Cardiovascular, Hematologic, and Lymphatic Systems Level 1

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. How is hemophilia inherited? A. X-linked recessive trait B. Y-linked recessive trait C. X-linked dominant trait D. Y-linked dominant trait

A. X-linked recessive trait rational: Hemophilia A is an X-linked recessive trait, not a dominant trait, meaning daughters who have the gene are carriers, and sons with the gene have the condition. The trait is not carried on the Y chromosome.

A nurse is teaching a client about the normal pathway followed during the cardiac cycle. In which sequence should the nurse list the structures, beginning with the first? A. Bundle of His B. Sinoatrial node C. Purkinje fibers D. Bundle branches E. Atrioventricular node

1. Sinoatrial node Correct 2. Atrioventricular node Correct 3. Bundle of His Correct 4. Bundle branches Correct 5. Purkinje fibers The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinus or SA node. The impulse quickly reaches the AV node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The electrical impulse then is conducted rapidly through the bundle of His to the ventricles via the left and right bundle branches. The bundle branches divide into smaller and smaller branches, finally terminating in tiny fibers called Purkinje fibers that reach the myocardial muscle cells or myocytes.

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? A. Hypokalemia B. Hypocalcemia C. Hyponatremia D. Hypomagnesemia

A. Hypokalemia rational: Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.

Which client is at greatest risk for the development of a venous thrombosis? A. A 76-year-old female with a 100-pack-per-year smoking history and hypertension B. A 68-year-old male on bed rest following a left hip fracture C. A 59-year-old male who is an intravenous drug user with hyperlipidemia D. A 42-year-old female with Factor V Leiden mutation on warfarin

B. A 68-year-old male on bed rest following a left hip fracture Venous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? A. The body initially attempts to compensate by releasing more red blood cells. B. The body initially attempts to compensate by maintaining peripheral vasoconstriction. C. The body initially attempts to compensate by decreasing mineralocorticoid production. D. The body initially attempts to compensate by producing less antidiuretic hormone (ADH).

B. The body initially attempts to compensate by maintaining peripheral vasoconstriction. RATIONAL: With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. Although producing more red blood cells is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure. With shock, more ADH is produced to promote fluid retention, which will elevate the blood pressure.

While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? A. Administer nitroglycerin and aspirin B. Slow the rate and monitor the vital signs C. Stop the transfusion and administer normal saline D. Ask the client to further describe the feeling and rate the pain

C. Stop the transfusion and administer normal saline The chest tightness or pressure and impending doom indicate the presence of an acute hemolytic reaction; other signs and symptoms include low back pain, tachycardia, tachypnea, and anxiety. The transfusion must be stopped immediately. Administering nitroglycerin and aspirin is appropriate for a possible myocardial infarction but not for a hemolytic reaction. Slowing the rate and monitoring the vital signs will increase the severity of symptoms and may increase morbidity or mortality. Exploring feelings will delay appropriate action.

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? A. Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily B. Give 1 L of 0.9% normal saline (NS) bolus over 4 hours C. Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr D. No prescription change

D. No prescription change Rational: The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.

A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent? A. Pulmonary edema B. Myocardial infarction C. Deep vein thrombosis D. Right ventricular heart failure

D. Right ventricular heart failure Right ventricular heart failure causes increased pressure in the systemic venous system, which leads to a fluid shift into the interstitial spaces. Because of gravity, the lower extremities are first affected in an ambulatory client. Pulmonary edema results in severe respiratory distress and peripheral edema with pink frothy sputum. Myocardial infarction itself does not cause peripheral edema. The edema in deep vein thrombosis will be constant and not disappear at night; redness is usually present.

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? A. Fever and chest pain B. Positive Homans sign C. Loss of sensation in the operative leg D. Tachycardia and petechiae over the chest

D. Tachycardia and petechiae over the chest Rational: Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurologic dysfunction; it is not an indication of a fat embolism.

What should the nurse do to prevent thrombus formation after most surgeries? a. Keep the client's bed gatched to elevate the knees. b. Have the client dangle the legs off the side of the bed. c. Have the client use an incentive spirometer every hour. d. Encourage the client to ambulate with assistance every few hours.

d. Encourage the client to ambulate with assistance every few hours. Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client's bed gatched to elevate the knees or having the client dangle the legs off the side of the bed cause increased popliteal pressure and impair venous return. Having the client use an incentive spirometer every hour helps prevent atelectasis, not thrombi.

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? A. Spinal stenosis B. Buerger disease C. Rheumatoid arthritis d. Intermittent claudication

d. Intermittent claudication Rational: Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.

A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order. 1. Change the intravenous (IV) administration set. 2. Stop the transfusion. 3. Notify the primary healthcare provider and blood bank. 4. Run 0.9% normal saline at a rapid rate.

1.stop transfusion 2.change iv set 3.run Normal saline @ rapid rate 4. notify primary health care provider The priority is to stop the transfusion. Failure to do so will make the reaction worse. Changing the IV administration set will prevent infusing any blood product remaining in tubing. Running normal saline rapidly will help to decrease shock and hypotension. Notifying the primary healthcare provider and blood bank would be the last step because this would take longer than the first three choices.

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? A. Prepare for blood transfusions. B. Notify the surgeon immediately. C. Make the client nothing by mouth (NPO). D. Administer the prescribed preoperative sedative.

B. Notify the surgeon immediately. Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms of shock.

The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation? A. To promote healing of the incision B. To decrease the incidence of urinary tract infections C. To use energy to help the client sleep better at night D. To keep blood from pooling in the legs to prevent clots

D. To keep blood from pooling in the legs to prevent clots The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? A. Asthma B. Anemia C. Endocarditis D. Reye syndrome

C. Endocarditis Streptococcal infection can be spread through the circulation to the heart; endocarditis results and affects the valves of the heart. Asthma, anemia, and Reye syndrome are not caused by beta-hemolytic streptococcus.

A primary healthcare provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse? A. "The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." B. "I wouldn't bother. For this diet all that you need to do is to reduce the amount of salt you use and fry foods in peanut oil." C. "You're right. Be careful to cook a small portion for each of you to eat to not waste food." D. "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen."

A. "The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." RATIONAL: Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals. Fried foods are not advocated on a heart-healthy diet; peanut oil is a monounsaturated fatty acid, and these acids should not exceed 15% of the calories of the diet. The responses "You're right. Be careful to cook a small portion for each of you to eat to not waste food" and "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen" can be discouraging and encourage noncompliance.

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg; the second sound is a swishing sound heard at 130 mm Hg; a tapping sound is heard at 100 mm Hg; a muffled sound is heard at 90 mm Hg; the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? A. 72 mm Hg B. 90 mm Hg C. 100 mm Hg D. 130 mm Hg

A. 72 mm Hg RATIONAL: When the sound disappears at 72 mm Hg, it is known as phase five of Korotkoff sounds; this reflects the diastolic pressure when the artery is no longer compressed and blood flows freely. 90 mm Hg is recorded as the diastolic pressure in adolescents and adults. The muffled sound heard at 90 mm Hg is phase four of Korotkoff sounds; the muffled sound represents the point at which the cuff pressure falls below the pressure within the arterial wall. This number is recorded as the diastolic pressure in infants and children. The tapping sound heard at 100 mm Hg is known as phase three of Korotkoff sounds; this reflects blood flow through an increasingly open artery as constriction of the cuff decreases. The swishing sound heard at 130 mm Hg is phase two of Korotkoff sounds; this is caused by blood turbulence.

A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. Which behavior by the client demonstrates an increase in client autonomy? A. Active participation in providing self-care B. Verbalizing realistic expectations of caregivers C. Discussing necessary lifestyle changes with family members D. Listing the indicators of recovery after a myocardial infarction

A. Active participation in providing self-care Planning self-care demonstrates decision-making by the client; participating in care enhances feelings of self-worth and autonomy. Expectations do not reflect autonomy. Discussing necessary lifestyle changes with family members does not reflect autonomy; it may be intellectualization. Listing the indicators for recovery after a myocardial infarction does not reflect autonomy; it may be intellectualization.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? A. Check for a pulse B. Start cardiac compressions C. Prepare to defibrillate the client D. Administer oxygen via an ambu bag

A. Check for a pulse Administer oxygen via an ambu bag The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement? A. Fear B. Depression C. Dependency D. Ambivalence

A. Fear Fear of a recurrent myocardial infarction or sudden death is common when the client's environment is to be changed to one that appears less vigilant. Depression is exhibited by withdrawal, crying, anorexia, and apathy, and it usually becomes more evident after discharge from the hospital. Dependency is exhibited by an unwillingness to increase exercise or perform tasks. Ambivalence is exhibited by contrasting emotions; the client's statement does not demonstrate this.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? A. Feeling of heaviness in both legs B. Intermittent claudication of the legs C. Calf pain on dorsiflexion of the foot D. Hematomas of the lower extremities

A. Feeling of heaviness in both legs Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.

A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? A. Normal sinus rhythm B. Sinus tachycardia C. Sinus bradycardia D. Sinus arrhythmia

A. Normal sinus rhythm Normal sinus rhythm reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? A. Notify the primary healthcare provider immediately B. Apply a warm, moist compress to the incision site C. Increase the intravenous fluid rate by 20 mL/hr D. Monitor vital signs more frequently

A. Notify the primary healthcare provider immediately The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, then warm, moist compresses may be applied. Increasing the intravenous fluid rate by 20 mL hourly will not resolve an embolus. Although monitoring vital signs is appropriate, it is an insufficient intervention; the healthcare provider must be notified so that anticoagulants can be prescribed.

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? A. Support systems that can assist the client at home B. Potential nursing homes in which the client can recuperate C. Agencies that can help the client regain activities of daily living D. Ways that the client can develop relationships with neighbors

A. Support systems that can assist the client at home The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.

The primary healthcare provider prescribes a transfusion of 2 units of packed red blood cells for a client. When administering blood, what is the priority nursing intervention? A. Make sure the client's family has received education. B. Warm the blood to 98° F (36.7° C) to prevent chills. C. Infuse the blood at a slow rate during the first 15 minutes. D. Draw blood samples from the client after each unit is transfused.

C. Infuse the blood at a slow rate during the first 15 minutes. RATIONAL: A slow rate provides time to recognize a reaction that is developing before too much blood is administered. Blood is not warmed to 98° F (36.7° C) to prevent chills; this could cause clotting and hemolysis. Educating the family is important but not a priority. Drawing blood samples from the client after each unit is transfused is not necessary.

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? A. A fever may lead to diaphoresis. B. A fever increases the cardiac output. C. An increased temperature indicates cerebral edema. D. An increased temperature may be a sign of hemorrhage.

B. A fever increases the cardiac output. Rational: Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.

An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. What does the nurse expect the primary healthcare provider to prescribe to confirm the presence of hypokalemia? A. A complete blood count B. A serum electrolyte level C. An arterial blood gas panel D.An x-ray film of long bones

B. A serum electrolyte level rational: Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and an x-ray film of long bones have no significance in diagnosing a potassium deficit.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? A. Apples B. Broccoli C. Cherries D. Cauliflower

B. Broccoli rational: Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.

A nurse is caring for a client who was admitted to the hospital with the diagnosis of tertiary syphilis. Which system of the body should the nurse assess most closely in this stage of the disease? A. Reproductive B. Cardiovascular C. Lower respiratory D. Lower gastrointestinal

B. Cardiovascular Tertiary syphilis is the last stage, affecting several body systems: skin, cardiovascular, and neurological. Aortic valvular disease and aortic aneurysms can occur. Although lesions occur on the genitalia during primary and secondary syphilis, the reproductive system is not the major body system affected in tertiary syphilis. Structures of the lower respiratory tract and gastrointestinal are not the major structures involved in tertiary syphilis.

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? A. The furosemide is causing dehydration. B. Cloudy urine may be indicative of infection. C. The client has inadequate hourly urine output. D. All of the indications are within normal findings.

B. Cloudy urine may be indicative of infection. Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.

A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? A. Arterial spasm B. Heart muscle schema C. Blocking of the coronary veins D. Irritation of nerve endings in the cardiac plexus

B. Heart muscle Schema Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? A. Tell the client to drink more fluids. B. Instruct the client to remain in bed. C. Gently rub the client's legs for circulation. D. Tell the client about the dangers of prolonged bed rest.

B. Instruct the client to remain in bed. Localized sensory changes may indicate nerve damage, impaired circulation, or thrombophlebitis. Activity should be limited. Bed rest is indicated to prevent the possibility of further damage. Symptoms indicate a possible problem with thrombus formation. While fluids may be helpful to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral intake. Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if present.

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client? A. Renin causes a gradual decrease in arterial pressure. B. Lipid plaque formation occurs within the arterial vessels. C. Development of atheromas within the myocardium is characteristic. D. Mobilization of free fatty acid from adipose tissue contributes to plaque formation.

B. Lipid plaque formation occurs within the arterial vessels. RATIONAL: The term atherosclerosis means a thickening of the arterial lining by lipid plaques, which become atheromas. Arterial pressure increases, not decreases, as a result of renin. Atheromas develop within the lining of the arteries, not within the cardiac muscle tissue. Mobilization of free fatty acids will produce an acid-base imbalance.

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? A. Slide slowly to the floor to prevent a fall and injury. B. Sit on the edge of the bed while they hold the client upright. C. Bend forward because this will increase blood flow to the brain. D. Lie down quickly so the legs can be raised above the heart level.

B. Sit on the edge of the bed while they hold the client upright. Rational: Sitting allows the nurses to support the client until orthostatic hypotension subsides. The client's stable pulse and color indicate that the situation does not warrant placing the client in the supine position. Sliding slowly to the floor to prevent a fall and injury, bending forward, or rapid movement will permit flexion of the vertebrae, which may traumatize the spinal cord. A light-headed feeling usually is transient until the body adapts to the upright position, so leg elevation is unnecessary.

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? A. Except with rare blood disorders, hemoglobin seldom affects oxygenation status. B. There are many other factors that affect oxygenation status more than hemoglobin does. C. A low hemoglobin level causes reduced oxygen-carrying capacity. D. Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status.

C. A low hemoglobin level causes reduced oxygen-carrying capacity. Rational: Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. Higher levels of hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. Hemoglobin does not reflect clotting ability.

A nurse is performing external cardiac compression. Which action should the nurse take? A. Extend the fingers over the sternum and chest with the heels of each hand side by side. B. Place the fingers of one hand on the sternum and the fingers of the other hand on top of them. C. Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it. D. Clench the hand into a fist and place the fleshy part of a clenched fist on the lower sternum.

C. Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it. Interlocking the fingers with the heel of one hand on the sternum and the heel of the other on top of it provides the best leverage for depressing the sternum. Thus, the heart is adequately compressed, and blood is forced into the arteries. Grasping the fingers keeps them off the chest and concentrates the energy expended in the heel of the hand while minimizing the possibility of fracturing ribs. Pressure spread over two hands may inadequately compress the heart and fracture the ribs. Application of pressure by the fingers is less effective; this provides inadequate cardiac compression. Both hands must be used; pressure on the lower portion of the sternum may fracture the xiphoid process, which can injure vital underlying organs.

he plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest? A. It prevents the further aggregation of platelets. B. It enhances the peripheral circulation in the deep vessels. C. It decreases the potential for further dislodgment of emboli. D. It maximizes the amount of blood available to damaged tissues.

C. It decreases the potential for further dislodgment of emboli. RATIONAL: Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation or the circulation of blood to damaged tissues.

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? A. Hematocrit 46% B. Hemoglobin 14.1 g/dL (141 mmol/L) C. Potassium 3.0 mEq/L (3.0 mmol/L) D. White blood cell 9200/mm3 (9.2 × 109/L)

C. Potassium 3.0 mEq/L (3.0 mmol/L) A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm3is within the normal range of 4000 to 11,000 cells/mm3 (4 to 11 × 109/L).

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization? A. To obtain the pressures in the heart chambers B. To determine the existence of congenital heart disease C. To visualize the disease process in the coronary arteries D. To measure the oxygen content of various heart chambers

C. To visualize the disease process in the coronary arteries rational: Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.

What is the nurse primarily attempting to prevent when caring for a client in the initial stages of chronic lymphocytic leukemia (CLL)? A. Injury B. Fatigue C.Infection D. Cachexia

C.Infection Rational: Although lymphocytosis is always present, defects in humoral and cellular immunity increase the risk for infection. Injury becomes an issue later in the disease when thrombocytopenia may develop. Fatigue becomes an issue later in the disease when anemia may develop. Although excessive weight loss is a concern, it does not pose the same threat as infection for clients with CLL.

A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, "What can I do to help myself?" How should the nurse respond? A. "Limit walking to as little as possible." B. "Reduce fluid intake to 1 L of liquid a day." C. "Apply moisturizing lotion on your legs several times a day." D. "Put on compression hose before getting out of bed in the morning."

D. "Put on compression hose before getting out of bed in the morning." As valves become incompetent, they allow blood to pool in the veins, which increases hydrostatic pressure and leads to further valve destruction. Compression hose provide external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. The legs are less congested after sleeping, and therefore the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Prolonged sitting, standing, or crossing the legs should be avoided because they reduce venous return. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin more supple, it will not treat enlarged and tortuous veins.

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? a. Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history B. Assess vital signs, obtain a history, and arrange for emergency x-ray films C. Conduct a thorough physical assessment, assess vital signs, and cover open wounds D. Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

D. Assess vital signs, control accessible bleeding, and determine the presence of critical injuries RATIONAL: A thorough physical assessment is too time-consuming initially; open wounds can be covered at a later time. Initial rapid assessment will determine priorities of care and subsequent actions. IV therapy and transfusions will be prescribed, but baseline data are needed to assess the client's present condition and the significance of future responses. Although important, obtaining a history and x-ray films can be postponed until bleeding is controlled and injuries are assessed.

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? A. Client pushes the airway out. B. Client has snoring respirations. C. Client's respirations are 16 breaths per min and shallow. D. Client's systolic blood pressure drops from 130 to 90 mm Hg

D. Client's systolic blood pressure drops from 130 to 90 mm Hg A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Shallow respirations of 16 breaths per min is a common response to depressant effects of anesthesia.

A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action? A. Abdominal pain B. Respiratory distress C. Sudden hemorrhage D. Postural hypotension

D. Postural hypotension RATIONAL: After administration of certain antihypertensives or opioids, a client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when an upright position is assumed. Postural or orthostatic hypotension occurs, and blood supply to the brain is temporarily decreased. Abdominal pain, respiratory distress, and sudden hemorrhage will not be prevented by the intervention described.

A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations? A. Long-term use of an irritant-type laxative B. Emotional response resulting in physical symptoms C. Inadequate dietary practices resulting in altered bowel function D. Systemic responses of the body to a localized inflammatory process

D. Systemic responses of the body to a localized inflammatory process rational: With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).

A client with peripheral arterial insufficiency tells the nurse that walking sometimes results in severe pain in the calf muscles. Which information should the nurse share with the client? a. This is called rest pain. b. This is called intermittent claudication. c. This is called phantom limb sensation. d. This is called Raynaud phenomenon.

b. This is called intermittent claudication. Intermittent claudication is pain that results when the arterial system is unable to provide adequate blood flow to the tissues in the presence of increased demands for oxygen and nutrients during exercise; it is relieved by rest. Rest pain is not a response to exercise; it occurs in the extremities during rest, especially at night. Phantom limb sensation is the presence of unusual sensations or pain in the removed portion of an amputation. Raynaud phenomenon is intermittent episodes of constricted arteries and arterioles in response to extreme cold or emotional stress, causing pallor, paresthesias, and pain.

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. a. Weight loss b. Unusual fatigue c. Dependent edema d. Nocturnal dyspnea e. Increased urinary output

b. Unusual fatigue c. Dependent edema d. Nocturnal dyspnea rational: Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia; women more commonly report unusual fatigue than men. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure. Orthopnea, a compensatory mechanism, limits venous return, which decreases pulmonary congestion and promotes ventilation, easing the dyspnea. Weight gain, not loss, occurs because of fluid retention. Urinary output decreases, not increases, with heart failure because the sympathetic nervous system and the renin-angiotensin-aldosterone system stimulate the retention of sodium and water in the kidneys.

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram? a. Elevate the foot of the bed. b.Encourage the client to void. c. Maintain the high-Fowler position. d. Assess the client's affected extremity.

d. Assess the client's affected extremity. rational: Because of the trauma associated with insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of the heart. A general anesthetic is not used; therefore, voiding usually is not a concern. Maintaining the high-Fowler position is unsafe because it increases pressure in the groin area, which may dislodge the clot at the catheter insertion site, resulting in bleeding; it also impedes arterial perfusion and venous return.