195 Test 2
A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
Low serum potassium level
Which dysrhythmia is common in older clients?
Sinus bradycardia is a common dysrhythmia in older clients.
Which type of lymphocyte is responsible for cellular immunity?
T lymphocyte T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity.
Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6F(37.6C) a heart rate of 102 beats/minute, regular, slightly labored respirations at 26 breaths per minute and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes the highest priority?
The nursing diagnosis of acute pain takes highest priority because it increases the client's pulse and blood pressure. During the acute phase of an MI, low-grade fever is an expected result of the body's response to myocardial tissue necrosis.
A nurse is reading a journal article about white blood cells and how they function. The nurse demonstrates understanding of the article by identifying which white blood cell as a granulocyte? Select all that apply.
eosinophils basophils neutrophils Granulocytes are defined by the presence of granules in the cytoplasm of the cell.
Who obtains informed consent?
physician The nurse witnesses the signature.
The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best response?
"An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks." An aspirin a day is a common nonprescription medication that improves outcomes in clients with CAD due to its antiplatelet action.
An older adult patient with a recent history of syncope has undergone an initial diagnostic workup that has failed to identify the cause of his fainting. As a result, continuous electrocardiographic (ECG) monitoring (Holter monitoring) has been ordered. When initiating this diagnostic testing, what patient education should the nurse provide?
"Record your activities in your log so that they can be cross-referenced with your ECG readings."
Platelets/mm3
150,000 to 300,000
RBCs/mm3
4.5 to 5.5 million
The nurse has just admitted a 66 year old patient for cardiac surgery. The patient tells the nurse that she is afraid of dying while undergoing surgery. The nurse should be aware that:
A further assessment of anxiety is required. An assessment of anxiety levels is required in the patient to assist in identifying fears and developing coping mechanisms for those fears. If anxiety is high it may interfere with teaching, and surgical outcome is poor. Preoperative fears are normal, but they should not be ignored and won't necessarily go away on their own.
A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is:
Albumin
A nurse is teaching about risk factors that increase the probability of heart disease to a community group. Which risk factors will the nurse include in the discussion?
Family history of coronary heart disease. Age greater than 45 years for men. Age greater than 65 years for women. BMI of 25 or greater. African-American descent. Elevated C-reactive protein.
The clients CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client?
Iron With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin.
The nurse is writing a plan of care for a client with a cardiac dysrhythmia. What would be the priority goal for the client?
Maintain adequate cardiac output. For client safety, the most appropriate goal is to maintain cardiac output to prevent worsening complications as a result of decreased cardiac output. A resting rate of less than 70 bpm is not appropriate for every client. Chest pain is more closely associated with acute coronary syndrome than with dysrhythmias. Nursing actions cannot normally influence the physical structure of the heart.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?
Myeloid stem cell.
A nurse cares for a client with iron-deficiency anemia. Which treatment will the nurse anticipate the client receiving?
Oral iron supplementation.
A client with heart failure has been receiving an intravenous infusion at 150 mL/hr. Now the client is short of breath. The nurse auscultates crackles bilaterally and notes neck vein distention and tachycardia. Using critical thinking skills, what should the nurse do first?
Slow the infusion and notify the physician. Discontinuing the infusion is not appropriate, because having a vascular access will be important.
A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition?
The condition is likely caused by a vitamin B12 deficiency. 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 the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid.
A client will be having a bone marrow aspiration to determine the status of bloodcell formation. What role does the nurse have during the test?
The nurse assists the physician and supports the client during the procedure.
A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient?
The patient had a vagal response. When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response.
A patient with a diagnosis of HIV exhibits a decreased level of T lymphocytes. What consequence does this state present for this patient?
The patient is particularly susceptible to infection. Because T cells directly kill foreign substances, a T-cell deficit renders an individual susceptible to infection.
Both the liver and the spleen have a role in erythrocyte metabolism. How would this role best be described?
The spleen removes erythrocytes after 120 days, and the liver removes severely damaged erythrocytes. Erythrocytes circulate in the blood for about 120 days, after which the spleen removes them; the liver removes severely damaged erythrocytes. The rate of erythrocyte production is regulated by erythropoietin, a hormone released by the kidneys.
While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?
Use an electric razor when assisting the client with shaving. Petechiae is associated with severe thrombocytopenia, placing the client at risk for bleeding.
What deficiencies are characterized by the production of abnormally large erythrocytes?
Vitamin B12 and folate
The nurse cares for a 56-year-old client who received an implantable cardioverter defibrillator (ICD) 2 days prior. The client tells the nurse "My wife and I can never have sex again now that I have this ICD." What is the nurse best response by the nurse?
You seem apprehensive about resuming sexual activity.
B lymphocytes
form in the bone marrow and release antibodies that fight bacterial infections *humoral immunity*
The nurse in a cardiac clinic is taking vital signs of a 58-year-old man who is 3 months status post myocardial infarction (MI). While the physician is seeing the client, the client's spouse approaches the nurse and asks about sexual activity. "We are too afraid he will have another heart attack, so we just don't have sex anymore." The nurse's best response is which of the following?
"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." The physiologic demands are greatest during orgasm. The level of activity is equivalent to walking 3 to 4 miles per hour on a treadmill. Erectile dysfunction may be a side effect of beta-blockers, but other medications may be substituted.
The nurse is caring for a client with a diagnosis of atrial fibrillation. The onset was approximately 2 to 3 days ago. The client is scheduled for a transesophageal echocardiogram this morning. The client's spouse asks what this test is for. The best response by the nurse is which of the following?
"This test will show any blood clots in the heart and if it is safe to do a cardioversion." When contemplating cardioversion for the client with atrial fibrillation, the absence of a thrombus in the atria can be confirmed by transesophageal echocardiogram.
A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?
"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."
Hematocrit
45%
WBCs/mm3
5,000 to 10,000
A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate?
Administer acetaminophen 500mg PO, as ordered. After a 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 biopsy, 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.
Which of the following cell types are produced from pluripotential stem cells? A. Erythrocytes B. Platelets C. Lymphocytes D. All options are correct E. Leukocytes
All options are correct.
The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?
Altered patterns frequently affect the heart's ability to pump blood effectively.
The nurse recognizes this as the most common hematologic condition associated with aging.
Anemia Anemia is the most common hematologic condition affecting elderly patients; with each successive decade of life, the incidence of Anemia increases. Anemia frequently results from iron deficiency (in the case of blood loss) or from a nutritional deficiency, particularly folate or vitamin B12 deficiency or protein calorie malnutrition; it may also result from inflammation or chronic disease.
The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which measures should the nurse complete to prevent the development of deep venous thrombosis (DVT) and possible pulmonary embolism (PE)?
Apply antiembolism stockings. Sequential pneumatic compression devices. Discouraging the crossing of legs. Avoiding elevating the knees on the bed, omitting pillows in the popliteal space, and begining passive exercises followed by active exercises to promote circulation and prevent venous status.
A patient with thrombocytopenia due to chemotherapy develops a nose bleed (epistaxis). What is the nurse's expected response?
Apply pressure to the nares and position the patient in a high Fowler's position, leaning slightly forward. Sitting upright decreases the risk of aspiration of blood and pressure is applied for a minimum of five minutes. Ice may also be applied to the nares. The patient's mouth should be open so that blood can drain rather than be swallowed, which may cause vomiting.
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?
Assess for elevated blood urea nitrogen levels.
A patient has returned to the nursing unit after having a percutaneous coronary intervention (PCI) in the hospital's cardiac catheterization laboratory. The nurse who is providing care for this patient should prioritize what assessment?
Assessing the patient for the signs and symptoms of hemorrhage. Monitoring the patient for bleeding post-PCI is a priority. Kidney function, peripheral circulation, and infection are also valid assessment parameters but the significant risk of bleeding associated with PCI necessitates that assessments related to this problem be prioritized.
The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult?
Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process.
Which of the following cells are capable of differentiating into plasma cells?
B lymphocytes B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies called immunoglobulins (Ig), which are protein molecules that destroy foreign material by several mechanisms. T lymphocytes, eosinophils, and neutrophils do not differentiate into plasma cells.
What is the priority nursing diagnosis for a client experiencing anemia? A.Risk for injury related to poor blood clotting B.Fatigue related to decreased cellular oxygenation C.Risk of infection related to decreased leukocytes D. Imbalanced nutrition; less than body requirements related to anorexia
B. Fatigue related to decreased cellular oxygenation. A low red blood cell (RBC) count decreases oxygen availability to the tissues, and fatigue, shortness of breath, and weakness may be noted.
Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions?
Basophils Basophils contain histamine and are an integral part of hypersensitivity reactions. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunogolubulins. The neutrophil functions in preventing or limiting bacterial infection via phagocytosis.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.
A nurse is caring for a patient who is 73 years old with a platelet count of 5,000/mm3 resulting from myelodysplastic syndrome. At 10 PM, the patient complains of a headache. What should be the nurse's immediate action to take?
C. Notify the healthcare provider. Platelet counts ≤10,000/ mm3 are associated with serious episodes of spontaneous bleeding, including intracranial hemorrhage; thus complaints of headaches or change in the level of consciousness necessitates immediate notification of the health care provider.
A patient presents to her primary care provider with a complaint of a "cold that just won't go away." She has a CBC drawn, revealing the following: WBC 4.5: segs 5, bands 0, lymphs 45, eosinophils 5, basophils 5, monocytes 5, blasts 35. What is the patient's absolute neutrophil count a. 500 b. 250 c. 225 d. 2,250
C. The formula for determining the absolute neutrophil count (ANC) is the white blood cell (WBC) count multiplied by the sum of the %neutrophil count (segs) and %bands. An ANC <500 is severe neutropenia and is associated with high risk for infection.
Medical management of cardiac failure uses similar methodology whether it is right-sided or left-sided. Measures such as dietary modification, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. The primary goal in the medical management of heart failure is to reduce:
Cardiac Workload.
A community health nurse is participating in a healthy-living workshop that has been sponsored by a local seniors' center. The discussion has turned to the problem of heart failure, and the nurse is emphasizing preventative measures. When teaching older adults to decrease their future risks of developing heart failure, the nurse should emphasize what action?
Close blood pressure monitoring and vigilant adherence to hypertension therapy
A 75-year-old woman visited her health care provider for an annual check-up. She told the doctor that she feels exhausted all the time and barely has the energy to go out of her home, run errands, and visit friends. The nurse expects that the health care provider will order which of the following lab studies based on the most common hematologic condition affecting the elderly?
Complete blood count. Anemia is the most common hematologic condition affecting the elderly. It frequently results from iron or nutritional deficiencies, or the bone marrow's ability to respond to the body's need for red blood cells. A complete blood count is needed to assess the hemoglobin and hematocrit levels.
The nurse is admitting a 32-year-old woman who is to undergo major surgery and will be on bed rest for at least 48 hours. While doing the admission assessment, the patient tells the nurse that she takes oral contraceptives. The nurse should recognize that this puts the patient at an increased risk of developing what health problem?
Deep vein thrombosis (DVT) Oral contraceptive use increases blood coagulability. With bed rest, the patient may be at increased risk of developing DVT.
A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions?
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. Answers: Relieves Pain Decreases ischemia Dilates Blood vessels Reduces myocardial oxygen consumption.
A nurse is providing care to a cancer client. Which protein in plasma function as immunologic agents?
Gamma Globulins Globulins are divided into three groups: alpha, beta, and gamma. The gamma globulins are also called immunoglobulins. Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases.
Albumin is a protein in the plasma portion of the blood. Under normal conditions, albumin cannot pass through the wall of a capillary. What significance is this for the vascular compartment?
Helps retain fluid in the vascular compartment.
The nurse is caring for a client newly diagnosed with coronary artery disease (CAD). While developing a teaching plan for the client to address modifiable risk factors for CAD, the nurse will include which factors? Select all that apply.
Obesity Elevated blood pressure (Hypertension) Hyperlipidemia tobacco use diabetes mellitus metabolic syndrome and physical inactivity.
In the surgical group where you practice nursing, knowledge regarding hematopoiesis is used frequently in regards to client post-surgical care. Which of the following is true for the variation in the normal number of erythrocytes?
People who engage in strenuous activity have an increased number of erythrocytes. *To maximize the transport of oxygen and carbon dioxide.
A nurse caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform?
Place the client in high Fowler's position
When a blood clot is no longer needed, what digests the fibrinogen and fibrin? a. plasminogen b. thrombin c. prothrombin d. plasmin
Plasmin. The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids, circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed (eg, after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the fibrinogen and fibrin. Prothrombin is converted to thrombin, which in turn catalyzes the conversion of fibrinogen to fibrin so a clot can form.
Which cells have the lifespan of approximately 7.5 days and one-third of their population remains in the spleen (unless needed to fight significant bleeding)?
Platelets
A client is scheduled to undergo a bone marrow aspiration and biopsy. The nurse understands that which site would most likely be used?
Posterior Iliac crest
A patient has been admitted to the medical unit because of an exacerbation of heart failure. Over the past hour, the patient has become increasingly restless, tachypneic, and short of breath, and pulse oximetry reveals SaO2 of 78%. Which of the following actions should the nurse prioritize?
Protecting the patien'ts airway and taking measures to promote gas exchange
Place the clotting cascade in the correct order. Prothrombin activator Prothrombin Thrombin Fibrogen Fibrin
Prothrombin activator Prothrombin Thrombin Fibrinogen Fibrin
An older adult patient presents to the physician's office with a complaint of exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?
RBC count A decreased red blood cell count is indicative of anemia, a common condition in older adults that results in fatigue.
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?
Respiratory alkalosis. Metabolic acidosis will occur as gas exchange becomes more imparied.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?
Weight Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous cactors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.
A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is ordered. The nurse knows that morphine is given because it:
lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. *When given to treat acute MI, morphine eliminates pain, reduces venous return to the heart, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart.
