evolve cardio, hematologic and lymphatic system 1

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? 1. Atrial fibrillation 2. Forearm laceration 3. Migraine headache 4. Respiratory infection

1. Atrial fibrillation Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli. Whereas a clot in the lower extremities (DVT) may be more likely to be the cause of a pulmonary embolus (PE), atrial fibrillation can shower clots that do not lodge in the brain (stroke) but make their way to the lungs resulting in a PE. A forearm laceration, migraine headache, or a respiratory infection does not cause venous stasis or blood viscosity that contributes to venous thromboembolism.

How does the human body conserve heat? Select all that apply. 1. By decreasing muscle activity in the body 2. Through peripheral vasodilation in the body 3. Through peripheral vasoconstriction in body 4. By shunting blood to the superficial body tissues 5. By shunting blood away from the skin surface.

1, 3, 5 1. By decreasing muscle activity in the body 3. Through peripheral vasoconstriction in the body 5. By shunting blood away from the skin surface The human body conserves heat through peripheral vasoconstriction in the body. During peripheral vasoconstriction, the warm blood is shunted away from the skin surface to minimize heat loss from the body. Shunting blood to superficial body tissues would facilitate loss of heat. Increased muscle activity causes heat loss; the body conserves heat through decreased muscle activity. The body conserves heat through peripheral vasoconstriction; vasodilation would cause heat loss.

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply. 1 Lack of hair 2 Thickened toenails 3 Pain at the ulcer site 4 Diminished pedal pulse 5 Brown skin discoloration

1,2,3,4 Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse - Prolonged lack of oxygen to hair follicles results in hair loss. - Prolonged lack of oxygen to the toes results in thickened toenails. - Arterial ulcers are painful because of the interruption of blood supply to peripheral tissues. - Inadequate arterial perfusion results in diminished volume of blood flow to the lower extremities. - Brown skin discoloration is characteristic of venous ulcers.

A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply. 1 Wound drainage 2 Diuretic therapy 3 Gastrointestinal (GI) suction 4 Parenteral infusion of 0.9% sodium chloride 5 Inappropriate anti-diuretic hormone (ADH) secretion

1,2,3,5 Wound drainage Diuretic therapy Gastrointestinal (GI) suction Inappropriate anti-diuretic hormone (ADH) secretion - Wound drainage can result in hyponatremia from loss of sodium ions. - Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. - Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. - With the syndrome of inappropriate anti-diuretic hormone (SIADH), high levels of the anti-diuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. - Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia

A client is experiencing tachycardia. Which adverse hemodynamic effects will the nurse consider when planning care for this client? Select all that apply. 1. Decreased ventricular filling time 2 Increased coronary artery filling 3 Decreased cardiac output 4 Increased atrial kick 5 Increased cardiac output

1,3 Decreased ventricular filling time Decreased cardiac output - Tachycardia is a fast heart rate; the fast heart rhythm may cause a decrease in cardiac output because of the decreased filling time for the ventricles. - There is also a decreased, not increased, time for coronary artery filling during diastole. - During atrial systole, a bolus of atrial blood is ejected into the ventricles; this step is called the atrial kick, and it contributes more blood to the cardiac output of the ventricles. - With fast heart rates, there is less time for the atria to fill, and therefore less blood (atrial kick) to pump.

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process? 1. A pulse rate irregularity 2. Equal apical and radial pulse rates 3. A pulse rate of 60 beats per minute 4. An apical rate obtainable at the fifth intercostal space and midclavicular line

1. A pulse rate irregularity Dysrhythmias are abnormal and are associated with acute or chronic pathologic conditions. An equal apical and radial pulse is expected; the radial pulse reflects ventricular contractions. The expected range in adults is 60 to 100 beats per minute. An apical rate obtainable at the fifth intercostal space and midclavicular line are the anatomical landmarks for locating the apex of the heart; they are unaffected by aging.

A client who is suspected of having leukemia has a bone marrow aspiration. What should the nurse do Immediately after the procedure? 1 Apply brief pressure to the site. 2 Have the client lie on the affected side. 3 Swab the site with an antiseptic solution. 4 Monitor vital signs every hour for 4 hours

1. Apply brief pressure to the site Brief pressure is generally enough to prevent bleeding at the aspiration site. Complications are rare; no special positions are required. The site is cleaned before aspiration. Frequent monitoring is unnecessary.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? 1. Arteriolar constriction occurs. 2. The cardiac workload decreases. 3. Contractility of the heart decreases. 4. The parasympathetic nervous system is triggered.

1. Arteriolar constriction occurs. The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.

A nurse is assessing the ECG rhythm strip. The nurse checks the P wave. Which function of the heart is the nurse assessing? 1. Atrial depolarization 2. Atrial repolarization 3. Ventricular depolarization 4. Ventricular repolarization

1. Atrial depolarization The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, visualization of atrial repolarization is obscured by the QRS complex. The T wave represents ventricular repolarization.

The client reports a "fluttering in my chest." The nurse analyzes the client's heart rhythm and notices that there are three P waves for each QRS complex. The waves have a sawtooth appearance. The atrial rate is 240 beats per minute, but the ventricular rate is only 80 beats per minute. The nurse notifies the primary healthcare provider for which rhythm? 1 Atrial flutter 2 Atrial fibrillation 3 Ventricular fibrillation 4 Atrial flutter with rapid ventricular response

1. Atrial flutter - Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate between 200 and 350 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular. - Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction (325-600 times/min). - Ventricular fibrillation (VF), sometimes called "V fib," is the result of electrical chaos in the ventricles and is life threatening. Impulses from many irritable foci fire in a totally disorganized manner so that ventricular contraction cannot occur. There are no recognizable ECG deflections. - Atrial flutter with rapid ventricular response occurs when atrial impulses cause a ventricular response greater than 100 beats per minute.

Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving warfarin therapy after a myocardial infarction? 1 Blood-clotting function of vitamin K 2 Neuromuscular function of vitamin B1 3 Calcium-absorbing function of vitamin D 4 Hemoglobin-forming function of vitamin B12

1. Blood-clotting function of vitamin K - A neonate lacks the ability to produce vitamin K because of a lack of bacteria in the intestine. After a cholecystectomy a client experiences interference with absorption of the fat-soluble vitamin K because of disruption in bile flow. A client who is receiving warfarin experiences inhibition of vitamin K-dependent activation of clotting factors. - Neuromuscular function of vitamin B1, calcium-absorbing function of vitamin D, and hemoglobin-forming function of vitamin B12 are not common nutritional problems for these clients.

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? 1. Cold, clammy skin 2. Slow, bounding pulse 3. Increased blood pressure 4. Hyperactive bowel sounds

1. Cold, clammy skin - The action of the sympathetic nervous system causes vasoconstriction, and as cellular and peripheral hypoperfusion progresses, the skin becomes cold, clammy, cyanotic, or mottled. - The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs; it has a low volume (weak, thready) because of peripheral vasoconstriction. - The blood pressure decreases because of continued hypoperfusion and multiorgan failure. - Bowel sounds are hypoactive or absent, not hyperactive.

A 78-year-old client comes to the health clinic presenting with fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL (105 mmol/L). Which is the most appropriate nursing intervention in response to these laboratory results? 1. Conduct a complete nutritional assessment of the client 2. Nothing, because these are expected values for this client's age 3. Advise the client to come back to the clinic to have the test repeated in three months 4. Investigate the cause of the anemia while understanding that mild anemia is an expected response to the aging process

1. Conduct a complete nutritional assessment of the client A nutritional assessment starts the investigation for a cause of the client's anemia and is an independent function of the nurse. These are not expected values; an intervention is indicated. Medical treatment should be initiated first, and then the test should be repeated to determine the client's response to therapy; It is not within the legal function of the nurse to give medical advice. Anemia is not an expected response to the aging process.

A 78-year-old client comes to the health clinic presenting with fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL (105 mmol/L). Which is the most appropriate nursing intervention in response to these laboratory results? 1. Conduct a complete nutritional assessment of the client 2 Nothing, because these are expected values for this client's age 3 Advise the client to come back to the clinic to have the test repeated in three months 4 Investigate the cause of the anemia while understanding that mild anemia is an expected response to the aging process

1. Conduct a complete nutritional assessment of the client A nutritional assessment starts the investigation for a cause of the client's anemia and is an independent function of the nurse. These are not expected values; an intervention is indicated. Medical treatment should be initiated first, and then the test should be repeated to determine the client's response to therapy; it is not within the legal function of the nurse to give medical advice. Anemia is not an expected response to the aging process.

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? 1. Deficient fluid volume 2. Impaired skin integrity 3. Inadequate nutritional intake 4. Decreased participation in activities

1. Deficient fluid volume - The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. - Although impaired skin integrity is a concern with dehydration, it is not the priority. - The rapid weight loss reflects a loss of fluid, not a loss of body tissue. - Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.

A client is admitted to the coronary intensive care unit. Which is the first step the nurse should take when developing a discharge teaching plan for this client? 1. Identifying the client's needs 2. Formulating the client's desired outcomes 3. Exploring the client's community resources 4. Assessing the client's personal support system

1. Identifying the client's needs - For teaching to be meaningful, the client must have a need to learn; also, readiness to learn is part of this assessment. - The nurse determines expected outcomes depending on mutually desired goals; also, this is not the first step when developing a discharge teaching plan. - Exploring the client's community resources is not the initial step; assessment of learning needs comes first. - Assessing the client's personal support system is not the initial intervention; the client's needs must be assessed first.

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first? 1. Raise the client to high-Fowler position 2. Obtain the apical pulse and blood pressure 3. Call the primary healthcare provider immediately 4. Monitor the pulse oximeter to ascertain the oxygen level

1. Raise the client to high-Fowler position. Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary healthcare provider immediately would not be useful without having a full set of vital signs. The vital signs should include the oxygen saturation, which the healthcare provider would expect the nurse to provide.

The client's heart monitor shows a regular rhythm made up of wide and bizarre-looking QRS complexes and no P waves. The rate is 40 beats per minute. How should the nurse interpret these findings? 1. Sinoatrial (SA) and atrioventricular (AV) nodes fail to initiate an impulse. 2. Purkinje fibers are suppressed. 3. SA node is stimulated. 4. AV node is stimulated.

1. Sinoatrial (SA) and atrioventricular (AV) nodes fail to initiate an impulse. - Idioventricular rhythm is a rhythm that is generated by the ventricular ectopic pacemaker. This rhythm emerges only when the SA and AV nodes fail to initiate an impulse. Because this last pacemaker is located in the ventricles, the QRS complex appears wide and bizarre with a slow rate. No P waves are present. Purkinje fibers can be a ventricular type of pacemaker and can be stimulated.

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what? 1. Tissue necrosis 2. Venous thrombosis 3. Pulmonary infarction 4. Respiratory infection

1. Tissue necrosis The body's inflammatory response to myocardial necrosis causes an elevation of temperature as well as leukocytosis within 24 to 48 hours after the event. Venous thrombosis and pulmonary infarction are not expected findings after a myocardial infarction. Respiratory infection is not common after myocardial infarction. Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.

Which client is at greatest risk for the development of a venous thrombosis? 1. A 76-year-old female with a 100-pack-per-year smoking history and hypertension 2. A 68-year-old male on bed rest following a left hip fracture 3. A 59-year-old male who is an intravenous drug user with hyperlipidemia 4. A 42-year-old female with Factor V Leiden mutation on warfarin

2. A 68-year-old male on bed rest following a left hip fracture - Venous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. - While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.

A nurse is teaching a client with Hodgkin disease about responses to whole-body radiation. Which clinical indicator increase should the nurse include in the teaching session? 1. Blood viscosity 2. Susceptibility to infection 3. Red blood cell (RBC) production 4. Tendency for pathologic fractures

2. Susceptibility to infection - Radiation exposure may lead to depression of the bone marrow, with subsequent insufficient white blood cells (WBCs) to combat infection. - There is no increase in the number of cells; therefore viscosity is not increased. - RBC production is decreased by radiation. - Pathologic fractures are not associated with radiation treatments

After teaching a client about a low-fat diet, what is most important for the nurse to document? 1. Client's weight loss goals 2. Client's ability to plan a low-fat meal 3. Client's receptiveness to the education 4. Education of family members/significant others as well as the client

2. Client's ability to plan a low-fat meal Documenting the client's ability to plan a low-fat meal demonstrates the client's ability to apply the education to lifestyle. Not all clients on a low-fat diet need to lose weight. Clients can be receptive to education but not understand it. It helps to include family members or significant others in the education. However, it is most effective if the clients themselves take ownership of their healthcare plan. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.

A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities? 1. Restrict fluids. 2. Elevate the legs. 3. Apply elastic bandages. 4. Do range-of-motion exercises.

2. Elevate the legs. Elevation of extremities promotes venous and lymphatic drainage by gravity. Restricting fluids and applying elastic bandages are dependent functions of the nurse. Doing range-of-motion exercises may have little effect on edema. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.

Before a femoral arteriogram is started, what should the nurse teach the client regarding the procedure? 1. Radioactive dye will be injected into the femoral vein 2. Local anesthesia will be used to decrease pain at the site 3. Contrast media will be injected into a small vessel of the foot 4. Medication will be administered intravenously to induce sleep

2. Local anesthesia will be used to decrease pain at the site Teaching the client that local anesthesia will be used to decrease any pain at the site reassures the client and allays fears of pain. The contrast medium used is not radioactive. The femoral artery is used for contrast media. The client will be awake during the procedure.

A client with a history of hypertension develops pedal edema and hepatomegaly. Which condition does the nurse determine the client is experiencing? 1. Left ventricular failure 2. Right ventricular failure 3. Restrictive pulmonary disease 4. Obstructive pulmonary disease

2. Right ventricular failure - The failing right ventricle fails to contract effectively, which causes a backup of blood into the right atrium and venous circulation, causing peripheral edema and hepatomegaly. - Left-sided heart failure results from left ventricular dysfunction, which prevents normal forward blood flow and causes blood to back up into the left atrium and pulmonary veins, causing pulmonary congestion. - Although dyspnea on exertion is associated with obstructive and restrictive pulmonary disease, hypertension and pedal edema are related to cardiac, not respiratory, problems.

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? Select all that apply 1. Thirst 2. Seizures 3. Erythema 4. Confusion 5. Constipation

2. Seizures 4. Confusion Confusion and seizures are associated with hyponatremia. Cellular swelling and cerebral edema are associated with hyponatremia; as extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into cerebral cells, leading to confusion and seizures. Thirst is a symptom of hypernatremia; it may indicate dehydration. Erythema is not associated with hyponatremia. Diarrhea, not constipation, is associated with hyponatremia.

A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. Which information should the nurse share with the client? 1. Choose only familiar sexual positions. 2. Select familiar settings for sexual activity. 3. Return to regular sexual activity in four to six weeks. 4. Depending upon your preference, take a hot or cold shower after intercourse.

2. Select familiar settings for sexual activity. An unfamiliar environment increases stress, which increases cardiac workload. It is advantageous to experiment with positions and find one that is relaxing and permits unrestricted breathing. It is generally safe to resume sexual activity 7 to 10 days after an uncomplicated MI. However, some physicians believe that the client should decide when ready to resume sex. Hot or cold showers should be avoided just before and after intercourse. Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety."

The nurse is caring for a client with a history of atrial fibrillation and a diagnosis of dehydration. What does the nurse anticipate that the plan of care will include? 1 A glass of water every hour until hydrated 2 Small, frequent intake of juices, broth, or milk 3 A short-term nasogastric tube for replacement of fluids and nutrients 4 A rapid intravenous (IV) infusion of an electrolyte and glucose solution

2. Small, frequent intake of juices, broth, or milk - Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. - Water does not supply the necessary electrolytes, and hyponatremia may result. - No data are present to indicate that the client cannot take fluids orally; a nasogastric tube is not necessary when the client can take fluids by mouth. - Rapid correction of a fluid and electrolyte imbalance is dangerous; therapy should promote a gradual correction

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand? 1. Plaque from within the veins is scraped. 2. The dilated saphenous veins are removed. 3. Superficial veins are sown together into deep veins. 4. An umbrella filter is placed in the large affected veins.

2. The dilated saphenous veins are removed. During a ligation, the saphenous vein is removed. Plaque is an arterial, rather than a venous, problem. Anastomosing (sewing together) superficial veins to deep veins is not done during this surgery; superficial and deep veins usually are attached by communicating veins. An umbrella filter placed in the large affected veins prevents emboli from traveling to the lung; it is not a vein ligation and stripping.

A client with peripheral arterial insufficiency tells the nurse that walking sometimes results in severe pain in the calf muscles. Which information should the nurse share with the client? 1. This is called rest pain. 2. This is called intermittent claudication. 3. This is called phantom limb sensation. 4. This is called Raynaud phenomenon.

2. This is called intermittent claudication. - Intermittent claudication is pain that results when the arterial system is unable to provide adequate blood flow to the tissues in the presence of increased demands for oxygen and nutrients during exercise; it is relieved by rest. - Rest pain is not a response to exercise; it occurs in the extremities during rest, especially at night. - Phantom limb sensation is the presence of unusual sensations or pain in the removed portion of an amputation. - Raynaud phenomenon is intermittent episodes of constricted arteries and arterioles in response to extreme cold or emotional stress, causing pallor, paresthesias, and pain.

Which client should a nurse consider the greatest risk for developing hypernatremia? 1 A 52-year-old who is receiving 0.45% NaCl intravenously 2 A 76-year-old who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a result of head trauma 3 A 63-year-old who has had watery diarrhea since traveling abroad 4 A 48-year-old who is admitted with a diagnosis of Addison disease

3. A 63-year-old who has had watery diarrhea since traveling abroad - Watery diarrhea involves loss of water in excess of sodium; this leads to an increased sodium concentration. - Intravenous 0.45% NaCl is a hypotonic solution; concentration of sodium is less than body fluids. - Increased secretion of antidiuretic hormone causes water retention, which decreases sodium concentration. - Addison disease involves hyposecretion of adrenocortical hormones, which leads to hyponatremia.

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? 1. Except with rare blood disorders, hemoglobin seldom affects oxygenation status. 2. There are many other factors that affect oxygenation status more than hemoglobin does. 3. A low hemoglobin level causes reduced oxygen-carrying capacity. 4. Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status.

3. A low hemoglobin level causes reduced oxygen-carrying capacity. Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. Higher levels of hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. Hemoglobin does not reflect clotting ability.

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? 1. Keep the client on bedrest 2. Have the client sit in a chair 3. Assist the client with ambulation 4. Encourage the client to bend at the knee.

3. Assist the client with ambulation. Mobility will reduce venous stasis and edema as well as promote arterial perfusion and healing. Bed rest is contraindicated because it promotes the development of thrombophlebitis and pulmonary emboli. Having the client sit in a chair constricts circulation at the hips and knees. Encouraging the client to bend at the knee is contraindicated.

A client who is receiving methotrexate for acute lymphocytic leukemia (ALL) develops a temperature of 101° F (38.3° C). The nurse notifies the primary healthcare provider. Aspirin 650 mg every 4 hours as needed for temperature equal to or greater than 101° F (38.3° C) is prescribed. What should the nurse do regarding this prescription? 1. Express concern about the dosage prescribed. 2. Request a prescription for an antacid. 3. Express concern about the type of antipyretic prescribed. 4. Ask if the frequency should be every 6 hours instead.

3. Express concern about the type of antipyretic prescribed. Aspirin is contraindicated in the presence of bleeding tendencies, which often occur with acute lymphocytic leukemia because of its inhibitory effect on platelet aggregation. Although expressing a concern about the dosage is within acceptable limits, this analgesic is contraindicated. Although an antacid will reduce the gastric irritation common with aspirin, this analgesic is contraindicated. Although the frequency is within acceptable limits, this analgesic is contraindicated. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? 1. Cataracts 2. Esophagitis 3. Kidney failure 4. Diabetes mellitus

3. Kidney failure Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures, such as tubules, glomeruli, and nephrons, leading to kidney failure. Retinopathy, resulting in blurred vision, retinal hemorrhage, and blindness, occurs with a long history of hypertension because of increased intravascular pressure, not cataracts. Esophagitis is caused by esophageal reflux disease, not a long history of hypertension. Hypertension does not cause diabetes mellitus; however, chronic elevations of serum glucose accelerate atherosclerosis, resulting in the development of hypertension.

A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action should the nurse take to prepare for the arrival of the client? 1. Reserve an operating room. 2 Organize equipment for a tracheotomy. 3 Prepare equipment for chest tube insertion. 4 Arrange for a portable chest x-ray examination.

3. Prepare equipment for chest tube insertion. - The priority is to reinflate the lungs and stabilize the client's respiratory status. - Reserving an operating room may be necessary later but is premature at this time. - Organizing equipment for a tracheotomy is unnecessary; an endotracheal tube should be used for maintenance of the airway if necessary. Arranging for a portable chest x-ray examination is not the priority at this time; this may be done later.

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding? 1. Sinus tachycardia 2. Normal sinus rhythm 3. Sinus rhythm with premature atrial contractions (PACs) 4. Sinus bradycardia with premature ventricular contractions (PVCs)

3. Sinus rhythm with premature atrial contractions (PACs) A PAC is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.12 seconds. P and QRS waves are consistent in shape. Bradycardia is defined as a heart rate less than 60 beats per minute.

A client with severe varicose veins has surgery that involves ligation, dissection, and removal of incompetent vessels. In which position should the nurse place the client after surgery? 1. Supine with the knee support of the bed raised 2. In a semi-Fowler position with the knees flexed 3. Supine with the legs elevated at a 15-degree angle 4. In a semi-Fowler position with the feet against a footboard

3. Supine with the legs elevated at a 15-degree angle Legs should be elevated to promote venous return by gravity. Supine with the knee support of the bed raised increases pressure on the popliteal space, which may interfere with venous return from the legs. Flexion of the knees and hips with legs lower than the heart interferes with venous return. A footboard prevents ankle exercises that would promote venous return; placing the legs lower than the level of the heart will not prevent venous stasis.

Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? 1. Relax in a reclining position 2. Sit upright with legs extended 3. Walk around at least every hour 4. Sit in any position that relieves pressure on the legs

3. Walk around at least every hour Muscle contraction associated with walking prevents pooling of blood in the extremities and dependent edema. Movement is required, not inactivity (reclining or sitting). Sitting in any position that relieves pressure on the legs does not include movement, which is essential to prevent thrombus formation.

A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available? 1. ¾ to 1 inch (2 to 2.5 cm) 2. ½ to ¾ inch (1.3 to 2 cm) 3. 1 to 1½ inches (2.5 to 3.8 cm) 4. 2 to 2½ inches (5 to 6.4 cm)

4. 2 to 2½ inches (5 to 6.4 cm) The sternum must be depressed at least 2 inches (5 cm) to compress the heart adequately between the sternum and vertebrae and to simulate cardiac pumping action. Depression of less than this is ineffectual for an adult. Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be.

A client on a 2-gram sodium diet states, "I never add salt to my food when I cook. I just need help selecting low-sodium foods." After receiving dietary education, the client creates sample menus. Which meal selection will cause the nurse to intervene? 1. Soft-cooked egg, toast, jelly, skim milk 2. Baked chicken, boiled potatoes, broccoli, coffee 3. Fillet of sole, baked potato, fresh fruit cup (berries and melons) 4. Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

4. Cottage cheese, crackers, relish dish (celery, olives, sweet pickles) Cottage cheese, crackers, and a relish dish (celery, olives, sweet pickles) have the highest sodium content. Meals consisting of soft-cooked egg, toast, jelly, and skim milk; baked chicken, boiled potatoes, broccoli, and coffee; and fillet of sole, baked potato, and fresh fruit cup (berries and melons) are low in sodium.

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? 1. Factor II 2. Factor III 3. Factor IX 4. Factor VIII

4. Factor VIII - Hemophilia type A, which is the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and III are distractors. - Factor IX is associated with hemophilia type B.

A nurse is determining whether or not a client's atrial rhythm is regular when reviewing the ECG rhythm strip. Which consistency of spacing will the nurse use to determine regularity? 1 P wave and the QRS complex 2 QRS complexes 3 QRS widths 4 P waves

4. P waves - The P wave represents atrial contraction. Regularity is assessed by using electronic or physical calipers, or a piece of paper and pencil. To determine atrial regularity, a.) identify the P wave and place one caliper point on the peak of the P wave. b.) Locate the next P wave and place the second caliper point on its peak. c.) The second point is left stationary, and the calipers are flipped over. If the first caliper point lands exactly on the next P wave, the atrial rhythm is perfectly regular. If the point lands one small box or less away from the next P wave, the rhythm is essentially regular. If the point lands more than one small box away, the rhythm is considered irregular. The same process can be performed with a simple piece of paper. Place the paper parallel and below the rhythm line, make a hatch mark below the first and second P waves, and then move the paper over to determine if the distance between the second and third P waves is equal to the first and second. When an atrial rhythm is perfectly regular, each P wave is an equal distance from the next P wave. This process is also used to assess ventricular regularity, except that the caliper points are placed on the peak of two consecutive R waves. QRS intervals can lengthen in response to new bundle branch blocks or with ventricular dysrhythmias.

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1. Elevate the foot of the bed. 2. Perform urinary catheter care every 12 hours. 3. Place in the high-Fowler position. 4. Perform a neurovascular assessment every 2 hours.

4. Perform a neurovascular assessment every 2 hours. Because of the trauma associated with the insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of or lower than the heart. A general anesthetic is not used; therefore voiding is not a concern. Keeping the client in the high-Fowler position is unsafe; this position increases pressure in the groin area, which can dislodge the clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, what is the most accurate measurement of the client's left ventricular pressure? 1 Right atrial pressure 2 Cardiac output by thermodilution 3 Pulmonary artery diastolic pressure 4 Pulmonary capillary wedge pressure

4. Pulmonary capillary wedge pressure - Pulmonary capillary wedge pressure is an indirect measure of left ventricular end-diastolic pressure, an indication of ventricular contractility. - Right atrial pressure measures only the function of the right side of the heart and indirectly its ability to receive blood. - Cardiac output by thermodilution does not measure intracardiac pressures. - Pulmonary artery diastolic pressure may not be as accurate an indicator of left ventricular pressure if chronic obstructive pulmonary disease or pulmonary hypertension exists.

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan about prevention of thrombophlebitis? 1. Wear snug-fitting pants 2. Sit with the knees flexed 3. Apply warm soaks to the legs daily 4. Put on compression stockings before arising

4. Put on compression stockings before arising - Donning compression stockings before getting out of bed provides support and promotes venous return; applying stockings while the legs are horizontal ensures that the stockings are in place before dependent edema occurs. - Wearing snug-fitting pants will cause constriction. - Sitting with the knees flexed promotes venous stasis and the formation of thrombophlebitis. - - Warm soaks resolve inflammation; they do not prevent the development of thrombophlebitis.

A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first? 1. Remove all jewelry. 2. Wash the chest area. 3. Use a grounded electrical source. 4. Remove medication patches on the chest.

4. Remove medication patches on the chest. Medication patches that interfere with electrode placement must be removed before application of electrodes because of possible burn caused by electrical conduction in the area of the patch. Jewelry usually is not a problem with the function of an automated external defibrillator. Skin preparation is unnecessary. The AED is battery-operated and does not need a grounded electrical source.

A client hospitalized for heart failure is receiving digoxin and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? 1. Monitoring vital signs and encouraging a vigorous aerobic exercise program 2. Providing written material on the adverse effects of the medication 3. Contacting Social Services for a home health nursing consultation 4. Teaching the client how to count the pulse

4. Teaching the client how to count the pulse Adverse effects of digoxin include many types of dysrhythmias. If the client's apical pulse rate is less than 60, the medication is "held" and the primary healthcare provider is notified. Because the client will be taking the medication at home, the client should be taught how to take an accurate pulse and to contact the healthcare provider if the rate falls outside predetermined parameters. The client will be assuming responsibility for drug administration at home; teaching is the priority. Vigorous exercise is not recommended for clients who have heart failure. Providing written material on the adverse effects may not meet all of the client's learning needs. There is nothing in the question to suggest the client requires home healthcare.

4. Ventricular tachycardia - Ventricular tachycardia has a rate of 140 to 200 or even 250 beats per min; the rhythm is usually regular but may vary. P waves are unidentifiable. PR intervals are unmeasurable. QRS complexes are wide and bizarre. - Atrial flutter is characterized by an atrial rate of 200 to 350 beats per min and a ventricular rate of approximately 150 beats per min; flutter to ventricular responses usually are 2:1, 3:1, or 4:1. - Atrial fibrillation is characterized by an atrial rate of 350 to 600 beats per min and a variable ventricular rate; the rhythm is grossly irregular. - Ventricular fibrillation reflects a rapid, feeble twitching/quivering of the ventricles; it has an irregular sawtooth configuration with unidentifiable PR intervals and QRS complexes

A client is receiving continuous ECG monitoring while intravenous medication is being administered for premature ventricular complexes (PVC). Which dysrhythmia does the nurse conclude that the client is experiencing when the following rhythm appears on the ECG monitor? 1. Atrial flutter 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia

The transducer is positioned so that the zero reference point is at the level of the atria of the heart. This is known as referencing. To place the reference point, the phlebostatic axis is identified.

Mark the component of a pressure monitoring system that should be positioned while referencing