Med-Surg:Cardiovascular and Hematology

A nurse is assisting in developing the plan of care for an older adult client who is to receive a unit of packed red blood cells (RBCs). Which of the following actions should the nurse recommend?

Verify the information on the packed RBCs with another nurse.

A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following information should the nurse include in the teaching?

"Avoid lifting both arms above your head when dressing."

A nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?

"Before taking my medication, I will check my blood pressure and radial pulse rate."

A nurse is assisting in the care of a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions?

0.9% sodium chloride

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. Available is a blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min?

10 gtt/min

A nurse is assisting in the care of a client who had an abdominal aortic aneurysm and is scheduled for surgery. The clients vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take?

Administer antihypertensive medication for the blood pressure

A nurse is checking for cardiac tamponade on a client who has pericarditis. Which of the following actions should the nurse take?

Auscultate blood pressure for pulses paradoxus

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?

Coarse crackles

A nurse in a clinic is collecting data from a client who has a history of peripheral arterial disease. Which of the following findings on the clients lower extremities should the nurse expect?

Cool, pale skin with minimal body hair

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Dependent edema

A nurse is collecting data from a client who has pericarditis. Which of the following manifestations should the nurse expect?

Dyspnea

A nurse is checking laboratory values for an adult client who has sickle cell anemia and is in crisis. For which of the following complications should the nurse monitor?

Elevated bilirubin

A nurse is caring for a client who has advanced heart failure. Which of the following actions should the nurse take?

Enforce fluid restrictions

A nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching?

Hypertension is a common adverse effect of this medication

A nurse is assisting in the plan of care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postoperative plan of care?

Initiate an aspirin regimen

A nurse is contributing to the plan of care for a client who has pernicious anemia. Which of the following interventions should the nurse recommend?

Initiate weekly injections of vitamin B12

A nurse is collecting data from a client who has fluid volume overload resulting from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (select all that apply)

Jugular vein distension Moist crackles Increased heart rate

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?

Lower Back Discomfort

A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take?

Monitor the client for ototoxicity

A nurse is collecting data from a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client?

Omega-3 fatty acids

A nurse is collecting data from a client who has manifestations of aplastic anemia. Which of the following findings should the nurse expect?

Petechiae and ecchymosis

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?

Position the client supine with his legs elevated when in bed

A nurse is caring for a client who has heart failure and is lethargic with muscle weakness. The client's telemetry reading displays dysrhythmias. Which of the following laboratory results should the nurse anticipate?

Potassium 2.8 mEq/L

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take?

Prepare for replacement of the missing clotting factor

A nurse is evaluating a clients repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory values should the nurse review?

Prothrombin time

A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first?

Stop the infusion of blood

A nurse is assisting in collecting data from a client who has a history of unstable angina. Which of the following findings should the nurse expect?

The client reports chest pain when at rest

A nurse is assisting in monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr?

Ventricular dysrhythmias

A nurse is caring for a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following finding should the nurse expect?

Weight gain of 1 kg (2.2 lb) in 1 day

A nurse is assisting in the preparation of a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first?

Witness informed consent.