NCLEX Cardiovascular, Hematologic, and Lymphatic Systems

A 6 year-old is admitted with sickle cell crisis. The patient has a FACE scale rating of 10 and the following vital signs: HR 115, BP 120/82, RR 18, oxygen saturation 91%, temperature 101.4'F. Select all the appropriate nursing interventions for this patient at this time? A. Administer IV Morphine per MD order B. Administer oxygen per MD order C. Keep NPO D. Apply cold compresses E. Start intravenous fluids per MD order F. Administer iron supplement per MD order G. Keep patient on bed rest H. Remove restrictive clothing or objects from the patient

A. Administer IV Morphine per MD order B. Administer oxygen per MD order E. Start intravenous fluids per MD order G. Keep patient on bed rest H. Remove restrictive clothing or objects from the patient

A client with aortic stenosis is scheduled for a valve replacement in 2 days. He tells the nurse, "I told my wife all she needs to know if I don't make it." What response is most therapeutic? A. "Men your age do very well." B. "You are worried about dying." C. "I know you are concerned, but your surgeon is excellent." D. "I'll get you a sleeping pill tonight because I know you will need it."

B. "You are worried about dying."

You're providing education to a patient with sickle cell anemia who is taking Hydroxyurea. You will make it priority to tell the patient to? A. Consume foods high in calcium and potassium B. Avoid sick people and maintain strict hand hygiene C. Take this medication with at least 8 oz of water D. Monitor your blood glucose level daily

B. Avoid sick people and maintain strict hand hygiene

Which type of hemoglobin is present in a patient who has sickle cell TRAIT? A. Hemoglobin AA B. Hemoglobin AS C. Hemoglobin SS D. Hemoglobin AC

B. Hemoglobin AS

A nurse is caring for a client who had a splenectomy. Which complication in the immediate postoperative period is priority for the nurse to assess for in this client? A. Infection B. Peritonitis C. Hemorrhage D. Intestinal obstruction

C. Hemorrhage

A nurse is discussing dietary guidelines to help reduce a client's risk for heart disease. What should the nurse teach the client? A. Eat small, frequent meals. B. Decrease the amount of proteins. C. Increase complex carbohydrates. D. Limit the amount of unsaturated fat.

C. Increase complex carbohydrates.

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply. A. Headache B. Thready pulse C. Decreased blood pressure D. Dizziness when standing up E. Crackles on lung auscultation

A. Headache E. Crackles on lung auscultation

A nurse is auscultating a client's heart sounds and hears S1. Which valves is the nurse assessing? A. Mitral and tricuspid B. Aortic and tricuspid C. Mitral and pulmonic D. Aortic and pulmonic

A. Mitral and tricuspid

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what? A. Tissue necrosis B. Venous thrombosis C. Pulmonary infarction D. Respiratory infection

A. Tissue necrosis

A patient is being tested for sickle cell disease. As the nurse, you know the ________ will assess for abnormal hemoglobin on the red blood cell, but will not differentiate between sickle cell disease and sickle cell trait. Therefore, the patient will need to have what other test to determine this? A. dithionite test; hemoglobin electrophoresis B. hemoglobin electrophoresis; sickledex C. edrophonium test, dithionite test D. sickledex; edrophonium test

A. dithionite test; hemoglobin electrophoresis

A 25 year-old pregnant female and her partner both have sickle cell trait. What is the percentage that their offspring will develop sickle cell anemia? A. 50% B. 25% C. 75% D. 100%

B. 25%

You're assisting a physician with sickle cell anemia screening. As the nurse you know that which patient population listed below is at risk for sickle cell disease? A. Native Americans B. African-Americans C. Pacific Islanders D. Latino

B. African-Americans

After multiple bee stings, a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what processes? A. Respiratory depression and cardiac arrest B. Bronchial constriction and decreased peripheral resistance C. Decreased cardiac output and dilation of major blood vessels D. Constriction of capillaries and decreased peripheral circulation

B. Bronchial constriction and decreased peripheral resistance

A young adult male client is undergoing tests to confirm the diagnosis of Hodgkin lymphoma. The wife states, "Don't you think it is unlikely for someone like my husband to have cancer?" The nurse's response is based on what information about Hodgkin lymphoma? A. More likely to affect women than men B. Diagnosed during adolescence and young adulthood C. Primarily a disease of older rather than younger adults D. Common among populations of Asian heritage

B. Diagnosed during adolescence and young adulthood

A client receiving 0.9% normal saline (NS) intravenously at keep vein open (KVO) complains of pain at the insertion site. The nurse notes that there is erythema and edema present at the access site. Based on the phlebitis scale, how should the nurse properly document the phlebitis? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

B. Grade 2

A 14 year-old female has sickle cell anemia. Which factors below can increase the patient's risk for developing sickle cell crisis? Select all that apply: A. Shellfish B. Infection C. Dehydration D. Hypoxia E. Low altitudes F. Hemorrhage G. Strenuous exercise

B. Infection C. Dehydration D. Hypoxia F. Hemorrhage G. Strenuous exercise

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? A. Metabolic alkalosis B. Myocardial hypoxia C. Decreased catecholamine secretion D. Increased parasympathetic nervous system stimulation

B. Myocardial hypoxia

A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. Which information should the nurse share with the client? A. Choose only familiar sexual positions. B. Select familiar settings for sexual activity. C. Return to regular sexual activity in four to six weeks. D. Depending upon your preference, take a hot or cold shower after intercourse.

B. Select familiar settings for sexual activity.

A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply. Which information from the client will cause the nurse to intervene? A. I have one glass of wine at supper. B. I lower my limb when sitting. C. I am a social smoker. D. I drink a lot of water.

C. I am a social smoker.

An 18 year-old male is taking Hydroxyurea for treatment of sickle cell anemia. Which option below indicates this medication is working successfully? A. The patient needs fewer blood transfusions. B. The patient experiences diuresis. C. The patient experiences an increase in fetal hemoglobin (Hbg F). D. The patient experiences a decrease in hemoglobin S.

C. The patient experiences an increase in fetal hemoglobin (Hbg F).

A client with hypertension is to follow a 2-gram sodium diet. Which client statement provides evidence that the nurse's dietary instructions are understood? A. "My fluid intake should be restricted." B. "I should limit the number of daily food servings." C. "Cheese can be added to my luncheon meat sandwiches." D. "Labels on prepackaged food products should be evaluated before purchase."

D. "Labels on prepackaged food products should be evaluated before purchase."

When receiving chemotherapy for non-Hodgkin lymphoma, a client states, "I get so sick to my stomach. The medication is useless." What is the best response by the nurse that uses the technique of paraphrasing? A. "You get sick to your stomach." B. "Tell me more about how you feel." C. "I'll get a prescription for an antiemetic." D. "You don't think the medication is helping you."

D. "You don't think the medication is helping you."

To determine the status of a client's carotid pulse, where should the nurse palpate? A. Below the mandible B. In the lateral neck region C. Along the clavicle at the base of the neck D. At the anterior neck, lateral to the trachea

D. At the anterior neck, lateral to the trachea

A client is admitted to the intensive care unit in pulmonary edema. What should the nurse expect when performing the admission assessment? A. Weak, rapid pulse B. Decreased blood pressure C. Radiating anterior chest pain D. Crackles at the base of each lung

D. Crackles at the base of each lung

You're providing seminar teaching to a group of nurses about sickle cell anemia. Which of the following is NOT a treatment for this condition? A. Blood transfusion B. Stem cell transplant C. Intravenous fluids D. Iron supplements E. Antibiotics F. Morphine

D. Iron supplements

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? A. Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily B. Give 1 L of 0.9% normal saline (NS) bolus over 4 hours C. Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr D. No prescription change

D. No prescription change (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure would be orthostatic hypotension and need intervention)

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, what is the most accurate measurement of the client's left ventricular pressure? A. Right atrial pressure B. Cardiac output by thermodilution C. Pulmonary artery diastolic pressure D. Pulmonary capillary wedge pressure

D. Pulmonary capillary wedge pressure

During an outpatient well visit with a patient who has sickle cell anemia, you make it PRIORITY to assess the patient's? A. hemoglobin A1C level B. heart rate C. reflexes D. vaccination history

D. vaccination history

The primary healthcare provider has prescribed for a client's apical pulse to be taken. Place the steps in the order that the nurse should follow to identify the client's point of maximal impulse (PMI) when taking the client's apical pulse. 1. Move the finger laterally along the fifth intercostal space to the midclavicular line. 2. Place the index finger in the second intercostal space, and continue palpating downward to the fifth intercostal space. 3. Slide the finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet). 4. Slide the finger to the edge of the left sternal border to the second intercostal space.

3. Slide the finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet). 4. Slide the finger to the edge of the left sternal border to the second intercostal space. 2. Place the index finger in the second intercostal space, and continue palpating downward to the fifth intercostal space. 1. Move the finger laterally along the fifth intercostal space to the midclavicular line.

The nurse notes that the client's ECG rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. How should the nurse interpret this strip? A. Second degree AV block Mobitz II B. First degree atrioventricular (AV) block C. Third degree AV block (complete heart block) D. Second degree AV block Mobitz I (Wenckebach)

A. Second degree AV block Mobitz II

The nurse is providing instructions to a client on how to reduce the dietary intake of sodium. Which information should the nurse include in the instructions? A. Avoid carbonated beverages B. Use steak sauce for flavoring foods C. Increase the intake of dairy products D. Restrict the use of artificial sweeteners

A. Avoid carbonated beverages

The nurse prepares a list of recommended foods for a client with hypertension who is to begin a 2-gram sodium diet. Which foods should the nurse include in the list? Select all that apply. A. Beef steaks B. Mushrooms C. Aged cheeses D. Luncheon meats E. Cooked broccoli

A. Beef steaks B. Mushrooms E. Cooked broccoli

How does the human body conserve heat? Select all that apply. A. By decreasing muscle activity in the body B. Through peripheral vasodilation in the body C. Through peripheral vasoconstriction in body D. By shunting blood to superficial body tissues E. By shunting blood away from the skin surface

A. By decreasing muscle activity in the body C. Through peripheral vasoconstriction in body E. By shunting blood away from the skin surface

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis? A. Cold, clammy skin B. Slow, bounding pulse C. Increased blood pressure D. Hyperactive bowel sounds

A. Cold, clammy skin

A mother brings in her 8 month-old child to the ER. The mother reports the baby has recently started being extremely fussy, has a fever, and swelling in the hands and feet. The child is diagnosed with sickle cell disease. As the nurse you know that the swelling in the hands and feet in the infant is termed? A. Dactylitis B. Erythromelaglia C. Dyshidrotia D. Phalitis

A. Dactylitis

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. A. Dependent edema B. Swollen hands and fingers C. Collapsed neck veins D. Right upper quadrant discomfort E. Oliguria

A. Dependent edema B. Swollen hands and fingers D. Right upper quadrant discomfort

The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? A. Dependent edema in the evening B. Chest pain that decreases with rest C. Palpitations in the chest when resting D. Frequent coughing with yellow sputum

A. Dependent edema in the evening

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply. A. Dependent rubor B. Warm extremities C. Ulcers on the toes D. Thick, hardened skin E. Delayed capillary refill

A. Dependent rubor C. Ulcers on the toes E. Delayed capillary refill

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement? A. Fear B. Depression C. Dependency D. Ambivalence

A. Fear

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply. A. Pallor B. Agitation C. Tachycardia D. Narrow pulse pressure E. Decreased respirations

A. Pallor B. Agitation C. Tachycardia D. Narrow pulse pressure

A client is brought into the emergency department with reports of chest pain. Which conditions does the nurse assess for in this client? Select all that apply. A. Pleurisy B. Pneumonia C. Gastroenteritis D. Costochondritis E. Myocardial infarction

A. Pleurisy B. Pneumonia D. Costochondritis E. Myocardial infarction

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.

B. Monitor the apical pulse and blood pressure.

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply. A. Nausea B. Palpitations C. Tachycardia D. Nervousness E. Warm, dry skin F. Increased respirations

B. Palpitations C. Tachycardia D. Nervousness

A client with squamous cell carcinoma of the tongue is to be treated with interstitially implanted radon seeds. Which consideration is priority when the nurse is planning room placement? A. Assign the client to any type of room. B. Place the client in a private room. C. Assign the client to a semiprivate room. D. Place the client with another client receiving the same type of therapy.

B. Place the client in a private room.

The spouse of a client who had emergency coronary artery bypass surgery asks why there is a dressing on the client's left leg. How should the nurse explain the dressing? A. "This is the access site for the heart-lung machine." B. "A filter is inserted in the leg to prevent embolization." C. "A vein in the leg was used to bypass the coronary artery." D. "The arteries in the extremities are examined during surgery."

C. "A vein in the leg was used to bypass the coronary artery."

You're educating the parents of a 12 year-old, who was recently treated for sickle cell crisis, on ways to prevent further sickle cell crises in the further. Which statement by the parents demonstrates they understood your instructions? A. "We will limit fluid intake during the day to 1-2 L a day." B. "Cold showers are best to help with pain associated with sickling." C. "We will avoid traveling to high altitude locations." D. "It is important we refuse all future vaccinations unless absolutely necessary."

C. "We will avoid traveling to high altitude locations."

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history? A. Cystitis as an adult B. Pleurisy as an adult C. Childhood strep throat D. Childhood German measles

C. Childhood strep throat

Which type of hemoglobin is present in a patient who has sickle cell anemia? A. Hemoglobin AA B. Hemoglobin AS C. Hemoglobin SS C. Hemoglobin AC

C. Hemoglobin SS

Which statement about how sickle cell anemia is passed to offspring is CORRECT? A. This disease is an x-linked recessive disease. B. Sickle cell anemia is an autosomal dominant disease. C. This condition is an autosomal recessive disease. D. Sickle cell anemia is rarely passed to offspring and is an autosomal x-linked dominant disease.

C. This condition is an autosomal recessive disease.

After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse? A. "Intermittent claudication will be reduced." B. "Your breathing will become regular and shallow." C. "Perspiration will be less when you run, and you'll use less energy." D. "You will be able to run progressively longer distances before tiring."

D. "You will be able to run progressively longer distances before tiring."

A client hospitalized for heart failure is receiving digoxin and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? A. Monitoring vital signs and encouraging a vigorous aerobic exercise program B. Providing written material on the adverse effects of the medication C. Contacting Social Services for a home health nursing consultation D. Teaching the client how to count the pulse

D. Teaching the client how to count the pulse