Cardiovascular, Hematological, Lymphatic

A client who is being treated for uncontrolled hypertension develops a nosebleed. After applying pressure to the nose, which action would the nurse take next?

Assess client's blood pressure

Which information will the nurse include when teaching a client with intermittent claudication in the lower legs?

Assess the feet daily for injuries.

Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply.

Crackles Coughing Orthopnea

Which findings in a client seen at the outpatient clinic support a diagnosis of an arterial ulcer? Select all that apply.

Lack of hair Thickened toenails Diminished pedal pulse

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock?

Tachycardia Restlessness Decreased urinary output

When a client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital, which finding will the nurse expect during the assessment?

Left upper quadrant tenderness (The spleen is normally not palpable, but splenomegaly usually accompanies chronic myelogenous leukemia, leading to a palpable and tender mass in the left upper abdomen. The urinary output is not affected with these conditions. Leukemias increase metabolic rate, leading to weight loss. With leukemia and splenomegaly there is decreased production and increased destruction of erythrocytes, leading to anemia.)

After a client has had a permanent demand pacemaker implanted, which finding by the nurse would be of most concern?

Pulse rate 40 beats/minute (Because a demand pacemaker would be set at a rate of at least 60 beats/minute, a pulse of 40 beats/minute indicates a need for rapidly assessing the cardiac monitor for failure of the pacemaker to capture or sense the client's underlying rate and notification of the health care provider. Blood on the dressing is normal after surgery, and the nurse would continue to monitor the dressing. Blood pressure of 104/76 mm Hg is at the low end of normal; the nurse would continue to monitor the blood pressure. Pain after pacemaker implantation is expected, and the nurse would administer prescribed analgesics.)

After a client sustains multiple internal injuries in a motor vehicle accident, the blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What is the likely cause of this drop in blood pressure?

Reduction in the circulating blood volume

When caring for a client who is in the postanesthesia care unit after receiving general anesthesia, which assessment finding would be most important for the nurse to report to the health care provider?

Systolic blood pressure decrease from 130 mm Hg to 90 mm Hg (Decreasing blood pressure postoperatively may indicate hemorrhage and requires prompt interventions such as increasing fluid infusions, transfusion, or return to the operating room. Attempting to push out the airway is an indication that the client may be able to breathe independently, a normal response after general anesthesia. Clients who have had general anesthesia are unresponsive to verbal stimulation until they start to recover from the effects of general anesthesia. A respiratory rate of 16 breaths/minute is within the normal range.)

When encouraging a client to seek testing and treatment for streptococcal pharyngitis, which complication will the nurse discuss?

Rheumatic fever

When caring for a client with multiple myeloma, which diagnostic test result will the nurse expect?

Bence Jones protein in the urine

When a client asks to be screened for human immunodeficiency virus (HIV) infection, which information will the nurse include in client teaching about the test?

Detects antibodies to HIV and may not detect acute infection

When the nurse is screening clients for hypertension, which finding would indicate a need to refer a client to a health care provider?

Diastolic blood pressure reading greater than 89 mm Hg

Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure?

Edema Ascites

Which finding on an electrocardiogram for a client complaining of chest pain indicates possible acute myocardial infarction?

Elevated ST segments (Elevated ST segments are an early typical finding after a myocardial infarction because of the altered repolarization of the heart. Flattened or depressed T waves indicate hypokalemia. Absence of P waves occurs in atrial and ventricular fibrillation. Q waves do not disappear with myocardial infarction, but large Q waves are seen late in the process of infarction.)

After the nurse has completed teaching a client with hypertension about a heart-healthy diet, which meal choice by the client indicates that the teaching has been effective?

Grilled steak and green salad

For the first hour after a client has a cardiac catheterization using the brachial artery, which action would the nurse take?

Monitor the vital signs every 15 minutes.

When a client with hypovolemic shock has a hematocrit value of 25%, which fluid therapy will the nurse prepare to infuse?

Packed red blood cells

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion?

Peripherally inserted central catheter (PICC) line (Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the intradermal or subcutaneous tissues. It is best infused through a central line, such as a PICC line. Midline catheters are peripherally inserted in the antecubital area or upper arm and are not recommended for infusion of vesicants because large amounts of fluid may escape into the subcutaneous tissues before the infiltration is noted. Infiltration of fluids occurs more frequently when fluids are infused through the smaller and more fragile peripheral veins.)

A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse knows to watch for what distinguishing sign unique to a fat embolus?

Petechiae

Which information will the nurse include when teaching a client with venous insufficiency about prevention of venous thrombosis?

Put on compression stockings before arising.

After the nurse has taught self-care management to a client admitted with sickle cell crisis, which client action indicates a need for more education?

Raises the knee position of the bed

Which topic will the nurse include in teaching for a client with Raynaud disease?

Tobacco avoidance