202 EAQ Cardiovascular, Hematologic, and Lymphatic Systems

What is the most important information the nurse can share with a client who is just diagnosed with hypertension?

"Continue with long-term follow-up care."

Several individuals who sustained urgent but nonemergent injuries are seated in the emergency department when an ambulance arrives with a client suspected of having a myocardial infarction. The nurse must explain to the waiting clients that they will have to wait longer for care. Which is the best explanation for the nurse to give?

"I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen."

A client develops a nonhealing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. Which would be the best response by the nurse?

"Pain occurs in the legs while walking because there is a lack of oxygen to the muscles."

A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best?

"The cause is incompetent valves of superficial veins."

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?

"The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow."

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse?

"This test will reflect any heart damage."

A nurse is discussing discharge instructions with a patient who had a coronary artery bypass graft (CABG). The client states, "My spouse is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse?

"You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort."

A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider?

A diastolic blood pressure that remains greater than 90 mm Hg

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 low hemoglobin level causes reduced oxygen-carrying capacity.

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?

Active participation in providing self-care

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

Administer oxygen using a face mask

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client?

Ambulate early and frequently

Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that what is the cause of the increase in the client's urinary output?

An expected effect of the dye used with the procedure

An emergency department nurse is admitting a client after an automobile collision. The primary healthcare provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit?

Apical heart rate of 142 beats/min

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." Which action should the nurse take?

Call the rapid response team.

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of?

Cardiac irritability

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?

Client's systolic blood pressure drops from 130 to 90 mm Hg.

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis?

Cold, clammy skin

Before discharging a client who had an inguinal herniorrhaphy, the nurse teaches the client about exercising to prevent venous stasis. How can the nurse achieve the best results?

Demonstrate specific exercises.

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure?

Dilation of blood vessels

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client?

Edema of the left leg

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask how this could happen in addition to many other questions. Hemophilia A is linked to a deficiency in what?

Factor VIII

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?

Fear

A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the primary healthcare provider probably will insert a pacemaker?

Heart block

A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take?

Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately.

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?

How long the client was anoxic

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?

Hypokalemia

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses?

Hypovolemic shock

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client?

Increase oxygen concentration to heart cells

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change?

Increased intravascular volume

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition?

Increased pressure within the circulatory system

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?

Instruct the client to remain in bed.

During chest physiotherapy (CPT) a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next?

Interrupt the therapy.

A thallium scan is prescribed for a client with a history of chest pain. Which information should the nurse include when explaining the purpose of the test to the client?

It assesses myocardial ischemia and perfusion.

The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia and is scheduled to wear a Holter monitor for 24 hours. What should the client should be instructed to do during the test?

Keep a diary of activities.

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication?

Kidney failure

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client?

Lipid plaque formation occurs within the arterial vessels.

A client has a tentative diagnosis of Hodgkin disease. How does the nurse expect the diagnosis to be confirmed?

Lymph node biopsy

A nurse is auscultating a client's heart sounds and hears S1. Which valves is the nurse assessing?

Mitral and tricuspid

A client had a ventricular demand pacemaker inserted. What is the priority nursing intervention immediately after the procedure?

Monitor the heart rate and rhythm.

A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse?

Notify the primary healthcare provider of the client's refusal of blood products.

The nurse notices sudden bursts of fast rhythm that end abruptly. The heart rate is 220 beats per minute during these bursts, but the P waves are very difficult to see. The QRS interval is normal. The nurse notifies the primary healthcare provider. Which rhythm did the nurse share with the primary healthcare provider?

Paroxysmal supraventricular tachycardia (PSVT)

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. Which recommendation by the nurse will help the client maintain blood vessel patency?

Practice relaxation techniques.

The nurse observes the following pattern on a client's electrocardiogram (ECG) strip. What dysrhythmia does the nurse identify?

Premature ventricular complex

The nurse encourages a client with Raynaud disease to stop smoking. Which primary goal is the nurse trying to achieve?

Prevent peripheral vasoconstriction

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment?

Pulsating abdominal mass

A client's blood pressure increases dramatically six hours after a femoral-popliteal bypass graft. Which priority concern motivates the nurse to inform the primary healthcare provider?

Rapidly increasing blood pressure may rupture the graft.

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?

Sinus tachycardia

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion?

Synchronizer switch is in the "on" position.

Which clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

Syncope

A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, what should the nurse on the medical-surgical unit should monitor the client for?

Tachycardia

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.

Tachycardia Restlessness Decreased urinary output

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?

Tachycardia and petechiae over the chest

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?

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

The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. What teaching will be included?

The client will need to stay In the supine position with the affected leg extended for several hours after the procedure.

Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon?

The client's intraarterial pressure may compromise the graft's viability.

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?

Troponin T (cTnT)

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?

Verify the pulse by using a Doppler.

During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client?

Visible pulsating abdominal mass