Cardiovascular

A nurse is reinforcing teaching with a client who was recently diagnosed with Raynaud's phenomenon how to prevent the onset of manifestations. Which of the following statements by the client should indicate to the nurse a need for further teaching? 1. "I will keep my house at a cool temperature" 2. "I will try to anticipate and avoid stressful situations" 3. I will complete the smoking cessation program I started" 4. "I will wear gloves when removing food from the freezer"

"I will keep my house at a cool temperature"; Raynaud's phenomenon occurs when the client is exposed to cold temperatures or stress causing painful vasoconstriction of the blood vessels.

An adult is scheduled for surgery. Which of the following sites should the nurse assess for possible placement of an IV catheter? (SATA) 1. Great saphenous vein 2. cephalic vein 3. dorsal plexus 4. basilic vein 5. external jugular vein

- Cephalic vein; located i inner arm - Basilic vein; originates from the back of the hand

A nurse is planning care for a client who has acute leukemia and received aggressive chemotherapy treatment. Which of the following hematologic laboratory abnormalities should the nurse expect to see? 1. Decreased platelet count 2. Increased hemoglobin 3. Decreased WBC 4. Increased platelet 5. Decreased RBC

- Decreased platelet - Decreased WBC - Decreased RBC

A nurse is giving a presentation about preventing DVT. Which of the following should the nurse include as a risk factor for this disorder? (SATA) 1. dehydration 2. oral contraceptive use 3. hyptertension 4. high calcium intake 5. immobility

-Dehydration; increases blood viscosity - Oral contraceptive use; thromboembolic events are an adverse effect of oral contraceptives - Immobility; leads to stasis of blood

In preparation for the discharge of a client with peripheral arterial disease, the nurse should reinforce which of the following instruction? 1. Apply a heating pad on a low setting to help relieve leg pain 2. Adjust the thermostat so that the environment is warm 3. Wear antiembolic stockings during the day 4. Rest with legs above heart level

Adjust thermostat so that the environment is warm; this prevents vasoconstriction. Do not apply heat directly to limb because sensation is diminished and burns could result. Should not wear constrictive clothing. Elevation slows the arterial blood flow to the feet.

A nurse is reinforcing teaching for a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following is appropriate to include in the teaching? 1. it is associated with decreased intake of iron 2. it results in an increased rate of RBC destruction 3. it is directly related to impaired liver function 4. it results from decreased bone marrow production of RBC

Aplastic anemia results from decreased bone marrow production of RBC

When checking a client's capillary refill, the nurse finds that the color returns to usual in 10 seconds. The nurse understands that this finding indicates which of the following? 1. Arterial insufficiency 2. venous insufficiency 3. within the expected range 4. thrombus formation in the vein

Arterial insufficiency

While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities? 1. ventricular depolarization 2. slow repolarization of ventricular Purkinje fibers 3. atrial depolarization 4. early ventricular repolarization

Atrial depolarization; typically initiated in the SA node.

A nurse is planning care for a client who has thrombocytopenia. The nurse understands that the client's plan of care should include which of the following? 1. restricting visitors to family members only 2. avoiding venipunctures whenever possible 3. limiting oral fluid intake 4. prohibiting fresh flowers in the client's room

Avoiding venipunctures whenever possible; clients have a decreased platelet count, which puts the client at risk for bleeding. Avoid activities and invasive procedures that may result in bleeding.

A client with valvular heart disease is at risk for developing left-sided heart failure. The nurse knows to monitor which of the following parameters to determine if the client has developed this disorder? 1. appetite 2. body weight 3. breath sounds 4. blood pressure

Breath sounds; manifestations of left-sided heart failure are crackles or wheezes

The nurse is reinforcing teaching regarding diet to a client after a myocardial infarction. The nurse evaluates the reinforcement as effective if the client selects which of the following options? 1. barbecued beef, beans, potato chips, tossed salad 2. baked turkey, mashed potatoes, squash and salad 3. bread, fried fish patty, potato salad, cole slaw 4. grilled pork chops, biscuits and brown gravy, sliced tomato

Baked turkey, mashed potatoes, squash and salad; low sodium, low fat diet is a usual cardiac diet

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? 1. a cardiac murmur 2. third heart sound (S3) 3. an expected heart sound 4. a fourth heart sound (S4)

Cardiac murmur; they create a whooshing or swishing sound.

A client's lab results report that the hemoglobin is 10g/dL and the hematocrit is 30%. For which of the following is the client at risk? 1. prolonged bleeding 2. cellular hypoxia 3. impaired immunity 4. fluid retention

Cellular hypoxia; these lab results indicate anemia.

A nurse reviewing lab values on a client who has idiopathic thrombocytopenic purpura. Which of the following lab results should the nurse expect to be decreased? 1. Circulating WBC 2. Circulating RBC 3. Circulating granulocytes 4. Circulating platelets

Circulating platelets; there should be a decrease in platelets because the anticoagulant pathways are impaired

A nurse is caring for a client who was recently admitted for atrial fibrillation. Which of the following assessment findings should the nurse report immediately? 1. ECG reflects A. fib with a heart rate of 112/min 2. aPTT result of 40 seconds 3. Client's skin is cool and clammy 4. Urine output is cloudy and odorous

Client's skin is cool and clammy; indicates poor vascular perfusion. Should immediately be assessed for additional signs of shock and notify provider immediately. Normal aPTT is 30-40 seconds.

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? 1. confusion 2. lethargy 3. unconsciousness 4. petechiae

Confusion; lethargy is the progressive stage of shock, unconsciousness is the irreversible stage of shock, and petechiae is the progressive stage of shock.

A nurse is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following nursing statements indicates an understanding of the condition? 1. DIC is controllable with lifelong heparin usage 2. DIC is characterized by an elevated platelet count 3. DIC is caused by abnormal coagulation involving fibrinogen 4. DIC is a genetic disorder involving vitamin K deficiency

DIC is caused by abnormal coagulation involving fibrinogen

A nurse is assisting with the care of a client who is receiving a blood transfusion. Which of the following indicates the client is experiencing a complication? 1. brisk capillary refill 2. difficulty breathing 3. Temperature 36.8 C. 4. Platelet count 170,000

Difficulty breathing; this is a manifestation of an air embolism, which is a complication that can occur during blood transfusion.

A nurse acknowledges a client's valid concerns who has a family history of hemophilia A. Which of the following symptoms may the client experience? 1. frequent rapid bleeding 2. minimal tendency to bruise 3. immediate clotting from a minor cut 4. disabling joint pain

Disabling joint pain; there may be hemorrhage into the joints due to deficiency of factor VIII

A nurse on a medical unit is caring for a client who has infective endocarditis. The nurse should observe the client for manifestations of a common complication of this disorder by monitoring for: 1. heart murmur 2. dyspnea 3. fever 4. petechiae

Dyspnea; emboli is a common complication of infective endocarditis and manifests as dyspnea. Heart murmurs, fever, and petechiae are manifestations of endocarditis.

A nurse is collecting data from a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? 1. necrotic foot ulcers 2. edema 3. hair loss 4. thick, deformed toenails

Edema; fluid accumulates in the veins and it leaks out into the surrounding tissues. Necrotic foot ulcers, hair loss, and thick, deformed toenails are manifestations of peripheral arterial disease.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back and shoulder, shortness of breath and nausea. Which of the following actions should the nurse perform first? 1. administer oxygen 2. begin ECG monitoring 3. ensure patent airway 4. assess pain

Ensure patent airway

A nurse is making a home visit to a client who receives diuretics daily for heart failure. Which of the following signs would the client manifest with hypokalemia? 1. pitting edema 2. fatigue 3. dyspnea 4. oliguria

Fatigue; expect fatigue due to muscle weakness. Polyuria is expected with hypokalemia. Pitting edema and dyspnea are manifestations of hypernatremia.

A nurse is reinforcing teaching with an older adult client who has just undergone insertion of a permanent pacemaker. The nurse should emphasize that a sign of pacemaker malfunction the client should report to the provider is 1. increased urine output 2. rapid pulse 3. fatigue 4. sneezing

Fatigue; pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia with manifestations of weakness, fatigue, and dizziness.

A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes the client is flushed, febrile, and experiencing chills. To establish a diagnosis of hemolytic transfusion reaction, the nurse should observe the client for which symptoms? 1. urticaria 2. anxiety 3. flank pain 4. headache

Flank pain; flank pain and hematuria are classic manifestations of hemolytic transfusion reaction. The kidneys are working harder to excrete hemolyzed RBCs.

A nurse is reinforcing discharge instructions for a client who developed DVT postop and receives anticoagulant therapy. Which of the following instructions should the nurse include? 1. applying cool compresses to her legs 2. wearing loose, non-constricting stockings 3. flexing her knees and feet frequently 4. taking an NSAID tablet daily

Flexing her knees and feet frequently; can help improve circulation and prevent stasis while the client is resting

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect? 1. frothy sputum 2. dependent edema 3. nocturnal polyuria 4. jugular distention

Frothy sputum; reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

The nurse is caring for a client who has just had a cardiac catheterization. The post procedure nursing care plan for this client should include which of the following nursing interventions? 1. Have the client rest in bed for 2-6 hours 2. keep the involved leg slightly flexed 3. elevate the head of the ed 45 degrees 4. keep the client NPO for 4 hours

Have the client rest in bed for 2-6 hours.

A client is preparing for an exercise stress test. Which of the following comments should indicate to the nurse that the client requires further reinforcement of teaching? 1. I will not smoke prior to my test 2. I'll take my heart medications the morning of my test 3. I'll get 8 hours of sleep the bight before the test 4. I'll skip my coffee the morning of my test

I'll take my heart medications the morning of my test; client should avoid medications that will prevent fluctuations in heart rate during the test

A young female adult client reports dyspnea, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8g/dL and hematocrit of 28 g/dL. Which of the following types of anemia are the findings consistent with? 1. Folic acid-deficiency anemia 2. normocytic anemia 3. iron-deficiency anemia 4. sickle cell anemia

Iron-deficiency anemia; caused from inadequate intake or iron on a consistent basis

A nurse on a telemtry unit is caring for a client who has premature ventricular contractions. While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse? 1. bounding pulsations 2. irregular pulsations 3. tachycardia 4. bradycardia

Irregular pulsations; the pause in usual heart rhythm results in irregular apical pulse

A nurse is preparing a client for an echocardiogram the following day. Which of the following instructions should the nurse include about the test? 1. it might cause slight discomfort in the chest area 2. it takes about 5-10 minutes 3. it requires lying quietly on one side 4. it is best to have no food or beverages the day of the test

It requires lying quietly on one side; an echocardiogram takes 30-60 minutes and is painless

Following admission, a client with vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1. rub the client's feet 2. obtain a pair of slipper socks 3. increase the client's oral fluid intake 4. place a moist heating pad under the client's feet

Obtain a pair of slipper socks

A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should the nurse administer first? 1. nitroglycerin 2. aspirina 3. oxygen 4. morphine sulfate

Oxygen; use the airway, breathing, circulation approach

A nurse is caring for a client who enters the emergency department complaining of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction? 1. check BP 2. auscultate heart tones 3. perform 12-lead ECG 4. determine if pain radiates to left arm

Perform 12-lead ECG

A nurse is caring for a client with right-sided heart failure. The nurse knows that a primary manifestation is 1. frothy sputum 2. dyspnea 3. orthopnea 4. peripheral edema

Peripheral edema; weakness in the right side of the heart allows blood to back up into the venous system

A nurse is reading a client's ECG tracing. Which component of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? 1. PR interval 2 QT interval 3. ST segment 4. QRS complex

QT interval; reflects the time it takes for ventricular depolarization and repolarization.

A provider suspects that a client might have pernicious anemia. The nurse caring for this client should expect the provider to prescribe which of the following diagnostic tests? 1. Sweat test 2. Haptoglobin 3. Antinuclear antibodies 4. Schilling test

Schilling test; urine test which determines the cause of vitamin B12 deficiency

A nurse is caring for a client who is admitted with a DVT of the left leg. Which of the following interventions should the nurse include in the client's plan of care? 1. application of ice to the extremity 2. strict bedrest 3. restriction of oral fluids 4. administration of vasodilating medications

Strict bedrest; should apply warm, moist heat rather then ice. Anticoagulants are used to prevent clot formation.

A nurse is assessing a client before administering a unit of RBC. Which of the following data are most important prior to transfusing the RBC? 1. skin color 2. fluid intake 3. temperature 4. hemoglobin level

Temperature; the nurse should monitor the client's temperature before, during, and after transfusion.

A nurse is monitoring a clinet who is receiving packed RBCs. Which of the following findings is expected during blood administration? 1. The drip chamber w/ filter is filled completely with blood 2. The packed RBCs are connected by Y tubing to normal saline 3. The blood has been infusing steadily for 5 hours with no client symptoms 4. A medication is being administered IV through the Y site closest to the client.

The packed RBCs are connected by Y tubing to normal saline; Y tubing with saline primes the line prior and after blood infusion. Blood products have a max administration time of 4 hours. Only normal saline can be given with blood products.

A nurse is collecting data on a client's cardiac functioning and auscultates an S3 sound. The nurse is aware that this sound represents which of the following/? 1. atrial gallop 2. ventricular gallop 3. closure of the aortic valve 4. closure of the pulmonic valve

Ventricular gallop

A nurse is assessing a client who has a vitamin K deficiency. Which of the following indicates the nurse understands the effects of Vitamin K? 1. Vitamin K reverses warfarin toxicity 2. Vitamin K promotes fibrinogen formation 3. Vitamin K is produced in the gastric juices 4. Vitamin K normalizes the clotting factors reflected in aPTT

Vitamin K reverses warfarin toxicity; it promotes prothrombin formation in the liver. It normalizes the clotting factors reflected in PT, not in aPTT.