NU372 EAQ Evolve Elsevier: HESI Prep Cardiovascular, Hematologic, Lymphatic
When a client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?", which is the nurse's best response? o "Let me ask your health care provider for you." o "No one knows the answer to that question." o "Tell me about what concerns you right now." o "It depends on how extensive the disease is."
o "Tell me about what concerns you right now." · The response, "Tell me what concerns you right now," is open-ended and encourages the client to share current thoughts and anxieties. It indicates that the nurse wants to hear about and address the client's concerns. Although the health care provider is also a good resource for information, the response, "Let me ask your primary health care provider for you," suggests the nurse does not want to discuss the subject and discourages further sharing of client concerns. Although it is true that no one knows how long a client will live after diagnosis of multiple myeloma, the response, "No one knows the answer to that question" discourages the client from sharing concerns or asking further questions of the nurse. The response, "It depends on how extensive the disease is" is true, but it is not open-ended and focuses only on physiological aspects of the diagnosis.
When a client is admitted to the postanesthesia care unit after surgery, how frequently will the nurse plan to assess the blood pressure? o Every 3 to 5 minutes o Every 10 to 15 minutes o Every 20 to 30 minutes o Every 40 to 60 minutes
o Every 10 to 15 minutes · During the first 2 postoperative hours, the blood pressure is monitored every 10 to 15 minutes to detect unstable vital signs that might indicate shock. Checking every 3 to 5 minutes is unnecessary, unless the client becomes hemodynamically unstable. Checking every 20 minutes or longer is unsafe because it is too long a period of time between blood pressure readings for a client who just had surgery.
Which complication is of most concern when the nurse is caring for a client with chronic lymphocytic leukemia (CLL)? o Bleeding o Fatigue o Infection o Cachexia
o Infection · In CLL, defects in humoral and cellular immunity increase the risk for infection, which can be life threatening. The other complications are also of concern but are not as dangerous as infection. Bleeding is possible because of thrombocytopenia associated with CLL, but the platelet count must drop to around 10,000 mm3 (10 × 109/L) before spontaneous bleeding occurs. Fatigue caused by CLL related anemia is also common, but not life threatening. Although excessive weight loss is a concern, it does not pose the same threat as infection for clients with CLL.
When performing a focused assessment on a client with a possible diagnosis of iron deficiency anemia, which locations would the nurse examine? Select all that apply. o Sclera o Nail beds o Conjunctivae o Palms of hands o Bony prominences
o Nail beds o Conjunctivae o Palms of hands · Nail beds lose their pink coloration because of reduced hemoglobin. A reduced amount of hemoglobin decreases pink color of the lining of the eyelids (conjunctiva). Palms of the hands will become pale because of the decreased hemoglobin. Sclera is observed for signs of jaundice, not anemia, when they become pale yellow to orange. Bony prominences are not assessed when a client has anemia. Bony prominences are examined for redness caused by pressure that, if prolonged, can lead to a break in the skin and development of pressure injuries.
Which action by the nurse is best when a client who had a myocardial infarction 2 days previously has a temperature of 100.2°F (37.9°C)? o Auscultate the chest for diminished breath sounds. o Encourage coughing and deep breathing every hour. o Record the temperature reading and continue to monitor it. o Suspect an infection and notify the health care provider immediately.
o Record the temperature reading and continue to monitor it. · Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2°F (37.9°C) is an expected response to myocardial necrosis, not a respiratory infection. Auscultating lung sounds and encouraging coughing and deep breathing are not necessary for the temperature elevation. A temperature of 100.2°F (37.9°C) is an expected response and is not an emergency requiring notification of the primary health care provider.
How would the nurse document this rhythm seen in a client on the telemetry unit? o Atrial flutter o Sinus tachycardia o Sinus bradycardia o Atrial fibrillation
o Sinus tachycardia · Sinus tachycardia is regular rhythm but at a rate higher than 100 beats/minute, with normal-appearing P waves and QRS complexes and a P wave preceding every QRS complex. Atrial flutter has sawtooth atrial waves occurring at a rate of 200 beats/minute to 350 beats/minute and ventricular rates typically at 75 beats/minute to 150 beats/minute. Sinus bradycardia is a regular rhythm, with a P wave preceding every QRS complex, but at a rate lower than 60 beats/minute. Atrial fibrillation is an irregular rhythm with no clear P waves.
How will the nurse position a client who presents to the emergency department with severe epistaxis? o Trendelenburg position o Semi-Fowler position on a stretcher o Sitting in a chair with head tilted back o Sitting with head tilted slightly forward
o Sitting with head tilted slightly forward · The sitting position will reduce bleeding and allow for assessment of the quantity of bleeding; leaning forward will prevent blood from entering the stomach and possible aspiration. Placing the client in the Trendelenburg position will increase pressure to the area of the nosebleed. Semi-Fowler position is better than flat but may lead to blood draining down the throat. Sitting upright is appropriate, but tilting the head back increases the risk of swallowing blood and possible aspiration.
When caring for a client with acute coronary syndrome who has frequent premature ventricular complexes (PVCs), the nurse will be most concerned about PVCs occurring in which phase of the cardiac cycle? o P wave o T wave o P-R interval o QRS complex
o T wave · The T wave is the period of repolarization of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation. If a premature ventricular contraction strikes on the P wave, it will not cause ventricular fibrillation; the P wave represents atrial contraction. The P-R interval represents the time it takes the impulse to travel from the sinoatrial (SA) node to the ventricular musculature, and a PVC during the PR interval will not cause ventricular fibrillation. QRS complex is the term used to represent the entire phase of ventricular contraction.
Which information will be included in teaching a client who is scheduled for a stress echocardiogram? o Do not eat or drink for 8 hours before the procedure. o The procedure will show how well the heart pumps with exercise. o You will need to lie flat in bed for several hours after the procedure. o Shellfish or iodine allergies are usually a contraindication to the procedure.
o The procedure will show how well the heart pumps with exercise. · A stress echocardiogram is noninvasive and uses echoes from high-frequency sound waves to study myocardial contraction with exercise. It can also assess for changes in valve function and for congenital defects. Clients will be expected to run on a treadmill and should not eat a large meal before the test, but a light meal and fluids a few hours before the test are appropriate. The client will exercise, and then lie on the left side for a few minutes while a postexercise echocardiogram is done. There is no need to lie flat for several hours postprocedure. Because no iodine-containing contrast dye is used, shellfish allergies are not a contraindication to stress echocardiography.
Which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker? o Shortness of breath o Substernal discomfort o Third-degree heart block o Premature ventricular contractions
o Third-degree heart block · The client in third-degree heart block will need a pacemaker to help support heart rate and cardiac output. Shortness of breath is not an indicator for pacemaker insertion. Substernal discomfort is not treated with pacing. Premature ventricular contractions are treated with medications, and a pacemaker is not indicated.
To avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer, which actions by the nurse are appropriate? Select all that apply. o Monitor for signs of alopecia. o Encourage an increase in fluids. o Wash hands before entering the client's room. o Advise use of a soft toothbrush for oral hygiene. o Report an elevation in temperature immediately. o Teach the client to avoid eating raw fruits or vegetables.
o Wash hands before entering the client's room. o Advise use of a soft toothbrush for oral hygiene. o Report an elevation in temperature immediately. · Bone marrow depression causes neutropenia; it is essential to prevent infection in this client by thorough hand washing before touching the client or client's belongings. Thrombocytopenia occurs with chemotherapy-induced bone marrow depression; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the primary health care provider immediately because it may be a sign of infection. Although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. Clients who have neutropenia may eat raw fruits and vegetables after washing off soil that may contain disease-causing microbes.
How is hemophilia A inherited? o X-linked recessive trait o Y-linked recessive trait o X-linked dominant trait o Y-linked dominant trait
o X-linked recessive trait · 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.
