AH2 Ch. 33, 35, 36, 39-40 Questions

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A. "My leg might turn very white after the surgery." B. "I should be concerned if my foot turns blue." C. "I should report a fever or any drainage." D. "Warmness, redness, and swelling are expected."

A. "My leg might turn very white after the surgery." Rationale: Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? A. "I should avoid eating hamburgers." B. "I must cut out bacon and canned foods." C. "I shouldn't put the salt shaker on the table anymore." D. "I should avoid lunchmeats but may cook my own turkey."

A. "I should avoid eating hamburgers." Rationale: Cutting out beef or hamburgers made at home is not necessary; however, fast-food hamburgers are to be avoided owing to higher sodium content.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? A. "I will call the provider if I have a cough lasting 3 or more days." B. "I will report to the provider weight loss of 2 to 3 pounds in a day." C. "I will try walking for 1 hour each day." D. "I should expect occasional chest pain."

A. "I will call the provider if I have a cough lasting 3 or more days." Rationale: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D. A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions Rationale: The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia.

The nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? A. An 18-year-old who had an emergency splenectomy B. A 22-year-old with recently diagnosed sickle cell anemia C. A 38-year-old with hemolytic anemia D. A 40-year-old alcoholic with liver disease

A. An 18-year-old who had an emergency splenectomy Rationale: Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms, and is at increased risk for infection.

A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure? A. Applying pressure to the biopsy site B. Inspecting the site for ecchymoses C. Sending the biopsy specimens to the laboratory D. Teaching the client about avoiding vigorous activity

A. Applying pressure to the biopsy site Rationale: The initial action should be to stop bleeding by applying pressure to the site.

Which statement reflects correct cardiac physical assessment technique? A. Auscultate the aortic valve in the second intercostal space at the right sternal border. B. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. C. Palpate the apical pulse over the third intercostal space in the midclavicular line. D. Assess for carotid bruit by auscultating over the anterior neck.

A. Auscultate the aortic valve in the second intercostal space at the right sternal border. Rationale: The aortic valve is auscultated at the second intercostal space at the right sternal border.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

A. Reproducible leg pain with exercise Rationale: Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.) A. Chest discomfort or pain B. Tachycardia C. Expectorating thick, yellow sputum D. Sleeping on back without a pillow E. Fatigue

A. Chest discomfort or pain B. Tachycardia E. Fatigue Rationale: Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? A. Fatigue B. Swelling of one leg C. Slow heart rate D. Brown discoloration of lower extremities

A. Fatigue Rationale: Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.) A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine

A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic E. Has cut down on caffeine Rationale: Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (select all that apply) A. Hematocrit: 32.8% B. Serum sodium: 130 mEq/L C. Serum potassium: 4.0 mEq/L D. Serum creatinine: 1.0 mg/dL E. Proteinuria F. Microalbuminuria

A. Hematocrit: 32.8% B. Serum sodium: 130 mEq/L E. Proteinuria F. Microalbuminuria Rationale: A hematocrit of 32.8% is low, indicating a dilutional ratio of RBCs to fluid. A serum sodium of 130 is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are all early warning signs of decreased compliance of the heart.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? A. Ibuprofen (Motrin) B. Hydrochlorothiazide (HydroDIURIL) C. NPH insulin D. Levothyroxine (Synthroid)

A. Ibuprofen (Motrin) Rationale: Long-term use of nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet

A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking D. Type 2 diabetes Rationale: Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease.

Which client has the highest risk for cardiovascular disease? A. Man who smokes and whose father died at 49 of myocardial infarction (MI) B. Woman with abdominal obesity who exercises three times per week C. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL D. Man who is sedentary and reports four episodes of strep throat

A. Man who smokes and whose father died at 49 of myocardial infarction (MI) Rationale: Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death.

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the provider immediately? A. Swelling and tenseness in the affected area B. Incisional pain and tenderness at the surgical site C. Pink, mobile fingers D. An order for heparin infusion

A. Swelling and tenseness in the affected area Rationale: Compartment syndrome may develop after an embolectomy; swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb.

The nurse is assigned to all of these clients. Which client should be assessed first? A. The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago B. The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

A. The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago Rationale: The client who had PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.

A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply) A. Total cholesterol: 280 mg/dL B. High density lipoprotein cholesterol: 55 mg/dL C. Triglycerides: 200 mg/dL D. Serum potassium: 3.7 mEq/dL E. Low density lipoprotein cholesterol: 160 mg/dL

A. Total cholesterol: 280 mg/dL C. Triglycerides: 200 mg/dL E. Low density lipoprotein cholesterol: 160 mg/dL Rationale: A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease.

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) A. Troponin 3.2 ng/mL B. Myoglobin 234 mcg/L C. C-reactive protein 13 mg/dL D. Triglycerides 400 mg/dL E. Lipoprotein-a 18 mg/dL

A. Troponin 3.2 ng/mL B. Myoglobin 234 mcg/L Rationale: Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L.

he nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 mm Hg C. Absent bowel sounds D. +3 pedal pulses

A. Urine output of 20 mL over 2 hours Rationale: Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria.

The nurse is assessing a client for hematologic function risks and seeks to determine whether there is a risk that cannot be reduced or eliminated. Which clinical health history question does the nurse ask to obtain this information? A. "Do you seem to have excessive bleeding or bruising?" B. "Does anyone in your family bleed a lot?" C. "Tell me what you eat in a day." D. "Where do you work?"

B. "Does anyone in your family bleed a lot?" Rationale: An accurate family history is important because many disorders that affect blood and blood clotting are inherited; genetics cannot be changed.

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? A. "I can use an electric razor or a regular razor." B. "Eating foods like green beans won't interfere with my Coumadin therapy." C. "If I notice I am bleeding a lot, I should stop taking Coumadin right away." D. "When taking Coumadin, I may notice some blood in my urine."

B. "Eating foods like green beans won't interfere with my Coumadin therapy." Rationale: Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? A. "I don't know how I am going to change my lifestyle." B. "I don't need to change. It hasn't killed me yet." C. "I don't think it is as bad as the doctors say." D. "I will have to change my diet and exercise more."

B. "I don't need to change. It hasn't killed me yet." Rationale: A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because "it hasn't killed me yet" indicates maladaptive denial.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I feel my heart beating in my abdominal area." B. "I just started to feel a tearing pain in my belly." C. "I have a headache. May I have some acetaminophen?" D. "I have had hoarseness for a few weeks."

B. "I just started to feel a tearing pain in my belly." Rationale: Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? A. "Monitor the pulses in your feet when you get home." B. "Keep your affected leg straight for 2 to 6 hours." C. "Do not take your blood pressure medications on the day of the procedure." D. "Take your oral hypoglycemic with a sip of water on the morning of the procedure."

B. "Keep your affected leg straight for 2 to 6 hours." Rationale: The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding.

A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" How does the nurse respond? A. "No, they don't." B. "The number varies with gender, age, and general health." C. "Yes, they do." D. "You have fewer red blood cells because you have anemia."

B. "The number varies with gender, age, and general health." Rationale: Telling the client that the number of red blood cells (RBCs) varies with gender, age, and general health is the most educational and reasonable response to the client's question.

The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A. "The doctor will place a small needle in your back and will withdraw some fluid." B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." C. "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area." D. "You will be sedated, so you will not be aware of anything."

B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." Rationale: It is accurate to describe a crunching sound or scraping sensation. Proper expectations minimize the client's fear during the procedure.

After reviewing the laboratory test results, the nurse calls the health care provider about which client? A. A 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 B. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 C. A 49-year-old with hemophilia and a platelet count of 150,000/mm3 D. A 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%

B. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 Rationale: The client with a fever is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed.

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? A. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures B. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index C. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging D. A client with acute coronary syndrome who has just been admitted and needs an admission assessment

B. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index Rationale: The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? A. Assess leg ulcers for evidence of infection. B. Administer a clonidine patch for hypertension. C. Obtain a request from the health care provider for a dietary consult. D. Develop a plan for discharge, and assess home care needs.

B. Administer a clonidine patch for hypertension. Rationale: Administering medication is within the scope of practice for the LPN/LVN.

Which statement about diagnostic cardiovascular testing is correct? A. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. C. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. D. The left side of the heart is catheterized first and may be the only side examined.

B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Rationale: Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? A. Assess the client for peripheral edema. B. Auscultate the client's posterior breath sounds. C. Notify the health care provider about the client's weight gain. D. Remind the client about dietary sodium restrictions.

B. Auscultate the client's posterior breath sounds. Rationale: Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? A. Calls the family to lift the client's spirits B. Considers further assessment for depression C. Sedates the client to decrease myocardial oxygen demand D. Tells the client that things will get better

B. Considers further assessment for depression Rationale: This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done.

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? A. Heart rate 52 beats/min B. Blood pressure 192/102 mm Hg C. Report of constipation D. Anxiety

B. Blood pressure 192/102 mm Hg Rationale: Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.

Which medication, when given in heart failure, may improve morbidity and mortality? A. Dobutamine (Dobutrex) B. Carvedilol (Coreg) C. Digoxin (Lanoxin) D. Bumetanide (Bumex)

B. Carvedilol (Coreg) Rationale: Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; this category of pharmacologic agents improves morbidity, mortality, and quality of life.

Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.) A. Squeezing, vise-like chest pain B. Chest pain relieved by sitting upright C. Chest and abdominal pain relieved by antacids D. Sudden-onset chest pain relieved by anti-inflammatory agents E. Pain in the chest described as sharp or stabbing

B. Chest pain relieved by sitting upright D. Sudden-onset chest pain relieved by anti-inflammatory agents E. Pain in the chest described as sharp or stabbing Rationale: The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? A. Ejection fraction is 25%. B. Client states that she is able to sleep on one pillow. C. Client was hospitalized five times last year with pulmonary edema. D. Client reports that she experiences palpitations.

B. Client states that she is able to sleep on one pillow. Rationale: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers.

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? A. Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted B. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes C. Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain D. Client who has many questions about the electrophysiology studies (EPS) scheduled for today

B. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Rationale: The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN.

Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with heart failure who is receiving dobutamine (Dobutrex) B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea C. Client with pericarditis who has a paradoxical pulse and distended jugular veins D. Client with rheumatic fever who has a new systolic murmur

B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea Rationale: The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? A. Client with abdominal pain and belching B. Client with pressure in the mid-abdomen and profound diaphoresis C. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows D. Client with claudication and fatigue

B. Client with pressure in the mid-abdomen and profound diaphoresis Rationale: Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety.

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? A. No intervention is needed; this is a normal reading. B. Collaborate with the health care provider to administer a positive inotropic agent. C. Administer a STAT dose of metoprolol (Lopressor). D. Ask the client to perform the Valsalva maneuver.

B. Collaborate with the health care provider to administer a positive inotropic agent. Rationale: A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min.

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? A. Increase red meat in the diet. B. Consume melons and baked potatoes. C. Add several portions of dairy products each day. D. Try replacing your usual breakfast with oatmeal or Cream of Wheat.

B. Consume melons and baked potatoes. Rationale: Melons and baked potatoes contain potassium.

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) A. Consuming a diet rich in fiber B. Elevated C-reactive protein levels C. Low blood pressure D. Elevated high-density lipoprotein (HDL) cholesterol level E. Smoking

B. Elevated C-reactive protein levels E. Smoking Rationale: Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease.

A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? A. Aplastic anemia B. Hemolytic anemia C. Infectious process D. Leukemia

B. Hemolytic anemia Rationale: An elevated reticulocyte count in an anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying RBCs. Therefore, more immature RBCs are in circulation.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? A. Right atrial pressure is 4 mm Hg. B. Mean arterial pressure (MAP) is 58 mm Hg. C. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. D. PO2 is reported as 78 mm Hg.

B. Mean arterial pressure (MAP) is 58 mm Hg Rationale: To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain.

The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased value causes concern because it is not age-related? A. Hemoglobin level B. Platelet (thrombocyte) count C. Red blood cell (RBC) count D. White blood cell (WBC) response

B. Platelet (thrombocyte) count Platelet counts do not generally change with age.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the provider? A. Partial thromboplastin time (PTT) 60 seconds B. Platelets 32,000/mm3 C. White blood cells 11,000/mm3 D. Hemoglobin 12.2 g/dL

B. Platelets 32,000/mm3 Rationale: UFH can also decrease platelet counts. Notify the provider if the platelet count is below 100,000 to 120,000/mm3. Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm3

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? A. Calcium 8.5 mEq/L B. Potassium 3.0 mEq/L C. Magnesium 2.1 mEq/L D. International normalized ratio (INR) of 1.0

B. Potassium 3.0 mEq/L Rationale: Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? A. Serum sodium level of 135 mEq/L B. Serum potassium level of 2.8 mEq/L C. Serum creatinine of 1.0 mg/dL D. Serum magnesium level of 1.9 mEq/L

B. Serum potassium level of 2.8 mEq/L Rationale: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy.

he nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? (Select all that apply.) A. Hypokalemia B. Sinus bradycardia C. Fatigue D. Serum digoxin level of 1.5 E. Anorexia

B. Sinus bradycardia C. Fatigue E. Anorexia Rationale: Digoxin toxicity may cause bradycardia. Fatigue and anorexia are symptoms of digoxin toxicity.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? A. The client has had intermittent substernal chest pain for 6 months. B. The client develops wheezes and dyspnea after eating crab or lobster. C. The client reports that a previous arteriogram was negative for coronary artery disease. D. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate

B. The client develops wheezes and dyspnea after eating crab or lobster. Rationale: The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure.

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? A. NPO status will cause the client to be thirsty. B. The dye causes an osmotic diuresis. C. The dye contains a heavy sodium load. D. The pedal pulses will be more easily palpable.

B. The dye causes an osmotic diuresis. Rationale: The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The risk for hypotension C. The potential for bradycardia D. Liver function tests

B. The risk for hypotension Rationale: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? A. Less than 30% of the daily caloric intake should be derived from proteins. B. Use canola oil rather than palm oil. C. Consume 10 mg of fiber daily. D. Work toward lowering your high-density lipoprotein (HDL) cholesterol levels.

B. Use canola oil rather than palm oil. Rationale: Palm oil is higher in saturated fats and should be avoided.

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? A. Saline infusion B. Morphine sulfate C. No treatment, continue monitoring D. Intravenous furosemide

D. Intravenous furosemide Rationale: Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? A. Psychiatric disturbance B. High sodium intake C. Physical inactivity D. Kidney disease

D. Kidney disease Rationale: Kidney disease is one of the most common causes of secondary hypertension.

The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question does the nurse ask the client? A. "Can you prepare your own meals?" B. "Has your weight changed by 5 pounds or more this year?" C. "How is your energy level compared with last year?" D. "What medications do you take daily, weekly, and monthly?"

C. "How is your energy level compared with last year?" Rationale: Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance for ADLs.

A client on anticoagulant therapy is being discharged. Which statement indicates that the client has a correct understanding of this therapy's purpose or action? A. "It is to dissolve blood clots." B. "It might cause me to get injured more often." C. "It should prevent my blood from clotting." D. "It will thin my blood."

C. "It should prevent my blood from clotting." Rationale: Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots.

The clinic nurse is discharging a 20-year-old client who had a bone marrow aspiration performed. What does the nurse advise the client to do? A. "Avoid contact sports or activity that may traumatize the site for 24 hours." B. "Inspect the site for bleeding every 4 to 6 hours." C. "Place an ice pack over the site to reduce the bruising." D. "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."

C. "Place an ice pack over the site to reduce the bruising." Rationale: Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure.

A client with a low platelet count asks why platelets are important. How does the nurse answer? A. "Platelets make your blood clot." B. "Blood clotting is prevented by your platelets." C. "The clotting process begins with your platelets." D. "Your platelets finish the clotting process."

C. "The clotting process begins with your platelets." Rationale: Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis. Platelets do not clot blood; they are a part of the clotting process or cascade of coagulation.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? A. "How does this make you feel?" B. "This can be caused by taking performance-enhancing drugs." C. "This may be caused by a genetic trait." D. "Just imagine how bad it would be if you weren't in good shape."

C. "This may be caused by a genetic trait." Rationale: Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? A. "Elevate your legs above heart level to prevent swelling." B. "Inspect your legs daily for brownish discoloration around the ankles." C. "Walk to the point of leg pain, then rest, resuming when pain stops." D. "Apply a heating pad to the legs if they feel cold."

C. "Walk to the point of leg pain, then rest, resuming when pain stops." Rationale: Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? A. "Are you afraid you will not be able to work?" B. "If you control your diabetes, you can avoid amputation." C. "Your concerns are valid; we can review some steps to limit disease progression." D. "What about the situation concerns you most?"

C. "Your concerns are valid; we can review some steps to limit disease progression." Rationale: It is important to validate the client's concern and offer needed information.

Which client does the medical unit charge nurse assign to an LPN/LVN? A. A 23-year-old scheduled for a bone marrow biopsy with conscious sedation B. A 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) C. A 48-year-old with chronic microcytic anemia associated with alcohol use D. A 62-year-old with atrial fibrillation and an international normalized ratio of 6.6

C. A 48-year-old with chronic microcytic anemia associated with alcohol use Rationale: Chronic microcytic anemia is not considered life-threatening and can be assigned to an LPN/LVN.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? A. Serum potassium level of 3.2 mEq/L B. Ejection fraction of 60% C. B-type natriuretic peptide (BNP) of 760 ng/dL D. Chest x-ray report showing right middle lobe consolidation

C. B-type natriuretic peptide (BNP) of 760 ng/dL Rationale: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL.

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? A. Dietary consult B. Sodium restriction C. Daily weight monitoring D. Restricted activity

C. Daily weight monitoring Rationale: A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent.

Which action does the nurse delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a female client with anemia? A. Asking the client about the amount of blood loss with each menstrual period B. Checking for sternal tenderness while applying fingertip pressure C. Determining the respiratory rate before and after the client walks 20 feet D. Monitoring her oral mucosa for pallor, bleeding, or ulceration

C. Determining the respiratory rate before and after the client walks 20 feet Rationale: Assessment of the respiratory rate before and after ambulation is within the scope of practice for UAP; UAP will report this information to the RN.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question? A. Enalapril (Vasotec) B. Sodium nitroprusside (Nipride) C. Dopamine (Intropin) D. Clevidipine (Butyrate)

C. Dopamine (Intropin) Rationale: Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure; it should not be used in hypertensive emergency.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings: Crackles in all fields S3 present Oliguria Diagnostic Findings: Ejection fraction 30% BNP 560 Sodium 130 mEq/L Provider Prescriptions: Diagnosis: HF Enalapril 10 mg orally daily Heparin 5000 units subcutaneously every 12 hours Furosemide 40 mg IV daily Strict I & O Which prescription does the nurse implement first? A. Enalapril B. Heparin C. Furosemide D. Intake and output (I & O)

C. Furosemide Rationale: The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss.

Which nursing action may be delegated to a nursing assistant working on the medical unit? A. Determine the usual alcohol intake for a client with cardiomyopathy. B. Monitor the pain level for a client with acute pericarditis. C. Obtain daily weights for several clients with class IV heart failure. D. Check for peripheral edema in a client with endocarditis.

C. Obtain daily weights for several clients with class IV heart failure. Rationale: Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A. Ankle-brachial index B. Dye allergy C. Pedal pulses D. Gag reflex

C. Pedal pulses Rationale: Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? A. Maintains NPO (nothing by mouth) until this resolves B. Calls in another nurse for a second opinion C. Performs a complete neurologic assessment and notifies the health care provider D. Explains to the client and family that this is expected after sedation

C. Performs a complete neurologic assessment and notifies the health care provider Rationale: Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A. Monitor pulse oximetry and cardiac rate and rhythm. B. Reassure the client that his distress can be relieved with proper intervention. C. Place the client in high-Fowler's position with the legs down. D. Ask a family member to remain with the client.

C. Place the client in high-Fowler's position with the legs down. Rationale: High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.

Which finding confirms the presence of a thromboembolism? A. Human chorionic gonadotropin (hCG) negative B. Crackles at bases C. Positive D-dimer ( >0.5mg/L) D. Right leg swelling

C. Positive D-dimer ( >0.5mg/L) Rationale: A D-dimer test is a global marker of coagulation activation; it measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is often used for the diagnosis of deep vein thrombosis when the client has few clinical signs, and stratifies clients into a high-risk category for reoccurrence.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? A. White blood cell count B. Low-density lipoproteins C. Serum troponin I level D. C-reactive protein

C. Serum troponin I level Rationale: Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications.

Which symptom reported by a client who has had a total hip replacement requires emergency action? A. Localized swelling of one of the lower extremities B. Positive Homans' sign C. Shortness of breath and chest pain D. Tenderness and redness at the IV site

C. Shortness of breath and chest pain Rationale: Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE.

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? A. Friction rub auscultated at the left lower sternal border B. Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Thickening of the endocardium

C. Splinter hemorrhages Rationale: Splinter hemorrhages are indicative of infective endocarditis.

Which sign/symptom is essential for the nurse to report to the provider when caring for a client with Raynaud's phenomenon? A. Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. B. The client's extremity became white, then red temporarily. C. The affected extremity becomes purple and cold. D. The client states that the digits are painful when they are white.

C. The affected extremity becomes purple and cold. Rationale: Cold, mottled extremities are indicative of occlusion, which could lead to gangrene.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. The client ambulates around the nursing unit with a walker. B. The nurse monitors the client's pulse and blood pressure frequently. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when he becomes tachycardic.

C. The nurse obtains a bedside commode before administering furosemide. Rationale: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? A. Auscultate the client's precordium for murmurs. B. Teach the client about the reason for the TEE. C. Reassure the client that the test is painless. D. Validate that the client has remained NPO.

D. Validate that the client has remained NPO. Rationale: Owing to the risk for aspiration, the client must be NPO before the procedure.

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? A. This blood pressure is good because it is a normal reading. B. This blood pressure indicates that the client has hypertension or high blood pressure. C. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. D. This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension.

C. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. Rationale: Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? A. Auscultation of crackles B. Pedal edema C. Weight loss of 6 pounds since the last visit D. Reports sucking on ice chips all day for dry mouth

C. Weight loss of 6 pounds since the last visit Rationale: Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? A. "Consume foods high in potassium." B. "Monitor for irregular pulse." C. "Monitor for muscle cramping." D. "Avoid grapefruit juice."

D. "Avoid grapefruit juice." Rationale: Grapefruit juice should be avoided with verapamil because it can enhance the action of the drug.

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? A. "I must stop taking my birth control pills." B. "I should drink lots of water so I don't get dehydrated." C. "I should exercise my legs when I have been sitting or standing for a long time." D. "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

D. "If I wear pantyhose, I won't have to wear the stockings the hospital gives me." Rationale: Wearing the graduated compression stockings is a prevention specific to the hospital setting; they are designed to prevent blood clots, unlike regular pantyhose

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? A. "This is a noninvasive test performed to assess your heart rhythm." B. "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." C. "This is a painless test that is done to assess the structure of your heart using sound waves." D. "This test evaluates you for potentially fatal cardiac rhythms."

D. "This test evaluates you for potentially fatal cardiac rhythms." Rationale: EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram.

A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? A. "How many hours are you sleeping at night?" B. "You are not getting enough iron." C. "You need to rest more when you are sick." D. "Your cells are delivering less oxygen than you need."

D. "Your cells are delivering less oxygen than you need." Rationale: The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.

The nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? A. A 42-year-old with anemia who is reporting shortness of breath when ambulating down the hallway B. A 47-year-old who recently had a Rumpel-Leede test and is requesting a nurse to "look at the bruises on my arm" C. A 52-year-old who has just had a bone marrow aspiration and is requesting pain medication D. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism

D. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism Rationale: The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for the severity of the situation first.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B. A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) C. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D. A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D. A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic Rationale: The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? A. Small amount of blood at the IV insertion site B. Heavy menstrual bleeding C. +1 pitting edema of the affected extremity D. Client stating that the year is 1967

D. Client stating that the year is 1967 Rationale:

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg Rationale. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion.

The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? A. Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) B. Determines who prepares the client's meals and plans an interview with him or her C. From a prepared list, finds out the client's food preferences D. Has the client write down everything he or she has eaten for the past week

D. Has the client write down everything he or she has eaten for the past week Rationale: Having the client provide a list of items eaten in the past week is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as protein, vitamin, and mineral intake.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? A. Give the digoxin; reassess the heart rate in 30 minutes. B. Give the digoxin; document assessment findings in the medical record. C. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. D. Hold the digoxin, and obtain a prescription for a potassium supplement.

D. Hold the digoxin, and obtain a prescription for a potassium supplement. Rationale: Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held.

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? A. Peptic ulcer disease B. Deep vein thrombosis (DVT) C. Osteoarthritis D. Marfan syndrome

D. Marfan syndrome Rationale: Marfan syndrome is a risk factor for cardiovascular disorders.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? A. Assess preprocedure medications the client took that day. B. Have the client sign the consent form before the procedure is performed. C. Educate the client about the need to remain on bedrest after the procedure. D. Obtain client vital signs and a resting electrocardiogram (ECG).

D. Obtain client vital signs and a resting electrocardiogram (ECG). Rationale: Vital signs and 12-lead ECGs can be obtained by UAP.

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? A. Determines the client's physical limitations B. Encourages alternate rest and activity periods C. Monitors and documents heart rate, rhythm, and pulses D. Positions the client to alleviate dyspnea

D. Positions the client to alleviate dyspnea Rationale: Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.

Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Drawing a partial thromboplastin time from a saline lock on a client with a pulmonary embolism B. Performing a capillary fragility test to check vascular hemostatic function on a client with liver failure C. Referring a client with a daily alcohol consumption of 12 beers for counseling D. Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia

D. Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia Rationale: Reporting findings during routine care is expected and required of unlicensed staff members.

Which vascular assessment by the student nurse requires intervention by the supervising nurse? A. Measuring capillary refill in the fingertips B. Assessing pedal pulses by Doppler C. Measuring blood pressure in both arms D. Simultaneously palpating the bilateral carotids

D. Simultaneously palpating the bilateral carotids Rationale: Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion.

All of these client assignments have been made by the charge nurse. Which assignment is questionable? A. The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy B. The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement C. The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL D. The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg

D. The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg Rationale: The client with a headache and high blood pressure has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. The client should be assigned to an experienced RN, who can assess for end-organ damage and administer IV medications.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? A. The client has diuresis of 400 mL in 24 hours. B. The client's blood pressure is 122/84 mm Hg. C. The client has an apical pulse of 82 beats/min. D. The client's weight decreases by 2.5 kg.

D. The client's weight decreases by 2.5 kg. Rationale: The best indicator of fluid volume gain or loss is daily weight; because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? A. C-reactive protein of 1 mg/dL B. Homocysteine level of 13 mmol/L C. Creatine kinase (CK) of 125 mg/dL D. Troponin of 5.2 ng/mL

D. Troponin of 5.2 ng/mL Rationale: The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL.

A client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? A. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine). B. Hold the client's hand and ask about concerns. C. Review the client's platelet (thrombocyte) count. D. Verify that the client has given informed consent.

D. Verify that the client has given informed consent. Rationale: Verifying informed consent must be done before the procedure can be performed. A signed permit must be on the client's chart.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? A. Men do not tend to report chest pain. B. Men are more likely than women to die after MI. C. Men more than women tend to deny the importance of symptoms. D. Women may experience extreme fatigue and dizziness as sole symptoms.

D. Women may experience extreme fatigue and dizziness as sole symptoms. Rationale: Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like.