NCLEX cardiovascular, hematologic, and lymphatic systems

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? A. Cervical B. Axillary C. Inguinal D. Mediastinal

A. Cervical

A client reports foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. Which client statement indicates to the nurse that further teaching is needed? A. "I will wear socks." B. "I will elevate my foot." C. "I will increase fluid intake." D. "I will drink a moderate amount of alcohol."

B. "I will elevate my foot."

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client? A. Take a baby aspirin every day B. Ambulate early and frequently C. Sit for prolonged periods of time D. Place a warm soak on the legs daily

B. Ambulate early and frequently

A client is admitted to the postanesthesia care unit after surgery, and electronic blood pressure monitoring is to be performed. How frequently should the nurse assess the client's blood pressure? A. Every 3 to 5 minutes B. Every 10 to 15 minutes C. Every 20 to 30 minutes D. Every 40 to 60 minutes

B. Every 10 to 15 minutes

When assessing for hemorrhage on a client who has a total hip replacement, what is the most important nursing action to implement? A. Measure the girth of the thigh. B. Examine the bedding under the client. C. Check the vital signs every 4 hours. D. Observe for ecchymosis at the operative site.

B. Examine the bedding under the client.

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.

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.

A client has a low hemoglobin level that is attributed to an iron deficiency. Which foods should the nurse recommend that the client increase in the diet? Select all that apply. A. Grapes B. Spinach C. Oranges D. Beef liver E. Cantaloupe

B. Spinach D. Beef liver

A client is admitted to the emergency department with a blood pressure of 240/150 mm Hg. The client complains of a severe headache, blurred vision, and swelling of the ankles. How should the nurse respond to the clinical manifestations? A. Obtain a glucose blood sample. B. Collect urine and blood samples. C. Assess the client's pulse and respirations. D. Place the client on bed rest in the supine position.

C. Assess the client's pulse and respirations.

A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. Which postoperative intervention on the day after surgery is appropriate for the nurse to implement? A. Keep the client on bed rest B. Have the client sit in a chair C. Assist the client with ambulation D. Encourage the client to bend at the knee

C. Assist the client with ambulation

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe? A. Lactated Ringer solution B. Serum albumin C. Blood replacement D. High molecular dextran

C. Blood replacement

A client with a history of hypertension and left ventricular failure arrives for a scheduled clinic appointment and tells the nurse, "My feet are killing me. These shoes got so tight." What is the nurse's best initial action? A. Weigh the client. B. Notify the primary healthcare provider. C. Take the client's pulse rate. D. Listen to the client's breath sounds.

D. Listen to the client's breath sounds.

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? A. Encourage frequent coughing. B. Elevate the client's lower extremities. C. Prepare for modified postural drainage. D. Place the client in the orthopneic position.

D. Place the client in the orthopneic position.

A client has a low hemoglobin level that is attributed to nutritional deficiency and the nurse provides dietary teaching. Which food choices highest in iron chosen by the client indicate that the nurse's instructions are effective? Select all that apply. A. Eggs B. Squash C. Carrots D. Spinach E. Apricots

A. Eggs D. Spinach

While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply. A. Pain in the calf B. Intermittent claudication C. Redness in the affected area D. Pitting edema of the lower leg E. Ecchymotic areas around the ankle F. Localized warmth in the lower extremity

A. Pain in the calf C. Redness in the affected area F. Localized warmth in the lower extremity

A blood transfusion is initiated after a client has emergency surgery. What should the nurse do first when the client develops fever, chills, and low back pain? A. Stop the blood and infuse saline B. Administer the prescribed antipyretic C. Obtain a prescription for an antihistamine D. Slow the rate of the transfusion and inform the blood bank

A. Stop the blood and infuse saline

A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities? A. Restrict fluids. B. Elevate the legs. C. Apply elastic bandages. D. Do range-of-motion exercises.

B. Elevate the legs.

An electrocardiogram is prescribed for a client complaining of chest pain. The nurse recognizes which as an early finding of an infarcted area of the heart? A. Flattened T waves B. Absence of P waves C. Elevated ST segments D. Disappearance of Q waves

C. Elevated ST segments

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 nurse is developing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. Which statement from the client indicates the nurse needs to intervene? A. "I will restrict my physical activity." B. "I will take one baby aspirin every day." C. "I will continue my smoking cessation program." D. "I will try to lose the extra weight I'm carrying around."

A. "I will restrict my physical activity."

A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond? A. "This surgery significantly decreases symptoms in most clients." B. "This procedure will enable your spouse to return to work after healing occurs." C. "Studies have consistently shown that this surgery increases an individual's life span." D. "Evidence substantiates that surgery can prevent progression of coronary artery disease."

A. "This surgery significantly decreases symptoms in most clients."

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

A client who is to have sclerotherapy asks the nurse, "How did I get varicose veins?" Which etiology should the nurse take into consideration when formulating a response? A. Short episodes of standing B. Defective valves within the veins C. Compression of leg muscles on the veins D. Formation of thrombophlebitis in the veins

B. Defective valves within the veins

A client is admitted to the critical care unit after receiving multiple injuries in a motorcycle accident. Twelve hours later the client reports increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed, and the client is scheduled for an emergency splenectomy. What should the nurse include when providing preoperative teaching? A. Probability of wound dehiscence B. Safety aspects of this type of surgery C. Expectation of postoperative bleeding D. Presence of abdominal drains for several days

D. Presence of abdominal drains for several days

Upon assessment the nurse discovers a client with heart failure has crackles in lower lung fields and dyspnea. Upon notifying the primary healthcare provider, the provider prescribes intravenous (IV) normal saline at 200 mL/hr and furosemide 120 mg orally stat. Which action should the nurse take next? A. Place the normal saline on an infusion pump to control the amount, and give the furosemide. B. Ask the healthcare provider why so much intravenous fluid is to be given to an older adult client, and give the furosemide as prescribed. C. Decline to give the intravenous fluid, saying it could cause circulatory overload, and give the furosemide as prescribed. D. Question the choice of solution, the amount to be given, and the dose of furosemide that has been prescribed.

D. Question the choice of solution, the amount to be given, and the dose of furosemide that has been prescribed.

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? A. Refer the client to a nutritionist after providing health teaching about a low-sodium diet. B. Place the client in a recumbent position and call the paramedics for transport to the hospital. C. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. D. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

D. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

The treatment regimen for a female diagnosed with Hodgkin disease, stage III, will start with nodal irradiation. Because the client and her husband have been trying to conceive a child, the client becomes visibly anxious when she learns that the radiation therapy includes the pelvic nodal area. The nurse refers the client to the primary healthcare provider when the client starts to question the treatment. What is the rationale for the nurse's actions? A. Radiation used is not radical enough to destroy ovarian function. B. Intermittent radiation to the area does not cause permanent sterilization. C. Reproductive ability may be preserved through a variety of interventions. D. Ovarian function will be destroyed temporarily but will return in about six months.

C. Reproductive ability may be preserved through a variety of interventions.

A client is admitted to the hospital for a total hip replacement. Included in the primary healthcare provider's prescriptions is a prescription for digoxin 2.5 mg by mouth daily. The nurse knows that digoxin is supplied in 0.125 mg tablets. What should the nurse do? A. Give half a tablet. B. Administer two tablets. C. Ask the client what dose was taken at home. D. Verify the prescription with the primary healthcare provider.

D. Verify the prescription with the primary healthcare provider.