Evolve: Cardiovascular, Blood, and Lymphatic System

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Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)? 1 "Increase your intake of fiber and fluid." 2 "Take the medication before you go to bed." 3 "Check your pulse before taking the medication." 4 "Contact your health care provider if your skin or sclera turn yellow."

1 "Increase your intake of fiber and fluid." Fiber and fluids help prevent the most common adverse effect of constipation and its complication, fecal impaction. The medication should be taken with meals. The pulse is not affected. Cholestyramine binds bile in the intestine; therefore, it reduces the incidence of jaundice.

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? 1 Cervical 2 Axillary 3 Inguinal 4 Mediastinal

1 Cervical 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 with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client? 1 Decreased white blood cells 2 Increased C-reactive protein 3 Increased sedimentation rate 4 Decreased serum glucose levels

1 Decreased white blood cells Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. Increased C-reactive protein and sedimentation rate elevate in acute inflammatory diseases; steroids help decrease it. Serum glucose levels increase with steroid use.

A client comes to the emergency department complaining of weakness and dizziness. The blood pressure is 90/60, pulse is 92 and weak, and body weight reflects a 3-pound loss in two days. The weather has been hot. The nurse concludes that the biggest concern for this client is: 1 Deficient fluid volume 2 Impaired skin integrity 3 Inadequate nutritional intake 4 Decreased participation in activities

1 Deficient fluid volume The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid.

The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? 1 Dependent edema in the evening 2 Chest pain that decreases with rest 3 Palpitations in the chest when resting 4 Frequent coughing with yellow sputum

1 Dependent edema in the evening Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.

A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of: 1 Digoxin (Lanoxin) 2 Captopril (Capoten) 3 Morphine sulfate (MS Contin) 4 Furosemide (Lasix )

1 Digoxin (Lanoxin)

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (Bumex) and digoxin (Lanoxin). What does the nurse determine is the cause of the depletion? 1 Diuretic therapy 2 Sodium restriction 3 Continuous dyspnea 4 Inadequate oral intake

1 Diuretic therapy Diuretic therapy that affects the loop of Henle generally involves the use of drugs (e.g., bumetanide) that directly or indirectly increase urinary sodium, chloride, and potassium excretion. Sodium restriction does not necessarily accompany administration of bumetanide. Dyspnea does not directly result in a depletion of electrolytes. Unless otherwise prescribed, oral intake is unaffected.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? 1 Feeling of heaviness in both legs. 2 Intermittent claudication of the legs. 3 Calf pain on dorsiflexion of the foot. 4 Hematomas of the lower extremities

1 Feeling of heaviness in both legs. Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homan sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.

A client develops iron deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased? 1 Ferritin level 2 Platelet count 3 White blood cell count 4 Total iron-binding capacity

1 Ferritin level Ferritin, a form of stored iron, is reduced with iron deficiency anemia. Platelets will be within the expected range or increased with iron deficiency anemia. Red, not white, blood cells are decreased with iron deficiency anemia. Total iron-binding capacity will be increased with iron deficiency anemia.

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. What recommendation by the nurse will help the client maintain blood vessel patency? 1 Practice relaxation techniques 2 Lead a more sedentary lifestyle 3 Decrease the amount of exercise 4 Increase saturated fats in the diet

1 Practice relaxation techniques

How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction? 1 Replace the top linen and only the necessary bottom linen. 2 Lift the client from side to side while changing the bed linen. 3 Change the linen from top to bottom without lowering the head of the bed. 4 Slide the client onto a stretcher to remake the bed and then slide the client back to the bed.

1 Replace the top linen and only the necessary bottom linen. Until a client's condition has reached some degree of stability after a myocardial infarction, routine activities such as changing sheets are avoided so that the client's movements will be minimized and the cardiac workload reduced. Lifting the client from side to side while changing the bed linen is contraindicated because it increases oxygen consumption and cardiac workload; also, it may strain the health team members who are lifting the client. Changing all the linen causes unnecessary movement, which increases oxygen demand and makes the heart work harder. Any activity is counterproductive to rest; rest must take precedence so that the cardiac workload is reduced.

A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. The nurse expects the client to describe the chest pain as: 1 Severe, intense 2 Burning and of short duration 3 Mild, radiating toward the abdomen 4 Squeezing, relieved by Maalox

1 Severe, intense

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to: 1 Stop the transfusion 2 Obtain the vital signs 3 Assess the pain further 4 Monitor the hourly urinary output

1 Stop the transfusion

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1 Syncope 2 Headache 3 Tachycardia 4 Hemiparesis

1 Syncope With complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope. Headache is not related to heart block. The heart rate usually is slow because the ventricular rhythm is not initiated by the SA node. Hemiparesis is not related to heart block unless decreased cerebral perfusion causes a brain attack.

The nurse provides discharge medication education to a client who has been switched from a prescription for heparin to a prescription for warfarin sodium (Coumadin). The nurse concludes that the teaching was effective when the client states, "I will: 1 Take acetaminophen (Tylenol) for my occasional headaches." 2 Spend most of the day working at my desk." 3 Ask my health care provider for antibiotics before going to the dentist." 4 Make an appointment to have a complete blood count drawn."

1 Take acetaminophen (Tylenol) for my occasional headaches." Acetaminophen should be used when an analgesic is required because it does not interfere with platelet aggregation. Acetylsalicylic acid (aspirin) should be avoided because it interferes with platelet aggregation. Immobility causes venous pooling and can predispose the client to deep vein thrombosis. Antibiotics are not necessary when going to the dentist; this is done when clients have cardiac problems, such as rheumatic fever or cardiac surgery. A prothrombin time (PT) or international normalized ratio (INR), not a complete blood count, needs to be done periodically.

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? 1 They help the venous blood return to the heart. 2 They will not cause discomfort, but gently massage the legs. 3 They are used instead of anticoagulant therapy. 4 They must be worn until the first time the client gets out of bed

1 They help the venous blood return to the heart. Deep vein thrombosis (DVT) is a potential complication of any surgery lasting longer than 30 minutes. The purpose of pneumatic compression devices is to increase venous return. Clients often complain about pneumatic compression devices being hot and itchy. In addition to the pneumatic compression devices, a mechanical form of DVT prophylaxis, pharmaceutical prophylaxis is often required. Pneumatic compression devices are continued until the client is up ambulating frequently throughout the day.

What is the most objective way that a nurse can assess the extent of edema in a client? 1 Weighing the client 2 Monitoring the intake and output 3 Performing the Trendelenburg test 4 Assessing the extent of pitting edema

1 Weighing the client One liter of fluid weighs approximately 2.2 pounds; weight reflects subtle changes in fluid balance. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. The Trendelenburg test facilitates assessment of venous peripheral vascular disease, not the extent of edema. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client.

1 1 Decreased white blood cells Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. Increased C-reactive protein and sedimentation rate elevate in acute inflammatory diseases; steroids help decrease it. Serum glucose levels increase with steroid use.

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg, the second sound is a swishing sound heard at 130 mm Hg, a tapping sound is heard at 100 mm Hg, a muffled sound is heard at 90 mm Hg, and the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1 72 mm Hg 2 90 mm Hg 3 100 mm Hg 4 130 mm Hg

1 72 mm Hg

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? (Select all that apply.) 1 Absence of hair on the toes 2 Superficial ulcer with irregular edges 3 Pitting edema of the lower extremities 4 Reports of pain associated with exercising 5 Increased pigmentation of the medial malleolus area

1 Absence of hair on the toes 4 Reports of pain associated with exercising The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when arterial flow is impaired. A superficial ulcer with irregular edges is associated with venous insufficiency; the ulcer associated with arterial insufficiency is deep, well demarcated, and may be gangrenous. Pitting edema of the lower extremities is associated with venous insufficiency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency and occurs as a result of degeneration of red blood cells (RBCs) that leak into surrounding tissue.

A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? (Select all that apply.) 1 Anemia 2 Dyspnea 3 Jaundice 4 Anasarca 5 Hyperexcitability

1 Anemia 2 Dyspnea 4 Anasarca (extreme generalized edema)

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? (Select all that apply.) 1 Anxiety 2 Chest pain 3 Irregular pulse 4 Fear of losing control 5 Feelings of depersonalization

1 Anxiety 2 Chest pain 3 Irregular pulse Anxiety is associated with both myocardial infarctions and panic attacks. The overwhelming chest pain that usually accompanies a myocardial infarction, due to myocardial ischemia, precipitates a feeling of impending death. Most people who have panic attacks eventually recognize that they are not going to die as a result of the attack. Chest pain is associated with both myocardial infarctions and panic attacks. Chest pain is associated with a myocardial infarction because of myocardial ischemia. It is often described as "vice-like" or "crushing" in nature. The chest discomfort during a panic attack usually is not as severe as the pain associated with a myocardial infarction. Dysrhythmias often accompany a myocardial infarction because the functioning of the electrical pathways and cardiac muscles in the heart is impaired. Clients having a panic attack may have palpitations and tachycardia. Fear of losing control usually is not a characteristic associated with a myocardial infarction. Fear of losing control or going crazy is among the criteria of the DSM-IV-TR for the diagnosis of panic attacks. A feeling of depersonalization is not a characteristic associated with a myocardial infarction. Depersonalization (feeling detached from the self) and derealization (feelings of unreality) are among the criteria of the DSM-IV-TR for the diagnosis of panic attacks.

A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? (Select all that apply.) 1 Avoid intramuscular injections. 2 Institute neutropenic precautions. 3 Monitor the white blood cell count. 4 administer prescribed anticoagulants. 5 Examine the skin for ecchymotic areas

1 Avoid intramuscular injections 5 Examine the skin for ecchymotic Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased white blood cells (WBCs), not platelets. Thrompbocytopenia refers to decreased platelets, not WBCs. Anticoagulants are contraindicated because of the increased bleeding risk.

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? (Select all that apply.) 1 Celery sticks 2 Ground beef 3 Fresh salmon 4 Luncheon meat 5 Cooked broccoli

1 Celery sticks 4 Luncheon meat Celery sticks are high in sodium and should be avoided. Luncheon meats are processed and have high sodium levels to help with their preservation and should be avoided. Beef is lower in sodium than are preserved meats; however, beef is high in saturated fat. Canned salmon is high in sodium, but fresh salmon is not. Broccoli does not have significant sodium levels.

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? 1 Cervical 2 Axillary 3 Inguinal 4 Mediastinal

A beta-blocker, atenolol (Tenormin), is prescribed for a client with moderate hypertension. What information should the nurse include when teaching the client about this medication? (Select all that apply.) 1 Change positions slowly 2 Take the medication before going to bed 3 Count the pulse before taking the medication 4 Mild weakness and fatigue are common side effects 5 It is safe to take concurrent over-the-counter (OTC) medications

1 Change positions slowly 3 Count the pulse before taking the medication 4 Mild weakness and fatigue are common side effects

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? (Select all that apply.) 1 Coughing 2 Orthopnea 3 Diaphoresis 4 Yellow sputum 5 Dependent edema

1 Coughing 2 Orthopnea 3 Diaphoresis Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Fluid in the pulmonary interstitial space and alveoli interferes with gas exchange. Sitting upright while leaning forward with the arms supported is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. Cold, clammy skin occurs from vasoconstriction caused by stimulation of the sympathetic nervous system. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood-tinged. When pulmonary pressure increases, cells in the alveoli lining are disrupted, and fluid that contains red blood cells moves into the alveoli. Pulmonary interstitial edema, not dependent edema, occurs.

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? (Select all that apply.) 1 Decreased urine 2 Hypotension 3 Dyspnea 4 Dry mucous membranes 5 Pulmonary edema 6 Poor skin turgor

1 Decreased urine 2 Hypotension 4 Dry mucous membranes 6 Poor skin turgor

1 Decreased urine 2 Hypotension 4 Dry mucous membranes 6 Poor skin turgor 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.

A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? (Select all that apply.) 1 Dependent edema 2 Distended abdomen 3 Polyuria at night 4 Collapsed neck veins 5 Cool extremities

1 Dependent edema 2 Distended abdomen 3 Polyuria at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by dependent edema, a distended abdomen, and polyuria at night. With left ventricular systolic dysfunction, cardiac output is diminished, leading to impaired tissue perfusion. Collapsed neck veins and cool extremities are key features of left-sided heart failure.

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? (Select all that apply.) 1 Dependent rubor 2 Warm extremities 3 Ulcers on the toes 4 Thick, hardened skin 5 Delayed capillary refill

1 Dependent rubor 3 Ulcers on the toes 5 Delayed capillary refill Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill greater than three seconds. Warm extremities and thick, hardened skin occur in the presence of venous disease. 26%of students nationwide answered this question correctly.

What clinical indicators are the nurse most likely to identify when taking the admission history of a client with right ventricular failure? (Select all that apply.) 1 Edema 2 Vertigo 3 Polyuria 4 Dyspnea 5 Palpitations

1 Edema 4 Dyspnea Heart failure is the failure of the heart to pump adequately to meet the needs of the body, resulting in a backward buildup of pressure in the venous system. Clinical manifestations include edema, ascites, hepatomegaly, tachycardia, dyspnea, and fatigue. Dyspnea occurs because of pulmonary congestion and inadequate delivery of oxygen to all body cells. Vertigo generally is not related to right ventricular failure. Because a diminished cardiac output decreases blood flow to the kidneys, there will be a decreased, not increased, urine output. Palpitations may indicate coronary insufficiency or infarction.

Which factors should the nurse identify that can precipitate hyponatremia? (Select all that apply.) 1 Gastrointestinal (GI) suction 2 Diuretic therapy 3 Inadequate antidiuretic hormone (ADH) secretion 4 Continuous bladder irrigation 5 Parenteral infusion of 0.9% sodium chloride

1 Gastrointestinal (GI) suction 2 Diuretic therapy 4 Continuous bladder irrigation

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? (Select all that apply.) 1 Iced tea 2 Red meat 3 Club soda 4 Hot cocoa 5 Chocolate pudding

1 Iced tea 4 Hot cocoa 5 Chocolate pudding Tea contains caffeine, which stimulates catecholamine release and acts as a cardiac stimulant; tea should be avoided. Hot cocoa contains chocolate, which contains caffeine; it stimulates catecholamine release and acts as a cardiac stimulant. Cocoa should be avoided. The chocolate in chocolate pudding has a high caffeine content, which may stimulate catecholamine release and act as a cardiac stimulant; chocolate should be avoided. Red meat does not stimulate the myocardium; however, it should be decreased or eliminated if serum cholesterol levels are elevated. Club soda does not contain caffeine and does not stimulate the myocardium; however, most club sodas contain sodium, which promotes fluid retention and should be avoided by a client with a cardiac condition.

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? (Select all that apply.) 1 Malaise 2 Confusion 3 Constipation 4 Swollen lymph glands 5 Oropharyngeal candidiasis

1 Malaise 4 Swollen lymph glands Development of HIV-specific antibodies (seroconversion) is accompanied by a flulike syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs one to three weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flulike syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or opportunistic infection that affects the neurological system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection.

A client is receiving total parenteral nutrition solution. Potassium has not been added to the solution. The nurse monitors the client for which signs of hypokalemia? (Select all that apply.) 1 Muscle weakness 2 Metabolic alkalosis 3 Cardiac dysrhythmias 4 Serum potassium of 5.5 mEq/L 5 Respiratory rate of 24 or higher

1 Muscle weakness 3 Cardiac dysrhythmias Potassium is a component of the sodium-potassium pump that is essential for cellular functioning, especially muscle contraction; a deficiency of either potassium or sodium results in weakness. Potassium is important for muscle contraction; the heart is a muscle and hypokalemia causes dysrhythmias. Decreased functioning of respiratory muscles may result in respiratory acidosis. A serum potassium level of 5.5 is within the upper range of normal. A low respiratory rate, not a rapid one, would be expected because of the weakened respiratory muscles.

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding? 1 Oliguria 2 Bradypnea 3 Pulse deficit 4 High potassium levels

1 Oliguria A decreased blood volume leads to a decreased blood pressure and glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, resulting in decreased urine output. The respirations become rapid and shallow to compensate for decreased cellular oxygenation. The peripheral pulse rate may be rapid and thready, but it is the same rate as the apical rate. Hypokalemia, not hyperkalemia, occurs because as sodium is retained, potassium is excreted.

A client develops internal bleeding after an abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? (Select all that apply.) 1 Pallor 2 Polyuria 3 Bradypnea 4 Tachycardia 5 Hypertension

1 Pallor 4 Tachycardia 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 has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? (Select all that apply.) 1 Raisins 2 Squash 3 Carrots 4 Spinach 5 Apricots

1 Raisins 4 Spinach Raisins and spinach are high in iron. Although squash contains some iron, it is not the best source. Although carrots contain some iron, they are not the best source Although apricots contain some iron, they are not the best source.

A nurse has administered sublingual nitroglycerine. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerin? 1 Relief of anginal pain 2 Improved cardiac output 3 Decreased blood pressure 4 Dilation of superficial blood vessels

1 Relief of anginal pain

A woman comes to the emergency department reporting signs and symptoms determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? (Select all that apply.) 1 Severe fatigue 2 Sense of unease 3 Choking sensation 4 Chest pain relieved by rest

1 Severe fatigue 2 Sense of unease

1 Severe fatigue 2 Sense of unease A myocardial infarction in women may be asymptomatic, atypical, or mild. Unique symptoms include overwhelming fatigue, a sense of uneasiness, indigestion, and shoulder tenderness . A sense of unease is a unique characteristic of a myocardial infarction in women. The client knows something is not right but cannot identify what it is. This uneasiness often is disregarded by the client. A choking sensation occurs in both men and women with a myocardial infarction. Chest pain relieved by rest occurs in both men and women with angina; it is caused by coronary artery spasms leading to myocardial ischemia. Angina frequently is a precursor to a myocardial infarction. Pain radiating down the left arm occurs in both men and women. It can radiate also to the neck, lower jaw, left arm, left shoulder, and, less frequently, the right arm and back.

1 Severe, intense

A client is discharged with a prescription for sustained-release nitroglycerin. What should the nurse teach the client about sustained-release nitroglycerin? 1 Swallow the capsule whole 2 Take milk with the medication 3 Hold the tablet under the tongue 4 Note a stinging feeling when the drug is under the tongue

1 Swallow the capsule whole The sustained-release capsule should be swallowed whole on an empty stomach. The capsule should not be chewed or crushed because the "beads" within the capsule are activated on a time-release schedule. Taking the capsule on an empty stomach promotes absorption of the drug. The sustained-release capsule is taken on an empty stomach. A sublingual tablet is held under the tongue, not swallowed; sustained release nitroglycerin is a capsule that needs to be swallowed. A stinging feeling when the drug is under the tongue may occur with a sublingual nitroglycerin tablet; sustained-release nitroglycerin is a capsule that should be swallowed whole.

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1 Syncope 2 Headache 3 Tachycardia 4 Hemiparesis

1 Take acetaminophen (Tylenol) for my occasional headaches."

Laboratory results of a client's blood after chemotherapy indicate bone marrow depression. What should the nurse encourage the client to do? (Select all that apply.) 1 Use a soft toothbrush. 2 Sleep with the head of the bed elevated. 3 Increase activity levels and take frequent walks. 4 Drink more citrus juices and eat more citrus fruits. 5 Read the ingredients in over-the-counter drugs before taking them

1 Use a soft toothbrush. 5 Read the ingredients in over-the-counter drugs before taking them

A male 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? 1 "I must touch the shunt several times a day to feel for the bruit." 2 "I have to take his blood pressure every day in the arm with the fistula." 3 "He will have to be very careful at night not to lie on the arm with the fistula." 4 "We really should check the fistula every day for signs of redness and swelling.

2 "I have to take his blood pressure every day in the arm with the fistula." 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. Exsanguination 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 client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the health care provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? 1 "I'm glad to hear you have felt well enough to stop the medication." 2 "It is important to take your medications daily to achieve optimal results." 3 "You must be quite frightened about having high blood pressure." 4 "You will need to document daily whether you took your medication or not."

2 "It is important to take your medications daily to achieve optimal results."

A nurse is caring for a client who is a victim of trauma and is to receive a blood transfusion. How should the nurse respond when the client expresses fear that acquired immunodeficiency disease (AIDS) may be acquired as a result of the blood transfusion? 1 "The blood is treated with radiation to kill the virus." 2 "Screening for the human immunodeficiency virus (HIV) antibodies has minimized this risk." 3 "The ability to directly identify HIV has eliminated this concern." 4 "Consideration should be given to donating your own blood for transfusion."

2 "Screening for the human immunodeficiency virus (HIV) antibodies has minimized this risk." Although blood is screened for the antibodies, there is a period between the time a potential donor is infected and the time when antibodies are detectable; there is still a risk, but it is minimal. There is no current method of destroying the virus in a blood transfusion. The screening tests involve identification of the antibody, not the virus itself; the virus can be identified by the polymerase chain reaction test but is not part of routine screening. Although many people consider autotransfusion for elective procedures, a trauma victim does not have this option.

A client is admitted to the postanesthesia care unit after surgery and electronic blood pressure monitoring is to be performed. The nurse should assess the client's blood pressure every: 1 3 to 5 minutes 2 10 to 15 minutes 3 20 to 30 minutes 4 40 to 60 minutes

2 10 to 15 minutes

A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client? 1 Pallor 2 Ankle edema 3 Yellowed toenails 4 Diminished pedal pulses

2 Ankle edema Ankle edema results from venous pooling with increased hydrostatic pressure; fluid moves from intravascular to interstitial spaces. Pigmentation, not pallor, may occur with varicosities. Yellowed toenails occur with arterial, not venous, insufficiency. Diminished pedal pulses occur with arterial, not venous, insufficiency.

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? 1 History of hypertensive disease 2 Emboli associated with atrial fibrillation 3 Developmental defect of the arterial wall 4 Inappropriate paroxysmal neural discharge

2 Emboli associated with atrial fibrillation

A nurse is caring for a client who has a prescription for a diuretic, 2-gram sodium diet, and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) level 42 mg/dL and creatinine 1.1 mg/dL. Considering the assessment findings, what is the most appropriate intervention by the nurse? 1 Sending the client's urine for analysis 2 Expecting an increase in the oral fluid intake 3 Placing the client on strict intake and output measurements 4 Notifying a nutritionist/dietitian so that sodium can be restricted further

2 Expecting an increase in the oral fluid intake

An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid and the serum electrolyte value demonstrates hyponatremia. The nurse concludes that the element that most likely contributed to the hyponatremia is: 1 Salt intake 2 Fluid intake 3 Sodium absorption 4 Glomerular filtration

2 Fluid intake Hemodilution has occurred because the 1500 mL of intravenous fluid has lowered the serum sodium level. An increase in salt intake is not the cause of the hyponatremia; in addition, the client has not eaten for several days. A decreased, not increased, reabsorption of sodium occurs in acute renal failure. A decreased, not increased, glomerular filtration rate occurs with renal failure.

What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1 Arterial spasm 2 Heart muscle ischemia 3 Blocking of the coronary veins 4 Irritation of nerve endings in the cardiac plexus

2 Heart muscle ischemia Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.

The nurse is providing care for a client that had an endarterectomy one month ago. The nurse explains the reason that clopidogrel (Plavix) is being prescribed. The nurse concludes that the teaching is understood when the client says, "The medication will: 1 Limit inflammation around my incision." 2 Help prevent further clogging of my arteries." 3 Lower the slight fever I have had since surgery." 4 Reduce the discomfort I feel at the surgical incision."

2 Help prevent further clogging of my arteries." Clopidogrel interferes with platelet aggregation, which impedes the formation of thrombi. Clopidogrel is a platelet aggregation inhibitor, not an anti-inflammatory. Clopidogrel is a platelet aggregation inhibitor, not an antipyretic. Clopidogrel is a platelet aggregation inhibitor, not an analgesic.

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common? 1 Increased urinary output 2 Increased cardiac workload 3 Decreased oxygen saturation 4 Decreased arterial blood pressure

2 Increased cardiac workload With anemia, the heart works harder to compensate for the reduced oxygen-carrying ability of the blood. With polycythemia, the heart works harder to propel more viscous blood through the circulatory system. Urinary output is not increased; it may be decreased to maintain blood volume in anemia and decrease blood viscosity in polycythemia. The percent of hemoglobin molecules saturated with oxygen is not affected. Clients with polycythemia will have increased blood pressure because of increased viscosity of the blood.

A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home? 1 No further drainage from the incisions 2 Increased edema in the leg that provided the donor graft 3 Mild incisional pain and tenderness for three to four weeks 4 Extreme fatigue and a mild fever occurring for several weeks

2 Increased edema in the leg that provided the donor graft Because the client is out of bed more at home and the leg used for the donor graft is in the dependent position, edema of this extremity usually increases. The internal mammary artery is the graft of choice and was probably used in the first CABG procedure, necessitating retrieval of a vessel from the leg. Serosanguinous drainage may persist after discharge. Mild incisional pain and tenderness may persist longer than 3 to 4 weeks because it takes 6 to 12 weeks for the sternum to heal. Extreme fatigue and a mild fever are not expected; these are associated with post-pericardiotomy syndrome and should be reported to the health care provider immediately.

A client with a history of hypertension develops dyspnea on exertion. What does the nurse conclude is the most likely cause of the client's dyspnea? 1 Cor pulmonale 2 Left heart failure 3 Bronchial spasms 4 Right ventricular failure

2 Left heart failure The failing left ventricle cannot accept blood that is returning from the lungs; this results in increased vascular pressure in the lungs. Cor pulmonale is associated with right ventricular failure. Bronchial spasms are associated with asthma. There is no evidence that the client has asthma. Right ventricular failure is associated with distended neck veins, hepatomegaly, anorexia, diminished urinary output, and respiratory distress.

When two nurses are getting an older adult out of bed, the client reports feeling lightheaded. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? 1 Slide slowly to the floor to prevent a fall and injury. 2 Sit on the edge of the bed while they hold the client upright. 3 Bend forward because this will increase blood flow to the brain. 4 Lie down quickly so the legs can be raised above the heart level.

2 Sit on the edge of the bed while they hold the client upright.

A client with stage III-B Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the health care provider to seek treatment for which response to chemotherapy? 1 Fever of 100° F 2 Sores in the mouth 3 Moderate diarrhea after treatment 4 Nausea for six hours after treatment

2 Sores in the mouth Stomatitis is a common response to chemotherapy and should be brought to the health care provider's attention because a swish-and-swallow anesthetic solution can be prescribed to make the client more comfortable. Although a low-grade fever may occur, it does not require immediate medical attention. Moderate diarrhea is expected and is not a cause for concern unless dehydration results. Nausea is expected but should be reported if it lasts more than 24 hours.

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will: 1 Turn off clients' IVs that have infiltrated." 2 Take clients' vital signs after their procedures are over." 3 Use unit written materials to teach clients before surgery." 4 Help by giving medications to clients who are slow in taking pills.

2 Take clients' vital signs after their procedures are over."

A nurse provides instruction when the beta-blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? 1 Move slowly when changing positions. 2 Take the medication before going to bed. 3 Expect to feel drowsy when taking this drug. 4 Count the pulse before taking the medication.

2 Take the medication before going to bed. Beta blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure. Therefore, the drug should be taken early in the morning to maximize its therapeutic effect. Orthostatic hypotension is a side effect of BBs, and the client should change positions slowly to prevent dizziness and falls. Drowsiness is a side effect of BBs, and the client should be taught precautions to prevent injury. The pulse rate should be taken before administration because ventricular dysrhythmias and heart block may occur with BBs.

What should the nurse expect the health care provider to prescribe if a client exhibits clinical indicators of warfarin (Coumadin) overdose? 1 Heparin 2 Vitamin K 3 Iron dextran (Imferon) 4 Protamine sulfate

2 Vitamin K

A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. The component of the complete blood count that the nurse is concerned about most is: 1 Red blood cells (RBCs) 2 White blood cells (WBCs) 3 Platelets 4 Hematocrit

2 White blood cells (WBCs) Antineoplastic drugs depress bone marrow, which causes leukopenia; the client must be protected from infection, which can be life threatening. RBCs diminish slowly and can be replaced with a transfusion of packed red blood cells. Platelets decrease as rapidly as WBCs, but complications can be limited with infusions of platelets. RBCs diminish slowly and can be replaced with a transfusion of packed red blood cells.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? 1 "I am unable to run a mile now." 2 "I wake up at night short of breath." 3 "My shoes seem larger lately." 4 "My wife says I snore very loudly."

2 "I wake up at night short of breath." Increased shortness of breath is often an indicator of fluid overload in the heart failure client

A male client with aortic stenosis is scheduled for a valve replacement in two 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? 1 "Men your age do very well." 2 "You are worried about dying." 3 "I know you are concerned, but your surgeon is excellent." 4 "I'll get you a sleeping pill tonight because I know you will need it."

2 "You are worried about dying."

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? (Select all that apply.) 1 Thirst 2 Anorexia 3 Leg cramps 4 Rapid, thready pulse 5 Dry mucous membranes

2 Anorexia 3 Leg cramps

A client with chronic heart failure is taking a diuretic twice a day. The health care provider prescribes a diet that includes the intake of dietary potassium. What foods that have a higher amount of potassium should the nurse instruct the client to consume? (Select all that apply.) 1 Corn 2 Bananas 3 Strawberries 4 Cucumber salad 5 Mashed sweet potatoes 6 Baked potatoes with skins

2 Bananas 6 Baked potatoes with skins A serving of banana (1 cup sliced, raw) has 594 mg of potassium. A serving of baked potato with the skin (1 potato, ½ lb) has 844 mg of potassium. A serving of corn (1 cup frozen kernels) contains 229 mg of potassium. A serving of strawberries (1 cup raw, capped, whole) has 247 mg of potassium. A serving of cucumber with the peel (six slices ⅛-inch thick by 2⅛ inches in diameter) has 42 mg of potassium. A serving of mashed sweet potatoes (1 cup solid pack, canned) has 125 mg of potassium.

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? (Select all that apply.) 1 Raw carrots 2 Boiled spinach 3 Sweet potatoes 4 Brussels sprouts 5 Asparagus spears

2 Boiled spinach 3 Sweet potatoes One cup of boiled spinach contains 6.42 mg of iron. One cup of mashed sweet potatoes contains 3.4 mg of iron. One cup of cut carrots contains 1 mg of iron. One cup of Brussels sprouts contains 1.1 mg of iron. One cup of cut asparagus contains 1.2 mg of iron.

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? (Select all that apply.) 1 Reduce calcium intake. 2 Change positions slowly. 3 Report peripheral edema. 4 Expect temporary hair loss. 5 Avoid drinking grapefruit juice.

2 Change positions slowly. 3 Report peripheral edema. 5 Avoid drinking grapefruit juice Changing positions slowly helps reduce orthostatic hypotension. Peripheral edema may occur as a result of heart failure and must be reported. Grapefruit juice affects the metabolism of calcium channel blockers and should be avoided. Reducing calcium intake is unnecessary because calcium levels are not affected. Hair loss does not occur.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. (Select all that apply.) 1 Olive oil 2 Chicken broth 3 Enriched whole milk 4 Red meats, such as beef 5 Vegetables and whole grains 6 Liver and other glandular organ meats

2 Chicken broth 3 Enriched whole milk 4 Red meats, such as beef 6 Liver and other glandular organ meats Chicken broth is high in sodium and should be avoided to prevent fluid retention and an elevated blood pressure. Enriched whole milk is high in saturated fats and contributes to hyperlipidemia; skim milk is the healthier choice. Red meats, such as beef, are high in saturated fats and should be avoided. Liver and other glandular organ meats are high in cholesterol and should be avoided. Olive oil is an unsaturated fat, which is a healthy choice. Vegetables and whole grains are low in fat and have soluble fiber, which may reduce the risk for heart disease.

When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? (Select all that apply.) 1 Thirst 2 Confusion 3 Tachycardia 4 Pale coloring 5 Poor tissue turgor

2 Confusion 5 Poor tissue turgor

A nurse assesses a client's intravenous site. What clinical finding leads the nurse to conclude that the intravenous (IV) site has been infiltrated? (Select all that apply.) 1 Redness along the vein 2 Coolness of skin near the insertion site 3 Swelling around the insertion site 4 Cessation in flow of solution 5 Vein feels hard and cordlike

2 Coolness of skin near the insertion site 3 Swelling around the insertion site 4 Cessation in flow of solution When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F), whereas body temperature is approximately 98.6° F; therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. In addition, the fluid in the interstitial space causes swelling around the insertion site, and the solution stops flowing. Redness along the vein, with the vein feeling hard and cordlike, is present with phlebitis.

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? (Select all that apply.) 1 Abdominal cramps 2 Decreased heart rate 3 Peripheral paresthesia 4 Decreased bowel sounds 5 Hyperactive deep tendon reflexes

2 Decreased heart rate 4 Decreased bowel sounds Because of potassium's role in the sodium-potassium pump , hypokalemia may cause nerve and muscle weakness, which may precipitate bradycardia and atrial dysrhythmias. On an ECG tracing, the T wave is depressed with hypokalemia. Decreased bowel sounds result from decreased bowel motility associated with hypokalemia. Gastrointestinal hyperactivity and diarrhea are related to hyperkalemia, not hypokalemia. Paresthesia and numbness in the extremities are associated with hyperkalemia, not hypokalemia. Deep tendon reflexes are depressed, not hyperactive, with hypokalemia.

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? (Select all that apply.) 1 Oliguria 2 Dry mouth 3 Palpitations 4 Constipation 5 Urinary retention 6 Orthostatic hypotension

2 Dry mouth 3 Palpitations 4 Constipation 6 Orthostatic hypotension Dry mouth is a side effect of Nalbuphine HCl. Palpitations are a side effect of Nalbuphine HCl. Constipation is a common side effect of Nalbuphine HCl. Orthostatic hypotension may occur with Nalbuphine HCl. The ability to form urine is not affected; an increased urinary output or frequency may occur. Urinary urgency, not retention, is a reaction to Nalbuphine HCl.

The nurse is reviewing a teaching plan for a client that has been prescribed a 2-gram sodium diet. The plan should include which foods that are low in sodium? 1 Meat and fish 2 Fruits and juices 3 Milk and cheese 4 Dry cereals and grains

2 Fruits and juices

A client with a history of type 1 diabetes is diagnosed with heart failure. Digoxin (Lanoxin) is prescribed. When administering the medication, the nurse should: 1 Administer the medication with 8 ounces of orange juice 2 Monitor the client for atrial fibrillation and first-degree heart block 3 Administer the digoxin one hour after the client's morning insulin 4 Withhold the medication if the apical pulse rate is greater than 60 beats/min

2 Monitor the client for atrial fibrillation and first-degree heart block The speed of conduction is decreased when digoxin is given, and this can result in premature beats, atrial fibrillation, and first-degree heart block. Digoxin does not deplete potassium and therefore orange juice does not need to be given; orange juice is high in calories and needs to be calculated in the diet. Insulin and digoxin can be given at the same time. The purpose of the drug is to reduce a rapid heart rate and therefore be administered; it should be withheld when the client's heart rate decreases below a parameter set by the health care provider (e.g., 60 beats per minute).

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. What locations on the client's body should the nurse assess? (Select all that apply.) 1 Sclera 2 Nail beds 3 Lining of eyelids 4 Palms of hands 5 Bony prominences

2 Nail beds 3 Lining of eyelids 4 Palms of hands Nail beds lose their pink coloration because of reduced hemoglobin. A reduced amount of hemoglobin decreases pink color of the lining of the eyelids. Palms of the hands will become pale because of the decreased hemoglobin. Sclerae are observed for signs of jaundice, not anemia, when they become pale yellow to orange. Bony prominences are not assessed when a client has anemia. Bony prominences are examined for redness caused by pressure that, if prolonged, can lead to a break in the skin and development of pressure ulcers.

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? (Select all that apply.) 1 Nausea 2 Palpitations 3 Tachycardia 4 Nervousness 5 Warm, dry skin 6 Increased respirations

2 Palpitations 3 Tachycardia 4 Nervousness Palpitations are of neurogenic origin associated with hypoglycemia; the sympathetic nervous system is stimulated by the decline in blood glucose. Tachycardia occurs with low serum glucose levels because of sympathetic nervous system activity. Nervousness, anxiety, and shakiness occur as a result of sympathetic nervous system stimulation associated with hypoglycemia. Nausea, vomiting, and abdominal cramps are associated with hyperglycemia. The client will feel hungry with hypoglycemia. Warm, dry skin is a sign of hyperglycemia, caused by dehydration associated with osmotic diuresis related to glycosuria. The skin will be cool and moist with hypoglycemia. Increased respirations are signs of ketoacidosis from insufficient insulin to prevent fat breakdown for energy; they are compensatory responses that occur in an attempt to blow off carbon dioxide and raise the serum pH. There is no particular change in respirations with hypoglycemia.

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? (Select all that apply.) 1 Diabetes insipidus 2 Profuse diaphoresis 3 Excess sodium intake 4 Removal of the parathyroid glands 5 Rapid IV infusion of 5% dextrose in water

2 Profuse diaphoresis 5 Rapid IV infusion of 5% dextrose in water

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the health care provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" The best reply by the nurse is, "This test will: 1 Detect your heart sounds." 2 Reflect any heart damage." 3 Help us change your heart's rhythm." 4 Tell us how much stress your heart can tolerate."

2 Reflect any heart damage."

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? (Select all that apply.) 1 Discolored toenails 2 Reports of leg fatigue 3 Localized heat in a calf 4 Reddened areas on a leg 5 Tortuous veins in the legs 6 Pain in lower extremities when standing

2 Reports of leg fatigue 5 Tortuous veins in the legs 6 Pain in lower extremities when standing

2 Reports of leg fatigue 5 Tortuous veins in the legs 6 Pain in lower extremities when standing Leg fatigue is a common clinical manifestation caused by venous stasis and inadequate tissue oxygenation. Vein walls weaken and dilate resulting in distended, protruding veins that appear tortuous and darkened. As vein walls weaken and dilate venous pressure increases and the valves become incompetent; venous stasis and inadequate oxygenation result in leg pain. Discolored toenails result from a fungus under the nail or chronic hypoxia, not varicose veins. Localized heat in a calf is a sign of thrombophlebitis. Reddened areas on a leg are indicative of thrombophlebitis.

A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? 1 Monitoring vital signs and encouraging a vigorous aerobic exercise program. 2 Taking the apical pulse before drug administration and teaching the client how to count the pulse. 3 Contacting Social Services for a home health nursing consultation. 4 Providing written material on the adverse effects of the medication.

2 Taking the apical pulse before drug administration and teaching the client how to count the pulse.

A nurse is caring for a client who had pelvic surgery. The nurse should monitor for which clinical manifestations of thrombophlebitis? (Select all that apply.) 1 Pruritus of the calf 2 Tender area on the leg 3 Warm area over the calf 4 Pitting edema of the ankle 5 Reddened area at the ankle

2 Tender area on the leg 3 Warm area over the calf

2 Vitamin K

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? (Select all that apply.) 1 Anorexia 2 Vomiting 3 Constipation 4 Muscle weakness 5 Irregular heart rate

2 Vomiting 4 Muscle weakness 5 Irregular heart rate

2 Vomiting 4 Muscle weakness 5 Irregular heart rate Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.

An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client? 1 "Adhere to the medical regimen." 2 "Remain normoglycemic for three weeks." 3 "Demonstrate correct use of the insulin pump." 4 "List three self-care activities that help control the diabetes."

3 "Demonstrate correct use of the insulin pump."

A client complains of 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. The nurse concludes that further teaching is needed when the client states what? 1 "I will wear socks." 2 "I will quit smoking." 3 "I will elevate my foot." 4 "I will increase fluid intake."

3 "I will elevate my foot."

Which client should a nurse consider the greatest risk for developing hypernatremia? 1 52-year-old who is receiving 0.45% NaCl intravenously 2 76-year-old who developed syndrome of inappropriate antidiurectic hormone secretion (SIADH) as a result of head trauma 3 63-year-old who has had watery diarrhea since traveling abroad 4 48-year-old who is admitted with a diagnosis of Addison disease

3 63-year-old who has had watery diarrhea since traveling abroad Watery diarrhea involves loss of water in excess of sodium; this leads to an increased sodium concentration. Intravenous 0.45% NaCl is a hypotonic solution; concentration of sodium is less than body fluids. Increased secretion of antidiuretic hormone causes water retention, which decreases sodium concentration. Addison disease involves hyposecretion of adrenocortical hormones, which leads to hyponatremia.

While obtaining a health history, a nurse expects a client admitted to the hospital with chronic heart failure to report: 1 Tingling in the upper extremities 2 Feeling bloated after eating 3 A need to use three pillows at night to sleep 4 Swelling of the ankles that is more apparent in the morning

3 A need to use three pillows at night to sleep Heart failure causes a fluid volume excess that results in pulmonary edema and dyspnea in the supine position. Tingling in the upper extremities and feeling bloated after eating 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 who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects that a diagnostic finding specific for multiple myeloma is: 1 Occult blood in the stool 2 Low serum calcium levels 3 Bence Jones protein in the urine 4 Positive bacterial culture of sputum

3 Bence Jones protein in the urine Bence Jones protein (globulin) results from tumor cell metabolites. It is present in clients with multiple myeloma. Occult blood in the stool is not specific for the diagnosis of multiple myeloma; it is a late complication of multiple myeloma related to coagulation defects. Hypercalcemia, not hypocalcemia, occurs with multiple myeloma because of bone erosion. Multiple myeloma is not caused by a bacterial infection.

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. What is the goal of the medical regimen for this client? 1 Increase left ventricular filling and improve cardiac output. 2 Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias. 3 Decrease the workload on the heart and promote maximum coronary artery filling. 4 Increase venous return to the right atrium and increase pulmonary arterial blood flow.

3 Decrease the workload on the heart and promote maximum coronary artery filling.

A nurse reviews the laboratory test results of a client with emphysema who is recovering from a myocardial infarction. The nurse obtains the client's vital signs and performs a physical assessment. Which prescribed medication should the nurse consider the priority at this time? 1 Albuterol (Proventil) 2 Warfarin (Coumadin) 3 Metoprolol (Lopresor) 4 Acetaminophen (Tylenol)

3 Metoprolol (Lopresor)

A client with a cardiac dysrhythmia is receiving digoxin (Lanoxin) and verapamil (Calan). Because of the combined effect of these two medications, the nurse assesses the client for: 1 Physical agitation 2 Reflex stimulation 3 Myocardial depression 4 Respiratory stimulation

3 Myocardial depression

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery? 1 Increasing activity tolerance 2 Preventing cardiac dysrhythmias 3 Promoting physical and emotional rest 4 Maintaining potassium and sodium intake

3 Promoting physical and emotional rest The major goal is to decrease the workload of the heart; physical and emotional rest reduces cardiac oxygen demand. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. There is no indication that the client has a history of dysrhythmias. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart.

A health care provider in the emergency department identifies that a client is in mild hypovolemic shock. Which type of drug should the nurse anticipate will be prescribed? 1 Loop diuretic 2 Cardiac glycoside 3 Sympathomimetic 4 Alpha-adrenergic blocker

3 Sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output. Diuretics promote excretion of fluid, which will exacerbate hypovolemia associated with hypovolemic shock. Cardiac glycosides slow and strengthen the heartbeat; they do not increase the blood pressure and may decrease it. Alpha-adrenergic blockers decrease peripheral resistance, resulting in a decreased blood pressure.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1 Diuresis, irritability, and fever 2 Lethargy, cold skin, and hypertension 3 Thirst, cool skin, and orthostatic hypotension 4 Bounding pulse, restlessness, and slurred speech

3 Thirst, cool skin, and orthostatic hypotension With hypovolemic shock extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.

A nurse is teaching a client who had a myocardial infarction about the prescribed 1500-calorie, 2-gram-sodium, weight-reducing diet. Which low-sodium, low-calorie nutrients should the nurse recommend that the client include in the diet? (Select all that apply.) 1 Lean steak 2 Celery sticks 3 Baked chicken 4 Tuna fish salad 5 Mashed potatoes

3 Baked chicken 5 Mashed potatoes

When assessing a client with heart failure, the nurse asks when the client most notices an increase in symptoms. Which activity should the nurse expect will cause the client the greatest distress? 1 Getting up from bed in the morning 2 Walking to visit the next-door neighbor 3 Climbing a flight of stairs to the bedroom 4 Leaving the table immediately after a meal

3 Climbing a flight of stairs to the bedroom

Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? (Select all that apply.) 1 Constipation 2 Hypokalemia 3 Irregular pulse rate 4 Change in visual acuity 5 Orthostatic hypotension

3 Irregular pulse rate 5 Orthostatic hypotension Dysrhythmias, including second-degree heart block, are cardiovascular side effects of valsartan . It also may precipitate angina pectoris, myocardial infarction, and brain attack (CVA). Angiotensin II receptor antagonists, such as valsartan, block vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle, thus reducing the blood pressure; dizziness, orthostatic hypotension, and excessive hypotension may occur. Diarrhea, not constipation, may occur with valsartan. Hyperkalemia, not hypokalemia, may occur with valsartan. Valsartan does not cause altered visual acuity.

What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open-heart surgery? 1 Restrict family visits 2 Withhold analgesic medications 3 Plan for maximum periods of rest 4 Keep the room light on most of the time

3 Plan for maximum periods of rest

A client who had a myocardial infarction receives a prescription for a beta-blocker and a nitroglycerin patch. The nurse determines that the purpose of the nitroglycerin patch is to decrease the: 1 Pulse rate, thereby strengthening cardiac contractility 2 Cardiac output, thereby reducing the cardiac workload 3 Preload of the heart, thereby reducing the cardiac workload 4 Coronary artery lumens, thereby reducing peripheral resistance

3 Preload of the heart, thereby reducing the cardiac workload Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect; it dilates coronary arteries, reduces myocardial ischemia, strengthens contractility, and increases efficiency of cardiac output. Decreasing the pulse rate does not strengthen cardiac contractility. Cardiac output is increased, not decreased. Peripheral resistance is affected not by dilating the coronary arteries but by dilating the peripheral arteries.

A nurse observes the following dysrhythmia on a client's cardiac monitor. What rhythm does the nurse identify? 1 Atrial flutter 2 Atrial fibrillation 3 Ventricular fibrillation 4 Ventricular tachycardia

3 Ventricular fibrillation

The nurse is making rounds on a patient who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? (Select all that apply.) 1 Monitor for signs of alopecia. 2 Encourage an increase in fluids. 3 Wash hands before entering the client's room. 4 Advise use of a soft toothbrush for oral hygiene. 5 Report an elevation in temperature immediately. 6 Encourage the client to eat raw, fresh fruits and vegetables

3 Wash hands before entering the client's room. 4 Advise use of a soft toothbrush for oral hygiene. 5 Report an elevation in temperature immediately.

A client with type 2 diabetes is taking one glyburide (Micronase) tablet daily. The client asks whether an extra pill should be taken before exercise. What is the nurse's best reply? 1 "You will need to decrease how much you are exercising." 2 "An extra pill will help your body use glucose when exercising." 3 "The amount of medication you need to take is not related to exercising." 4 "Do not take an extra pill because you may become hypoglycemic when exercising."

4 "Do not take an extra pill because you may become hypoglycemic when exercising."

A client with hypertension is to follow a 2-gram sodium diet. Which client statement provides evidence that the nurse's dietary instructions are understood? 1 "My fluid intake should be restricted." 2 "I should limit the number of daily food servings." 3 "Salt should not be used during cooking but can be used at the table." 4 "Labels on prepackaged food products should be evaluated before purchase."

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

A health care provider prescribes a dose of medication that is much higher than is recommended for the clinical situation, and directs the nurse to give the medication immediately. Which response by the nurse is most appropriate? 1 "The dose is too high. I do not feel comfortable administering this dose." 2 "Please tell me how you arrived at this dose. I think your calculations are incorrect." 3 "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug." 4 "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself."

4 "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself." The response "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself" informs the health care provider of the nurse's dilemma and legal position without creating an adversarial professional position. A confrontational response may make the health care provider look and feel incompetent and jeopardize the collegial relationship. "The dose is too high. I do not feel comfortable administering this dose," "Please tell me how you arrived at this dose. I think your calculations are incorrect," and "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug" are confrontational responses that may make the health care provider look and feel incompetent and jeopardize the collegial relationship.

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure? 1 110 to 119 mm Hg 2 120 to 129 mm Hg 3 130 to 139 mm Hg 4 140 to 159 mm Hg

4 140 to 159 mm Hg

What client response indicates to the nurse that a vasodilator medication is effective? 1 Pulse rate decreases from 110 to 75 2 Absence of adventitious breath sounds 3 Increase in the daily amount of urine produced 4 Blood pressure changes from 154/90 to 126/72

4 Blood pressure changes from 154/90 to 126/72

A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a client is hypertensive? 1 Tachycardia 2 Extended Korotkoff sound 3 Sustained systolic pressure ranging from 110 to 120 mm Hg 4 Diastolic blood pressure that remains higher than 90 mm Hg

4 Diastolic blood pressure that remains higher than 90 mm Hg A sustained diastolic pressure that exceeds 90 mm Hg reflects pathology and indicates hypertension. Tachycardia reflects the heart rate, not the pressures within the arteries. Extended Korotkoff sound is heard when measuring blood pressure by auscultation; it is unrelated to hypertension. Sustained systolic pressure ranging from 110 to 120 mm Hg is an expected systolic blood pressure.

Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider? 1 Blurred vision 2 Dizziness on rising 3 Excessive urination 4 Difficulty breathing

4 Difficulty breathing

A client whose total cholesterol level is found to be 210 mg/dL at a screening session at a health fair asks the nurse what to do in light of this result. The nurse responds, "Your level is: 1 High and you may need medication." 2 Within the acceptable range and no action is required." 3 Low and you should eat more foods that contain cholesterol." 4 Elevated slightly and a diet low in saturated fats should be followed."

4 Elevated slightly and a diet low in saturated fats should be followed." A level more than 200 mg/dL is considered elevated, and foods high in cholesterol and saturated fats should be limited in the diet. A level of 240 mg/dL or more is considered high. Levels more than 140 and less than 200 mg/dL are considered desirable. A low level is less than 140 mg/dL. Medical attention should be sought because low cholesterol levels are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and myeloproliferative disease.

The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" The nurse explains that the primary purpose of early ambulation is to: 1 Promote healing of the incision 2 Lower the incidence of urinary tract infections 3 Use energy to help the client sleep better at night 4 Keep blood from pooling in the legs to prevent clots

4 Keep blood from pooling in the legs to prevent clots

A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of: 1 Inadequate arterial blood supply." 2 Delayed healing of tissues after an injury." 3 Increased production of melanin in the area." 4 Leakage of red blood cells through the vascular wall."

4 Leakage of red blood cells through the vascular wall."

A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Recognizing that adherence to a medical regimen improves with understanding, the nurse explains that the salt must be limited to: 1 Prevent an increase in blood pressure from tissue edema. 2 Reduce the circulating blood volume via a diuretic effect. 3 Reduce the amount of edema present, which interferes with heart action. 4 Prevent further accumulation of fluid, which increases the workload of the heart.

4 Prevent further accumulation of fluid, which increases the workload of the heart.

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? 1 Signs of shock 2 Visible peristaltic waves 3 Radiating abdominal pain 4 Pulsating abdominal mass

4 Pulsating abdominal mass 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.

Digoxin (Lanoxin) and furosemide (Lasix) are prescribed for a client with the diagnosis of pulmonary edema. What client response to digoxin is unrelated to toxicity? 1 Nausea 2 Yellow vision 3 Irregular pulse 4 Pulse of 64

4 Pulse of 64

4 Pulse of 64 A pulse of 64 is acceptable when the client is receiving digoxin; digoxin lengthens the atrioventricular conduction time, which slows the heart rate; toxicity may be present if the heart rate drops to less than 60. Nausea is a symptom of toxicity; nausea and vomiting can occur because of gastric irritation and its action at central nervous system sites. Yellow vision is a symptom of toxicity; xanthopsia (yellow vision) is caused by digoxin's effect on visual cones. An irregular pulse is a sign of toxicity; premature nodal or ventricular impulses and varying degrees of heart block can occur because of slowed transmission of impulses through the atrioventricular node.

A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first? 1 Remove all jewelry 2 Wash the chest area 3 Use a grounded electric source 4 Remove any medication patches

4 Remove any medication patches Medication patches must be removed before application of electrodes because of possible electrical conduction in the area of the patch causing a burn. Jewelry usually is not a problem with the function of an automated external defibrillator. Skin preparation is unnecessary. The AED is battery operated and does not need a grounded electric source.

The client is receiving multiple blood transfusions after having extensive abdominal surgery. If the client develops fever, chills, and lower back pain, and seems very nervous, what will be the nurse's first action? 1 Notify the blood bank 2 Notify the health care provider 3 Reduce the rate of the blood transfusion 4 Stop the blood and infuse normal saline

4 Stop the blood and infuse normal saline

When a client has a myocardial infarction, one of the major manifestations is a decrease in conductive energy provided to the heart. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart? 1 Heart rate 2 Refractory period 3 Pulmonary pressure 4 Strength of contractions

4 Strength of contractions A direct relationship exists between the strength of cardiac contractions and electrical conductions through the myocardium. The heart rate is related to such factors as sinoatrial (SA) node function, partial pressures of oxygen and carbon dioxide, and emotions. Refractory period is the period when the heart is at rest, not when it is contracting. Pulmonary pressure does not influence action potential; it becomes increased in the presence of left ventricular failure.

A nurse in the post-anesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider? 1 Client pushes the airway out. 2 Client has snoring respirations. 3 Respirations of 16 breaths/min are shallow. 4 Systolic blood pressure drops from 130 to 90 mm Hg

4 Systolic blood pressure drops from 130 to 90 mm Hg

The nurse has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 and 164/98. What is the appropriate nursing action in response to these readings? 1 Refer the client to a nutritionist after providing health teaching about a low-sodium diet. 2 Place the client in a recumbent position and call the paramedics for transport to the hospital. 3 Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. 4 Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

4 Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

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? 1 The arterial blood supply is inadequate. 2 There is delayed healing in the area after an injury. 3 The production of melanin in the area has increased. 4 There is leakage of red blood cells (RBCs) through the vascular wall.

4 There is leakage of red blood cells (RBCs) through the vascular wall. 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 client has been receiving digoxin (Lanoxin). The client calls the clinic and complains of "yellow vision." What is the nurse's best response? 1 "This is related to your illness rather than to your medication." 2 "Take the medication because this is not a serious side effect." 3 "This side effect is only temporary. You should continue the medication." 4 "The medication should be discontinued. Come to the clinic this afternoon."

4 "The medication should be discontinued. Come to the clinic this afternoon."

Which significant risk factors for coronary heart disease carry a greater risk for women than for men? (Select all that apply.) 1 Obesity 2 Smoking 3 Hypertension 4 Diabetes mellitus 5 Low levels of high-density lipoprotein (HDL) cholesterol

4 Diabetes mellitus 5 Low levels of high-density lipoprotein (HDL) cholesterol Diabetes is twice as strong a predictor of coronary heart disease in women as in men; diabetes cancels the cardiac protection that estrogen provides to premenopausal women. A low level of HDL-C (less than 35 mg/dL) has a greater bearing on coronary heart disease in women than in men and is the most important lipid factor in women; the significance of this is unclear. Obesity, smoking, and hypertension are risk factors common to both women and men

4 Difficulty breathing Dyspnea may indicate development of pulmonary edema, which is a life-threatening condition. Blurred vision may occur in some people, but it is not life-threatening. Dizziness on rising and excessive urination are common side effects of this medication, which are not life-threatening.

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings should alert the nurse to the possible development of the life threatening response of thrombocytopenia? (Select all that apply.) 1 Fever 2 Diarrhea 3 Headache 4 Hematuria 5 Ecchymosis

4 Hematuria 5 Ecchymosis Hematuria is blood in the urine. Thrombocytes are involved in the clotting mechanism; thrombocytopenia is a reduced number of thrombocytes in the blood. Ecchymosis is a superficial bruise caused by bleeding under the skin or mucous membrane. With thrombocytopenia, bleeding occurs because there are insufficient platelets. Fever is unrelated to thrombocytopenia. Fever is a sign of infection; infection results when the white blood cells are reduced (leukopenia). Diarrhea is unrelated to thrombocytopenia; diarrhea may result from the effects of chemotherapy on the rapidly dividing cells of the gastrointestinal system. Headache is unrelated to thrombocytopenia; headache may be caused by the effects of chemotherapy on central nervous system cells or indicate that the leukemia has invaded the central nervous system.

A client takes isosorbide dinitrate (Isordil) daily. The client states, "I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can't take sildenafil and isosorbide dinitrate at the same time." The nurse explains that taking both of these medications concurrently may result in severe: 1 Nausea 2 Tachypnea 3 Constipation 4 Hypotension

4 Hypotension Concurrent use of sildenafil and a nitrate, which causes vasodilation, may result in severe, potentially fatal hypotension. Nausea is not a side effect associated with concurrent use of sildenafil and a nitrate. Tachypnea is not a side effect associated with concurrent use of sildenafil and a nitrate. Sildenafil may cause diarrhea, not constipation.

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1 Elevate the foot of the bed 2 Perform urinary catheter care every 12 hours 3 Place in the high-Fowler position 4 Perform a neurovascular assessment every two hours

4 Perform a neurovascular assessment every two hours Because of the trauma associated with the insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of or lower than the heart. A general anesthetic is not used; therefore, voiding is not a concern. Keeping the client in the high-Fowler position is unsafe; this position increases pressure in the groin area, which can dislodge the clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.

A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis? (Select all that apply.) 1 Pitting edema of the ankle 2 Reddened area at the ankle 3 Pruritus on the side of the calf 4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel

4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel Thrombophlebitis, not uncommon after abdominal surgery, is inflammation of a vein; it is associated with the formation of a clot (thrombus) in a vein in the leg. Findings associated with thrombophlebitis include pain, redness, swelling, and heat. Warmth along the course of the involved vessel is related to the inflammatory process accompanying the thrombus. Although swelling accompanies thrombophlebitis, it is not a pitting edema. Thrombophlebitis usually is located in the area of the calf, not over a bony prominence. Itching is not a symptom of phlebitis.

A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. What is an appropriate postoperative nursing intervention on the day after surgery?

Assist the client with walking. Mobility reduces venous stasis and edema and enhances arterial perfusion and healing. Sitting in a chair is contraindicated; it constricts circulation at the hips and knees. Bed rest is contraindicated because it promotes the development of thrombophlebitis and pulmonary emboli. Elevating the legs will limit arterial perfusion.

A client had surgery on the shoulder and the nurse is to obtain a brachial pulse. Use the illustration to indicate where the nurse should palpate to best obtain the brachial pulse rate.

The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral

In the supine position with the affected leg extended for several hours postprocedure. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. With the femoral approach, bed rest is maintained for several hours. Mild sedation is used for adult clients; the client is conscious. Post-procedural dietary restrictions are minimal, if any.

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? 1 The signs and symptoms of pericarditis 2 The possible need for prophylactic antibiotic therapy before dental work 3 That cardiac surgery will have to be done eventually for the other valves 4 That pregnancy and childbirth are too stressful when one has this problem

The possible need for prophylactic antibiotic therapy before dental work Antibiotic therapy before invasive procedures, such as dental work, is often prescribed to prevent endocarditis because these situations may introduce infectious agents systemically. Infective endocarditis, not pericarditis, may occur. Endocarditis is an infection of the endothelial surface of the heart and valves. Pericarditis is an inflammation of the pericardium, the membranous sac enveloping the heart. There is no evidence of pathology of other valves. Childbirth is not contraindicated; however, prophylactic antibiotic therapy may be administered to prevent endocarditis.

A nurse is assessing arterial perfusion in a client who had surgery with placement of a graft for an aneurysm in the left femoral artery. Mark the site of the pulse that should be assessed to determine maximum arterial perfusion distal to the operative site.

The pulse most distal to the graft should be assessed first to determine adequacy of circulation. The pedal pulse is located on the top of the foot and is the most distal peripheral pulse.

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

a) Slide the finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet) b) Slide the finger to the edge of the left sternal border to the second intercostal space c) Place the index finger in the second intercostal space and continue palpating downward to the fifth intercostal space d) Move the finger laterally along the fifth intercostal space to the midclavicular line

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