Cardiovascular, Hematologic, and Lymphatic Systems

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock? 1. Oliguria 2. Crackles 3. Dyspnea 4. Bounding pulse

1

A client admitted for mitral valve surgery tells the nurse, "I am not worried at all about the surgery!" Which response by the nurse is best? 1. "You really don't need to hide your anxieties." 2. "You sure came to the right place for a valve job." 3. "I'm glad to see you're handling the situation well." 4. "I think you may still have questions about the surgery."

3

A client who has multiple myeloma tells the nurse about plans for airline travel to visit family members. Which topic will the nurse include in discharge planning? 1. Avoidance of travel to prevent fatigue 2. Need to restrict fluid intake when flying 3. Ways to prevent infection during travel 4. How to fill prescriptions away from home

3

Which complication is most likely to occur in the immediate postoperative period after a client has had a splenectomy? 1. Infection 2. Peritonitis 3. Hemorrhage 4. Intestinal obstruction

3

Which finding in a client who has just returned to the nursing unit after having right upper lobectomy requires the most rapid action by the nurse? 1. 100 mL of blood in the chest tube drainage chamber 2. Complaint of 9/10 (0 to 10 scale) right side chest pain 3. Deviation of the client's trachea to the left side 4. Decreased breath sounds on the client's right side

3

After the nurse teaches a client with hyperlipidemia about dietary changes, which client statement indicates that the teaching has been effective? 1. "I guess I will need to cut out all fat or cholesterol in my diet." 2. "I love fried foods, but I will plan to use hydrogenated oil for frying." 3. "The main important dietary change will be to avoid eating any eggs." 4. "I like steak but will plan to broil it and have a salad along with the meat."

4

To determine whether therapy for vitamin B12 deficiency is effective, which action will the nurse take? 1. Monitor electrolyte levels. 2. Assess skin integrity. 3. Check for peripheral edema. 4. Review hemoglobin and hematocrit levels

4

After the home health nurse obtains a radial pulse rate of 136 beats/minute in a client with chronic atrial fibrillation, which action would the nurse take next? 1. Ask about any new stressors in the client's life. 2. Take the client's apical pulse for a full minute. 3. Notify the health care provider about the heart rate. 4. Ask whether prescribed medications have been taken.

2

Which changes that occur with aging increase the risk for hypothermia in older adults? Select all that apply. One, some, or all responses may be correct. 1. Increased metabolic rate 2. Increased shivering response 3. Decreased amount of body fat 4. Diminished energy reserves

2-3-4

When a client receiving hemodialysis has an external shunt for circulatory access, the nurse would be most concerned about which possible complication? 1. Infection 2. Hemorrhage 3. Skin breakdown 4. Impaired circulation

2.

While caring for a client who has just returned after a cardiac catheterization using the femoral artery, the nurse notes that the pedal pulses are not palpable and the foot is cool. Which action would the nurse take? 1. Notify the health care provider immediately. 2. Apply pressure to the femoral insertion site. 3. Increase the intravenous fluid flow rate. 4. Monitor the insertion site and foot frequently.

1

An arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client is most likely to exhibit these blood gas results? 1. A client with pulmonary fibrosis 2. A client with uncontrolled type 1 diabetes 3. A client who has been vomiting for 3 days 4. A client who takes sodium bicarbonate for indigestion

1

Which collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehydration, a heart rate of 100 beats/minute, and blood pressure of 104/62 mm Hg? 1. Offer frequent oral fluids for several hours. 2. Administer 1 liter of normal saline over 2 hours. 3. Give fluid and electrolytes per nasogastric tube. 4. Infuse 500 mL of lactated Ringer's solution over 30 minutes.

1

Which finding for a client who has just returned to the nursing unit after an emergency cardiac catheterization would be most important to report to the primary health care provider? 1. Anxiety about the results of the procedure 2. ST-segment elevation on the electrocardiogram 3. Pain at the femoral artery catheter insertion site 4. Premature atrial contractions on the cardiac monitor

2

When caring for a client admitted with massive vomiting of blood, which finding would be of most concern to the nurse? 1. Hematocrit of 35% 2. Cool hands and feet 3. Heart rate 124 beats/minute 4. Stools positive for occult blood

3

When the nurse is screening clients for hypertension, which finding would indicate a need to refer a client to a health care provider? 1. Report of pain as the blood pressure cuff is inflated 2. Systolic blood pressure result higher than 120 mm Hg 3. Diastolic blood pressure reading greater than 89 mm Hg 4. Loud Korotkoff sounds as the blood pressure cuff is deflated

3

When the nurse is assessing a client with osteolytic lesions caused by multiple myeloma, which finding will be most important to communicate to the health care provider? 1. Bruising at injection sites 2. Calcium level 10.2 mg/dL (2.55 mmol/L) 3. Elevated urine protein level 4. New onset weakness in both legs

4

Which is the priority nursing intervention immediately after a client has a ventricular demand pacemaker inserted? 1. Encourage fluids. 2. Assess the implant site. 3. Monitor the heart rate and rhythm. 4. Encourage turning and deep breathing.

3.