ATI Learning System Med-Surg Cardiovascular and Hematology Practice Quiz
A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. Available is a blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
10 gtt/min
A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following information should the nurse include in the teaching? A) "Avoid lifting both arms above your head when dressing." B) "Use your cell phone on the same ear as the pacemaker site is located." C) "Avoid travel by airplane." D) "Hiccups are an expected outcome of having a pacemaker."
CORRECT -> A) "Avoid lifting both arms above your head when dressing." The nurse should reinforce that the client should avoid lifting her arm or shoulder on the side of the pacemaker because dislodgement of the pacer leads can occur. INCORRECT -> B) "Use your cell phone on the same ear as the pacemaker site is located." The nurse should reinforce that the client should use her cell phone on the opposite ear to prevent interference with the pacemaker function. INCORRECT -> C) "Avoid travel by airplane." The nurse should reinforce to the client that there is no travel restriction when the client has a pacemaker. Airport security screening equipment will not harm the function of the pacemaker. INCORRECT -> D) "Hiccups are an expected outcome of having a pacemaker." The nurse should reinforce that the client should report experiencing hiccups because this is a complication that can indicate a lead wire is displaced and is stimulating the diaphragm.
A nurse is caring for a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A) A weight gain of 1 kg (2.2lbs) in 1 day B) Pitting edema +1 C) Client reports a nocturnal cough D) B-Type Natriuretic Peptide (BNP) level of 100pg/mL
CORRECT -> A) A weight gain of 1 kg (2.2lbs) in 1 day A weight gain of 1 kg in 1 day alerts the nurse that the client might be retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening. INCORRECT -> B) Pitting edema +1 Pitting edema, a visible finger indentation after application of pressure, alerts the nurse that the client has retained fluid and demonstrates that there is fluid in the client's tissues. Pitting edema is rated on a scale of mild (+1) to severe (+3). Pitting edema of +3 is an indication that the client has developed fluid volume overload and the heart failure is worsening. INCORRECT -> C) Client reports a nocturnal cough The client who is in the early stages of heart failure might report a cough that is irritating, occurs at night, and is nonproductive. INCORRECT -> D) B-Type Natriuretic Peptide (BNP) level of 100pg/mL Serum BNP levels increase as a result of the ventricular hypertrophy that occurs in heart failure. A BNP level above 100pg/mL is indicative of heart failure. Levels continue to increase with the severity of heart failure.
A nurse is assisting in the care of a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? A) Administer antihypertensive medication for blood pressure B) Monitor that urinary output is 20 ml/hr C) Withhold pain medication to prepare for surgery D) Take vital signs every 2 hr
CORRECT -> A) Administer antihypertensive medication for blood pressure. The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall. INCORRECT -> B) Monitor that urinary output is 20 ml/hr. The nurse should monitor that the client has adequate kidney profusion determined by urinary output of at least 30 ml/hr. Oliguria can indicate a rupture of the aneurysm. INCORRECT -> C) Withhold pain medication to prepare for surgery. The nurse should administer pain medication because pain occurs due to pressure from the aneurysm on the lumbar nerves. Pain can also cause hypertension. INCORRECT -> D) Take vital signs every 2 hr. The nurse should take the client's vital signs at least every 15 min in order to monitor for a sudden drop in blood pressure, which can indicate a rupture of the aneurysm.
A nurse is collecting data from a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? A) Omega-3 fatty acids B) Antioxidants C) Vitamins A, D, and C D) Beta-carotene
CORRECT -> A) Omega-3 fatty acids Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels. INCORRECT -> B) Antioxidants Antioxidants are substances that occur naturally in many fruits and vegetables, as well as in nuts, grains, and even some meat, poultry, and fish. Beta-carotene, vitamins A, C, E, and selenium are some of the most commonly known antioxidants. Studies have suggested that antioxidants can slow or even prevent the development of cancer; however, they are not found in fish oil. INCORRECT -> C) Vitamins A, D, and C Vitamins A, D, and C are not substances found in fish oil. INCORRECT -> D) Beta-carotene Beta-carotene is the precursor to vitamin A. Beta-carotene functions as a fat-soluble antioxidant, which can help protect the body from deleterious free-radical reactions. It is not found in fish oil.
A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? A) Position the client supine with his legs elevated when in bed B) Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr C) Tell the client to sit with his legs dependent after ambulating D) Reinforce with the client that he should wear knee-length socks for 2 weeks after surgery
CORRECT -> A) Position the client supine with his legs elevated when in bed The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart. INCORRECT -> B) Encourage the client to ambulate for 15 min every hour while awake for the first 24hr The nurse should encourage the client to ambulate for 5 to 10 min every hour while awake to prevent venous stasis. INCORRECT -> C) Tell the client to sit with his legs dependent after ambulating The nurse should discourage the client from sitting or standing for any duration to prevent venous stasis. Feet should be elevated above the heart to prevent venous stasis. INCORRECT -> D) Reinforce with the client that he should wear knee-length socks for 2 weeks after surgery The nurse should reinforce with the client that he should wear graduated compression stockings for up to 1 week after surgery to promote venous return.
A nurse is caring for a client who has heart failure and is lethargic with muscle weakness. The client's telemetry reading displays dysrhythmias. Which of the following laboratory results should the nurse anticipate? A) Potassium 2.8 mEq/L B) Digoxin level 0.7 ng/mL C) Hemoglobin 11.5 g/dL D) Calcium 8.0 mg
CORRECT -> A) Potassium 2.8 mEq/L Manifestations of hypokalemia include muscle weakness and cramps, confusion, and drowsiness. Hypokalemia can also result in life-threatening dysrhythmias. INCORRECT -> B) Digoxin level 0.7 ng/mL The client has a digoxin level within the therapeutic range of 0.5 to 0.8 ng/mL. INCORRECT -> C) Hemoglobin 11.5 g/dL The manifestations of mild anemia include headache, palpitations, and shortness of breath with exertion. INCORRECT -> D) Calcium 8.0 mg Manifestations of hypocalcemia include numbness and tingling of the hands and feet, abdominal cramping, and tetany. Severe hypocalcemia can cause hypotension and ECG changes.
A nurse is assisting in collecting data from a client who has a history of unstable angina. Which of the following findings should the nurse expect? A) The client reports chest pain when at rest B) Nitroglycerin relieves chest pain C) Physical exertion does not precipitate chest pain D) Chest pain lasts less than 5 min
CORRECT -> A) The client reports chest pain when at rest The client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetals) angina, caused by an artery spasm. INCORRECT -> B) Nitroglycerin relieves chest pain The client who has unstable angina will have minimal if any, relief of chest pain from nitroglycerin. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction. INCORRECT -> C) Physical exertion does not precipitate chest pain The client who has unstable angina will report chest pain or discomfort with exertion, which can limit the client's activity. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction. INCORRECT -> D) Chest pain lasts less than 5 min. The client who has unstable angina will have chest pain lasting longer than 15 min. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.
A nurse is assisting in developing the plan of care for an older adult client who is to receive a unit of packed red blood cells (RBCs). Which of the following actions should the nurse recommend? A) Verify the information on the packed RBCs with another nurse B) Administer the packed RBCs through an 18-gauge IV catheter C) Infuse the packed RBCs over 2 hr D) Allow the packed RBCs to warm at room temperature for 1 hr before starting the transfusion
CORRECT -> A) Verify the information on the packed RBCs with another nurse The nurse should verify the information on the label of the packed RBCs with another nurse. She should also verify the information on the label with the provider's order, the blood administration form from the blood bank, and the client's armband and blood bracelet. INCORRECT -> B) Administer the packed RBCs through an 18-gauge IV catheter The nurse should administer packed RBCs through a 20- or 22-gauge catheter for an older adult client to prevent rupture of the client's fragile blood vessels at the infusion site. INCORRECT -> C) Infuse the packed RBCs over 2 hr The nurse should administer packed RBCs slowly to allow the older adult client's body time to adjust to the increased fluid volume. The blood should be infused for over 4 hr. INCORRECT -> D) Allow the packed RBCs to warm at room temperature for 1hr before starting the transfusion The nurse should start the blood within 30 min after arriving on the unit, to decrease the risk of bacterial growth.
A nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and has a new prescription for a beta-blocker. Which of the following client statements indicates an understanding of the teaching? A) "I should eat foods high in saturated fat." B) "Before taking my medication, I will check my blood pressure and radial pulse rate." C) "I will exercise once a week for an hour at the health club." D) "I will stop taking my medication when my blood pressure is within a normal range."
INCORRECT -> A) "I should eat foods high in saturated fat." The client should consume foods low in saturated fat to decrease further atherosclerotic plaque development in the arteries. CORRECT -> B) "Before taking my medication, I will check my blood pressure and radial pulse rate." A beta-blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration. INCORRECT -> C) "I will exercise once a week for an hour at the health club." The client should exercise at least three to five times a week for a minimum of 30 min each. INCORRECT -> D) "I will stop taking my medication when my blood pressure is within a normal range." The client should not discontinue the prescribed medication because adherence to a medical regimen when taking medication will help to prevent complications following myocardial infarction.
A nurse is assisting in the care of a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions? A) 0.45% sodium chloride B) Dextrose 5% in 0.9% sodium chloride C) Dextrose 10% in water D) 0.9% sodium chloride
INCORRECT -> A) 0.45% sodium chloride The solution 0.45% sodium chloride is a hypotonic solution and should not be used for fluid replacement. This solution can cause lysis of red blood cells because it has fewer solutes than the cell, and osmotic pressure pulls the fluid into the few cells remaining. INCORRECT -> B) Dextrose 5% in 0.9% sodium chloride The solution of dextrose 596 in 0.996 sodium chloride is a hypertonic solution and should not be used for fluid replacement. This solution will diffuse into the cells of the tissue, having no effect on circulating volume. When the fluid surrounding the cells is hypertonic or has more solutes than the cells, osmotic pressure pulls the fluid from the cells. INCORRECT -> C) Dextrose 10% in water The solution of dextrose 10% in water is a hypertonic solution and should not be used for fluid replacement. This solution will diffuse into the cells of the tissue, having no effect on circulating volume. When the fluid surrounding the cells is hypertonic or has more solutes than the cells, osmotic pressure pulls the fluid from the cells. CORRECT -> D) 0.9% sodium chloride Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products.
A nurse is contributing to the plan of care for a client who has pernicious anemia. Which of the following interventions should the nurse recommend? A) Administer ferrous sulfate supplementation B) Increase dietary intake of folic acid C) Initiate weekly injections of vitamin B12 D) Initiate a blood transfusion
INCORRECT -> A) Administer ferrous sulfate supplementation The nurse should recommend administering ferrous sulfate to a client who has iron-deficiency anemia, which is a decrease in the red blood cells caused by inadequate intake of dietary iron. INCORRECT -> B) Increase dietary intake of folic acid The nurse should recommend an increase in the intake of food containing folic acid for a client who has megaloblastic anemia, which is a decrease in the red blood cells caused by folate deficiency. CORRECT -> C) Initiate weekly injections of vitamin B12 The nurse should recommend that weekly injections of vitamin B12 be initiated for a client who has pernicious anemia and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract. INCORRECT -> D) Initiate a blood transfusion The nurse should recommend that a blood transfusion be initiated for a client who has aplastic anemia when bleeding is life-threatening from low platelet count or if a client has blood loss from trauma or surgery.
A nurse is collecting data from a client who has pericarditis. Which of the following manifestations should the nurse expect? A) Bradycardia B) Relief of chest pain with deep inspiration C) Dyspnea D) Chest pain that increases when sitting upright
INCORRECT -> A) Bradycardia The client who has pericarditis will have tachycardia because of decreased cardiac output and oxygen perfusion. INCORRECT -> B) Relief of chest pain with deep inspiration Chest pain associated with pericarditis will increase with deep inspiration due to increased pressure on the pericardial sac. CORRECT -> C) Dyspnea The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade. INCORRECT -> D) Chest pain that increases when sitting upright Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac.
A nurse is checking for cardiac tamponade on a client who has pericarditis. Which of the following actions should the nurse take? A) Check for hypertension B) Auscultate for loud, bounding heart sounds C) Auscultate blood pressure for pulsus paradoxus D) Check for a pulse deficit
INCORRECT -> A) Check for hypertension. The client who has cardiac tamponade will have hypotension because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. INCORRECT -> B) Auscultate for loud, bounding heart sounds. The client who has cardiac tamponade will have muffled heart sounds on auscultation because of the fluid compressing the atria and ventricles. CORRECT -> C) Auscultate blood pressure for pulsus paradoxus. The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. INCORRECT -> D) Check for a pulse deficit. The nurse will not detect cardiac tamponade by checking for a pulse deficit. This is performed by checking the apical and radial pulses simultaneously to determine if the rate is the same. If the rate is different, the findings indicate cardiac dysrhythmia.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? A) Decreased capillary refill B) Dyspnea C) Dizziness D) Dependent edema
INCORRECT -> A) Decreased capillary refill Decreased capillary refill occurs in clients who have decreased cardiac output resulting from left-sided heart failure. INCORRECT -> B) Dyspnea When the left side of the heart fails, blood return from the lungs via the pulmonary vein is slowed, causing fluid buildup in the lungs that results in shortness of breath. INCORRECT -> C) Dizziness Dizziness occurs in clients who have decreased cardiac output resulting from left-sided heart failure. CORRECT -> D) Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema.
A nurse is assisting in the preparation of a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A) Hang an IV infusion of 0.9% sodium chloride with the blood B) Check the client's identification number with the number on the blood C) Witness the informed consent D) Prepare the blood with a Y-type infusion set
INCORRECT -> A) Hang an IV infusion of 0.9% sodium chloride with the blood. The nurse should hang an IV infusion of 0.996 sodium chloride with the blood to dilute the blood and maintain the IV infusion line. However, the nurse should take a less invasive intervention first. INCORRECT -> B) Check the client's identification number with the number on the blood. The nurse should check the client's identification number with the number on the blood to ensure the client receives the correct unit of blood. With another nurse, the nurse should check the provider's prescription, the identity of the blood product, the client, and the compatibility (blood type and Rh factor) of the blood and the client. However, the nurse should take a less invasive intervention first. CORRECT -> C) Witness the informed consent. The nurse should apply the least invasive priority-setting framework. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, as witnessing the informed consent is the least invasive it is the action that should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion on a client. INCORRECT -> D) Prepare the blood with a Y-type infusion set. The nurse should prepare the blood using a Y-type infusion set, as a special blood filter is required for the administration of packed RBCs. However, the nurse should use a less restrictive intervention first.
A nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching? A) Hospitalization is required when administering each treatment. B) The maximum effect of the medication will occur in 6 months. C) Hypertension is a common adverse effect of this medication. D) Blood transfusions are needed with each treatment.
INCORRECT -> A) Hospitalization is required when administering each treatment. The nurse should reinforce with the client that epoetin alfa can be self-administered at home. INCORRECT -> B) The maximum effect of the medication will occur in 6 months. The nurse should reinforce with the client that the maximum effect of epoetin alfa will occur in 2 to 3 months. CORRECT -> C) Hypertension is a common adverse effect of this medication. The nurse should reinforce in the teaching that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level. INCORRECT -> D) Blood transfusions are needed with each treatment. The nurse should reinforce with the client that epoetin alfa is administered to decrease the need for periodic blood transfusions.
A nurse is checking laboratory values for an adult client who has sickle cell anemia and is in crisis. For which of the following complications should the nurse monitor? A) Hypokalemia B) Lead poisoning C) Hypercalcemia D) Elevated bilirubin
INCORRECT -> A) Hypokalemia The client is at risk for hyperkalemia if he receives blood transfusions during a crisis. Stored blood releases increased amounts of potassium due to red blood cell hemolysis. INCORRECT -> B) Lead poisoning The client who has sickle cell anemia and has received numerous blood transfusions is not at risk for lead poisoning because lead is not found in the blood. INCORRECT -> C) Hypercalcemia The client is at risk of having hypocalcemia if he receives blood transfusions during a crisis. The citrate in the transfused blood bonds with calcium, causing calcium to be excreted. CORRECT -> D) Elevated bilirubin The client who has sickle cell anemia and is in crisis will have elevated bilirubin because hemolysis of the abnormal red blood cells occurs.
A nurse is assisting in monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24hr? A) Infective endocarditis B) Pericarditis C) Ventricular dysrhythmias D) Pulmonary emboli
INCORRECT -> A) Infective endocarditis Infective endocarditis occurs when bacteria invades the endothelial surface of the heart. Infective endocarditis is usually seen in clients who have prosthetic heart valves or pacemakers. INCORRECT -> B) Pericarditis Pericarditis can occur 1 to 12 weeks following a myocardial infarction. Pericarditis is an inflammation of the pericardial sac that surrounds the heart and is usually a result of infection, connective tissue disorders, or trauma. CORRECT -> C) Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system. INCORRECT -> D) Pulmonary emboli Pulmonary emboli occur if the client develops heart failure following myocardial infarction. Pulmonary emboli are found more commonly with valvular disorders, atrial fibrillation, or deep-vein thrombosis.
A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first? A) Maintain the IV access with 0.9% sodium chloride B) Stop the infusion of blood C) Send the blood container and tubing to the blood bank D) Obtain a urine sample
INCORRECT -> A) Maintain the IV access with 0.9% sodium chloride Maintaining IV access by initiating an infusion of 0.9% sodium chloride solution using a new IV administration set is important. However, there is another action that is the nurse's priority. CORRECT -> B) Stop the infusion of blood The nurse should apply the urgent vs. non-urgent priority-setting framework when caring for this client. Using this framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction. INCORRECT -> C) Send the blood container and tubing to the blood bank The nurse should send the blood container and tubing to the blood bank for a repeat typing and culture. However, there is another action that is the nurse's priority. INCORRECT -> D) Obtain a urine sample The nurse should obtain a urine sample from the client to determine if hemoglobin is in the urine. However, there is another action that is the nurse's priority.
A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A) Midsternal chest pain B) Thrill C) Pitting edema in lower extremities D) Lower back discomfort
INCORRECT -> A) Midsternal chest pain A client who has an abdominal aortic aneurysm will have back and abdominal pain. Midsternal chest pain is a manifestation of myocardial infarction. INCORRECT -> B) Thrill The nurse should auscultate for a bruit heard over the location of the mass. INCORRECT -> C) Pitting edema in lower extremities Pitting edema is a manifestation of heart failure. This is not a finding with an abdominal aortic aneurysm. CORRECT -> D) Lower back discomfort Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicates that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? A) Obtain blood samples to test platelet function B) Prepare for replacement of the missing clotting factor C) Administer aspirin for the client's pain D) Place the bleeding joint in the dependent position
INCORRECT -> A) Obtain blood samples to test platelet function Coagulation tests that measure platelet function, such as bleeding time, are used to diagnose, not treat, hemophilia. CORRECT -> B) Prepare for replacement of the missing clotting factor Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints. INCORRECT -> C) Administer aspirin for the client's pain Medications that interfere with clotting function, such as aspirin, NSAIDs, and some herbal supplements, should be avoided. INCORRECT -> D) Place the bleeding joint in the dependent position The affected joint should be elevated to allow the blood to drain away from the joint.
A nurse in a clinic is collecting data from a client who has a history of peripheral arterial disease. Which of the following findings on the client's lower extremities should the nurse expect? A) Pitting edema B) Areas of reddish-brown pigmentation C) Cool, pale skin with minimal body hair D) Sunburned appearance with desquamation
INCORRECT -> A) Pitting edema The client who has venous insufficiency can display pitting edema because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. This also can be a manifestation of congestive heart failure due to coronary artery disease. INCORRECT -> B) Areas of reddish-brown pigmentation The client who has venous insufficiency can display areas of reddish-brown pigmentation because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. CORRECT -> C) Cool, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses. INCORRECT -> D) Sunburned appearance with desquamation Desquamation, which is the loss of bits of outer skin by peeling or shedding, is associated with sunburn, Kawasaki's disease, and various other skin lesions.
A nurse is caring for a client who has advanced heart failure. Which of the following actions should the nurse take? A) Place the client in low-Fowler's position B) Assist the client to use the incentive spirometer every 4hr C) Weigh the client every other day D) Enforce fluid restrictions
INCORRECT -> A) Place the client in low-Fowler's position The nurse should place the client in high-Fowler's position to decrease dyspnea and improve impaired oxygenation from fluid retention in the lungs. INCORRECT -> B) Assist the client to use the incentive spirometer every 4hr The nurse should assist the client to use the incentive spirometer every 2hr to promote coughing and improve impaired oxygenation. INCORRECT -> C) Weigh the client every other day The nurse should weigh the client every day to determine the amount of fluid retention and if there is a need for a diuretic to decrease fluid overload in the lungs and lower extremities. CORRECT -> D) Enforce fluid restrictions The nurse should enforce fluid restrictions to help reduce fluid retention in the lungs and lower extremities.
A nurse is collecting data from a client who has manifestations of aplastic anemia. Which of the following findings should the nurse expect? A) Plethoric appearance of facial skin B) Glossitis and weight loss C) Jaundice with an enlarged liver D) Petechiae and ecchymosis
INCORRECT -> A) Plethoric appearance of facial skin The client who has polycythemia vera will have a plethoric (dark, flushed) manifestation of the facial skin and mucous membranes. INCORRECT -> B) Glossitis and weight loss The client who has pernicious anemia will have manifestation of glossitis (smooth, beefy-red tongue) and weight loss. INCORRECT -> C) Jaundice with an enlarged liver The client who has sickle cell anemia will have manifestations of jaundice with an enlarged liver and spleen. CORRECT -> D) Petechiae and ecchymosis The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.
A nurse is assisting in the plan of care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postoperative plan of care? A) Reinforce teaching with the client about a long-term conditioning program B) Administer scheduled doses of acetaminophen C) Check for peak laboratory markers of myocardial damage D) Initiate an aspirin regimen
INCORRECT -> A) Reinforce teaching with the client about a long-term conditioning program. The nurse should reinforce teaching about cardiac rehabilitation prior to the client's discharge from the facility. INCORRECT -> B) Administer scheduled doses of acetaminophen. The nurse should plan to administer scheduled doses of aspirin post-procedure. This maintains the patency of the client's coronary arteries following the PTCA by preventing platelet aggregation and thrombus formation around the newly placed stent. INCORRECT -> C) Check for peak laboratory markers of myocardial damage. The nurse should monitor for peak laboratory markers of myocardial damage following myocardial infarction and reperfusion with thrombolytic therapy. CORRECT -> D) Initiate an aspirin regimen. The nurse should plan to initiate an aspirin regimen or another antiplatelet agent. The antiplatelet medication maintains the patency of the stent by reducing platelet aggregation.
A nurse is evaluating a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory values should the nurse review? A) WBC count B) Prothrombin time C) Platelet count D) Hematocrit
INCORRECT -> A) WBC count The nurse should review the client's WBC count if there is a possible infection. CORRECT -> B) Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time. INCORRECT -> C) Platelet count The nurse should review the client's platelet count following administration of platelets. INCORRECT -> D) Hematocrit The nurse should review the client's hematocrit following the administration of packed RBCs.
A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take? A) Weigh the client weekly B) Monitor the client for ototoxicity C) Place the client on a 24hr urine collection analysis D) Monitor for hypoglycemia
INCORRECT -> A) Weigh the client weekly The nurse should weigh the client daily to determine the amount of fluid excreted after administration of the loop diuretic. CORRECT -> B) Monitor the client for ototoxicity The nurse should monitor the client for ototoxicity and reinforce that the client should report any manifestations of hearing impairment while on the loop diuretic. The nurse should use caution when a loop diuretic is used in conjunction with other ototoxic medications, such as aminoglycoside antibiotics. INCORRECT -> C) Place the client on a 24-hr urine collection analysis The nurse should monitor the client's intake and output to determine effectiveness of the loop diuretic. A 24-hr urine collection is completed for a study of kidney function. INCORRECT -> D) Monitor for hypoglycemia The nurse should monitor the client for hyperglycemia because a loop diuretic can inhibit insulin release.
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy pink sputum. The nurse auscultates loud, bubbly sounds of inspiration. Which of the following adventitious breath sounds should the nurse document? A) Wheezes B) Coarse crackles C) Rhonchi D) Friction rub
INCORRECT -> A) Wheezes The client who has wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway. CORRECT -> B) Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing. INCORRECT -> C) Rhonchi The client who has rhonchi will manifest coarse, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airway and stops the sound. INCORRECT -> D) Friction rub The client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration.
A nurse is collecting data from a client who has fluid volume overload resulting from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply) Jugular vein distension Moist crackles Postural hypotension Increased heart rate Fever
Jugular vein distension is CORRECT. The increase in venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles is CORRECT. This is an indicator of pulmonary edema that can quickly lead to death. Postural hypotension is INCORRECT. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in hypertension and tachycardia. Increased heart rate is CORRECT. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses. Fever is INCORRECT. Fever is common in clients who are experiencing dehydration, not fluid volume excess.
