ATI- Med-Surg: Cardiovascular & Hematology
A nurse is providing teaching about lifestyle changes to a client who had an MI and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?
"Before taking my medication, I will count my radial pulse rate"
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions?
0.9% sodium chloride Rationale: isotonic solutions are used to replace lost volume.
A nurse is preparing to transfuse 250 mL of packed RBCs to a client over 4 hrs. 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?
10 gtt/min
A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's VS are BP 160/98 mm Hg, HR 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take?
Administer antihypertensive medication for BP Rationale: hypertension can cause a sudden rupture of the aneurysm. ; Oliguria can indicate a rupture of the aneurysm. ; should administer pain meds because the pain is due to the pressure of the aneurysm (can cause hypertension). ; take VS every 15mins to monitor for a sudden drop in BP, which can indicate a rupture.
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter?
Atrial rate of 300/min with QRS complex of 80/min Rationale: Idicates a lack of conduction between the atria and ventricles - the additional beats are not conducting.
A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take?
Auscultate for loud, bounding heart sounds. Rationale: shown with a systolic BP >10 mm Hg higher on expiration than on inspiration. ; will have hypotension and muffled heart sounds. ; cardiac tamponade is due to a sudden decrease in cardiac output from the fluid compressing the atria and ventricles.
A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect?
Chest pain lasts longer than 15 min
A nurse is caring for a client who had a MI 5 days ago. The client has a sudden onset of SOB and begins coughing frothy, pink sputum. The nurse auscultates loud, bubble sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?
Coarse crackles Rationale: heard at the end of inspiration and not cleared by coughing. heard due to partially blocked airways by fluid.
A nurse is assessing a client who has right-sided HF. Which of the following findings should the nurse expect?
Dependent edema Rationale: blood return form the venous system is impaired by a weakened R heart Sx of L-sided HF: decreased capillary refill, dyspnea, and dizziness (orthopnea)
A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect?
Dry, pale skin with minimal body hair Rationale: Due to narrowing of the arteries in the legs and feet from tissue damage - sx: intermittent claudication (leg pain w/ exercise), cold or numb feet at rest, loss of hair on lower legs, and weakened pulses.
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching?
Hypertension is a common adverse effect of this medication. Rationale: Due to the rise in production of erythrocytes and other blood cell types. Used to treat anemia associated with kidney disease or medication therapy.
A nurse is monitoring a client who has HF related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect?
Increased pulmonary congestion Rationale: due to r-sided heart failure ; dyspnea is a sign of this
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan?
Initiate weekly injections of vitamin B-12. Rationale: start with weekly and then slowly decrease to monthly
A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor?
Iron toxicity Rationale: from an overuse of frequent blood transfusions
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.)
JVD Moist crackles Increased HR Rationale: excessive pressure causes all of the these. Fever occurs with dehydration. Hypertension and tachycardia are also signs of fluid volume overload.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?
Lower back discomfort Rationale: back and abdominal pain would be seen as well as a bruit over the location of the mass.
A nurse is completing a medication history for 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?
Omega-3 fatty acids Rationale: this can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels.
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect?
Petechiae and ecchymosis Rationale: very common in this type of anemia, as well as dyspnea on exertion. ; sickle-cell anemia will should jaundice with an enlarged liver & spleen. ; pernicious anemia will show glossitis (smooth, beefy-red tongue) & weight loss. ; polycythemia vera will show plethoric (dark, flushed) of the facial skin & mucous membranes.
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?
Position the client supine with his legs elevated when in bed. Rationale: Elevating legs about the heart helps to promote venous return by gravity. ; Ambulate 5-10 min every hour while awake ; discourage sitting or standing for a long duration ; wear graduated compression stockings for up to 1 week after surgery.
A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change?
Potassium 2.8 mEq/L Rationale: flattened T-wave indicates a low potassium level
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?
Prepare for replacement of the missing clotting factor Rationale: Hemophilia is a bleeding disorder when blood clots slowly and abnormal bleeding occurs. Caused by a deficiency of common clotting factor. ; joint should be elevated so that blood will drain away from the joint
A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review?
Prothrombin Time Rationale: plasma rich in clotting factors. It is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.
A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take?
Remove the unit of plasma immediately and start an IV infusion of normal saline solution. Rationale: they're not compatible so transfusion should be stopped immediatley
A nurse is administering a unit of packed RBCs to a client who is post-op. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first?
Stop the infusion of blood. Rationale: this holds highest priority due to the allergic reaction occurring. ;
A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect?
Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. Rationale: You can see pacing spikes when the HR is lower than what is set.
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hrs?
Ventricular dysrhythmias Rationale: After an MI, the conduction system is typically irritable and prone to dysrhythmias due to most likely ischemic tissue. ; Pericarditis can occur 10 days to 2 months after an MI due to an infection, tissue disorder, or trauma. ; Pulmonary emboli only occurs is HF follows an MI but more commonly with valvular disorders, atrial fibrillation, or a DVT
A nurse is assessing a client who has late-stage HF and is experiencing fluid volume overload. Which of the following findings should the nurse expect?
Weight gain 1 kg (2.2 lb) in 1 day Rationale: indicates the pt is retaining fluid ; should look for pitting edema of +3 ; early stages of HF show a cough that is irritating, occurs at night, and is nonproductive ; BNP level >100 show HF
A nurse is preparing to transfuse a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse take first?
Witness the informed consent.
A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect?
dyspnea with hiccups Rationale: Sx are dyspnea, hiccups, and anon-productive cough. ; seen on an ECG as an ST-T spiking. ; chest pain would increase with deep inspiration. ;chest discomfort will decrease when sitting upright or leaning forward.
A nurse is planning 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 post-procedure plan of care?
monitor for bleeding Rationale: due to the administration of heparin and removal of the femoral sheath. ; plan to admin doses of aspirin
