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ATI pulmonary embolism chapter 24 1. A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

1. A. CORRECT: A client who has a BMI of 30 is considered obese and is at increased risk for a blood clot. B. INCORRECT: A woman who is postmenopausal has decreased estrogen levels and is not at risk for developing a pulmonary embolism. C. CORRECT: A fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. D. INCORRECT: A client who is a marathon runner increases the blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism. E. CORRECT: A client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.

Chapter 41 anemias 1. A nurse is planning care for a client who has a Hgb of 7.5 and a Hct of 21.5. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Provide assistance with ambulation. B. Monitor oxygen saturation. C. Weigh the client weekly. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods.

1. A. CORRECT: A client who has anemia may experience dizziness and should be assisted when ambulating to prevent a fall. B. CORRECT: Oxygen saturation should be monitored in a client who has anemia due to the decreased oxygen-carrying capacity of the blood. C. INCORRECT: The client should be weighed daily. D. CORRECT: Stool testing is performed to identify a possible cause of anemia due to gastrointestinal bleeding. E. CORRECT: A client who has anemia may experience fatigue, and rest periods should be planned to conserve energy.

ATI chapter 42 coagulation disorders 1. A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following indicates that the client's clotting factors are becoming depleted? (Select all that apply.) A. Platelets 100,000/mm³ B. Fibrinogen levels 97 mg/dL C. Fibrin degradation products 4.3 mcg/mL D. D-dimer 179 ng/mL E. Sedimentation rate 38 mm/hr

1. A. CORRECT: In DIC, platelet levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. B. CORRECT: In DIC, fibrinogen levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. C. INCORRECT: Fibrin degradation products are increased when DIC occurs. D. INCORRECT: A D-dimer level is increased when DIC occurs. E. INCORRECT: The sedimentation rate is increased, but it is not an indicator of DIC.

1. A nurse in a clinic is caring for a client who has suspected anemia. The nurse should anticipate a prescription from the provider for which of the following tests? A. INR B. Platelet count C. WBC count D. Hgb

1. A. INCORRECT: An INR test identifies the effectiveness of warfarin therapy. B. INCORRECT: A platelet count identifies an alteration in immune response. C. INCORRECT: A WBC count identifies the presence of an infection. D. CORRECT: An Hgb test is prescribed to confirm a diagnosis of anemia.

1. A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding? A. Edema around the client's ankles and feet B. Ulceration around the client's medial malleoli C. Scaling eczema of the client's lower legs with stasis dermatitis D. Pallor on elevation of the client's limbs and rubor when his limbs are dependent

1. A. INCORRECT: Edema around the ankles and feet is an expected finding in a client who has venous stasis. B. INCORRECT: Ulceration around the medial malleoli is an expected finding in a client who has venous stasis. C. INCORRECT: Scaling eczema of the lower legs with stasis dermatitis is an expected finding in a client who has venous stasis. D. CORRECT: In a client who has chronic PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered.

ATI chapter 40 1. A nurse should remain with a client during the first 15 min of a blood transfusion to A. verify the blood is being transfused. B. assess for an adverse reaction. C. explain the procedure to the client. D. obtain blood specimens.

1. A. INCORRECT: Verifying the blood being transfused occurs prior to blood administration. B. CORRECT: Assessment of the client during the first 15 min of the transfusion is important because this is when most blood reactions occur. C. INCORRECT: Explanation of the procedure should be done prior to blood administration. D. INCORRECT: Blood specimens are obtained only in the event of a blood reaction.

2. A nurse is planning caring for a client who had a surgical placement of an synthetic graft to repair an aneurysm. Which of the following interventions should the nurse include in the plan of care? A. Assess pedal pulses. B. Monitor for an increase in pain below the graft site. C. Maintain client in high Fowler's position. D. Administer prescribed antiplatelet agents. E. Report an hourly urine output of 60 mL.

2. A. CORRECT: Pulses distal to the graft site should be monitored to detect possible occlusion of the graft. B. CORRECT: Pain below the graft site can be an indication of graft occlusion or rupture. C. INCORRECT: The head of the bed should be maintained at less than 45° to prevent flexion of the graft. D. CORRECT: Antiplatelet agents and anticoagulants are prescribed to prevent thrombus formation. E. INCORRECT: An hourly urine output of 60 mL/hr is an expected finding.

2. A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions? A. With the affected limb hanging from the bed B. With the affected limb elevated on pillows C. With the head of the bed raised D. In a side-lying, recumbent position

2. A. CORRECT: The client will prefer sleeping with the affected extremity in a dependent position because this relieves pain. B. INCORRECT: This sleeping position does not promote circulation in the lower extremity. C. INCORRECT: This sleeping position does not promote circulation in the lower extremity. D. INCORRECT: This sleeping position does not promote circulation in the lower extremity.

3. A nurse is providing teaching for a client who is to have a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates a need for further teaching? A. "Cancer can be detected in the fluid being tested." B. "I will feel a heavy pressure sensation in my hip bone." C. "The type of antibiotic I need to take can be determined by this test." D. "I will be awake during the procedure."

3. A. INCORRECT: The presence of cancer can be determined by this test. B. INCORRECT: The client will feel brief pain or pressure with this test. C. CORRECT: A culture and sensitivity test determines the type of antibiotics that a client who has an infection needs to take. D. INCORRECT: A client is awake during a bone marrow biopsy.

2. A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? (Select all that apply.) A. Stop the transfusion. B. Send the blood bag and IV tubing to the blood bank. C. Maintain an IV infusion with 0.9% sodium chloride. D. Elevate the client's feet. E. Obtain blood cultures.

2. A. CORRECT: The first action is to stop the infusion. B. CORRECT: The blood bag and administration tubing are sent to the laboratory for analysis. C. CORRECT: 0.9% sodium chloride solution should be administered through new IV tubing. D. INCORRECT: The client's feet are elevated if sepsis or septic shock is suspected following a transfusion. E. INCORRECT: Blood specimens are not routinely obtained unless sepsis is suspected.

2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: heart rate 117/min, respiratory rate 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this time? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a spiral CT scan.

2. A. INCORRECT: Notifying the provider about the client's condition is important, but it is not the priority action by the nurse at this time. B. INCORRECT: Administration of IV heparin is treatment used to dissolve a blood clot, but it is not the priority action by the nurse at this time. C. CORRECT: When using the airway, breathing, circulation (ABC) priority approach to care, the nurse determines meeting the client's oxygenation needs by administering oxygen therapy is the priority action. D. INCORRECT: Obtaining a spiral CT scan to detect the presence and location of the blood clot is important, but it is not the priority action by the nurse at this time.

2. A nurse is teaching a client who has a new prescription for ferrous sulfate (Feosol). Which of the following should be included in the teaching? A. Stools will be dark red in color. B. Take with a glass of milk if gastrointestinal distress occurs. C. Foods high in vitamin C will promote absorption. D. Take for 14 days.

2. A. INCORRECT: Stools will be dark green to black in color when taking iron. B. INCORRECT: Milk binds with iron and decreases its absorption. C. CORRECT: Vitamin C enhances the absorption of iron by the intestinal tract. D. INCORRECT: Iron therapy usually takes 4 to 6 weeks for Hgb and Hct to return to the normal reference range.

2. A nurse is assessing a client and suspects the client is experiencing disseminated intravascular coagulation (DIC). Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

2. A. INCORRECT: Tachycardia is a finding that is indicative of DIC. B. INCORRECT: Hypotension is a finding that is indicative of DIC. C. CORRECT: Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC. D. INCORRECT: Xerostomia is dryness of the mouth and is not indicative of DIC.

2. A nurse is caring for a client who has hemophilia. The nurse should anticipate a prescription from the provider for which of the following tests? A. RBC B. TIBC C. aPTT D. MCH

2. A. INCORRECT: The RBC identifies the presence of anemia and is not indicated for a client who has a clotting disorder. B. INCORRECT: The TIBC identifies the presence of iron deficiency anemia and is not indicated for a client who has a clotting disorder. C. CORRECT: The aPTT checks the clotting factors in a client who has hemophilia. D. INCORRECT: The MCH indicates the presence of anemia and is not indicated for a client who has a clotting disorder.

3. A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should be included in the teaching? (Select all that apply.) A. "You will need a monthly injection of vitamin B12 for the rest of your life." B. "Using the nasal spray form of vitamin B12 on a daily basis may be an option." C. "An oral supplement of vitamin B12 taken on a daily basis may be an option." D. "You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet." E. "Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia."

3. A. CORRECT: A client who had a gastrectomy will require monthly injections of vitamin B12 for the rest of his life. B. CORRECT: Cyanocobalamin nasal spray used daily is an option for a client who had a gastrectomy. C. INCORRECT: Oral supplements of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the stomach. D. INCORRECT: Dietary sources of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the stomach. E. INCORRECT: Dietary sources of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the stomach.

3. A nurse is monitoring a client who began receiving a unit of blood 10 min ago. Which of the following should pose an immediate concern for the nurse? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F) posttransfusion B. Dyspnea C. Heart rate increase from 74/min pretransfusion to 81/min posttransfusion D. Client report of itching E. Client appears flushed

3. A. CORRECT: A slight increase in temperature is an expected finding. B. CORRECT: Dyspnea may indicate a transfusion reaction. C. INCORRECT: A slight increase in heart rate is an expected finding. D. CORRECT: A client's report of itching may indicate a transfusion reaction. E. CORRECT: A flushed appearance of the client may indicate a transfusion reaction.

3. A nurse is teaching a client who has a new prescription for clopidogrel (Plavix). Which of the following should be included in the teaching? (Select all that apply.) A. Effects may not be apparent for several weeks. B. Monitor for the presence of black, tarry stools. C. Instruct the client to use an electric razor. D. Schedule a weekly PT test. E. Advise the client about food sources containing vitamin K.

3. A. CORRECT: Therapeutic benefits may not occur for several weeks when taking Plavix. B. CORRECT: Evidence of GI bleeding, such as abdominal pain, coffee-ground emesis, or black, tarry stools should be monitored and reported to the provider. C. INCORRECT: Bleeding precautions are required for a client taking anticoagulants, not antiplatelet medications. D. INCORRECT: PT and INR levels are monitored regularly in a client taking warfarin (Coumadin). E. INCORRECT: A client who is taking warfarin (Coumadin) should be advised about food sources containing vitamin K.

3. A nurse is discussing a new diagnosis of an aneurysm with a client. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following is an appropriate response by the nurse? A. "The wall of an artery becomes thin and flexible." B. "It is due to turbulence in blood flow in the artery." C. "It is due to abdominal enlargement." D. "It is due to hypertension."

3. A. INCORRECT: An aneurysm ruptures as a result of thickening in the intima of the artery and a lack of elasticity in the vessel wall, which is usually under pressure due to hypertension. B. INCORRECT: A bruit is objective data, which indicates the presence of an aneurysm, not the cause of rupture. C. INCORRECT: Abdominal distention may occur when an aneurysm ruptures, but it is not the cause of the rupture. D. CORRECT: Hypertension increases pressure within the arterial walls, resulting in rupture.

3. A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed? A. Petechiae on the upper chest B. Hypotension C. Cyanotic nail beds D. Severe headache

3. A. INCORRECT: Petechiae on the upper chest can indicate impaired clotting. B. INCORRECT: Hypotension can indicate impaired clotting. C. CORRECT: Cyanotic nail beds indicate microvascular clotting is occurring and should be immediately reported to avoid ischemic loss of the fingers or toes. D. INCORRECT: Severe headache can indicate cerebral bleeding.

3. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."

3. A. INCORRECT: The nurse should document all allergies. Morphine can be prescribed to manage the client's discomfort due to a blood clot, but is not the immediate concern at this time. B. CORRECT: The greatest risk to the client is the possibility of bleeding from a peptic ulcer. Further assessment should be completed and the nurse should notify the provider of the finding. C. INCORRECT: The client's history of a blood clot is important for the nurse to know, but it is not the immediate concern at this time. D. INCORRECT: The client report of pain with breathing is important for the nurse to know, but it is not the immediate concern at this time.

4. A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following medications should the nurse anticipate administering to the client? A. Heparin B. Vitamin K C. Antibiotic D. Antilipemic

4. A. CORRECT: Heparin may be administered to decrease the formation of microclots, which deplete clotting factors. B. INCORRECT: Vitamin K promotes blood coagulation and is not a medication that is prescribed for a client who has DIC. C. INCORRECT: An antibiotic is given to treat bacterial infections and is not a medication that the nurse should anticipate being administered to a client who has DIC. D. INCORRECT: An antilipemic is given to treat hyperlipidemia and is not a medication that the nurse should anticipate being administered to a client who has DIC.

4. A nurse is completing an integumentary assessment of a client who has anemia. Which of the following is an expected finding? A. Absent turgor B. Spoon-shaped nails C. Shiny, hairless legs D. Yellow mucous membranes

4. A. INCORRECT: Absent skin turgor is a finding in a client who has dehydration. B. CORRECT: Deformities of the nails, such as being spoon-shaped, are a finding in a client who has anemia. C. INCORRECT: These findings are present in a client who has peripheral vascular disease. D. INCORRECT: The client who has anemia will have pale nail beds and mucous membranes.

4. A nurse is admitting a client with a suspected occlusion of a graft of the abdominal aorta. Which of the following is an expected clinical finding? A. Increased urine output B. Bounding pedal pulse C. Increased abdominal girth D. Redness of the lower extremities

4. A. INCORRECT: Decreased urine output is an expected finding with occlusion of a graft of the aorta. B. INCORRECT: Decreased or absent pedal pulse is an expected finding with occlusion of a graft of the aorta. C. CORRECT: Abdominal distention is an expected finding with occlusion of a graft of the aorta. D. INCORRECT: Pallor or cyanosis of the extremities is an expected finding with occlusion of a graft of the aorta.

4. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

4. A. INCORRECT: Tachypnea is a clinical manifestation associated with a pulmonary embolism. B. CORRECT: A pleural friction rub is a clinical manifestation associated with a pulmonary embolism. C. INCORRECT: Hypotension is a clinical manifestation associated with a pulmonary embolism. D. CORRECT: Petechiae is a clinical manifestation associated with a pulmonary embolism. E. CORRECT: Tachycardia is a clinical manifestation associated with a pulmonary embolism.

4. A nurse is completing preoperative teaching with a client who will undergo an elective surgical procedure that will include a blood transfusion. Which of the following statements by the nurse should be included in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "We will have you come in to donate your blood the day before surgery." D. "You will receive the blood you donated 4 weeks prior to the surgery."

4. A. INCORRECT: The client should donate blood for an autologous transfusion no sooner than 5 weeks in advance, up to 72 hr prior to surgery. B. INCORRECT: A homologous transfusion involves receiving a transfusion of blood from donors other than the recipient. C. INCORRECT: The client should donate blood for an autologous transfusion no sooner than 5 weeks in advance, up to 72 hr prior to surgery. D. CORRECT: An autologous transfusion involves collecting a client's blood no sooner than 5 weeks in advance, up to 72 hr prior to surgery so it can be transfused during an elective surgery.

4. A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin (Coumadin). The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse? A. "I will remind your provider that you are already receiving heparin." B. "Laboratory findings indicated that two anticoagulants were needed." C. "It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued." D. "Only one of these medications is being given to treat your deep-vein thrombosis."

4. A. INCORRECT: Warfarin is prescribed for 3 to 4 days before discontinuing IV heparin. B. INCORRECT: IV heparin is monitored to achieve adequate therapeutic levels in treating a DVT. C. CORRECT: Warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. Therefore, it takes 3 to 4 days before the clotting factors that are present decay and the therapeutic effects of warfarin occur. D. INCORRECT: Heparin and warfarin are both effective in treating DVTs.

4. A nurse is caring for a client who is having a bone marrow biopsy. What actions should the nurse take? Use the ATI Active Learning Template: Diagnostic Procedure to complete this item to include the following: A. Nursing Interventions: Describe two for each of the pre, intra, and postoperative periods. B. Potential Complications: Identify two. C. Client Education: Describe two teaching points.

4. Using the ATI Active Learning Template: Diagnostic Procedure A. Nursing Interventions ●● Pre ◯◯ Ensure that the client has signed the informed consent form. ◯◯ Position the client in a prone or side-lying position. ●● Intra ◯◯ Administer sedative medication. ◯◯ Assist with the procedure. ◯◯ Apply pressure to the biopsy site. ◯◯ Place a sterile dressing over the biopsy site. ●● Post ◯◯ Monitor for evidence of infection and bleeding. ◯◯ Apply ice to the biopsy site. ◯◯ Administer mild analgesics; avoid aspirin or medications that affect clotting. B. Potential Complications ●● Bleeding and infection C. Client Education ●● Explain the procedure to be performed: use of local anesthesia, sensation of pressure or brief pain. ●● Report excessive bleeding and evidence of infection to the provider. ●● Check the biopsy site daily. It should be clean, dry and intact. ●● If there are sutures, return in 7 to 10 days for removal.

5. A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

5. A. CORRECT: Clients who have undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. B. INCORRECT: An elevated sedimentation rate does not place the client at risk for hemorrhage. C. INCORRECT: An incident of exercise-induced asthma does not place the client at risk for hemorrhage. D. INCORRECT: An elevated platelet count does not place the client at risk for hemorrhage.

5. A nurse is reviewing clinical manifestations of a thoracic aortic aneurysm with a newly hired nurse. Which of the following should the nurse include in the discussion? (Select all that apply.) A. Cough B. Shortness of breath C. Upper chest pain D. Diaphoresis E. Altered swallowing

5. A. CORRECT: Cough is a manifestation of a thoracic aortic aneurysm. B. CORRECT: Shortness of breath is a manifestation of a thoracic aortic aneurysm. C. INCORRECT: Report of severe back pain is a clinical finding of thoracic aortic aneurysm. D. INCORRECT: Diaphoresis is a clinical finding of dissecting aortic aneurysm. E. CORRECT: Difficulty swallowing is a manifestation of a thoracic aortic aneurysm.

5. A nurse is observing a newly hired nurse on the unit who is preparing to administer a blood transfusion. Which of the following actions by the newly hired nurse requires intervention by the nurse? A. Inserts a large-bore IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) C. Administers 0.9% sodium chloride IV D. Assesses for a history of blood-transfusion reactions

5. A. INCORRECT: A large-bore IV catheter is used for administering blood products. B. CORRECT: Verification of the client's identify, blood compatibility, and expiration date of the blood is done with another nurse. Assistive personnel cannot be asked to perform this task. C. INCORRECT: Blood and blood products are infused with 0.9% sodium chloride. IV solutions containing dextrose cannot be used. D. INCORRECT: The nurse should assess for a client history of blood-transfusion reactions to identify any potential risks for future reactions.

5. A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to A. massage both legs firmly with lotion prior to applying the stockings. B. apply the stockings in the morning upon awakening and before getting out of bed. C. roll the stockings down to the knees if they will not stay up on the thighs. D. remove the stockings while out of bed for 1 hr, four times a day to allow the legs to rest.

5. A. INCORRECT: Massaging the affected area can dislodge a clot and cause embolism. B. CORRECT: Applying stockings in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. Legs are less edematous at this time. C. INCORRECT: Rolling stockings down can restrict circulation and cause edema. D. INCORRECT: Stockings should remain in place throughout the day and are removed before going to bed to provide continuous venous support. If the stockings are removed, such as for a bath or shower, then the legs should be elevated before the stockings are reapplied.

5. A nurse in a clinic receives a phone call from a client seeking information about his new prescription for erythropoietin (Epogen). Which of the following information should be reviewed with the client? A. The client needs an erythrocyte sedimentation rate (ESR) test weekly. B. The client should have his hemoglobin checked twice a week. C. Oxygen saturation levels should be monitored. D. Folic acid production will increase.

5. A. INCORRECT: The effectiveness of erythropoietin is evaluated by changes in the hematocrit. B. CORRECT: Hemoglobin and hematocrit are monitored twice a week. C. INCORRECT: Blood pressure is monitored for an increase. D. INCORRECT: Erythropoietin promotes increased production of RBCs.

5. A nurse is developing a plan of care for a client who has disseminated intravascular coagulation (DIC). Which interventions should the nurse include in the plan of care? Use the ATI Active Learning Template: Systems Disorder to complete this item to include Patient-Centered Care: Describe five interventions.

5. Using ATI Active Learning Template: Systems Disorder ●● Patient-Centered Care ◯◯ Monitor for signs of microemboli (cyanotic nail beds, pain). Regularly take vital signs and assess hemodynamic status. ◯◯ Monitor for signs of organ failure or intracranial bleed (oliguria, decreased level of consciousness). ◯◯ Monitor laboratory values for clotting factors. ◯◯ Administer fluid volume replacement. ◯◯ Transfuse blood, platelets, and other clotting products. ◯◯ Monitor for complications from the administration of blood and blood products. ◯◯ Avoid use of NSAIDs. ◯◯ Administer supplemental oxygen. ◯◯ Provide protection from injury. ◯◯ Instruct client to avoid Valsalva maneuver (could cause cerebral hemorrhage). ◯◯ Implement bleeding precautions (avoid use of needles).

6. A nurse is caring for a client who is receiving a blood transfusion. What nursing actions should the nurse anticipate if a transfusion reaction is suspected? Use the ATI Active Learning Template: Nursing Skill to complete this item to include the following: A. Indications: ●● Describe the four types of reactions and the time of onset. ●● Describe three medications that may be administered and for which reaction. B. Potential Complications: Describe two nursing actions for each.

6. Using the ATI Active Learning Template: Nursing Skill A. Indications ●● Types of reactions and onset ◯◯ Acute hemolytic - immediate ◯◯ Febrile - 30 min to 6 hr after transfusion ◯◯ Mild allergic - During or up to 24 hr after transfusion ◯◯ Anaphylactic - immediate B. Potential Complications ●● Circulatory overload ◯◯ Administer oxygen. ◯◯ Monitor vital signs. ◯◯ Slow the infusion rate. ◯◯ Administer diuretics as prescribed. ◯◯ Notify the provider immediately. ●● Medications ◯◯ Antipyretics (acetaminophen [Tylenol]) - febrile ◯◯ Antihistamines (diphenhydramine [Benadryl]) - mild allergic ◯◯ Antihistamines, corticosteroids, vasopressors - anaphylactic ●● Sepsis and septic shock ◯◯ Maintain patent airway. ◯◯ Administer oxygen. ◯◯ Administer antibiotics as prescribed. ◯◯ Obtain blood samples for culture. ◯◯ Administer vasopressors in late phase. ◯◯ Elevate client's feet. ◯◯ Assess for disseminated intravascular coagulation.

6. A nurse is developing a poster presentation on peripheral arterial disease (PAD) for a community health fair. What content should the nurse include on the poster? Use ATI Active Learning Template: Systems Disorder to complete this item to include the following: A. Description of Disease Process B. Risk Factors: Describe at least six. C. Objective Data: Describe at least six findings. D. Client Education: Describe at least two actions by the client related to proper positioning and two actions related to promoting vasodilation.

6. Using the ATI Active Learning Template: Systems Disorder A. Description of Disease Process: PAD is inadequate blood flow of the lower extremities due to atherosclerosis. The intima and media of the arteries becomes thickened, and plaques may form on the walls of the arteries, making them rough and fragile. The arteries progressively stiffen and the lumen narrows, decreasing blood supply to tissues and increasing resistance to blood flow. It is classified as either an inflow or outflow type of PAD. B. Risk Factors ●● Hypertension ●● Hyperlipidemia ●● Diabetes mellitus ●● Cigarette smoking ●● Obesity ●● Sedentary lifestyle ●● Familial predisposition ●● Age C. Objective Data ●● Bruits over femoral and aortic arteries ●● Decreased capillary refill of toes (greater than 3 seconds) ●● Decreased or nonpalpable pulses ●● Loss of hair on the lower extremities ●● Dry, scaly mottled skin ●● Thick toenails ●● Cold, cyanotic extremity ●● Pallor of extremity with elevation ●● Dependent rubor ●● Muscle atrophy ●● Ulcers and possible gangrene of toes D. Client Education ●● Actions related to positioning ◯◯ Avoid crossing the legs. ◯◯ Avoid wearing restrictive garments. ◯◯ Keep legs elevated to reduce swelling but not above the level of the heart. ●● Actions to promote vasodilation ◯◯ Maintain a warm environment. ◯◯ Wear insulated socks. ◯◯ Avoid applying direct heat to the extremity. ◯◯ Avoid exposure to cold. ◯◯ Avoid stress, caffeine, and nicotine.

6. A nurse educator is presenting a community education program on anemia to a group of clients. What should be included in this presentation? Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following: A. Description of Disorder/Disease Process: Describe and identify at least three causes. B. Objective and Subjective Data: Identify at least three of each form of data. C. Laboratory Tests: Describe the importance of the TIBC test.

6. Using the ATI Active Learning Template: Systems Disorder A. Description of Disorder/Disease Process ●● Anemia is an abnormally low amount of circulating red blood cells, hemoglobin concentration, or both. It may be due to blood loss, inadequate production or increased destruction of red blood cells, and dietary deficiencies of folic acid, iron, erythropoietin, and/or vitamin B12. B. Objective and Subjective Data ●● Objective Data ◯◯ Shortness of breath and fatigue with exertion ◯◯ Tachycardia, palpitations, dizziness, or syncope upon standing or with exertion ◯◯ Pallor, pale nail beds, pale mucous membranes, nail bed deformities ◯◯ Smooth, sore, bright-red tongue ●● Subjective Data ◯◯ May be asymptomatic, pallor, fatigue, irritability, numbness and tingling of extremities, dyspnea on exertion, sensitivity to cold, pain, and hypoxia with sickle-cell crisis C. Laboratory Tests ●● This test is an indirect measurement of serum transferrin, a protein that binds with iron and transports it for storage. Serum transferrin is an indicator of the total iron stores in the body.

6. A nurse educator is presenting a program to nurses on care of the client with an aneurysm. What should the educator include in this program? Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following sections: A. Risk Factors: Describe three. B. Diagnostic Procedures: Describe two. C. Nursing Interventions: Describe at least four.

6. Using the ATI Active Learning Template: Systems Disorder A. Risk Factors ●● Male sex ●● Atherosclerosis ●● Uncontrolled hypertension ●● Tobacco use ●● Age-related changes to the artery (loss of elastin, thickening of the intima, progressive fibrosis) B. Diagnostic Procedures ●● X-rays ●● CT scans ●● Ultrasonography C. Nursing Interventions ●● Take vital signs every 15 min until stable. Then, every hour, monitoring for increased blood pressure. ●● Assess pain (onset, quality, duration, severity). ●● Assess temperature, circulation, and range of motion of extremities. ●● Monitor cardiac rhythm continuously. ●● Monitor hemodynamic findings. ●● Monitor ABGs, Sa02, electrolytes, CBC laboratory findings. ●● Monitor hourly urine output. ●● Administer oxygen as prescribed. ●● Obtain and maintain IV access. ●● Administer medications as prescribed.

6. A nurse is caring for a client who has a pulmonary embolism. Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following sections: A. Description of Disorder/Disease Process B. Patient-Centered Care: ●● Describe three nursing interventions. ●● Identify two medications.

6. Using the Active Learning Template: Systems Disorder A. Description of Disorder/Disease Process ●● A pulmonary embolism (PE) occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a blockage in the pulmonary vasculature. ●● Emboli originating from deep-vein thrombosis (DVT) are the most common cause. Tumors, bone marrow, amniotic fluid, and foreign matter can also become emboli. B. Patient-Centered Care ●● Nursing Interventions ◯◯ Administer oxygen therapy as prescribed to relieve hypoxemia and dyspnea. Position the client to maximize ventilation (high-Fowler's = 90%). ◯◯ Initiate and maintain IV access. ◯◯ Administer medications as prescribed. ◯◯ Provide emotional support and comfort to control client anxiety. ◯◯ Monitor changes in level of consciousness and mental status. ●● Medications ◯◯ Anticoagulants - enoxaparin (Lovenox), heparin, and warfarin (Coumadin) ◯◯ Thrombolytic therapy - alteplase (Activase) and streptokinase (Streptase)

1. A nurse in the emergency department is assisting with the admission of a client who has a possible dissecting abdominal aortic aneurysm. Which of the following is the priority nursing intervention? A. Administer pain medication as prescribed. B. Ensure a warm environment. C. Administer IV fluids as prescribed. D. Initiate a 12-lead ECG.

Application Exercises Key 1. A. INCORRECT: Administering pain mediation is important, but it is not the priority nursing intervention. B. INCORRECT: Ensuring a warm environment is important, but it is not the priority nursing intervention. C. CORRECT: Using the ABC priority-setting framework, the greatest risk to the client is inadequate circulatory volume. The priority nursing intervention is to administer IV fluids. D. INCORRECT: Initiating a 12-lead ECG is important, but it is not the priority nursing intervention.