ATI cardiovascular

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? a. Position the client supine with his legs elevated when in bed. b. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr. c. Tell the client to sit with his legs dependent after ambulating. d. Instruct the client to wear knee-length socks for 2 weeks after surgery.

A. Position the client supine with his legs elevated when in bed. rationale: The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.

nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions Should the nurse take? a. Obtain blood samples to test platelet function. b. Prepare for replacement of the missing clotting factor. c. Administer aspirin for the client's pain. d. Place the bleeding joint in the dependent position.

B. Prepare for replacement of the missing clotting factor. Rationale: Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints.

A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take? a. Continue to monitor for manifestations of a transfusion reaction. b. Remove the unit of plasma immediately and start an IV infusion of normal saline solution. c. Continue the transfusion and repeat the type and crossmatch. d. Prepare to administer a dose of diphenhydramine IV.

B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution. Rationale: A client who receives FFP that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.

A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take? a. Check for hypertension. b. Auscultate for loud, bounding heart sounds. c. Auscultate blood pressure for pulsus paradoxus. d. Check for a pulse deficit.

C. Auscultate blood pressure for pulsus paradoxus. Rationale: The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is atleast 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? a. Pitting edema b. Areas of reddish-brown pigmentation c. Dry, pale skin with minimal body hair d. Sunburned appearance with desquamation

C. Dry, pale skin with minimal body hair Rationale: A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? a. Bradycardia with S-T segment depression b. Relief of chest pain with deep inspiration c. Dyspnea with hiccups. d. Chest pain that increases when sitting upright

C. Dyspnea with hiccups. Rationale: The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching? a. Hospitalization is required when administering each treatment. b. The maximum effect of the medication will occur in 6 months. c. Hypertension is a common adverse effect of this medication. d. Blood transfusions are needed with each treatment.

C. Hypertension is a common adverse effect of this medication. Rationale: The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? a. Administer ferrous sulfate supplementation. b. Increase dietary intake of folic acid. c. Initiate weekly injections of vitamin B12- d. Initiate a blood transfusion.

C. Initiate weekly injections of vitamin B12 rationale: The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? a. Chest pain is relieved soon after resting. b. Nitroglycerin relieves chest pain. c. Physical exertion does not precipitate chest pain. d. Chest pain lasts longer than 15 min.

D. Chest pain lasts longer than 15 min. Rationale: The client who has unstable angina will have chest pain lasting longer than 15 min. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) Jugular vein distension Moist crackles Postural hypotension Increased heart rate Fever

Jugular vein distension is correct. The increase in venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles is correct. This is an indicator of pulmonary edema that can quickly lead to death. Postural hypotension is incorrect. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in hypertension and tachycardia. Increased heart rate is correct. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses. Fever is incorrect. Fever is common in clients who are experiencing dehydration, not fluid volume excess.