Exam 2 rationales
One of the unique manifestations of sickle cell disease is ______, a type of pneumonia triggered by decreased hemoglobin and infiltrates in the lungs.
Acute chest syndrome Explanation: Acute chest syndrome is characterized by respiratory symptoms, such as coughing, wheezing, tachypnea, and chest pain. Vaso-occlusive crisis causes decrease in tissue perfusion.
A nurse is providing education to a client about monitoring blood pressure readings at home. What reminders will the nurse review with the client? Select all that apply. Answer: Avoid talking during the measurement. Sit with both feet on the ground during the measurement. Ensure at least 5 minutes of quiet rest before measurements. Be sure the forearm is well supported at heart level while taking blood pressure
Answer: Avoid talking during the measurement. Sit with both feet on the ground during the measurement. Ensure at least 5 minutes of quiet rest before measurements. Be sure the forearm is well supported at heart level while taking blood pressure Rationale: Instructions for the client regarding measuring the blood pressure at home include the following: (1) Avoid smoking cigarettes or drinking caffeine for 30 minutes before measuring blood pressure; (2) sit quietly for 5 minutes before the measurement (no talking); and (3) have the forearm supported at heart level, with both feet on the ground during the measurement of the blood pressure.
A nurse is educating a client about monitoring blood pressure readings at home. Which of the following will the nurse be sure to emphasize? a. "Be sure the forearm is well supported above heart level while taking blood pressure." b. "Avoid smoking cigarettes for 8 hours prior to taking blood pressure." c. "Sit with legs crossed when taking your blood pressure." d. "Sit quietly for 5 minutes prior to taking blood pressure."
Answer: "Sit quietly for 5 minutes prior to taking blood pressure."
A nurse working in the medical intensive care unit has a patient admitted with mitral stenosis. The nurse is precepting a new graduate and explains the pathophysiology of the condition. Which of the following statements made by the new graduate would reflect an appropriate understanding of the disease process? Choose all that apply. a. "There is a narrowing between the left atrium and left ventricle." b. "Increased blood flow in the left atrium causes left atrial hypertrophy." c. "Mitral stenosis is caused by an obstruction between the right atrium and ventricle." d. "It is caused by a tear that leads to the lungs becoming congested."
Answer: A, B "There is a narrowing between the left atrium and left ventricle." "Increased blood flow in the left atrium causes left atrial hypertrophy." Rationale: Poor left ventricular filling can cause decreased cardiac output. The increased blood volume in the left atrium causes it to dilate and hypertrophy. The left atrium and ventricle are affected with mitral stenosis. Mitral regurgitation causes the lungs to become congested.
The nursing instructor is teaching nursing students about myocardial contractility and ejection fractions. What diagnostic tests can determine client ejection fractions? Select all that apply. a. Echocardiogram b. Cardiac catheterization c. Magnetic resonance imaging d. Positron emission tomography scan e. Troponin levels
Answer: A, B, C Echocardiogram Cardiac catheterization Magnetic resonance imaging Rationale: Echocardiogram, cardiac catheterization, and magnetic resonance imaging can provide ejection fraction estimates. The positron emission tomography scan reveals areas of decreased blood flow in the heart. Troponin levels are cardiac markers and do not measure ejection fractions.
A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply. a. Reduces myocardial oxygen consumption b. Decreases the urge to use tobacco c. Dilates blood vessels d. Decreases ischemia e. Relieves pain
Answer: A, C, D, E Reduces myocardial oxygen consumption Dilates blood vessels Decreases ischemia Relieves pain Rationale: Nitroglycerin dilates blood vessels and reduces the amount of blood returning to the heart, which reduces the workload of the heart and myocardial oxygen consumption. As the dilated vessels allow more blood supply to the heart, ischemia and pain are reduced. Nitroglycerin does not affect the urge to use tobacco.
What can decrease myocardial contractility? a. Acidosis b. Alkalosis c. Administration of digoxin
Answer: Acidosis Rationale: Contractility is depressed by hypoxemia, acidosis, and certain medications, such as beta-adrenergic blocking medications. Contractility is enhanced by sympathetic neuronal activity and specific medications like digoxin.
A nurse is preparing a client for cardiac catheterization. The nurse knows that which nursing intervention must be provided when the client returns to the room after the procedure? a. Withhold analgesics for at least 6 hours after the procedure. b. Assess the puncture site frequently for hematoma formation or bleeding. c. Inform the client that he or she may experience numbness or pain in the leg. d. Restrict fluids for 6 hours after the procedure.
Answer: Assess the puncture site frequently for hematoma formation or bleeding Rationale: Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as ordered and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client's system.
Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply. a. Beta-blockers may cause sedation. b. With thiazide diuretics, monitor serum potassium levels. c. With adrenergic inhibitors, cough is a common side effect. d. With ACE inhibitors, assess for bradycardia. e. Direct vasodilators may cause headache and tachycardia.
Answer: B, E With thiazide diuretics, monitor serum potassium concentration. Direct vasodilators may cause headache and tachycardia. Rationale: Thiazide diuretics may deplete potassium; many clients will need potassium supplementation. Direct vasodilators may cause headache and increased heart rate. Adrenergic inhibitors can cause sedation and fatigue. Beta-blockers may induce decreased heart rate; pulse rate should be assessed before administration. Angiotensin-converting enzyme inhibitors can induce a mild to a severe dry cough.
32. The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs? a. Loop diuretic and antiplatelet aggregator b. Loop diuretic and calcium channel blocker c. Combination of hydralazine and isosorbide dinitrate d. Combination of digoxin and normal saline e. Loop diuretic and antiplatelet aggregator
Answer: Combination of hydralazine and isosorbide dinitrate A combination of hydralazine and isosorbide dinitrate may be an alternative for clients who cannot take ACE inhibitors.
The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs? a. Loop diuretic and anti-platelet aggregator b. Loop diuretic and calcium channel blocker c. Combination of hydralazine and isosorbide dinitrate d. Combination of digoxin and normal saline
Answer: Combination of hydralazine and isosorbide dinitrate Rationale: A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.
The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse? a. Hold the medication and call the health care provider. b. Administer the medication and check the blood pressure in 30 minutes. c. Administer a saline bolus of 250 mL and then administer the medication. d. Administer the hydralazine and hold the dinitrate.
Answer: Hold the medication and call the health care provider. Rationale: A combination of hydralazine and isosorbide dinitrate may be another alternative for patients who cannot take ACE inhibitors. Nitrates (e.g., isosorbide dinitrate) cause venous dilation, which reduces the amount of blood return to the heart and lowers preload. Hydralazine lowers systemic vascular resistance and left ventricular afterload. If these medications lead to severe hypotension, the nurse should hold the medication and call the health care provider.
7. A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patient's consequent risk of what complication of treatment? a. Hypovolemia b. Vitamin B12 deficiency c. Thrombocytopenia d. Iron overload
Answer: Iron overload Rationale: Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.
A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation? a. Fourth heart sound (S4) b. Orthostatic hypotension c. Increased PR interval d. Irregularly irregular heart rate
Answer: Irregularly irregular heart rate Rationale: An irregularly irregular heart rate indicates atrial fibrillation and should be investigated further. It's normal for an elderly client to have a prolonged systole, which causes an S4 heart sound. It's also normal for an elderly client to have slowed conduction, causing an increased PR interval. As a person ages, it's normal for baroreceptors in the body to decrease their response to changes in body position, which can cause orthostatic hypotension
The combination of hydralazine and isosorbide dinitrate is a suitable alternative to which medication in a patient with heart failure and bilateral renal artery stenosis? a. Furosemide b. Lisinopril c. Carvedilol d. Ivabradine e. Digoxin
Answer: Lisinopril Rationale: Patients with bilateral renal artery stenosis should not be prescribed ACE inhibitors or ARBs. When an ACE inhibitor or ARB cannot be used to treat heart failure, a suitable alternative is the combination of hydralazine and isosorbide dinitrate
The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD may result in what? a. Development of an atrial-septal defect b. Myocardial ischemia c. Formation of a pulmonary embolism d. Release of potassium ions from cardiac cells
Answer: Myocardial ischemia Rationale: Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Clients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital.
7. A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? a. Potassium b. Calcium c. Platelet count d. White blood cell (WBC) count
Answer: Potassium Rationale: Diuretics, such as furosemide, are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin, and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.
A client is returning home after having a bone marrow aspiration and biopsy. Which statement indicates that teaching by the nurse has been effective? a. "I can resume my normal activities." b. "The area might ache for 1 to 2 days." c. "I should take aspirin if I have any pain." d. "I can go to the gym to lift weights later."
Answer: The area might ache for 1 to 2 days." Explanation: Potential complications of either bone marrow aspiration or biopsy include bleeding and infection. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow aspiration, but the site of a biopsy may ache for 1 or 2 days. The client should be instructed to perform no rigorous activity for 1 to 2 days. Aspirin-containing analgesics should be avoided immediately after the procedure as this might cause or aggravate bleeding. Rigorous exercise should be avoided for 1 to 2 days.
The client asks the nurse why a stress test is needed. What statement best explains the rationale for the health care provider to order a cardiac stress test?
Answer: The health care provider wants to identify if the heart failure is from coronary artery disease. Rationale: Cardiac stress testing or cardiac catheterization is performed to determine whether the coronary artery disease and cardiac ischemia are causing the heart failure. The nurse is generalizing when saying everything is being evaluated. Explaining that heart failure is causing weakness and fatigue does not answer the need for the stress test. The stress test does not diagnose the client's stage of heart failure.
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority? a. Withhold food and fluids. b. Position the client on his side. c. Introduce a nasogastric (NG) tube. d. Insert an oral airway.
Answer: Withhold food and fluids. Rationale: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns.
The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options. Due to the client's high risk for developing _______ as a result of the prescribed medication, the nurse focuses on monitoring the client for _______. a. Hypokalemia b. Ventricular arrhythmia c. Hyponatremia d. Nausea e. Hyperuricemia f. Joint swelling
Answer: hypokalemia, ventricular arrhythmia Rationale: Furosemide, a loop diuretic, is often prescribed for clients who experience fluid volume overload due to a diagnosis of heart failure (HF). The client who is newly prescribed furosemide for the treatment of hypervolemia due to HF is at a high risk for developing fluid and electrolyte abnormalities, with a high risk for hypokalemia. Hypokalemia is a potentially life-threatening complication of loop diuretic therapy due to the risk for cardiac arrhythmias. When assessing a client for hypokalemia, the nurse monitors the client for ventricular arrhythmias. This is a priority in the provision of care for a client who is prescribed furosemide for the treatment of heart failure. Although hyponatremia and hyperuricemia are both potential side effects associated with diuretic therapy, they are not high risks for the client who is prescribed furosemide. Although a symptom of hyponatremia is nausea and joint pain is a symptom of hyperuremia, these are not findings that are expected for a client who experiences hypokalemia due to furosemide therapy.
A client is brought to the ED reporting fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the xlient has been treated for a sore throat three times in the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client's diagnosis? a. sickle cell anemia b. iron deficiency anemia c. aplastic anemia d. hemolytic anemia
Aplastic anemia Explanation: Aplastic anemia can be congenital or acquired, but most cases are idiopathic. It can be triggered by infection. The manifestations of aplastic anemia are symptoms of anemia, purpura (bruising), retinal hemorrhages, significant neutropenia, and thrombocytopenia. Other lymphadenopathies and splenomegaly sometimes occur.
A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention? Assess the client's hemoglobin and platelets. Assess the client's pulse and blood pressure. Check the client's history. Assess the client's skin.
Assess the client's hemoglobin and platelets. Explanation: Clients with AML may develop pallor from anemia and a tendency to bleed because of a low platelet count. Assessing the client's hemoglobin and platelets will help to determine whether this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's vital signs are: Temperature 99.8 F (37.7 C); BP 104/68; pulse 76. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry and swollen. What is the most appropriate action for the nurse to take? A. Encourage the client to perform isometric leg exercise to improve circulation in the legs. B. Document findings and check the client again in 1 hour. C. Slow the IV fluid rate to prevent any more swelling at the puncture site. D. Contact the health care provider and report the findings.
Contact the health care provider and report the findings. Explanation: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the health care provider immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.
What pathophysiological concept related to sickle cell disease predisposes a client with sickle cell disease to pneumonia? Damage to the spleen increases the risk for infection. Damage to the lymphatic system increases the risk for infection. Sequestration of sickled cells lead to infection in the area of sequestration. Sequestration of sickled cells lead to infection in the area distal to the sequestration.
Damage to the spleen increases the risk for infection. Explanation: Sickle cell disease can damage the spleen by thrombosis and subsequent damage or necrosis of tissue. This damage to the spleen increases the risk for infection, predisposing the client to pneumonia and acute chest syndrome. Sequestration causes thrombosis, not infection
A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, what will the nurse assess for? Adventitious lung sounds Hair loss Diarrheal stools Laryngeal edema
Diarrheal stools Explanation: Side effects of radiation therapy are limited to the area being irradiated. Clients who have abdominal radiation therapy may experience diarrhea. If the lesions were in the upper chest, then the client may experience adventitious lung sounds or laryngeal edema as side effects. Hair loss is associated more with chemotherapy than radiation therapy.
A patient was admitted to the hospital with the following lab values: hemoglobin 5 g/dL, abnormally shaped erythrocytes, leukocyte count 2000/mm3 with hypersegmented neutrophils and a platelet count of 48,000/mm3. The platelets appear abnormally large. A bone marrow biopsy was competed and revealed hyperplasia. Based on this information, the nurse determines that patient most likely has which of the following diagnoses? a) Sickle cell anemia b) Folic acid deficiency c) Thalassemia d) Hemolytic anemia
Folic acid deficiency Explanation: Anemia caused by a deficiency of folic acid cause bone marrow and peripheral blood changes. The erythrocytes that are produced are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid stem cell are also abnormal. A bone marrow analysis reveals hyperplasia (abnormal increase in the number of cells). Pancytopenia (a decrease in all myeloid stem cell-derived cells) can develop. In advanced stages of disease, the hemoglobin value may be as low as 4 to 5 g/dL, the leukocyte count 2,000 to 3,000/mm3, and the platelet count less than 50,000/mm3. Cells that are released into the circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be abnormally large. The erythrocytes are abnormally shaped. Page 907
A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will receive? Induction therapy Supportive therapy Antimicrobial therapy Standard therapy
Induction therapy Explanation: Despite advances in understanding of the biology of AML, substantive advances in treatment response rates and survival rates have not occurred for decades, with the exception of advances made in treating APL (see later discussion). Even for patients with subtypes that have not benefited from advances in treatment, cure is still possible. The overall objective of treatment is to achieve complete remission, in which there is no evidence of residual leukemia in the bone marrow. Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks.
A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage? Iron chelation therapy Oxygen therapy Therapeutic phlebotomy Anticoagulation therapy
Iron chelation therapy Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.
After undergoing a liver biopsy, a client should be placed in which position? a) Right lateral decubitus position b) Semi-Fowler's position c) Supine position d) Prone position
Right lateral decubitus position Explanation: After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.
UNIT 6 A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem?
Vitamin B12 deficiency Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are a smooth, beefy red, enlarged tongue and cranial nerve deficiencies.
A patient with Hodgkin's disease had a bone marrow biopsy yesterday and is complaining of aching, rated at a 5 (on a 1-10 scale), at the biopsy site. After assessing the biopsy site, which of the following nursing interventions is most appropriate? a) Administer the ordered acetaminophen 1000 mg po b) Notify the physician c) Administer the ordered aspirin (ASA) 325 mg po d) Reposition the patient to a high Fowler's position and continue to monitor the pain
a) Administer the ordered paracetamol 500 mg po After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most patients have no discomfort after a bone marrow aspiration, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding.
The nurse is caring for a client with acute myeloid leukemia (AML) with high uric acid levels. What medication does the nurse anticipate administering that will prevent crystallization of uric acid and stone formation? Allopurinol Filgrastim Hydroxyurea Asparaginase
allopurinol Explanation: Massive leukemic cell destruction from chemotherapy results in the release of intracellular electrolytes and fluids into the systemic circulation. Increases in uric acid levels, potassium, and phosphate are seen; this process is referred to as tumor lysis (cell destruction) syndrome. The increased uric acid and phosphorus levels make the client vulnerable to renal stone formation and renal colic, which can progress to acute renal failure. Clients require a high fluid intake, and prophylaxis with allopurinol (Zyloprim) to prevent crystallization of uric acid and subsequent stone formation.
UNIT 5 A Nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal? a. Potassium b. B-type natriuretic peptide (BNP) c. C-reactive protein (CRP) d. Platelet count
b. B-type natriuretic peptide (BNP) The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.
A nurse is caring for a client with a history of GI bleeding, sickle cell anemia, and a platelet count of 22,000/μl. The client, who is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour, complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. For which administration route should the nurse question an order? a) Oral b) Subcutaneous (subQ) c) I.M. d) I.V.
c) I.M. Explanation: A client with a platelet count of 22,000/μl bleeds easily. The nurse should avoid using the I.M. route because the area is highly vascular. The client may bleed readily when penetrated by a needle, and it may be difficult for the nurse to stop the bleeding. The client's existing I.V. access would be the best route, especially because I.V. morphine is effective almost immediately. Oral and subQ routes are preferred over I.M., but they're less effective for acute pain management than I.V.
