Cardiovascular & Hematology

A nurse is providing information to a client who is scheduled for an exercise electrocardiography test. Which of the following client statements indicates an understanding of the teaching? A. "I will not drink coffee 4hr prior to the test" B. "I can eat a light meal 1hr prior to the test" C. "I can have a cigarette up to 30min prior to the test" D. "I will take my heart medication on the day of the test"

A. "I will not drink coffee 4hr prior to the test"

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? A. "I would never have believed I could get used to enjoying my food without salt" B. "My blood pressure device at home usually shows about 156/98 or so" C. "I make sure I take my blood pressure medicine when I have headaches" D. "My blood pressure pills are very expensive. Could I take a cheaper medication"?

A. "I would never have believed I could get used to enjoying my food without salt"

A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home? A. "I'll stick with soft foods for now" B. "My family will be bringing me fresh flowers today" C. "I'll use a new disposable razor each day" D. "I"ll blow my nose more often to avoid nosebleeds"

A. "I'll stick with soft foods for now" RATIONALE: To prevent bleeding from mouth trauma

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? SATA A. "You'll have to lie flat for several hours after the procedure" B. "You'll receive medication to relax you before the procedure" C. "You'll feel a cool sensation after the injection of the dye" D. "You'll have to keep your leg straight after the procedure" E. "You'll have to limit the amount of fluid you drink for the first 24hr"

A. "You'll have to lie flat for several hours after the procedure" B. "You'll receive medication to relax you before the procedure" D. "You'll have to keep your leg straight after the procedure" RATIONALE: Not C- would feel a hot flash

A nurse is caring for a client who is undergoing conservative treatment for DVT. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibrinolysis that will eventually dissolve the clot" B. "Your body has a mechanism that will keep the clot stable in its present location" C. "The clot will break into tiny fragments and float harmlessly in your bloodstream D. "Treatment with heparin will dissolve the clot and keep other clots from forming"

A. "Your body has a process called fibrinolysis that will eventually dissolve the clot"

A nurse is caring for a client who has an upper GI bleed and a hematocrit of 24%. Prior to initiating a transfusion of PRBCs, which of the following actions should the nurse take? SATA A. Assess and document the client's vital signs B. Restart the IV with a 22-gauge needle C. Verify with another nurse the blood type and Rh of the PRBCs D. Hang a bag of lactated ringers IV solution E. Change IV tubing to a set that has a filter

A. Assess and document the client's vital signs C. Verify with another nurse the blood type and Rh of the PRBCs E. Change IV tubing to a set that has a filter RATIONALE: NOT B- should be a 20gauge or larger needle; NOT D- 0.9% sodium chloride should be used; lactated ringers is not used because it causes clotting and hemolysis of the blood cells

A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? A. BNP of 200 B. Bradycardia C. Fluid restriction of 3L/day D. 4g sodium diet

A. BNP of 200 RATIONALE: A client who has HF will have an elevated human B-type natriuretic peptide level of >100. Endogenous BNP is released into the clients bloodstream due to decreased cardiac output, a process called natriuresis B- should be tachycardia C- should be 2L/day D- should be 3g/day

A nurse is teaching a client who has iron deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Beef liver B. Oranges C. Turnips D. Whole milk

A. Beef liver

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onion s

A. Chicken breast and corn on the cob

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. Place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort

A. Elevate the affected leg

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals

A. Elevated ST segments

A nurse is assessing a client who has isotonic dehydration, Which of the following findings should the nurse expect? A. Increased hematocrit level B. Bradycardia C. Distended neck veins D. Decreased urine specific gravity

A. Increased hematocrit level RATIONALE: This is d/t hemoconcentration caused by reduced plasma fluid volume B- would have tachycardia C- would have flat neck veins D- would have increased urine specific gravity

A nurse is teaching a client who has iron deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

A. Lentils

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and MI. Which of the following manifestations should the nurse identify as indications of MI? A. Nausea and vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea

A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom

A nurse is caring for an older adult client who had an acute MI. When assessing this client, the nurse should identify that older adults are prone to complications from MI from poor tissue perfusion because of which of the following age related factors? A. Peripheral vascular resistance increases B. The sensitivity of blood pressure-adjusting baroreceptors increases C. Blood is hypercoaguable and clots more quickly D. Cardiac medications are less effective

A. Peripheral vascular resistance increases

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 minutes every hour while awake for the first 24 hours 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: Legs should be elevated above the clients heart to promote venous return via gravity; it will also be important following discharge to periodically position the legs above the heart B- should be 5-10 minutes every hour while awake C- discourage dependent sitting to prevent venous stasis D- wear graduated compression stockings for up to 1 week after surgery

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 mEq/L B. Digoxin level 0.7ng/mL C. Hemoglobin 9.8g/dL D. Calcium 8.0 mg

A. Potassium 2.8 mEq/L RATIONALE: A flattened T wave or the development of U waves is indicative of a low potassium level -Digoxin therapeutic level is 0.5-0.8 -A low hemoglobin manifests as tachycardia on the ECG (normal range 12-18) -A low calcium level can manifest as a prolonged S-T segment and a prolonged QT interval

A nurse is providing teaching about lifestyle changes to a client who has experiences myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? A. "I should eat foods that are high in saturated fat" B. "Before taking my medication, I will count my radial pulse rate" C. "I will exercise once a week for an hour at the health club" D. "I will stop taking my medication when my blood pressure is within a normal range"

B. "Before taking my medication, I will count my radial pulse rate"

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? A. 'I should use salt sparingly while cooking" B. "I can have yogurt as a dessert" C. "I should use baking soda when I bake" D. "I should use canned vegetables instead of frozen"

B. "I can have yogurt as a dessert"

A nurse is providing discharge teaching to an adult female client who has ineffective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching? A. "I will ask my provider to change my contraception to an intrauterine device" B. "I will notify my doctor before I have dental procedures" C. "I will avoid using antiseptic mouthwash for oral care" D. "I will wear a mask when I go out in public"

B. "I will notify my doctor before I have dental procedures" -Will need antibiotic prophylaxis

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? SATA A. A client who is post menopausal B. A client who is vegetarian C. A middle adult male client D. A client who is pregnant E. A toddler who is overweight

B. A client who is vegetarian D. A client who is pregnant E. A toddler who is overweight RATIONALE: A toddler who is overweight may get most of their calories from milk and foods that are not considered healthy, putting them at risk for iron-deficiency anemia. Post-menopausal women are no longer at risk because they don't experience blood loss from menstruation

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? SATA A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6 hour period D. Ask another nurse to check the packed RBCs label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride

B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride RATIONALE: NOT A- should be 18 to 20 gauge to allow the PRBCs to flow easily and prevent occlusion of the catheter; NOT C- should be over 2-4 hours to decrease risk of bacterial contamination

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly

B. Crackles in the lung bases RATIONALE: LEFT- LUNGS, Right= Rest of body

A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema

B. Dysrhythmias RATIONALE: Dysrhythmias are the most common cause of death following MI; nurses need to monitor ECG's carefully for dysrhythmias

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? SATA A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary arterial pressure

B. Increased pulmonary congestion RATIONALE: Pulmonary congestion occurs due to right sided heart failure.

A 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 clients pain D. Place the bleeding joint in the dependent position

B. Prepare for replacement of the missing clotting factor RATIONALE: must prevent hemarthrosis (bleeding into joint space)

A nurse is transfusing a unit of B-positive fresh frozen plasma 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 with type O can only receive type O!!!

A nurse is providing discharge teaching for a client who has a newly inserted pacemaker. Which of the following instructions should the nurse include in the teaching? A. "Request a provider's prescription when traveling to alert airport security" B. "Stand at least 3 feet away while using a microwave" C. "Keep your cell phone 6 inches away from your pacemaker when making a call" D. "Avoid showering for the first 2 weeks following surgery"

C. "Keep your cell phone 6 inches away from your pacemaker when making a call" RATIONALE: This is to avoid interfering with the function of the generator inside the client's pacemaker

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions? A. "I should try to drink at least 2liters of fluid per day" B. "I can still fly out to visit my sister in Colorado for a while" C. "Physical activity is good for me, but I need to avoid overexertion" D. "I can still go skiing during the cold winter months"

C. "Physical activity is good for me, but I need to avoid overexertion" RATIONALE: Not A- the client should drink 3-4L/day to help prevent recurrence of sickle cell crisis

A nurse is preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in preoperative teaching? A. "You'll receive heavy sedation, so you might even sleep during the procedure" B. "You'll have to lie on your back throughout the procedure" C. "You'll feel a painful pulling sensation when the doctor withdraws the marrow" D. "Expect the procedure to take about an hour"

C. "You'll feel a painful pulling sensation when the doctor withdraws the marrow"

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? A. Pallor B. Jaundice C. Absence of hair on the legs D. Poor nail bed capillary refill

C. Absence of hair on the legs RATIONALE: PAD (arterial insufficiency)

A nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. 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: A client who has cardiac tamponade will have pulsus paradoxus, when the blood pressure is at least 10mmHg higher on expiration than on inspiration; this occurs because of sudden decrease in CO from the fluid compressing the atria and ventricles

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin

C. Check the affected extremity for warmth and redness

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST-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: A client who has pericarditis will experience dyspnea, hiccups and a nonproductive cough. These manifestations can indicate HF from pericardial compression due to constrictive pericarditis or cardiac tamponade

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Hct D. Decreased Hgb

C. Elevated Hct RATIONALE: elevated hematocrit as blood volume is reduced A- should be hyperkalemia B-should be hyponatremia (low Na, High K with burns)

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? A. Cholesterol level 195 B. Elevated HDL levels C. Elevated LDL levels D. Triglyceride level 135

C. Elevated LDL levels (desirable level should be <100mg/dL)

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? SATA A. Use a 5mL syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use

C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use RATIONALE: NOT A because a 5mL syringe generates too much pressure and could rupture the line; the nurse should use a 10mL syringe instead; NOT B because the nurse should use chlorhexidine for cleansing the insertion site

A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of 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

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? A. Headache B. Hemoptysis C. Nausea D. Diarrhea

C. Nausea RATIONALE: Nausea is a manifestation of MI. Manifestations of MI include chest pain in the jaw, shoulder, or abdomen, anxiety, dizziness, dyspnea, dysrhythmias, fatigue and palpitations

A nurse is assessing a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temperature C. Sudden oliguria D. Decreased respirations

C. Sudden oliguria RATIONALE: This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias

A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? A. Ferrous sulfate B. Epoetin alfa C. Vitamin B12 D. Folic acid

C. Vitamin B12

A nurse is preparing to transfuse a unit of packed red blood cells for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Compare the client's identification number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs

C. Witness the informed consent document

A nurse is teaching a 70-year old client about risk factors for heart failure. The client has mild asthma, dm, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? A. "My diabetes will not increase my risk of heart failure" B. "My asthma makes it more likely for me to have heart failure" C. "My age does not increase my risk of heart failure" D. "My coronary artery disease is a risk factor for heart failure"

D. "My coronary artery disease is a risk factor for heart failure"

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

D. 0.9% sodium chloride RATIONALE: Solutions of 0.9% sodium chloride, as well as lactated ringers solution are used for fluid volume replacement; sodium chloride (crystalloid) is a physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products

A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's care? A. Flexion of the extremities B. Therapeutic hypothermia C. Upright positioning D. Ample hydration

D. Ample hydration

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation

D. Impaired circulation

A nurse is reviewing laboratory results for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

D. Iron toxicity RATIONALE: A client who has received several blood transfusions is at risk of hemosiderosis, which is excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions -A- hyperkalemia is a risk, not hypo -C- hypocalcemia is a risk because the citrate in the transfused blood bonds with calcium (not hyper)

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation laboratory studies from the client B. Apply pneumatic compression boots to the client C. Request a referral for a speech-language pathologist D. Keep the client NPO

D. Keep the client NPO RATIONALE: keeping the client NPO due to the risk of aspiration from the stroke

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? A. Instruct the client about a long-term cardiac conditioning program B. Administer scheduled doses of acetaminophen C. Check for peak laboratory markers of myocardial damage D. Monitor for bleeding

D. Monitor for bleeding RATIONALE: Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis resolves

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion

D. Stop the medication infusion

A nurse observes tachycardia, dyspnea, a cough and distended neck veins in a client who is receiving a transfusion of packed RBCs. Which of the following interventions should the nurse use to prevent these manifestations in the client's next transfusion? A. Warm the unit of blood to room temperature before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can snack on fresh fruit" B. "I can continue to eat lunchmeat sandwiches" C. "I can have cottage cheese with my meals" D. "Canned soup is a good lunch option"

A. "I can snack on fresh fruit"

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. "I should check my heart rate at the same time each day" B. "I don't have to take my antihypertensive medications now that I have a pacemaker" C. "I should keep a pressure dressing over the generator until the incision is healed" D. "I cannot stand in front of our new microwave when it is on"

A. "I should check my heart rate at the same time each day"

A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? A. "I should remove the skin from poultry before eating it" B. "I will eat seafood once per week" C. "I should use margarine when preparing meals" D. "I can use whole milk in my oatmeal"

A. "I should remove the skin from poultry before eating it"

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000. Which of the following interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

A. Avoid IM injections

A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

A. Decreased albumin

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Eggs B. Squash C. Kale D. Tofu

A. Eggs RATIONALE: Other foods high in B12 are dairy products, animal protein, shellfish

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The clients hemoglobin level is 8g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

A. Erythropoietin RATIONALE: Normal hemoglobin levels are 12-16; EPO stimulates production of RBCs to treat anemia a/w chronic renal failure -Filgrastim stimulates the production of neutrophils to treat neutropenia

While participating in a community health fair, a nurse is providing information to a client who has a blood pressure of 150/90 during screening. Which of the following actions should the nurse take? A. Give the client a written record of his BP to bring to his provider B. Encourage the client to go to the nearest emergency department C. Instruct the client to follow-up with a provider within 6 months D. Explain to the client that he is not at risk unless he has manifestations of hypertension

A. Give the client a written record of his BP to bring to his provider

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

A. Hyperkalemia RATIONALE: High K= Low pH (acidosis)

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia RATIONALE: Furosemide (Lasix) causing loss of potassium, sodium, calcium and magnesium. S/S of hypokalemia include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats

A nurse is assessing a client who has fluid volume overload for a cardiovascular disorder. Which of the following manifestations should the nurse expect? SATA A. Jugular vein distention B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

A. Jugular vein distention B. Moist crackles D. Increased heart rate

A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps? A. Palpate the blood pressure and inflate the cuff above the systolic pressure B. Identify the first BP sounds audible on expiration and then on inspiration C. Inspect for jugular venous distention and notify the provider D. Deflate the cuff slowly and listen for the first audible sounds E. Subtract the inspiratory pressure from the expiratory pressure

A. Palpate the blood pressure and inflate the cuff above the systolic pressure D. Deflate the cuff slowly and listen for the first audible sounds B. Identify the first BP sounds audible on expiration and then on inspiration E. Subtract the inspiratory pressure from the expiratory pressure C. Inspect for jugular venous distention and notify the provider

A nurse is reviewing a client's repeat laboratory results 4 hours after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit

A. Prothrombin time RATIONALE: FFP's are rick in clotting factors and is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time

A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes B. Premature ventricular complexes at 12/min C. Telemetry monitoring showing pacing spikes with no QRS complexes D. Hiccups

A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes

A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? A. Turkey on whole-wheat bread bread B. Hamburger and french fries C. Frankfurter on a white roll D. Macaroni and cheese

A. Turkey on whole-wheat bread bread

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

A. Ventricular dysrhythmias RATIONALE: Ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1kg (2.2lb) in 1 day B. Pitting edema +1 C. Client report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100

A. Weight gain of 1kg (2.2lb) in 1 day RATIONALE: Worsening HF

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

B. Ankle swelling RATIONALE: Other manifestations include brown pigmentation and cellulitis

A nurse is caring for a client who has a platelet count of 50,000. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 5 minutes C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol

B. Apply pressure to the catheter removal site for 5 minutes

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS pattern

B. Atrial rate 300/min with QRS complex of 80/min RATIONALE: Lack of conduction between the atria and ventricles

A nurse is assessing for DIC in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? SATA A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distention

B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distention RATIONALE: Abd distention due to internal bleeding

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? A. Vertigo B. Epistaxis C. Exophthalmos D. Spondylolisthesis

B. Epistaxis RATIONALE: HTN is often asymptomatic, but when it is severely elevated, it can also cause HA's, dizziness, facial flushing & fainting

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? A. Magnesium 2.0mEq/L B. Hgb 6.5g/dL C. WBC count 9.6/mm3 D. Creatinine 0.8mg/dL

B. Hgb 6.5g/dL RATIONALE: Normal Hgb is 12-18g/dL; a low Hgb can cause fatigue, HA, pallor, dizziness and tachycardia

A nurse planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluids to 1000mL per day B. Measure the client's abdominal girth daily C. Check IV sites every 4 hours for bleeding D. Administer an enema as needed for constipation

B. Measure the client's abdominal girth daily RATIONALE: This is to monitor for manifestations of internal bleeding; the nurse should check IV sites every 2 hours for bleeding (C)

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm

B. Much greater amplitude than the usual QRS complexes RATIONALE: The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs

A nurse is administering a unit of PRBCs to a client who is postoperative. The client reports itching and hives 30 minutes after the infusion begins. Which of the following actions should the nurse take first? A. Maintain IV access with 0.9% Sodium Chloride B. Stop the infusion of blood C. Send the blood container and tubing to the blood bank D. Obtain a urine sample

B. Stop the infusion of blood

A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? A. "Drink at least 1 liter of fluid each day" B. "Continuously wear support hose" C. "Elevate your legs when sitting" D. "Use dental floss daily"

C. "Elevate your legs when sitting" RATIONALE: To avoid pooling and clot formation

A nurse is providing discharge teaching to client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions? A. "I need to stay active to prevent blood clots in my legs" B. "If I have a bad headache, I can take aspirin to get rid of it" C. "I should eliminate uncooked foods from my diet for now" D. 'I should eat more iron-fortified cereal to strengthen my blood"

C. "I should eliminate uncooked foods from my diet for now" RATIONALE: The client can help prevent infection by eating throughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorgansims that cooking destroys, so the client should avoid raw foods"

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection" B. "Platelets help break down clots in the body" C. "Platelets plug breaks in blood vessels" D. "Platelets produce the molecules that carry oxygen"

C. "Platelets plug breaks in blood vessels"

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 and B are PVD/CVI

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes D. Chicken bouillon and crackers

C. Grilled chicken salad with fresh tomatoes

A client is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include int he plan? A. Administer ferrous sulfate supplementation B. Increase dietary intake of folic acid C. Initiate weekly injections of B12 D. Initiate a blood transfusion

C. Initiate weekly injections of B12

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A. Thick, white coating on the clients tongue B. Decreased pulse rate C. Paresthesias in the hands and feet D. Joint pain in the extremities

C. Paresthesias in the hands and feet RATIONALE: Other manifestations include weight loss and fatigue -A is describing candidiasis

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

C. Report of sudden, severe back pain

A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D

C. Vitamin C

A charge nurse is observing a newly licensed nurse administering an IV mediation to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A. A dressing is not applied to the port site after use B. A 22 gauge non-coring needle is used to access the port C. Blood return is noted prior to administering the medication D. A solution of 5mL heparin 1000units/mL has been prepared

D. A solution of 5mL heparin 1000units/mL has been prepared RATIONALE: Implanted ports should be flushed after each use and at least once a month when not in use. This is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5mL heparin should be 100 units

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? A. Sudden hemoptysis B. Acute diarrhea C. Frontal headache D. Acute confusion

D. Acute confusion Rationale: common in ages 65 or older; other manifestations can include nausea, vomiting, dyspnea, diaphoresis, palpitations, fatigue

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? A. Have the client gently blow clots from the nose every 5 minutes B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the clients neck D. Apply lateral pressure to the clients nose for 10 minutes

D. Apply lateral pressure to the clients nose for 10 minutes

A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first? A. Press the analyze button on the machine B. Stop CPR and move away from the client C. Push the charge button to prepare to shock D. Apply the defibrillator pads to the client's chest

D. Apply the defibrillator pads to the client's chest RATIONALE: The pads should be applied without interrupting CPR

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 minutes

D. Chest pain lasts longer than 15 minutes

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependent edema

D. Dependent edema RATIONALE: The subsequent systemic venous backup leads to the development of dependent edema

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's hips and knees in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

D. Encourage increased fluid intake

A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic reaction? A. Bradycardia B. Paresthesia C. Hypertension D. Low back pain

D. Low back pain RATIONALE: Other manifestations include HA, chest pain, tachypnea, tachycardia, and dark urine

A nurse is showing a client who has right-sided heart failure an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

D. Superior vena cava

A nurse is caring for a client who has pernicious anemia. Which of the following factors should the nurse identify with this condition? A. Iron deficiency B. Hemolytic blood loss C. Folic acid deficiency D. Vitamin B12 deficiency

D. Vitamin B12 deficiency

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss D. Jaundice with enlarged liver E. Petechiae and ecchymosis

E. Petechiae and ecchymosis RATIONALE: In aplastic anemia, all 3 major blood components (RBC, WBC, platelets) are reduced/absent, which is known as pancytopenia and manifestations usually develop gradually

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client vital signs are blood pressure 160/90, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? A. Administer antihypertensive medication for blood pressure B. Monitor to ensure the client's urinary output is 20mL/hr C. Withhold pain medication to prepare the client for surgery D. Take the client's vital signs every 2hr

A. Administer antihypertensive medication for blood pressure RATIONALE: the BP can cause a sudden rupture of the aneurysm due to pressure on the arterial wall