Cardiac & Hematology ATI

A nurse is caring for a client who had a myocardial infarction five 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 R: A client had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are best sounds caused by movement of air through airway is partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.

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

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

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

Dyspnea with hiccups R: A client who has pericarditis will experience dyspnea, pick ups, and a non-productive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

A nurse is providing teaching to 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. R: The nurse should teach 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.

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

0.9% sodium chloride R: 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 physiological isotonic solution that replaces loss volume in the bloodstream and is the only solution to use when infusing blood products.

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter?

Atrial rate of 300/min with QRS complex of 80/min R: The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.

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

Lower Back Discomfort R: abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending down word and pressing on lumbar spinal nerve roots, causing pain.

A nurse is preparing to transfuse a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse take?

Witness the informed consent

A nurse is providing teaching about lifestyle changes to 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 count my radial pulse rate." R: A beta blocker will induce bradycardia. The client should take her pulse rate for one minute before self administration.

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The clients vital signs are BP 160/98 mm Hg, HR 102/min, RR 22/min, and SpO2 95%. Which of the following actions should the nurse take?

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

A nurse is completing an assessment history for a client who has a history of unstable angina. Which of the following findings should the nurse expect?

Chest pain lasts longer than 15 minutes. R: The client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.

A nurse in the clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect?

Dry, pale skin with minimal body hair R: 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 monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect?

Increased pulmonary congestion Pulmonary congestion occurs due to right sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and hyper trophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right sided heart failure.

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

Initiate weekly injections of vitamin B 12 R: The nurse initiate weekly injections and vitamin B 12 for client has pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by lack of intrinsic factor needed to absorb vitamin B 12 from the gastrointestinal tract.

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor?

Iron toxicity

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

JVD, moist crackles, increased HR R: Jugular vein distention is correct. The increase in venous pressure due to excessive circulating blood volume results in neck pain distention. Moist crackles is correct. This is an indicator of pulmonary edema that can quickly lead to death. 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 pulse. 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. Fever is incorrect. Fever is common and clients who are experiencing dehydration, not fluid volume excess.

Anderson is planning care for a client is having percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post procedure plan of care?

Monitor for bleeding

A nurse is completing a medication history for 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 R: 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 assessing for cardiac tamponade on a client who had a coronary artery bypass grafts. Which of the following actions should the nurse take?

Osculate BP for pulses paradoxes R: The client who has cardiac tamponade will have pulses paradoxes when the systolic blood pressure is at least 10 mm Hg higher on expiration then on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect?

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

A nurse is caring for a client who is post operative 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. R: The nurse should elevate the clients legs above his heart to promote venous return by gravity drain 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 has heart failure and whose telemetry reading displays a flattening of the T-wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change?

Potassium 2.8 mEq/L R: A flattened T-wave or the development of U waves is indicative of a low potassium level.

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 R: Hemophilia is a hereditary bleeding disorder in which blood clot 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.

The nurse is reviewing a clients repeat laboratory results 4 hours after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review?

Prothrombin time R: The nurse should review the clients 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 transfusing a unit of O-negative fresh frozen plasma to a client whose blood type is B positive. Which of the following actions should the nurse take?

Remove the unit of plasma immediately and start an IV infusion of normal Saline.

A nurse is administering a unit of packed RBCs to a client who is postoperative. The client reports itching and has hives 30 minutes after the infusion begins. Which of the following actions should the nurse take first?

Stop the infusion of blood. R: The nurse should apply the urgent versus non-urgent priority setting framework. Using this framework, the nurse should consider urgent needs a 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 a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect?

Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes R: The nurse should not expect Pacers bikes when the clients pulse is greater than the set rate of 72/min, because the clients intrinsic rate overrides the set rate of the pacemaker.

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

Ventricular dysrhythmias R: 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 assessing a client who has late-stage heart failure and is expecting fluid volume overload. Which of the following findings should the nurse expect?

Weight gain 1 kg (2.2 lb) in 1 day R: A weight gain of 1 kg in one day alert the nurse that the client is retaining fluid and is at risk of fluid volume overload. This is an indication that the clients heart failure is worsening.