Medical-Surgical:Cardiovascular and Hematology

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

Dyspnea The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

The nurse is reinforcing teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following information should the nurse include in the teaching?

SLE affects the connective tissue of the body. The nurse should inform the client that SLE originates in the connective tissues of the body and affects all organ systems.

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 Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the blood stream and is the only solution to use when infusing blood products.

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 reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. which of the following statements by the client indicates an understanding of the teaching?

"I will need to take this medication for the rest of my life" The nurse should reinforce with the client that cyclosporine is an immunosuppressive agent. It is used to reduce natural immunity in clients who receive organ transplants and prevent rejection. They need to take immunosuppressive therapy for the remainder of their lives.

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 The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.

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 The client who has sickle cell anemia and is in crisis will have an elevated bilirubin because hemolysis of the abnormal red blood cells occurs.

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

Enforce fluid restrictions The nurse should enforce fluid restrictions to help reduce fluid retention in the lungs and lower extremities.

A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider?

Increase in serum creatinine

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 The nurse should plan to initiate an aspirin regimen or another antiplatelet agent. The antiplatelet medication maintains the patency of the stent by reducing platelet aggregation.

A nurse is 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 The nurse should recommend that weekly injections of vitamin B12 be initiated for a client who has pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.

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 Jugular vein distension is correct. The increase in venous pressure due to excessive circulating blood volume results in neck vein distension.Moist crackles is correct. This is an indicator of pulmonary edema that can quickly lead to death.Postural hypotension is incorrect. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in hypertension and tachycardia.Increased heart rate is correct. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses.

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 Manifestations of hypokalemia include muscle weakness and cramps, confusion, and drowsiness. Hypokalemia can also result in life-threatening dysrhythmias.

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 Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range-of-motion in repeatedly affected joints.

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 The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.

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 The nurse should apply the urgent vs. nonurgent priority-setting framework when caring for this client. Using this framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.

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 weight gain of 1 kg in 1 day alerts the nurse that the client might be retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening.

a nurse is reinforcing instructions about immunizations with a client who is at 12 weeks of gestation. Which of the following vaccines is safe for the nurse to administer?

tetanus and diphtheria, inactive influenza

Vaccine to administer to a 5 year old

varicella ( second dose)

a nurse is caring a child who has pertussis. the childs parent asks the nurse what the common name for this disease is:

whooping cough

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." The nurse should reinforce that the client should avoid lifting her arm or shoulder on the side of the pacemaker because dislodgement of the pacer leads can occur.

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 beta blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration.

A nurse is reinforcing teaching about controlling a bleeding episode with a parent of a child who has hemophilia. Which of the following statements by the parent indicates a need for further teaching?

"I will apply warm compress over the site." The parent should apply ice over the site in order to slow the blood flow to the area.

A nurse is assisting in preparing a presentation at a community center about systemic lupus erythematosis (SLE). The nurse should identify which of the following groups of people as having the highest risk for developing this disorder?

A nurse is assisting in preparing a presentation at a community center about systemic lupus erythematosis (SLE). The nurse should identify which of the following groups of people as having the highest risk for developing this disorder?

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 The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.

4 month old vaccine

An infant should receive either a two dose series of the rotavirus vaccine (one at 2 months and another at 4 months) or a three dose series (one at 2 months, 4 months, and 6 months).

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 The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.

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 client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

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 Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to development of dependent edema.

A nurse is preparing an in-service about HIV for a group of newly hired assistive personnel. Which of the following statements should the nurse include about HIV transmission

HIV is transmitted through contact with infected body fluids The nurse should include in the teaching that HIV is transmitted through contact of infected body fluids such as seminal fluid, vaginal secretions, amniotic fluid and breast milk and other body fluids.

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 The nurse should reinforce in the teaching that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.

tonsilectomy clear liquid diet

Ice pops and apple juice

A nurse is planning care for a client who has immunosuppression following chemo. Which of the following interventions should the nurse include in the plan of care?

Limit the number of health care workers entering the room The nurse should limit the number of health care workers entering the client's room to prevent possible exposure to microorganism that can lead to an infection.

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 Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.

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 The nurse should monitor the client for ototoxicity and reinforce that the client should report any manifestations of hearing impairment while on the loop diuretic. The nurse should use caution when a loop diuretic is used in conjunction with other ototoxic medications, such as aminoglycoside antibiotics.

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 The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.

A nurse is 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 The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.

A nurse is caring for a client who was diagnosed with HIV 6 months ago. The client came to the clinic for testing to determine disease progression. Which of the following laboratory tests should the nurse expect the provider to prescribe?

Quantitative RNa assay. The quantitative RNA assay measures the viral load, or amount of HIV virus present. The nurse should expect this finding to be used to monitor disease progression and for treatment adjustment, as needed.

A nurse is caring for a child who has atopic dermatitis. Which of the following finding should the nurse expect?

Rashes with thick skin Atopic dermatitis is a chronic rash. A classic manifestation is lichenification, or thick, "leathery" skin.

a nurse is reinforcing discharge teaching with a client who is immunocompromised. Which of the following instruction should the nurse include in the teaching?

Restrict visitor with active infections is correct. The nurse should instruct the client to restrict visitors with an active infection to protect the client from contacting an infection due to the suppressed immune system. Instruct the client to eat cooked foods only is correct. The nurse should instruct the client eat cooked foods only to protect the client from contracting an infection from bacteria present on raw or undercooked food.

A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, "My heart is racing." The nurse notes that the clients face has become flushed. Which of the following actions should the nurse take first?

Stop the transfusion. The nurse should identify flushing and tachycardia as manifestations of an allergic reaction to the blood transfusion. The first action the nurse should take is to stop the transfusion immediately to prevent further reaction.

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 The client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina, caused by an artery spasm.

A nurse is caring for a child who has disseminated intravascular coagulation and is experiencing epistaxis. Which of the following actions should the nurse take?

The nurse should insert cotton into both the child's nostrils and apply continuous pressure to reduce bleeding.

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

The nurse should reinforce to the client to take his temperature once a daily to identify if a temperature is present due to the client's altered immune system.

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 After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.

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. The nurse should verify the information on the label of the packed RBCs with another nurse. She should also verify the information on the label with the provider's order, the blood administration form from the blood bank, and with the client armband and blood bracelet.

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. The nurse should apply the least invasive priority-setting framework. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, as witnessing the informed consent is the least invasive it is the action that should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion on a client.

A nurse is collecting data from a child who has sickle disease and is experiencing a vaso-occlusive crisis. Which of the following findings should the nurse expect?

c. pain (a client who is experiencing a vaso-oclusive crisis typically has severe pain resulting from tissue hypoxia and necrosis.) A client who is experiencing a vaso-oclusive crisis typically has severe pain resulting from tissue hypoxia and necrosis.

A nurse is reinforcing home instructions for a client who has an immunodeficiency. Which of the following client statements indicates a need for further teaching

i will take my temp once a week.

a nurse is a pediatric clinic is caring for a child who has iron deficiency anemia and is to start taking ferrous sulfate syrup. which of the following instructions should the nurse give the parent?

offer the medication through a straw The parent should have the child drink the medication through a straw to prevent staining of the teeth and to mask the taste.

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 Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels.

A nurse is contributing to the plan of care for a child who has sickle cell crisis. Which of the following actions should the nurse recommend to include?

promote hydration with IV Hydration by IV and oral fluids is necessary to reduce blood viscosity and prevent sickling.

Gardisil

vaccine for HPV