Medical-Surgical: Cardiovascular and Hematology

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?

Monitor for bleeding.

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?

Weight gain 1 kg (2.2 lb) in 1 day

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?

Atrial rate of 300/min with QRS complex of 80/min

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusion. For which of the following complications should the nurse monitor?

Iron toxicity

A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client?

Omega-3 fatty acids

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?

Position the client supine with his legs elevated when in bed.

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review?

Prothrombin time

A nurse is transfusing a unit of O-negative fresh frozen plasma to a client whose blood type is B positive. Which of the following actions should the nurse take?

Remove the unit of plasma immediately and start an IV infusion of normal saline solution.

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?

Ventricular dysrhythmias

A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect?

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

A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?

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

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?

0.9% sodium chloride

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. Available is a blood administration set that delivers 10 get/mL. The nurse should set the manual blood transfusion to deliver how many got/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 get/min

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take?

Administer antihypertensive medication for blood pressure.

A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take?

Auscultate blood pressure for pulses paradoxes.

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?

Chest pain lasts longer than 15 min.

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?

Coarse crackles

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Dependent edema

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?

Dry, pale skin with minimal body hair

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect?

Dyspnea with hiccups

A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching?

Hypertension is a common adverse effect of this medication.

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?

Increased pulmonary congestion

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan?

Initiate weekly injections of vitamin B12.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.)

Jugular vein distension. Moist crackles. Increased heart rate.

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?

Lower back discomfort

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect?

Petechiae and ecchymosis

A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change?

Potassium 2.8 mEq/L

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?

Prepare for replacement of the missing clotting factor.

A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first?

Stop the infusion of blood.

A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) to a client who has anemia. Which of the following actions should the nurse take first?

Witness the informed consent.