Cardio (Med/Surg)

During a yearly physical examination a complete blood count (CBC) is performed to determine a client's hematologic status. Which laboratory result will the nurse check? Blood glucose Hemoglobin (Hb) C-reactive protein Blood urea nitrogen (BUN)

Hemoglobin (Hb) Rationale A CBC includes red blood cell (RBC) count and RBC indices, white blood cell (WBC) count and WBC differential count, Hb, hematocrit (Hct), and platelet count. A blood glucose level is not part of a CBC. The C-reactive protein level is not part of a CBC. BUN is not part of a CBC.

A nurse is obtaining a health history on a client admitted to the hospital with heart failure. Which assessment finding will the nurse expect the client to report? Feeling bloated after eating Tingling in the upper extremities Needing to use three pillows at night to sleep Swelling of the ankles that is more apparent in the morning

Needing to use three pillows at night to sleep Rationale Heart failure causes a fluid volume excess that results in pulmonary edema and dyspnea in the supine position, requiring pillows to sleep. Feeling bloated after eating and tingling in the upper extremities are unrelated to the cardiopulmonary system. Dependent edema usually occurs after standing or walking; swelling of the ankles is more evident in the evening.

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan about prevention of thrombophlebitis? Wear snug-fitting pants Sit with the knees flexed Apply warm soaks to the legs daily Put on compression stockings before arising

Put on compression stockings before arising Rationale Donning compression stockings before getting out of bed provides support and promotes venous return; applying stockings while the legs are horizontal ensures that the stockings are in place before dependent edema occurs. Wearing snug-fitting pants will cause constriction. Sitting with the knees flexed promotes venous stasis and the formation of thrombophlebitis. Warm soaks resolve inflammation; they do not prevent the development of thrombophlebitis.

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 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings? Cardiogenic shock Hypervolemic shock Hemorrhagic shock Septic shock

Hemorrhagic shock Rationale The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? "I am unable to run a mile (1.6 kilometers) now." "I wake up at night short of breath." "My wife says I snore very loudly." "My shoes seem larger lately."

"I wake up at night short of breath." Rationale Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath.

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

Crackles at the base of each lung Rationale Crackles are the sound of air passing through fluid in the alveolar spaces. With pulmonary edema, fluid moves from the intravascular compartment into the alveoli. With hypervolemia, the pulse is bounding. The blood pressure is increased with hypervolemia. Radiating anterior chest pain will occur with angina or a myocardial infarction.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask how this could happen in addition to many other questions. Hemophilia A is linked to a deficiency in what? Factor II Factor III Factor IX Factor VIII

Factor VIII Rationale Hemophilia type A, which is the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and III are distractors. Factor IX is associated with hemophilia type B.

A client is hospitalized with chest pain. The client's spouse voices concern about how pale the client is. What is the best response by the nurse? "Tell me your concerns regarding the paleness." "Paleness is expected in patients with heart problems." "Other people get pale and recover without any complications." "I can understand why you are worried, but your spouse will be alright."

"Tell me your concerns regarding the paleness." Rationale The response, "Tell me your concerns regarding the paleness," addresses the spouse's concerns and encourages further verbalization of feelings. The response, "Paleness is expected in patients with heart problems," does not focus on the spouse's underlying concerns and keeps the discussion on a physiologic level. The responses, "Other people get pale and recover without any complications," and "I can understand why you are worried, but your spouse will be alright," provide false reassurance and cut off further verbalization of feelings.

A nurse is auscultating a client's heart. Where should the nurse listen to hear S 1 the loudest? Base of the heart Apex of the heart Left lateral border Right lateral border

Apex of the heart A nurse is auscultating a client's heart. Where should the nurse listen to hear S 1 the loudest?

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? Avoid carbonated beverages Use steak sauce for flavoring foods Increase the intake of dairy products Restrict the use of artificial sweeteners

Avoid carbonated beverages Rationale Carbonated beverages generally are high in sodium and should be avoided. Steak sauce is high in sodium and should be avoided. Many dairy products contain sodium and should be avoided. Artificial sweeteners do not contain sodium and do not have to be restricted.

A client is receiving whole-body radiation for Hodgkin disease. Which side effect should the nurse expect as a result of this therapy? Increased tendency to bleed Increased tendency for fractures Decreased number of erythrocytes Decreased susceptibility to infection

Decreased number of erythrocytes Depression of the bone marrow interferes with hemopoiesis, resulting in anemia. A decrease in the number of cells occurs, and therefore there is an increase in blood viscosity and a more rapid clotting time. Pathologic fractures result from the disease, not from the treatment. Radiation causes increased susceptibility to infection as a result of the decreased number of white blood cells.

Which symptoms indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. Decreased urine Hypotension Dyspnea Dry mucous membranes Pulmonary edema Poor skin turgor

Decreased urine Hypotension Dry mucous membranes Poor skin turgor Rationale Lowered urinary output, hypotension, dry mucous membranes, and poor skin turgor are all symptomatic of dehydration. Dyspnea and pulmonary edema may be caused by fluid overload.

The nurse administers oxygen to a client during the early postoperative period after open heart surgery. Why is this necessary? The client will have closed-chest drainage in place. Hypoxia can precipitate respiratory alkalosis. Reduced oxygen levels can stimulate dysrhythmias. Increased respiratory rates add to postoperative pain.

Reduced oxygen levels can stimulate dysrhythmias. Rationale Inadequate oxygenation can cause premature ventricular complexes. Although the client will have closed-chest drainage in place, it does not explain why adequate oxygenation is important. Hypoxia can precipitate respiratory acidosis; hyperventilation causes respiratory alkalosis. Postoperative pain can increase the respiratory rate; increased respiratory rate does not increase the pain level.

A client sustains multiple internal injuries in a motor vehicle accident. While performing the client's initial assessment, the nurse identifies that the client's blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What most likely has caused this drop in blood pressure? Reduction in the circulating blood volume Diminished vasomotor stimulation to the arterial wall Vasodilation resulting from diminished vasoconstrictor tone Cardiac decompensation resulting from electrolyte imbalance

Reduction in the circulating blood volume A client sustains multiple internal injuries in a motor vehicle accident. While performing the client's initial assessment, the nurse identifies that the client's blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What most likely has caused this drop in blood pressure?

A client is seen in the clinic with sickle cell anemia. The primary healthcare provider has prescribed an iron supplement to treat the client's anemia. What is the nurse's primary concern in regard to giving the supplement? Giving iron with this condition is contraindicated. Finding a straw is necessary to prevent staining of teeth. When giving iron, orange juice is needed to improve absorption. Warning about stools changing to black will prevent undue stress.

Giving iron with this condition is contraindicated. Rationale Giving iron is contraindicated as sickled cells do not incorporate the iron, so it will build up in the body, causing pain rather than being absorbed. Liquid iron should be administered with a straw to prevent staining teeth, but not with this condition. Giving iron with orange juice is correct, but not to a person with sickle cell anemia. Feces will turn dark with iron supplements; however, this client should not be receiving iron.

A client is brought to emergency services after a motor vehicle accident. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. Based on this information, the nurse assesses the client for which early response to decreased arterial pressure? Warm and flushed skin Confusion and lethargy Increased pulse pressure Reduced peripheral pulses

Reduced peripheral pulses Rationale Hypovolemia results in a decreased cardiac output and a decreased arterial pressure, which are reflected by a feeble, weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. Confusion and lethargy are late signs of shock. The pulse pressure narrows with decreased cardiac pressure associated with hypovolemic shock.

A client with liver dysfunction reports bleeding gums. In addition, the nurse observes small facial hemorrhagic lesions. What should the nurse conclude that the client needs? Vitamin C Folic acid Vitamin A Vitamin K

Vitamin K Rationale Petechiae represent evidence of capillary bleeding; the diseased liver is no longer able to metabolize vitamin K, a process that is necessary to activate blood clotting factors. Although vitamin C does help capillary stability, it is not associated with liver dysfunction. Folic acid is stored in the liver but is not involved in the blood clotting process. Vitamin A is not involved in blood clotting, even though the transformation of carotene to vitamin A takes place in the liver.

A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse? "These pacing wires can be attached to a temporary pacemaker to shock the heart if it starts beating too fast." "This type of pacemaker will automatically defibrillate the heart if the heart forgets to beat." "The pacemaker will maintain a constant cardiac rhythm." "In case of too slow of a heart rate, the epicardial leads are attached to a pacemaker to maintain a normal rate."

"In case of too slow of a heart rate, the epicardial leads are attached to a pacemaker to maintain a normal rate." A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse?

A client with angina pectoris is scheduled for a stress echocardiogram. What should the nurse tell the client that an echocardiogram is? A tool used solely to determine the cause of chest pain A noninvasive approach to assess cardiovascular status A modality of minimal value in planning treatment for angina An invasive test that measures the body's reaction to progressive increases in exertion

A noninvasive approach to assess cardiovascular status Rationale A stress echocardiogram is noninvasive and uses echoes from pulsed high-frequency sound waves to locate and study the movements and dimensions of cardiac structures; it assesses myocardial disease, valve function, congenital heart defects, blood flow abnormalities, and systemic and pulmonic hypertension. A stress echocardiogram assesses structural defects as well as blood flow abnormalities. A stress echocardiogram is valuable in diagnosing and indicating treatment for a variety of conditions involving the heart's structure and function. A stress echocardiogram is not an invasive examination.

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? Cystitis as an adult Pleurisy as an adult Childhood strep throat Childhood German measles

Childhood strep throat Rationale Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart.

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client? Edema of the left leg Mobility of the left leg Positive left-sided Babinski reflex Presence of left arterial peripheral pulse

Edema of the left leg Rationale Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return. Difficulty with mobility occurs with musculoskeletal or neuromuscular problems. Positive left-sided Babinski reflex is associated with neurologic deficits in the corticospinal tracts. Presence of a left arterial peripheral pulse is made to determine the status of the arterial, not venous, system.

After flushing a client's left forearm saline lock (SL) with normal saline, the client begins to report a painful and burning sensation at the insertion site. Which is the most appropriate action for the nurse to take? Remove the angiocatheter and saline lock and restart the SL in another site. Document the findings per protocol and reassess the site in eight hours. Flush the angiocatheter and saline lock again with sterile water. Change the dressing and apply a new clean dressing.

Remove the angiocatheter and saline lock and restart the SL in another site. Rationale The angiocatheter has slipped out of the vein and infiltrated into the tissue and needs to be removed and restarted in another site. The nurse then needs to document the actions and follow protocol for reassessment. Flushing the angiocatheter with sterile water would only increase the pain and aggravate the infiltration site. Changing the dressing will not help infiltration.

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? Monitoring vital signs and encouraging a vigorous aerobic exercise program Providing written material on the adverse effects of the medication Contacting Social Services for a home health nursing consultation Teaching the client how to count the pulse

Teaching the client how to count the pulse Rationale Adverse effects of digoxin include many types of dysrhythmias. If the client's apical pulse rate is less than 60, the medication is "held" and the primary healthcare provider is notified. Because the client will be taking the medication at home, the client should be taught how to take an accurate pulse and to contact the healthcare provider if the rate falls outside predetermined parameters. The client will be assuming responsibility for drug administration at home; teaching is the priority. Vigorous exercise is not recommended for clients who have heart failure. Providing written material on the adverse effects may not meet all of the client's learning needs. There is nothing in the question to suggest the client requires home healthcare.

An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? Monitor for cardiovascular irregularities. Inquire about changes in bowel patterns. Assess for leg muscle twitching or weakness. Assess for signs and symptoms of dehydration.

Monitor for cardiovascular irregularities. Rationale Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.

A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? "I must touch the shunt several times a day to feel for the bruit." "I have to take his blood pressure every day in the arm with the fistula." "He will have to be very careful at night not to lie on the arm with the fistula." "We really should check the fistula every day for signs of redness and swelling."

"I have to take his blood pressure every day in the arm with the fistula." Rationale Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus. Hemorrhage can occur in a matter of minutes if the cannula is dislodged. Redness and swelling are signs of infection, which is a complication of cannulization.

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." Which action should the nurse take? Call the rapid response team. Perform a nutritional assessment. Discuss possible sources of stress for the panic attack. Provide reassurance while helping the client to deep breathe.

Call the rapid response team. Rationale These are classic symptoms of a myocardial infarction; further medical evaluation and intervention are needed immediately. Performing a nutritional assessment presumes a dietary problem when a more serious situation may exist. Discussing possible sources of stress for the panic attack considers only an emotional source of the reported symptoms and ignores a potential medical emergency. Providing reassurance while helping the client to deep breathe provides false reassurance and ignores a potential medical emergency.

Within 4 to 6 hours after a client has a myocardial infarction, the nurse expects which blood level to increase? Lactate dehydrogenase (LDH-1) Creatine kinase-MB band (CK-MB) Erythrocyte sedimentation rate (ESR) Serum aspartate aminotransferase (AST)

Creatine kinase-MB band (CK-MB) Rationale CK-MB is an isoenzyme of creatine phosphokinase (CPK) found in cardiac muscle; it increases in 4 to 6 hours after chest pain and begins to decline in 12 to 24 hours. LDH-1 increases within 6 to 12 hours after the onset of pain. ESR is nonspecific; it indicates the presence of inflammation or infection. AST increases within the first 12 hours; it is not specific enough to provide a definitive indicator within 4 to 6 hours.

A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data? Loss of battery power Functioning as expected Failure to stimulate the heart Ignoring the client's heartbeat

Failure to stimulate the heart Rationale If pacemaker spikes are present, the pacemaker is firing appropriately, but the lack of resulting QRS complexes indicates that it is not stimulating or "capturing" the heart. Loss of battery power is indicated by a slowing or irregular heart rate. Each pacemaker spike should be followed by a QRS complex. A fixed or asynchronous pacemaker is designed to work independently of the client's intrinsic rhythm.

A healthcare provider makes the diagnosis that an obese client has primary hypertension. Which priority information should the nurse include when preparing a teaching plan for this client? Causes of the hypertension Need for exercise three times a week Foods recommended on a low-calorie and low-sodium diet Complications that involve the vascular and neurologic systems

Foods recommended on a low-calorie and low-sodium diet Rationale Even a slight reduction in weight along with reduced sodium intake can result in a significant reduction in blood pressure. If the blood pressure can be reduced with diet, then the dosage of medications can be reduced. The exact cause of primary hypertension is unknown. It is recommended that 30 minutes of moderate intensity activity be performed daily. Preparing a teaching plan for complications that involve the vascular and neurologic systems is premature.

The nurse is watching the technician obtain a 12-lead ECG. In which area should the nurse make sure the technician places the V 1 lead? Halfway between V 2 and V 4 Fourth intercostal space, left sternal border Fourth intercostal space, right sternal border Fifth intercostal space, left midclavicular line

Fourth intercostal space, right sternal border Rationale Positions for these six leads are as follows: V 1: fourth intercostal space, right sternal border; V 2: fourth intercostal space, left sternal border; V 3: halfway between V 2 and V 4; V 4: fifth intercostal space, left midclavicular line; V 5: fifth intercostal space, left anterior axillary line; V 6: fifth intercostal space, left midaxillary line.

The nurse is caring for a client who is receiving therapy for vitamin B 12 deficiency. Which finding indicates that the therapy is having the desired effect? Normal serum electrolyte levels Healthy skin integrity Resolution of peripheral edema Improved hemoglobin and hematocrit levels

Improved hemoglobin and hematocrit levels Rationale Vitamin B12is essential for appropriate maturation of red blood cells; therefore relieving the deficiency is expected to improve hemoglobin and hematocrit (H & H) levels and decrease hypoxia-related problems. This disorder is known as pernicious anemia. Normal serum electrolytes, healthy skin integrity, and resolution of peripheral edema, if present, would be secondary to improved hemoglobin and hematocrit levels.

The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively? Administering supplemental oxygen Maintaining a reduced blood pressure Keeping the client in a supine position Monitoring the peripheral vascular status

Maintaining a reduced blood pressure Rationale Maintaining a low blood pressure reduces the risk of aortic rupture. Administering supplemental oxygen may or may not be necessary. Keeping the client in a supine position may or may not be necessary. Monitoring will help identify whether an aneurysm has ruptured, but it will not prevent rupture.

A client who has a history of several myocardial infarctions is admitted to the hospital for an unrelated medical condition. Because of the client's history, the nurse is concerned about the possibility of the client experiencing right ventricular failure. Which early indication of right ventricular failure should the nurse monitor for in this client? Chest pain Bradypnea Bradycardia Peripheral edema

Peripheral edema Rationale Increased venous pressure resulting from backup of blood, as the right ventricle of the heart fails, forces capillary fluid to seep into interstitial spaces, resulting in peripheral edema. Chest pain may be present with a myocardial infarction or cardiovascular insufficiency. Tachypnea and dyspnea, not bradypnea, occur with right ventricular failure. Bradycardia does not occur; the heartbeats may vary in intensity, or a bounding pulse may be felt.

A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse knows to watch for what distinguishing sign that is unique to a fat embolus? Oliguria Dyspnea Petechiae Confusion

Petechiae A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse knows to watch for what distinguishing sign that is unique to a fat embolus?

A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. How should the nurse position the client's feet and legs? Place them dependent to the torso. Position them dependent by using a fully extended knee gatch. Raise them to a two-pillow height above the buttocks. Elevate them by raising the foot of the bed on blocks.

Place them dependent to the torso. Rationale Gravity will assist the flow of blood to the dependent legs and feet. An extended knee gatch keeps extremities horizontal, not dependent, and does not facilitate blood flow to the feet. Elevation impedes flow of arterial blood to the extremities; it facilitates venous return.

The nurse is interpreting an electrocardiogram rhythm. What part of the electrical pattern represents ventricular contraction? P wave T wave PR interval QRS interval

QRS interval Rationale Atrial and ventricular depolarization and repolarization are represented on the electrocardiogram (ECG) as a series of waves: the P wave followed by the QRS complex and the T wave. The first deflection is the P wave associated with right and left atrial depolarization followed by the QRS complex that reflects ventricular depolarization.

A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. How would the nurse expect the client to describe the chest pain? Severe, intense Burning and of short duration Mild, radiating toward the abdomen Squeezing, relieved by nitroglycerin

Severe, intense Rationale Blockage of myocardial blood supply causes accumulation of unoxidized metabolites in the muscle; this affects nerve endings and causes severe, intense chest pain. Burning chest pain is not the type of pain associated with a myocardial infarction. Mild chest pain, radiating toward the abdomen, is not the type of pain associated with a myocardial infarction. Nitroglycerin relieves pain associated with angina, not pain associated with myocardial infarction.

In addition to atrial fibrillation, which cardiac dysrhythmia exhibited by a client does the nurse determine may be converted to sinus rhythm by cardioversion? Cardiac standstill First degree heart block Supraventricular tachycardia Frequent premature complexes

Supraventricular tachycardia Rationale Cardioversion involves administration of precordial shock, which is synchronized with the R wave to interrupt the heart rate. It is used for atrial fibrillation, supraventricular tachycardia, and ventricular tachycardia with a pulse when pharmaceutical preparations fail. The heart is stopped by the electrical stimulation, and it is hoped that the sinoatrial (SA) node will take over as pacemaker. Because there are no R waves in a cardiac standstill, defibrillation and not cardioversion should be done. Premature ventricular complexes suggest an irritable myocardium and generally respond to antidysrhythmic agents.

Which nursing action should be included in the plan of care for a client who has a permanent fixed (asynchronous) pacemaker inserted? Instruct the client that it is better to sleep on two pillows Encourage the client to reduce activity from former levels Teach the client to keep daily accurate records of the pulse Inform the client that the pacemaker functions when the heart rate drops below a preset rate

Teach the client to keep daily accurate records of the pulse Rationale A permanent fixed (asynchronous, fixed rate) pacemaker is set at a predetermined rate; if a pulse rate is more or less than the preset rate, the pacemaker may be malfunctioning. The client need not alter previous sleeping habits. Regular activity may be resumed when healing has occurred. Informing the client that the pacemaker functions when the heart rate drops below a preset rate educates the client about the purpose of a pacemaker that provides on-demand pacing.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. The RR intervals are relatively consistent. One P wave precedes each QRS complex. The ST segment is higher than the PR interval. Four to eight complexes occur in a 6-second strip. The QRS complex ranges from 0.12 to 0.2 seconds.

The RR intervals are relatively consistent. One P wave precedes each QRS complex. Rationale The consistency of the RR intervals indicates a regular rhythm. A normal P wave before each complex indicates the impulse originated in the sinoatrial (SA) node. Elevation of the ST segment is a sign of cardiac ischemia and unrelated to the rhythm. The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100 beats/min. Fewer than six complexes per 6 seconds equals a heart rate less than 60 beats/min. The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 second.

The primary healthcare provider prescribes warm intravenous fluids for a client with a body temperature of 28 °C. During administration of the fluids, it is important for the nurse to continuously monitor what? The client's liver function The client's cardiac function The client's red blood cell count The client's blood platelet count

The client's cardiac function Rationale Body temperature less than 30 °C indicates the need of core rewarming. Core rewarming is done by administering warm intravenous solutions, gastric lavage with warm fluid, peritoneal lavage with warm fluid, and by allowing inhalation of warmed oxygen. Core rewarming may result in cardiac dysrhythmias; therefore, the nurse monitors for cardiac function continuously to ensure safety in the client. Administration of warm intravenous fluids may not disturb liver function; therefore, there is no need to monitor liver function. Core rewarming with warm intravenous fluids may not decrease the red blood cell count and blood platelet count; therefore, there is no need to monitor the blood cell count.

A client in the emergency department is diagnosed with atrial fibrillation. Initially the primary healthcare provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm? The vagus nerve is stimulated. The glottis closes momentarily. Thoracic pressure decreases. Respiratory pattern is interrupted.

The vagus nerve is stimulated. Rationale Inhaling and forcing the diaphragm and chest muscles against a closed glottis increase intrathoracic pressure, which affects the vagus nerve and slows the heart. Although the glottis closes, this does not interrupt the dysrhythmia. Thoracic pressure increases, not decreases, during the Valsalva maneuver. Although the respiratory pattern is interrupted briefly, this does not interrupt the dysrhythmia.

A client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a screening session at a health fair asks the nurse what to do in light of this result. How should the nurse respond? "Your cholesterol is high, and you may need medication." "This is within the acceptable range, and no action is required." "Your level is low; you should eat more foods that contain cholesterol." "Your cholesterol is elevated slightly. A diet low in saturated fats should be followed."

"Your cholesterol is elevated slightly. A diet low in saturated fats should be followed Rationale A level more than 200 mg/dL (5 mmol/L) is considered elevated, and foods high in cholesterol and saturated fats should be limited in the diet. A level of 240 mg/dL (6.2 mmol/L) or more is considered high. Levels between 140 and 200 mg/dL (2 mmol/L to 5 mmol/L) are considered desirable. A low level is less than 140 mg/dL (2.0 mmol/L). Medical attention should be sought, because low cholesterol levels are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and myeloproliferative disease.

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process? A pulse rate irregularity Equal apical and radial pulse rates A pulse rate of 60 beats per minute An apical rate obtainable at the fifth intercostal space and midclavicular line

A pulse rate irregularity Rationale Dysrhythmias are abnormal and are associated with acute or chronic pathologic conditions. An equal apical and radial pulse is expected; the radial pulse reflects ventricular contractions. The expected range in adults is 60 to 100 beats per minute. An apical rate obtainable at the fifth intercostal space and midclavicular line are the anatomical landmarks for locating the apex of the heart; they are unaffected by aging.

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic? International normalized ratio (INR) is between 2 and 3 Prothrombin time (PT) is 2.5 times the control value Activated partial thromboplastin time (APTT) is double the control value Activated clotting time (ACT) is in the range of 70 to 120

Activated partial thromboplastin time (APTT) is double the control value Rationale Activated partial thromboplastin time should be 1.5 to 2.5 for the control of heparin therapy. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT increases to a range of 150 to 200 when heparin reaches therapeutic levels.

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe? Lactated Ringer solution Serum albumin Blood replacement High molecular dextran

Blood replacement Rationale Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

What is the most definitive test to confirm a diagnosis of multiple myeloma? Bone marrow biopsy Serum test for hypercalcemia Urine test for Bence Jones protein X-ray films of the ribs, spine, and skull

Bone marrow biopsy Rationale A definite confirmation of multiple myeloma can be made only through a bone marrow biopsy; this is a plasma cell malignancy with widespread bone destruction. Although calcium is lost from bone tissue and hypercalcemia results, this is not a confirmation of the disease. Although Bence Jones protein is found in the urine, it does not confirm the disease. X-ray films will show the characteristic "punched-out" areas caused by the increased number of plasma cells, which contributes to the making of the diagnosis. The definitive diagnosis is made on biopsy.

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of? Atrial fibrillation Cardiac irritability Impending heart block Ventricular tachycardia

Cardiac irritability Rationale Cardiac irritability is the cardinal reason for PVCs. Atrial fibrillation is a type of dysrhythmia, not the cause of PVCs; the source of atrial fibrillation is the atrium, not the ventricles. Impending heart block type of dysrhythmia is associated with interference with the conduction system. Ventricular tachycardia is a type of dysrhythmia, not the cause of PVCs.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? Constriction of the superficial vessels dilates the deep vessels. Constriction of the peripheral vessels increases the force of flow. Dilation of the superficial vessels causes constriction of collateral circulation. Dilation of the peripheral vessels causes reflex constriction of visceral vessels.

Constriction of the peripheral vessels increases the force of flow. Rationale Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.

A nurse expects that a client with right-sided heart failure will exhibit which of these signs or symptoms? Oliguria Pallor Cool extremities Distended neck veins

Distended neck veins Rationale Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria, pallor, and cool extremities are key features of left-sided heart failure.

A client who had injection sclerotherapy for varicose veins is advised to wear compression (support) stockings. What is most important for the nurse to explain to the client about compression stockings? Put the stockings on at the first sign of discomfort. Don the stockings before getting out of bed in the morning. Ensure that the cuff of the stockings reaches the middle of the knees. Substitute elastic bandages for compression stockings if they are more comfortable.

Don the stockings before getting out of bed in the morning. Rationale To prevent distention of the veins, stockings should be applied before the legs are placed in a dependent position. Stockings should be used preventively before the discomfort associated with venous pressure and edema occurs. Knee-high stockings should end 2 inches (5.1 cm) below the knee to avoid popliteal pressure, which limits venous return. Stockings apply uniform pressure. Elastic bandages may slip or develop wrinkles, creating uneven pressure and constriction; edema may result.

A primary healthcare provider decides to omit a treatment that was part of a course of chemotherapy for a client because the client demonstrates myelosuppression. What information would be appropriate for the nurse to give to the client regarding myelosuppression? Calcium carbonate and vitamin D must be increased in the diet because of the effects of myelosuppression. Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. The development of myelosuppression explains why the client has nausea, vomiting, anorexia, and alopecia. Frequent testing for restlessness, muscle control, and pupillary response is necessary because the meninges may be irritable.

Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. Rationale Myelosuppression involves a decreased number of red blood cells (anemia), resulting in a reduced oxygen-carrying capacity of the blood and fatigue. A decreased number of white blood cells (leukopenia) results in a potential for infection. A decreased number of platelets (thrombocytopenia) results in a potential for bleeding. Myelosuppression is not related directly to calcium carbonate and vitamin D; myelosuppression, a reduction in bone marrow activity, results in decreased numbers of red blood cells (RBCs), white blood cells (WBCs), and platelets. Myelosuppression is not related to nausea, vomiting, anorexia, or alopecia. Myelosuppression is related to bone marrow activity, not the nervous system.

A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient care analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next? Give naloxone intravenous push med (IVP) per protocol. Assess the client's pain level on a 10-point scale. Document the findings and reassess in 2 hours. Call the rapid response team.

Give naloxone intravenous push med (IVP) per protocol. Rationale A respiratory rate of 10 breaths per min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for postoperative opioid-induced respiratory depression. Pain level also is a part of the PCA documentation protocol. According to protocol, PCA status needs to be documented every 2 hours for the first day and then every 4 hours. The rapid response team might still need to be called, but naloxone must be given first.

A client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period? Hypercalcemia may result from parathyroid damage. Hypotension and bradycardia may result from thyroid storm. Tetany may result from underdosage of thyroid hormone replacement. Hoarseness and airway obstruction may result from laryngeal nerve damage.

Hoarseness and airway obstruction may result from laryngeal nerve damage. Rationale Laryngeal nerve injury can cause laryngeal spasms, resulting in airway obstruction. Parathyroid damage results in hypocalcemia, not hypercalcemia. Thyroid storm (thyroid crisis) is characterized by the release of excessive levels of thyroid hormone, which increases the metabolic rate. An increase in the metabolic rate increases vital signs, resulting in hypertension, not hypotension, and tachycardia, not bradycardia. Tetany is caused by a decrease in parathormone, a parathyroid hormone, not a thyroid hormone.

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who just had a cardiac arrest? Age of the client How long the client was anoxic Heart rate of the client before the arrest Emergency medications available for the client

How long the client was anoxic Rationale Irreversible brain damage will occur if a client is anoxic for more than four minutes. The age of the client does not affect the response by the arrest team. The earlier heart rate is of minimal importance; the rhythm is more significant. Although a variety of emergency medications must be available, their administration is prescribed by the healthcare provider.

A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client? Obstructive Neurogenic Cardiogenic Hypovolemic

Hypovolemic Rationale Hypovolemic shock occurs when an abdominal aneurysm ruptures. Shock ensues because fluid volume becomes depleted as the heart continues to pump blood out of the ruptured vessel. Obstructive shock occurs from physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism. Neurogenic shock results from decreased neuromuscular tone, which reduces vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client? Prevent dyspnea Prevent cyanosis Increase oxygen concentration to heart cells Increase oxygen tension in the circulating blood

Increase oxygen concentration to heart cells Rationale Administration of oxygen increases the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although administering oxygen will increase oxygen tension in the circulating blood, it is not specific to heart cells, which are hypoxic when there is a myocardial infarction from a coronary occlusion.

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change? Decreased afterload Decreased heart rate Increased stroke volume Increased intravascular volume

Increased intravascular volume Rationale As fluid is administered intravenously or retained by the kidneys, the intravascular fluid volume increases, resulting in increased preload and afterload, increasing pulmonary artery wedge pressure. Increased, not decreased, afterload will cause an increase in the pulmonary artery wedge pressure. Afterload is the peripheral resistance against which the left ventricle must pump. A decreased heart rate will not increase pulmonary artery wedge pressure. After a pulmonary artery wedge pressure reaches 20 mm Hg, the stroke volume does not increase significantly.

A client has a tentative diagnosis of Hodgkin disease. How does the nurse expect the diagnosis to be confirmed? Bone scan Lymph node biopsy Computed tomography (CT) scan Radioactive iodine ( 131I) uptake study

Lymph node biopsy Rationale The diagnosis depends on the identification of characteristic histologic features of an excised lymph node. A bone scan is a diagnostic device to assess bony metastasis of cancers. CT scans identify the extent of the disease in the abdominal and thoracic cavities. A radioactive iodine ( 131I) uptake study is not indicated for Hodgkin disease; it is used for radiotherapy or diagnosis of thyroid diseases.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased Pco 2 levels

Metabolic acidosis Rationale Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco 2 level will increase in profound shock.

What is the most essential nursing care for a client who just had a cardiac catheterization? Maintain the semi-Fowler position. Monitor the apical pulse and blood pressure. Take the temperature hourly until it stabilizes. Encourage frequent coughing and deep breathing.

Monitor the apical pulse and blood pressure. 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.

A client had a ventricular demand pacemaker inserted. What is the priority nursing intervention immediately after the procedure? Encourage fluids. Assess the implant site. Monitor the heart rate and rhythm. Encourage turning and deep breathing.

Monitor the heart rate and rhythm. Rationale Assessment of the heart's rate and rhythm determines how the newly implanted pacemaker is functioning. Unless the client is dehydrated, encouraging fluid will increase the workload of the heart. Although assessing the implant site and encouraging turning and deep breathing are appropriate actions, the priority is to assess the functioning of the pacemaker.

An 80-year-old client with a history of coronary artery disease is admitted to the hospital for observation after a fall. During the night the client has an episode of paroxysmal nocturnal dyspnea. In what position should the nurse place the client to best decrease preload? Contour Orthopneic Recumbent Trendelenburg

Orthopneic Rationale The client's paroxysmal dyspnea was probably caused by sleeping in bed with the legs at the level of the heart; the orthopneic position increases venous return from dependent body areas, increasing the intravascular volume. Sitting up and leaning forward while keeping the legs dependent slows venous return and increases thoracic capacity. Although the contour position elevates the client's head, it does not place the legs in a dependent enough position to substantially decrease venous return. The recumbent position is contraindicated. Venous return increases when the lower extremities are at the level of the heart. Also, the pressure of the abdominal organs against the diaphragm decreases thoracic capacity. The Trendelenburg position is contraindicated. Venous return increases when the lower extremities are higher than the level of the heart. Also, the pressure of the abdominal organs against the diaphragm decreases thoracic capacity.

The nurse is providing information about blood pressure to an unlicensed health care worker and recalls that the factor that has the greatest influence on diastolic blood pressure is what? Renal function Cardiac output Oxygen saturation Peripheral vascular resistance

Peripheral vascular resistance Rationale Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure.

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? Assign the client to any type of room. Place the client in a private room. Assign the client to a semiprivate room. Place the client with another client receiving the same type of therapy.

Place the client in a private room. Rationale Radon seeds emit radiation; the client should be isolated in a private room to decrease radiation to others. Assigning the client to any type of room is inappropriate and unsafe because the treatment emits radiation. A semiprivate room is contraindicated because this will expose other clients to radiation. A room with clients receiving the same therapy is contraindicated because this will expose other clients to radiation.

Upon assessment the nurse discovers a client with heart failure has crackles in lower lung fields and dyspnea. Upon notifying the primary healthcare provider, the provider prescribes intravenous (IV) normal saline at 200 mL/hr and furosemide 120 mg orally stat. Which action should the nurse take next?

Rationale The choice of normal saline at 200 mL/hr should be questioned for using saline, which is inclined to retain fluid, and the amount, which would be too much for most older adult persons' cardiac status to tolerate. This client is in heart failure as evidenced by crackles and dyspnea, and pulmonary edema is occurring. Using an infusion pump to infuse solution assures the prescribed amount is infused but does not address that this is too much. Giving a higher dose needs to be questioned, and the nurse can refuse to follow prescriptions that are outside of standards. Giving a medication without understanding normal range and information violates standards. In addition, older adult clients do not metabolize medication as efficiently as younger clients.

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling light-headed. The client is pale and has a rapid pulse. What does the nurse conclude that the client's symptoms indicate? Hyperventilation Shock Anxiety Infection

Shock Rationale The clinical findings are early signs of shock. Shock ensues rapidly after a ruptured aortic aneurysm because of profound hemorrhage. The nurse can observe hyperventilation by watching the client's breathing patterns; rapid respirations are expected with hyperventilation. There are no data that indicate that the client is hyperventilating. Anxiety usually is not associated with light-headedness unless there is accompanying hyperventilation. The signs and symptoms are not inclusive enough to indicate infection; there is no indication of fever.

A client's cardiac monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. The nurse concludes that the client is experiencing what? Atrial fibrillation Sinus tachycardia Ventricular fibrillation First-degree atrioventricular block

Sinus tachycardia Rationale The presence of a P wave before each QRS complex indicates a sinus rhythm; a heart rate greater than 100 regular beats per minute is referred to as tachycardia. Atrial fibrillation has no well-defined P waves, there are 350 or more beats per minute, there are random ventricular beats, and the rhythm is irregular. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD) or peripheral arterial disease. Which is the most beneficial lifestyle modification the nurse should teach this client? Stop smoking Control blood glucose Start a walking program Eat a low-fat, low-cholesterol diet

Stop smoking Rationale Smoking is the single most important risk factor for peripheral arterial diseases, and cessation should be encouraged. Although hyperglycemia is a contributing factor, it is not the primary risk factor for LEAD. Although a sedentary lifestyle is a contributing factor, it is not the primary risk factor for LEAD. Although a high-fat, high-cholesterol diet is a contributing factor, it is not the primary risk factor for LEAD.

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply. Tachycardia Restlessness Warm, moist skin Decreased urinary output Bradypnea

Tachycardia Restlessness Decreased urinary output Rationale The heart rate increases and the respiratory rate increases in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/hr because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand? Plaque from within the veins is scraped. The dilated saphenous veins are removed. Superficial veins are sown together into deep veins. An umbrella filter is placed in the large affected veins.

The dilated saphenous veins are removed. Rationale During a ligation, the saphenous vein is removed. Plaque is an arterial, rather than a venous, problem. Anastomosing (sewing together) superficial veins to deep veins is not done during this surgery; superficial and deep veins usually are attached by communicating veins. An umbrella filter placed in the large affected veins prevents emboli from traveling to the lung; it is not a vein ligation and stripping.

A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client's question? The arterial blood supply is inadequate. There is delayed healing in the area after an injury. The production of melanin in the area has increased. There is leakage of red blood cells (RBCs) through the vascular wall.

There is leakage of red blood cells (RBCs) through the vascular wall. Rationale Increased venous pressure alters the permeability of the veins, allowing extravasation of RBCs; lysis of RBCs causes brownish discoloration of the skin. Varicose veins do not affect the arterial circulation. Although healing may be delayed, the brownish discoloration does not result from trauma. There is no increase in melanocyte activity in individuals with varicose veins.

A nurse is developing a health teaching plan for clients with pacemakers. Which activity should the nurse teach these clients to avoid? Having a computed tomography (CT) scan Standing near a microwave Swimming in saltwater Touring a power plant

Touring a power plant Rationale Large electrical fields can change pacemaker settings and should be avoided. These clients should avoid magnetic resonance imaging (MRI), not a CT scan. Modern microwaves are shielded and do not cause pacemaker problems. Water, regardless of whether it is fresh or saltwater, will not affect a pacemaker.

A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Which blood types can be used? Type O positive Type AB positive Type A or O negative Type A or AB negative

Type A or O negative Rationale Both A and O negative blood are compatible with the client's blood. A negative is the same as the client's blood type and preferred; in an emergency, type O negative blood also may be given. Although type O blood may be used, it will have to be Rh negative; Rh positive blood is incompatible with the client's blood and will cause hemolysis. Type AB positive blood is incompatible with the client's blood and will cause hemolysis. Type A negative blood is compatible with the client's blood, but type AB negative is incompatible and will cause hemolysis.

An older adult with peripheral vascular disease has stopped smoking, and the client's children want to make the home environment safe. What should the home healthcare nurse emphasize when providing instructions? Observe for evidence of blurred vision Use measures that can prevent thermal injuries Reduce fluid intake to prevent peripheral edema Limit activities to reduce the workload on the heart

Use measures that can prevent thermal injuries Rationale The ability to perceive extremes in temperature is limited in the presence of peripheral vascular disease. Prevention of thermal injury through avoidance of hot and cold (e.g., hot water, heating pads, ice packs) is advised. Blurred vision is not associated with peripheral vascular disease. Limiting fluid intake may precipitate dehydration, increasing the risk of thrombophlebitis. Limiting fluids may be indicated if a client has heart failure, not peripheral vascular disease. Limiting activities to reduce the workload on the heart may be important for a client with heart failure, not with peripheral vascular disease.

During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client? Severe radiating abdominal pain Pattern of visible peristaltic waves Visible pulsating abdominal mass Cyanosis with other symptoms of shock

Visible pulsating abdominal mass Rationale As the heart contracts, an expanding midline mass may be visible to the left of the umbilicus. Severe radiating abdominal pain is not definitive for abdominal aortic aneurysm. There is no problem or pathology in the intestinal tract; patterning of visible peristaltic waves is associated with intestinal obstruction. Cyanosis with other symptoms of shock is not definitive for abdominal aortic aneurysm; pallor occurs with shock.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The mother shares that she is 4 weeks pregnant and questions as to whether this pregnancy will result in a child with hemophilia. What is the best response by the nurse? Probably not, because there is a 50% risk of a mother who is a carrier transmitting the disease, and one child already has the condition. With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child. Definitely, because the one child has hemophilia, all future pregnancies will result in children with the condition. If the father has the condition and the mother is a carrier, the child automatically will have hemophilia.

With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child. Rationale With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child. The odds are the same with each pregnancy and do not change based upon a previous pregnancy. One child currently having the condition does not affect this pregnancy. A recessive trait will not automatically mean all future pregnancies will result in children with hemophilia.If the father has the condition and the mother is a carrier, this does not guarantee that the child will inherit the condition.

A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram (ECG). Which explanation should the nurse include when teaching the client about this procedure? "This is a noninvasive test to check your heart's response to physical activity." "This test is the definitive method to identify the actual cause of your chest pain." "The findings of this test will be of minimal assistance in the treatment of angina." "The findings from this minimally invasive test will show how your body reacts to exercise."

"This is a noninvasive test to check your heart's response to physical activity." Rationale This test evaluates the heart's ability to meet the need for additional oxygen in response to the stress of exercising. Changes in the ECG identify dysrhythmias and ST changes indicative of myocardial ischemia. This test assists in the differential diagnosis of chest pain; the diagnosis of heart disease is made via the results of a variety of diagnostic procedures and laboratory tests. This is a valuable test that will influence the diagnosis and treatment of heart disease. This is a noninvasive test.

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

"A vein in the leg was used to bypass the coronary artery." Rationale The response that a vein in the leg was used to bypass the coronary artery provides information and reduces anxiety. The nurse understands that the greater saphenous vein of the leg is used to bypass the diseased coronary artery, and one surgical team obtains the vein while another team performs the chest surgery; this shortens the surgical time and decreases the risks of surgery. The internal mammary arteries are the grafts of choice, but the surgery is usually longer because of the necessity of dissecting the arteries from the chest wall. In addition, the internal mammary arteries may have been used in a previous bypass surgery. Cardiopulmonary bypass (extracorporeal circulation) is accomplished by placement of a cannula in the right atrium, vena cava, or femoral vein to withdraw blood from the body; blood is returned to the body via a cannula in the aorta or the femoral artery. Off-pump surgery is used for minimally invasive surgical techniques. A filter is not inserted in the leg to prevent embolization during a coronary artery bypass graft (CABG). The arteries in the extremities are not examined during a CABG.

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? "My ankles are swollen." "I am tired at the end of the day." "When I eat a large meal, I feel bloated." "I have trouble breathing when I walk rapidly."

"I have trouble breathing when I walk rapidly." Rationale Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.

A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond? "This surgery significantly decreases symptoms in most clients." "This procedure will enable your spouse to return to work after healing occurs." "Studies have consistently shown that this surgery increases an individual's life span." "Evidence substantiates that surgery can prevent progression of coronary artery disease."

"This surgery significantly decreases symptoms in most clients." Rationale The majority of those who have this surgery have marked relief from their symptoms because the flow of blood to myocardial cells is increased. Whether the procedure will enable the client to return to work depends on the client's presurgical condition and occupation, not the surgery itself. So far, studies have failed to show that coronary artery bypass surgery affects life span. The surgery itself does not affect the disease process; clients must reduce risk factors (obesity, smoking, and high-fat/high-cholesterol diet) as well.

A nurse is developing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. Which statement from the client indicates the nurse needs to intervene? "I will restrict my physical activity." "I will take one baby aspirin every day." "I will continue my smoking cessation program." "I will try to lose the extra weight I'm carrying around."

"I will restrict my physical activity." Rationale Physical activity need not be restricted; clients who have had a myocardial infarction have a cardiovascular rehabilitation exercise program prescribed. Exercise should become a part of the client's lifestyle. Taking one baby aspirin every day is desirable because aspirin decreases platelet aggregation. Continuing a smoking cessation program is desirable because cigarette smoking causes arterial constriction. Trying to lose the extra weight the client is carrying around is desirable because obesity increases the body's oxygen demands, which increases the workload of the heart.

The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement? "Red blood cells appear normal in size and color; however, there is a decreased amount produced." "The red blood cells have an increased life span with a decrease in normal functioning." "Administration of vitamins B 12 and folate will help to treat this type of long-term anemia." "This is the mildest form of anemia and is easily corrected through administration of blood products."

"Red blood cells appear normal in size and color; however, there is a decreased amount produced." Rationale Anemia of chronic disease results in a decrease in the production of red blood cells (RBCs) in response to chronic inflammation; the red blood cells are normal size, shape, and color. There is a decrease in the life span of the RBC, and the administration of folate or B 12 will not correct the anemia, as these levels are generally within normal limits. This form of anemia can be very severe, and treatment is directed at identification and management of the underlying cause.

A client has serially decreasing blood pressures after surgery. Which mechanisms involved in the regulation of blood pressure should the nurse consider? Select all that apply. 1. Dilation of arterioles to increase peripheral resistance. 2. Activation of regulators that control renal angiotensin II. 3. Release of vasodilators, for example antidiuretic hormone. 4. Increase of left ventricular stroke volume to maintain blood volume. 5. Enervation of the sympathetic nervous system to constrict arterioles.

2, 4, 5 Rationale When the kidney senses a decreased circulating blood volume angiotensin I is released, which produces angiotensin II, a powerful vasoconstrictor; also, it stimulates the adrenal cortex to release aldosterone, which causes active reabsorption of sodium and water. Baroreceptors in the aortic arch and carotid sinus respond to altered arterial pressure, initiating events that ultimately stimulate peripheral vasoconstriction, thus increasing cardiac output. Alpha 1-adrenergic receptors are located in vascular smooth muscles and, when stimulated, cause vasoconstriction of the blood vessels. Arterioles will constrict, not dilate, to increase peripheral resistance. Antidiuretic hormone (vasopressin) will cause vessels to constrict, not dilate.

A client's arterial blood gas report indicates that pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L (20 mmol/L). Which client should the nurse consider is most likely to exhibit these results? A 54-year-old with vomiting A 17-year-old with panic attacks A 24-year-old with diabetic ketoacidosis A 65-year-old with advanced emphysema

A 24-year-old with diabetic ketoacidosis Rationale The low pH and bicarbonate levels are consistent with metabolic acidosis, which can be caused by excess ketones, a result of diabetic ketoacidosis. A 54-year-old with vomiting most likely will experience metabolic alkalosis from loss of gastric hydrochloric acid. A 17-year-old with panic attacks most likely will experience respiratory alkalosis from hyperventilation. A 65-year-old with advanced emphysema most likely will experience respiratory acidosis.

A nurse in the emergency department is assigned to care for four clients. Which client should the nurse see first? A client with a head injury A client with a fractured femur A client with ventricular fibrillation A client with a penetrating abdominal wound

A client with ventricular fibrillation Rationale Ventricular fibrillation will cause irreversible brain damage and then death within minutes because the heart is not pumping blood to the brain. Defibrillation, or CPR until defibrillation is possible, must be initiated immediately. Although head injury, fractured femur, and penetrating abdominal wound require prompt treatment, death is not as imminent as with ventricular fibrillation.

A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? Septic shock Cardiogenic shock Neurogenic shock Anaphylactic shock

Anaphylactic shock Rationale Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.

A healthcare provider prescribes thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do? Slightly slit the top of the stockings to relieve pressure. Leave the antiembolism stockings off to prevent tissue damage. Roll the top of the stockings to below the knees to limit popliteal pressure. Ask the healthcare provider if an elastic bandage can be used in place of the stockings.

Ask the healthcare provider if an elastic bandage can be used in place of the stockings. Rationale An elastic bandage can be adjusted to the varying proportions of the client's legs. Cutting the stockings to relieve pressure is inappropriate and will decrease the effectiveness of the stockings. Leaving the antiembolism stockings off to prevent tissue damage is unsafe; this permits venous stasis. Rolling the top of the stockings to below the knees to limit popliteal pressure will increase the pressure in the popliteal space, which increases venous stasis and the risk of thrombophlebitis.

A healthcare provider prescribes epoetin subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first? Demonstrate the injection technique Assess the client's readiness to learn Explain how to perform sterile technique Encourage the client to contact a home healthcare agency

Assess the client's readiness to learn Rationale Readiness to learn, including attitude and physical ability to see and use equipment, must be assessed before the skill can be taught. Demonstrating the injection technique as an initial intervention may be overwhelming for the client. Explanations are not as effective as a demonstration and a return demonstration when a skill is being taught. Encouraging the client to contact a home healthcare agency may or may not be necessary. If a referral is necessary, the nurse should assist in the referral process.

A nurse is assessing the ECG rhythm strip. The nurse checks the P wave. Which function of the heart is the nurse assessing? Atrial depolarization Atrial repolarization Ventricular depolarization Ventricular repolarization

Atrial depolarization Rationale The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, visualization of atrial repolarization is obscured by the QRS complex. The T wave represents ventricular repolarization.

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? Atrial fibrillation Forearm laceration Migraine headache Respiratory infection

Atrial fibrillation Rationale Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli. Whereas a clot in the lower extremities (DVT) may be more likely to be the cause of a pulmonary embolus (PE), atrial fibrillation can shower clots that do not lodge in the brain (stroke) but make their way to the lungs resulting in a PE. A forearm laceration, migraine headache, or a respiratory infection does not cause venous stasis or blood viscosity that contributes to venous thromboembolism.

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? Cervical Axillary Inguinal Mediastinal

Cervical Rationale Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows after the disease progresses.

A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit, the client's vital signs remained stable for 1 hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first? Check the dressing on the incision Increase the intravenous flow rate Elevate the head of the client's bed Continue monitoring the client's vital signs

Check the dressing on the incision Rationale The data indicate impending shock; the dressing should be assessed for signs of hemorrhage. Although increasing the intravenous flow rate may be done eventually, it is not the priority and requires a primary healthcare provider's prescription. There are no signs of respiratory distress; if hemorrhage is confirmed, the supine position is preferable. The client may be hemorrhaging and needs immediate intervention.

A nurse is caring for a client 8 hours after surgery. The client's portable wound drainage device is half full of drainage. After emptying the drainage collection chamber, how will the nurse create negative pressure in the system? Attaching the device to a wall suction unit Milking the tubing toward the suction device Compressing the device while closing the air plug Keeping the device in a position lower than the site of insertion

Compressing the device while closing the air plug Rationale Compressing the device expels air in the unit, and closing the plug while it is compressed reestablishes the closed system and creates negative pressure. A portable suction device usually is not attached to a mechanical suction machine. Milking the tubing promotes patency but will not create negative pressure. Although a portable wound drainage container is kept below the level of the insertion site, which facilitates drainage by gravity, this will not create negative pressure in the system.

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? Stridor Crackles Wheezes Friction rubs

Crackles Rationale Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are not heard with heart failure, but with asthma. Friction rubs are not heard with heart failure, but with pleurisy.

An electrocardiogram is prescribed for a client complaining of chest pain. The nurse recognizes which as an early finding of an infarcted area of the heart? Flattened T waves Absence of P waves Elevated ST segments Disappearance of Q waves

Elevated ST segments Rationale Elevated ST segments are an early typical finding after a myocardial infarct because of the altered contractility of the heart. Flattened or depressed T waves indicate hypokalemia. Absence of P waves occurs in atrial and ventricular fibrillation. Q waves may become distorted with conduction or rhythm problems, but they do not disappear unless there is cardiac standstill.

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment? Decreased breath sounds Elevated serum troponin I Decreased creatine kinase-MB (CK-MB) Elevated brain natriuretic peptide (BNP) level

Elevated serum troponin I Rationale Elevations of troponin I levels are indicative and specific for cardiac muscle damage. Decreased breath sounds would indicate a pulmonary problem. An increase in CK-MB would indicate MI. Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction.

A 75-year-old client with a history of hypertension has arrived for a routine annual health screening. The nurse obtains a sitting blood pressure in the client's left arm of 160/100 mm Hg. What action should the nurse take next? Advise the client to restrict fluid and sodium intake, then begin to develop a teaching plan for the client. Inform the primary healthcare provider immediately of the client's blood pressure reading. Record the findings, recognizing that the result is expected for an older adult with a history of hypertension. Evaluate the client for symptoms related to extreme hypertension.

Evaluate the client for symptoms related to extreme hypertension. Rationale Further assessment is necessary before the nurse can plan a course of action. Even with a history of hypertension, it is a priority to determine if the client is having symptoms that may require immediate intervention related to the extreme hypertension. Critical symptoms include: severe headache, visual changes, chest pain, and shortness of breath. Getting the blood pressure in a safe range should occur before advising the client to restrict fluid and sodium intake. The nurse must gather more data before consulting with the primary healthcare provider. This is not an expected blood pressure for an older adult.

A client demonstrates signs and symptoms of a transfusion reaction. The nurse immediately stops the infusion; what should the nurse's next action be? Obtain blood pressure in both arms. Send a urine specimen to the laboratory. Hang a bag of normal saline with new tubing. Monitor the intake and output every 15 minutes.

Hang a bag of normal saline with new tubing. Rationale The tubing must be replaced to avoid infusing the blood left in the original tubing; the normal saline infusion will maintain an open line for any further intravenous (IV) treatment. All vital signs should be taken eventually; blood pressure may be taken on either arm, not necessarily both. A urine sample is collected after the blood transfusion is stopped, the tubing replaced, and a bag of normal saline hung. The specimen will be analyzed to determine kidney function. Although the intake, and especially the output, should be monitored to assess kidney function, this is not the priority.

A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, what should the nurse on the medical-surgical unit should monitor the client for? Lethargy Tachycardia Deep breathing Abdominal pain

Tachycardia Rationale Tachycardia is a cardiovascular compensatory mechanism as the effort to circulate the decreasing blood volume intensifies. Lethargy is not an initial response to blood loss. The client is more apt to be restless; lethargy may occur later. Breathing may be rapid, not deep, with blood loss. Abdominal pain is not a response to blood loss.

A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply. Pallor Polyuria Bradypnea Tachycardia Hypertension

Pallor Tachycardia Rationale Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension occurs in response to hemorrhage as the person experiences hypovolemia.

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances? Restrict family visits Withhold analgesic medications Plan for maximum periods of rest Keep the room light on most of the time

Plan for maximum periods of rest Rationale Sleep deprivation alone can cause these disturbances because of the interruption in rapid eye movement (REM) sleep. Lack of contact with significant others increases anxiety and feelings of isolation, which can lead to disturbances in rest. Pain limits or interrupts periods of sleep and rest. Analgesics should be administered as prescribed. Constant light increases cerebral arousal and limits sleep.

A client is prescribed prolonged bed rest after surgery. The nurse expects which complication to possibly occur secondary to a compromised circulation from the calf veins? Cerebral embolism Pulmonary embolism Dry gangrene of a limb Coronary vessel occlusion

Pulmonary embolism Rationale The pulmonary capillary beds are the first small vessels that the embolus encounters once it is released from the calf veins. Pressure on the popliteal space causes venous stasis, promoting thrombus formation. Dry gangrene occurs when the arterial rather than the venous circulation is compromised. The other complications (cerebral embolism and coronary vessel occlusion) will not occur because the embolus will enter the pulmonary system first.

A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include? Keep the stockings on 2 hours and off 2 hours. Wear the stockings only at bedtime when activity decreases. Put the stockings on before rising in the morning. Leave the stockings in place until the primary healthcare provider advises otherwise.

Put the stockings on before rising in the morning. Rationale Support hose apply external pressure on the veins, preventing the retrograde pressure or flow that may occur in the standing or sitting positions; application before rising prevents the veins from having the opportunity to become engorged. If keeping the stockings on 2 hours and off 2 hours is followed, at some point the feet will be dependent before the stockings are put on; venous pooling and edema may occur. Application of elastic stockings at this time can cause tissue trauma. The stockings usually need not be worn while in bed with the feet elevated during sleep, because gravity prevents venous pooling. Stockings must be removed so that the legs can be washed and dried at least daily.

A home care nurse makes an initial visit to a 60-year-old client with heart failure. The client lives with her daughter, who is addicted to drugs and a single parent of seven children. When the nurse enters the home, the client is feeding a 6-month-old granddaughter and preparing dinner for the rest of the family. A 14-year-old grandson, disabled and in a wheelchair, states that his mother is sleeping. What should the nurse do? Sit down with the client and exchange identifying data. Accept coffee when offered by the client and socialize for a few minutes. Ask the client whether it is all right to look around the apartment and evaluate environmental conditions. Question the client to determine whether there is a private place to take a health history and perform an examination.

Question the client to determine whether there is a private place to take a health history and perform an examination. Rationale Collecting a health history, performing a physical assessment, and developing a nurse-client relationship are accomplished best if the environment is quiet and private. This is not the setting for sitting down with the client and exchanging identifying data because there are too many distractions and a lack of privacy. Accepting coffee may be an imposition and is not the best way to develop trust. Assessment of the environment can be done less obviously while interacting with the client.

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first? Raise the client to high-Fowler position Obtain the apical pulse and blood pressure Call the primary healthcare provider immediately Monitor the pulse oximeter to ascertain the oxygen level

Raise the client to high-Fowler position Rationale Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary healthcare provider immediately would not be useful without having a full set of vital signs. The vital signs should include the oxygen saturation, which the healthcare provider would expect the nurse to provide.

After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves? Removing the dilated superficial veins Bypassing the varicosities with artificial veins Stripping the cholesterol deposits from the veins Creating fistulas between superficial and deep veins

Removing the dilated superficial veins Rationale The saphenous vein is ligated at its juncture with the femoral vein; injection sclerotherapy is used as the method of choice, but in chronic venous insufficiency and recurrent thrombophlebitis, surgery may be necessary. A bypass is unnecessary; the deep veins compensate for the removed saphenous vein. Cholesterol plaques are characteristic of atherosclerosis, an arterial, not venous, disease. Communicating veins normally exist between the superficial and deep veins; they are ligated to prevent further engorgement and varicosities.

One week after admission to the cardiac care unit, a client displays an outburst of anger and tells the nurse to get out of the room. Which is the most appropriate nursing action? Administer the prescribed sedative. Return when the client has calmed down. Point out that this behavior is inappropriate. Notify the primary healthcare provider of the client's behavior.

Return when the client has calmed down. Rationale Returning when the client has calmed down indicates recognition that the client's reaction is understandable; it creates a climate of acceptance and eventually promotes expression of feelings. Administering the prescribed sedative delays the client's use of coping responses. Pointing out that this behavior is inappropriate creates a situation in which the client will be hesitant to express any feelings. Notifying the primary healthcare provider of the client's behavior suggests that the nurse is unable to deal with the situation and is unnecessary.

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? "Men your age do very well." "You are worried about dying." "I know you are concerned, but your surgeon is excellent." "I'll get you a sleeping pill tonight because I know you will need it."

You are worried about dying." Rationale "You are worried about dying" is a reflective statement that conveys acceptance and encourages further communication. The response "Men your age do very well" is false reassurance that does not lessen anxiety. The response "I know you are concerned, but your surgeon is excellent" is false reassurance and cuts off communication; this statement does not encourage the client to discuss feelings. The reliance on a pill to help the client in this instance evades the problem and cuts off further communication.

Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that what is the cause of the increase in the client's urinary output? An expected effect of the dye used with the procedure Increased cardiac output as a result of the procedure An improvement of urinary functioning after the catheterization A physiologic effect of the prescribed intravenous (IV) rate of 50 mL/hr

An expected effect of the dye used with the procedure Rationale The dye used is hypertonic and has a diuretic effect. A cardiac catheterization is a diagnostic procedure, not a therapeutic one; it neither improves cardiac function nor increases cardiac output, and it does not improve urinary functioning. An IV rate of 50 mL/hr will not cause a urinary output three times the amount of intake.

A client with varicose veins is scheduled for surgery. Which clinical finding does the nurse expect to identify when assessing the lower extremities of this client? Pallor Ankle edema Yellowed toenails Diminished pedal pulses

Ankle edema Rationale Ankle edema results from increased venous pressure. Pigmentation, not pallor, may occur with varicosities. Yellowed toenails occur with arterial, not venous, insufficiency. Diminished pedal pulses occur with arterial, not venous, insufficiency.

An emergency department nurse is admitting a client after an automobile collision. The primary healthcare provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit? Urine output of 50 mL/hr Blood pressure of 150/90 mm Hg Apical heart rate of 142 beats/min Respiratory rate of 16 breaths/min

Apical heart rate of 142 beats/min Rationale In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood flow to body organs. Urine output would fall to less than 30 mL/hr, because a decreased blood volume causes a decreased glomerular filtration rate. The blood pressure is decreased because of the decreased blood volume. Respiratory rate of 16 breaths/min is within the accepted range of 12 to 20 breaths/min; the respiratory rate is rapid with hypovolemic shock.

A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse? Increased blood volume Hyperactivity of the heart Increased cardiac sufficiency Decreased force of contraction

Decreased force of contraction Rationale A direct relationship exists between systolic blood pressure and the force of left ventricular contraction. A decreased pulse pressure is associated with heart failure or hypovolemia. A decreased blood volume is indicated by a decreased pulse pressure. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac sufficiency.

A client is admitted to the cardiac care unit with a diagnosis of myocardial infarction. The client asks the nurse, "What is causing the pain I am having?" Which explanation of the cause of the pain is the most appropriate response by the nurse? Compression of the heart muscle Release of myocardial isoenzymes Rapid vasodilation of the coronary arteries Inadequate oxygenation of the myocardium

Inadequate oxygenation of the myocardium Rationale Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain.

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment? Signs of shock Visible peristaltic waves Radiating abdominal pain Pulsating abdominal mass

Pulsating abdominal mass Rationale As the heart contracts, an expanding midline mass can be palpated to the left of the umbilicus. Signs of shock are not definitive for an abdominal aortic aneurysm unless the aneurysm ruptures. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not definitive for an abdominal aortic aneurysm.

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness? Hepatitis A Rheumatic fever Spinal meningitis Rheumatoid arthritis

Rheumatic fever Rationale Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the heart's valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of streptococcal infections have limited the occurrence of rheumatic heart disease. Hepatitis A, an inflammation of the liver, is caused by the hepatitis A virus (HAV), not by bacteria. The most common causes of meningitis, an infection of the membranes surrounding the brain and spinal cord, include Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Rheumatoid arthritis is believed to be an autoimmune disorder; it is not caused by microorganisms.

Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon? The increased blood pressure can cause the graft to occlude. The hypervolemia needs to be corrected immediately. The client's cardiovascular status can precipitate a brain attack. The client's intraarterial pressure may compromise the graft's viability.

The client's intraarterial pressure may compromise the graft's viability. Rationale The client is hypertensive, and the intraarterial pressure is elevated; this increased pressure can cause the arterial suture line to rupture. Blood pressure causing the graft to occlude is unlikely because the blood pressure is elevated and the client is at risk for bleeding. Hypervolemia is an assumption; other causes, such as arterial constriction, can precipitate hypertension. Although cardiovascular status can precipitate a brain attack, the priority for this client is protecting the graft.

Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? Troponin Myoglobin Homocysteine Creatine kinase (CK)

Troponin Rationale Troponin is the biomarker of choice for a myocardial infarction. Troponin, specifically subtypes cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI), reflects myocardial muscle protein released into circulation soon after injury. Troponin increases as quickly as CK and remains increased for 2 weeks. Although myoglobin is one of the first cardiac markers to increase after a myocardial infarction (MI), it lacks cardiac specificity. Homocysteine is produced when proteins break down, but it is more indicative of cardiovascular disease than a myocardial infarction. CK isoenzyme levels, especially the creatine phosphokinase (MB) subunit, begin to increase in 3 to 6 hours, peak in 12 to 24 hours, and are increased for 48 hours after the occurrence of the infarct. Although reliable in assisting with an early diagnosis of MI, it is not as sensitive or specific as the troponin test.

A client reports foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. Which client statement indicates to the nurse that further teaching is needed? "I will wear socks." "I will elevate my foot." "I will increase fluid intake." "I will drink a moderate amount of alcohol."

"I will elevate my foot." Rationale Elevating the leg decreases the flow of blood to the lower extremity because it must flow without the assistance of gravity. Wearing socks should be encouraged because it keeps the feet warm, increasing arterial dilation and perfusion. Increasing fluid intake decreases the viscosity of blood, possibly preventing thrombus formation, and should be encouraged. Alcohol in moderation is useful as a drug to stimulate the dilation of blood vessels.

A client who had abdominal surgery 24 hours ago reports pain in the left calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do first? Elevate both legs. Keep both legs dependent. Administer the prescribed analgesic. Administer the prescribed antipyretic.

Elevate both legs. Rationale The clinical findings indicate a possible thrombophlebitis. The legs should be elevated and the healthcare provider notified immediately. A thrombus may progress to a pulmonary embolus. The legs should be kept elevated until the client is evaluated by the healthcare provider. Administering an analgesic for pain may obscure the problem in the calf, place the client in jeopardy, or further delay treatment. Administering an antipyretic is treatment for fever, not a thrombus.

A nurse reviews the plan of care for a client who is recovering from the acute phase of left ventricular failure. Which dietary restriction will the nurse expect to be included in the plan? Sodium Calcium Potassium Magnesium

Sodium Rationale Restriction of sodium reduces the amount of water retention, thus reducing cardiac workload. Calcium is restricted in individuals who develop renal calculi. Potassium is not restricted, especially if a diuretic is prescribed, because this drug facilitates the loss of potassium in the urine. Magnesium is not restricted.

A nurse is teaching a client with Hodgkin disease about responses to whole-body radiation. Which clinical indicator increase should the nurse include in the teaching session? Blood viscosity Susceptibility to infection Red blood cell (RBC) production Tendency for pathologic fractures

Susceptibility to infection Rationale Radiation exposure may lead to depression of the bone marrow, with subsequent insufficient white blood cells (WBCs) to combat infection. There is no increase in the number of cells; therefore viscosity is not increased. RBC production is decreased by radiation. Pathologic fractures are not associated with radiation treatments.

A client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me." What is the best response by the nurse? "A vascular rehabilitation program may help you." "You should be sitting with your feet elevated, not walking." "Try again tomorrow because maybe you will have a better day." "They are not good friends if they are not willing to walk with you."

"A vascular rehabilitation program may help you." Rationale Peripheral vascular rehabilitation includes exercise and walking programs that encourage new growth of vessels around the obstructed artery; this may improve peripheral perfusion and the ability to walk; eventually, walking with friends may be introduced into the walking program. Inactivity is contraindicated; elevation of the legs diminishes peripheral arterial circulation. The response "Try again tomorrow because maybe you will have a better day" provides false reassurance. The response "They are not good friends if they are not willing to walk with you" is an opinion that should be avoided; it does not focus on the client's need to improve walking ability.

Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching? "I'll get pillows for you. I want you to be as rested as possible." "It's not a good idea, but you do look uncomfortable. I'll get one." "We don't allow pillows under the legs because you will get too warm." "A pillow under the knees can result in clot formation because it slows blood flow."

"A pillow under the knees can result in clot formation because it slows blood flow." Rationale Flexing the hips and pressure against the popliteal space impedes venous return, increasing the risk for clot development. Although comfort and rest should be encouraged, placing pillows under the knees is contraindicated. Pillows under the knees produce pressure, not warmth.

A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding? "Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." "Blood enters the heart from the inferior vena cava; it then flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." "Blood enters the heart from the aorta, flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricle, and finally exits through the superior vena cava." "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."

"Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta." Rationale "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta" correctly describes the flow of blood through the heart after birth. The ductus arteriosis is a fetal structure that is not present in the adult heart. Blood enters the right side of the heart via the inferior and superior vena cava; blood flows from the right atrium, to the right ventricle, to the lungs, and then to the left atrium. Blood exits, not enters, the heart from the aorta.

A woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the triage nurse's best response? "Give me your name and address. I am sending an ambulance to your home. You need emergency care." "It sounds as if your cast may be constricting the blood flow in your leg. You probably need a new cast." "It sounds like you are having an allergic response to the medication. Is there someone there who can drive you to the hospital?" "You are experiencing an interaction between your pain and oral contraceptive medications. You need to come to the emergency department now for care."

"Give me your name and address. I am sending an ambulance to your home. You need emergency care." Rationale The client's clinical manifestations, along with the history of a recent fracture, immobilization, and use of an oral contraceptive, suggest a pulmonary embolism. An ambulance will limit the woman's use of her leg, which may prevent further emboli. The client's clinical findings are not indicative of compression syndrome. Tingling, numbness, cool skin, and lack of capillary refill are signs and symptoms of compression syndrome. The clinical manifestations do not support an allergic reaction. An allergic response may cause shortness of breath, but it does not cause calf pain. The client may be experiencing a pulmonary embolism, not an interaction between the two medications.

Several individuals who sustained urgent but nonemergent injuries are seated in the emergency department when an ambulance arrives with a client suspected of having a myocardial infarction. The nurse must explain to the waiting clients that they will have to wait longer for care. Which is the best explanation for the nurse to give? "We will be busy for a while. Unfortunately, we have to take care of this other client first." "I recognize that you have been waiting for quite a while, but it now looks like you will have to wait even longer." "There is going to be an additional delay. The client who just arrived had a heart attack, and that client needs care first." "I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen."

"I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen." Rationale The response "I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen" describes the delay while not divulging the nature of the problem as required by Health Insurance Portability and Accountability Act (HIPAA); Canada: Personal Health Information Protection Act (PHIPA). It requests their patience and indirectly asks for their understanding. Also, they are promised the same conscientious level of care when they are treated. The response "We will be busy for a while. Unfortunately, we have to take care of this other client first" is curt and uncaring. Although the response "I recognize that you have been waiting for quite a while, but it now looks like you will have to wait even longer" requests their patience; it does not explain why there is a delay. The response "There is going to be an additional delay. The client who just arrived had a heart attack, and that client needs care first" violates HIPAA confidentiality requirements.

A client has a mitral valve replacement, and the nurse provides health teaching to promote optimum health. Which client statement supports the nurse's conclusion that the client needs further teaching? "I should wear a Medic Alert bracelet." "I will start a vigorous aerobic exercise program." "I will take antibiotics when I have my teeth repaired." "I should go to the doctor when I get a respiratory infection."

"I will start a vigorous aerobic exercise program." Rationale Strenuous physical exercise should be avoided because the valve may be unable to accommodate the associated increase in cardiac output. The extent of physical exercise should be prescribed by the healthcare provider. A Medic Alert bracelet is advisable to provide information in case of an emergency. Antibiotic prophylaxis is necessary to prevent endocarditis. Respiratory infections may need to be treated with antibiotics because some microorganisms may damage the valves of the heart.

An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? "The prevalence of hypertension is about equal for women of all races." "The higher-risk population is composed of African-American men and women." "The highest-risk population consists of older Caucasian-American men and women." "The prevalence of hypertension is greater for African-American men than for African-American women."

"The higher-risk population is composed of African-American men and women." Rationale African-Americans represent a higher-risk population than Caucasian-Americans for hypertension; the reason is unknown. African-American women are more frequently affected by hypertension than are Caucasian women. African-Americans of both sexes have a higher prevalence than Caucasian-Americans of both sexes. African-American women have a higher risk than African-American men.

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse? "This test will detect your heart sounds." "This test will reflect any heart damage." "This procedure helps us change your heart's rhythm." "The ECG will tell us how much stress your heart can tolerate."

"This test will reflect any heart damage." Rationale Changes in an ECG will reflect the area of the heart that is damaged because of hypoxia. A stethoscope is used to detect heart sounds. Medical interventions, such as cardioversion or cardiac medications, not an ECG, can alter heart rhythm. An ECG will reflect heart rhythm, not change it. Identifying how much stress a heart can tolerate is accomplished through a stress test; this uses an ECG in conjunction with physical exercise.

A client experiences elevated triglycerides and cholesterol. The client appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." Which is the nurse's most appropriate response? "Well, yes, that will certainly lower the amount of your blood fats." "That's good, but be sure to compensate by adding more carbohydrates." "You need some fat to supply the necessary fatty acids, so it's mainly just a need to cut down on the amount of fat you consume." "You need some cholesterol in your diet because your body cannot manufacture it, so just avoid excessive amounts."

"You need some fat to supply the necessary fatty acids, so it's mainly just a need to cut down on the amount of fat you consume." Rationale The essential fatty acids, linoleic acid and linolenic acid, are necessary for muscle tissue integrity, especially of the myocardium. All fats cannot and should not be eliminated from the diet. Carbohydrates do not contain the essential fatty acids, linoleic acid and linolenic acid. The body does manufacture cholesterol.

The nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram. Which clinical finding is most significant when assessing the left extremity before the arteriogram? Mottling of the leg Coolness of the foot Absence of the pedal pulse Thickening of the toenails on the foot

Absence of the pedal pulse Rationale Absence of the left pedal pulse indicates inadequate circulatory status of the left lower extremity. Mottling of the left leg may indicate impaired circulation, but observation of both extremities for comparison is necessary. Coolness of the left foot is a less significant indication of arterial occlusive disease than the absence of a pulse. Thickening of the toenails on the left foot is not as significant as the pulse; this can occur because of inadequate circulation, aging, or fungal infection.

A client is admitted to the emergency department with a blood pressure of 240/150 mm Hg. The client complains of a severe headache, blurred vision, and swelling of the ankles. How should the nurse respond to the clinical manifestations? Obtain a glucose blood sample. Collect urine and blood samples. Assess the client's pulse and respirations. Place the client on bed rest in the supine position.

Assess the client's pulse and respirations. Rationale Baseline pulse and respiratory rates will aid in monitoring treatment efficacy and help identify concurrent problems, such as heart failure and dysrhythmias. It is unnecessary to obtain a glucometer reading; the client's serum glucose level is unrelated to this hypertensive episode. Collecting urine and blood samples is not the priority at this time; this may be done later. Bed rest is appropriate; however, positioning the client in the supine position may precipitate respiratory distress; a semi-Fowler to high-Fowler position should be maintained to facilitate respirations.

A client has left ventricular heart failure. For which clinical indicators should the nurse assess the client? Select all that apply. Ascites Crackles Peripheral edema Dyspnea on exertion Jugular vein distention

Crackles Dyspnea on exertion Rationale Pressure in the pulmonic circulation increases when the left ventricle fails; fluid moves from the intravascular compartment into the alveoli, causing crackles. Pressure in the pulmonic circulation increases when the left ventricle fails; fluid in the alveoli impairs gas exchange, which causes dyspnea on exertion. Ascites, a sign of right ventricular failure, results from an increased hydrostatic pressure in the systemic circulation; fluid moves out of the intravascular compartment into the abdominal cavity. Peripheral edema, a sign of right ventricular failure, results from an increased hydrostatic pressure in the systemic circulation. Fluid moves out of the intravascular compartment into the interstitial compartment. Jugular vein distention, a sign of right ventricular failure, results from hypervolemia.

A blood transfusion of packed cells has been prescribed for a client. The nursing unit is extremely busy. How should the nurse manager delegate for the task of blood administration? Assign a licensed practical nurse (LPN) and a nursing assistant (Canada: continuing care assistant) to verify the blood is correct, and have the LPN monitor the client 15 minutes after hanging the product. Have two registered nurses ascertain that the client identification and blood product are correct with no discrepancies, hang the blood, and check in 15 minutes. Have all identification verified by registered nurses, then have the registered nurse hang the product and monitor the client, staying with the client during the initial 15 minutes. Have the product and name band verified by a registered nurse, hang, and monitor every hour until infused within a 10-hour period or discontinued.

Have all identification verified by registered nurses, then have the registered nurse hang the product and monitor the client, staying with the client during the initial 15 minutes. A blood transfusion of packed cells has been prescribed for a client. The nursing unit is extremely busy. How should the nurse manager delegate for the task of blood administration?

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses? Bladder spasms Polycythemia vera Hypovolemic shock Pulmonary hypertension

Hypovolemic shock Rationale These signs occur with hypovolemic shock because less blood is being circulated to vital centers in the brain. A large loss of blood may occur during and after orthopedic surgery. Urinary retention, not bladder spasms, may occur after general anesthesia. Bladder spasms are associated with intermittent suprapubic pain. Anemia and deep vein thrombosis, not an increase in the total red blood cells (polycythemia vera), tend to occur after a total hip replacement. Polycythemia vera is associated with headache, irritability, and paresthesias of the hands and feet. Atelectasis and pneumonia, not pulmonary hypertension, tend to occur after general anesthesia. Pulmonary hypertension is associated with dyspnea, substernal chest pain, and fatigue.

What is the term for shock associated with a ruptured abdominal aneurysm? Vasogenic shock Neurogenic shock Cardiogenic shock Hypovolemic shock

Hypovolemic shock Rationale When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

A client is recovering from a myocardial infarction. Which action should the nurse take before developing the client's teaching plan? Identify the learning needs of the client. Determine the nursing goals for the client. Explore the use of group teaching for the client. Evaluate the community resources available to the client.

Identify the learning needs of the client. Rationale For teaching to be meaningful, the client must have a need to learn and a readiness to learn. These factors need to be identified before a teaching plan is formulated. Determining the nursing goals for the client eliminates the client from the goal-setting process; active participation by the client increases motivation and retention. Exploring the use of group teaching for the client is not the initial step; learning needs must be determined first to see if group learning is appropriate; also, group learning must be available as an option. Evaluating community resources is not the initial step; assessment of learning needs comes first.

A nurse is caring for a client who had radical neck surgery. For which complication associated with this surgery should the nurse assess this client? Pulmonary edema Cardiogenic shock Atrophy of chest muscles Rupture of the carotid artery

Rupture of the carotid artery Rationale Because of the proximity of the carotid artery to the surgical area and the possibility that age or the disease process has weakened the carotid artery, the client should be monitored for signs of hemorrhage related to carotid rupture. Pulmonary edema and cardiogenic shock are related to cardiac decompensation, which are not expected complications of radical neck surgery. With a radical neck dissection the trapezius muscle, not chest muscles, may atrophy.

A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse? Identifying the concerns and helping the client explore feelings Telling the client that it is important to be especially careful with diet and stress Suggesting that the client discuss the feelings of vulnerability with the primary healthcare provider Understanding that the client is frightened and suggesting a talk with the psychiatric nurse

Identifying the concerns and helping the client explore feelings Rationale The nurse must first analyze the feelings that are implied in the client's question and reflect these to help the client verbalize and explore them; the focus is on collecting more data. Although telling the client that it is important to be especially careful with diet and stress may be true, it does not respond to the feelings implicit in the client's comment. The suggestion that the client discuss feelings of vulnerability with the primary healthcare provider avoids responsibility of helping the client explore feelings; it cuts off communication. No data presented at this time suggest that a referral to a psychiatric nurse is warranted. This response also cuts off communication when the client has expressed a need; the nurse is avoiding responsibility to assist the client.

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition? Loss of cellular constituents in blood Rapid osmosis from tissue spaces to cells Increased pressure within the circulatory system Rapid diffusion of solutes and solvents into plasma

Increased pressure within the circulatory system Rationale Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure, fluid moves into the tissues, causing edema, and into the abdominal cavity, causing ascites; ascites leads to an increased abdominal girth. There is no loss of the cellular constituents in blood with right ventricular heart failure. Ascites is the accumulation of fluid in an extracellular space, not intracellular. The opposite of rapid diffusion of solutes and solvents into plasma results when there is a pressure increase in the systemic circulation.

A client who recently was diagnosed as having myelocytic leukemia discusses the diagnosis by referring to statistics, facts, and figures. The nurse determines that the client is using which defense mechanism? Projection Sublimation Identification Intellectualization

Intellectualization Rationale Intellectualization is the use of reasoning and thought processes to avoid the emotional aspects of a situation; this is a defense against anxiety. Projection is denying unacceptable traits and regarding them as belonging to another person. Sublimation is a defense wherein the person redirects the energy of unacceptable impulses into socially acceptable behaviors or activities. Identification is the reduction of anxiety by imitating someone respected or feared.

A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention? Monitor the vital signs every 15 minutes Maintain the client in the supine position Keep the client's lower extremities in extension Administer the prescribed oxygen at 4 L/min via nasal cannula

Monitor the vital signs every 15 minutes Rationale A cardiac catheterization may cause cardiac irritability; therefore the client's vital signs should be monitored every 15 minutes for 1 hour and then every 30 minutes for the next 2 hours until stable. The vital signs may then be monitored every 4 hours. When a brachial artery is used for catheter insertion, a low-Fowler, not supine, position usually is recommended because it promotes respirations. Keeping the client's lower extremities in extension is not necessary. A brachial, not femoral, artery was used for the catheter insertion. Although administering the prescribed oxygen at 4 L/min via nasal cannula may be done, it is not the priority. The client's response to the procedure is the priority.

What clinical finding should the nurse expect when assessing a client who had a splenectomy? Lung crackles Pain on inspiration Shortness of breath Excessive secretions

Pain on inspiration Rationale Because of the location of the spleen, expansion of the thoracic cavity during inspiration causes pain at the operative site. The presence of crackles indicates accumulation of secretions, which is not an expected outcome; nursing care is designed to prevent this complication. Because limited activity decreases oxygen consumption, shortness of breath is not a common complaint. Excessive secretions are not expected; accumulation of secretions can be prevented by coughing and deep breathing.

A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical? Edema of the feet and ankles Reddened and painful areas on the calves Pain when exercising and thickening of the toenails Ulcers around the ankles and reports of a dull ache in the legs

Pain when exercising and thickening of the toenails Rationale Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these adaptations may be associated with decreased cardiac output related to heart failure.

The left foot of a client with a history of intermittent claudication becomes increasingly cyanotic and numb. Gangrene of the left foot is diagnosed, and because of the high level of arterial insufficiency, an above-the-knee amputation (AKA) is scheduled. Which response by the client best demonstrates emotional readiness for the surgery? Explains the goals of the procedure Displays few signs of anticipatory grief Participates in learning perioperative care Verbalizes acceptance of permanent dependency needs

Participates in learning perioperative care Rationale Active participation in self-care indicates a readiness to learn; it demonstrates that the client is interested in future expectations. Explaining the goals of the procedure may indicate intellectual readiness but not necessarily emotional readiness. An expected change in body image precipitates the grieving process; a client may be in denial if no concerns are expressed. The client need not be dependent permanently; verbalizing acceptance of permanent dependency needs indicates the need for more teaching and emotional support.

A client is admitted to the hospital for surgical replacement of the mitral valve with a mechanical valve. Which risk factor would be the primary reason that the nurse must frequently check pulses in the client's legs after surgery? Atrial fibrillation Postsurgical bleeding Arteriovenous shunting Peripheral thromboembolism

Peripheral thromboembolism Rationale Depending on the type of replacement mitral valve used during surgery, thrombus formation on the valve surface with subsequent emboli has the highest risk of occurring with mechanical valves, which require long-term anticoagulation therapy. Atrial fibrillation is assessed by cardiac monitoring and comparing peripheral and apical pulses for deficit. Bleeding is detected by checking the wound dressing and observing for signs of shock (e.g., lowered blood pressure, tachycardia, restlessness). Arteriovenous shunting is not a danger after mitral valve replacement.

A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client. What should the plan include? Eliminating travel plans to combat anemia-related fatigue Reinforcing a positive mental attitude to improve prognosis Preventing infection; the client is at risk for leukopenia Restricting fluid intake; the client is at risk for congestive heart failure

Preventing infection; the client is at risk for leukopenia Rationale The bone marrow is impaired with multiple myeloma; the effectiveness of white blood cells and immunoglobulin is reduced, which increases susceptibility to bacterial infections. Travel can be accomplished with careful planning and adequate rest periods. Although a positive mental attitude can contribute to quality of life and may even extend life, generally it does not change the prognosis. The client is encouraged to drink plenty of fluids to help dilute the Bence Jones protein fragments in the urine, which may help prevent kidney damage.

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding? Sinus tachycardia Normal sinus rhythm Sinus rhythm with premature atrial contractions (PACs) Sinus bradycardia with premature ventricular contractions (PVCs)

Sinus rhythm with premature atrial contractions (PACs) Rationale A PAC is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.12 seconds. P and QRS waves are consistent in shape. Bradycardia is defined as a heart rate less than 60 beats per minute.

The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip? First degree atrioventricular (AV) block Second degree AV block Mobitz I (Wenckebach) Second degree AV block Mobitz II Third degree AV block (complete heart block)

Third degree AV block (complete heart block) Rationale Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second-degree AV block type I, also called Mobitz I or Wenckebach heart block, is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s).

A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction? This prevents an increase in blood pressure from tissue edema. This reduces the circulating blood volume by a diuretic effect. This reduces the amount of edema, which interferes with heart action. This prevents further fluid accumulation, which increases the workload of the heart.

This prevents further fluid accumulation, which increases the workload of the heart. Rationale An increase in total body fluid causes an increase in intravascular volume and cardiac workload. Salt in the diet contributes to fluid retention and edema. Fluid in the interstitial compartment will not increase blood pressure. Excess fluid in the intravascular compartment will increase blood pressure. Limiting sodium will not have a diuretic effect; it will reduce additional fluid retention. Diuretics, not a sodium-restricted diet, reduce the amount of edema present, which interferes with heart action.