipitate hyponatremia? Select all that apply. One, some, or all responses may be correct. a. Wound drainage b. Diuretic therapy c. Gastrointestinal (GI) suction d. Parenteral infusion of 0.9% sodium chloride e. Inappropriate antidiuretic hormone (ADH) secretion

a. Wound drainage b. Diuretic therapy c. Gastrointestinal (GI) suction e. Inappropriate antidiuretic hormone (ADH) secretion

Which topic will the nurse include in teaching for a client with Raynaud disease? a. tobacco avoidance b. need for increased exercise

a. tobacco avoidance

Elevation of homocysteine is a risk factor for (coronary artery disease or myocardial necrosis), but not an indicator of acute myocardial necrosis.

coronary artery disease Elevation of homocysteine is a risk factor for coronary artery disease, but not an indicator of acute myocardial necrosis.

A hematocrit of 35% is slightly low, but a low hematocrit would be expected in a client who had just been admitted after vomiting a large amount of blood. Y/N

yes