ATI Cardiovascular & Hematology
A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The clients vital signs are BP 160/98, HR 102/min, R 22/min, SpO2 95%. Which of the following actions should the nurse take? a) Administer antihypertensive medication for BP b) Monitor that urinary output is 20 ml/hr c) Withhold pain meds to prepare for surgery d) Take vital signs every 2 hours
a) Administer antihypertensive medication for the elevated BP because HTN can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.
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) a) Jugular vein distension b) Moist crackles c) Postural hypotension d) Increased heart rate e) Fever
a) Jugular vein distention : The increase in venous pressure due to excessive circulating blood volume results in neck vein distention b) Moist crackles : An indicator of pulmonary edema that can quickly lead to death d) Increased heart rate : fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses
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? a) Omega-3 fatty acids b) Antioxidants c) Vitamins A, D and C d) Beta-carotene
a) Omega-3 fatty acids Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels
A nurse is reviewing a client's repeat lab results 4 hrs after administering fresh frozen plasma (FFP). Which of the following lab results should the nurse review? a) Prothrombin time b) WBC count c) Platelet count d) Hematocrit
a) Prothrombin time The nurse should review the clients prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time
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? a) Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes b) The client is experiencing premature ventricular complexes at 12/min c) Telemetry monitoring shows pacing spikes with no QRS complexes d) The client is experiencing hiccups
a) Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min, because the client's intrinsic rate overrides the set rate of the pacemaker.
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? a) weight gain 1 kg (2.2 lb) in 1 day b) Pitting edema +1 c) Client report of nocturnal cough d) B-Type Natriuretic Peptide (BNP) level of 100 pg/mL
a) weight gain 1kg (2.2lbs) in 1 day A weight gain of 2.2 lbs in 1 day alerts the nurse that the client is retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening.
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? a) Obtain blood samples to test platelet function b) Prepare for replacement of the missing clotting factor c) Administer aspirin for the client's pain d) Place the bleeding joint in the dependent position
b) Prepare for replacement of the missing clotting factor Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints.
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? a) Continue to monitor for manifestations of a transfusion reaction b) Remove the unit of plasma immediately and start an IV infusion of normal saline solution c) Continue the transfusion and repeat the type and crossmatch d) Prepare to administer a dose of diphenhydramine IV
b) Remove the unit of plasma immediately and start an IV infusion of normal saline solution A client who receives FFB that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.
A nurse is administering a unit of packed 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? a) Maintain the IV access with 0.9% sodium chloride b) Stop the infusion of blood c) send the blood container and tubing to the blood bank d) Obtain a urine sample
b) stop the infusion of blood The nurse should apply the urgent vs nonurgent priority setting framework. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.
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? a) Check for hypertension b) Auscultate for loud, bounding heart sounds c) Auscultate blood pressure for pulsus paradoxus d) Check for a pulse deficit
c) Auscultate blood pressure for pulsus paradoxus The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration that on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles
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? a) Pitting edema b) Areas of reddish-brown pigmentation c) Dry, pale skin with minimal body hair d) Sunburned appearance with desquamation
c) Dry, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on lower legs, and weakened pulses.
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? a) Hospitalization is required when administering each treatment b) The maximum effect of the medication will occur in 6 months c) Hypertension is a common adverse effect of this medication d) Blood transfusions are needed with each treatment
c) HTN is a common adverse effect of epoetin alfa because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin, Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the rbc level.
The nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hrs? a) Infective endocarditis b) Pericarditis c) Ventricular dysrhythmias d) Pulmonary emboli
c) ventricular dysrhythmias After an MI, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the hearts electrical system.
A nurse is assessing a client who has right sided heart failure. Which of the following findings should the nurse expect? a) Decreased capillary refill b) Dyspnea c) Orthopnea d) Dependent edema
d) Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to development of the dependent edema.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? a) Midsternal chest pain b) Thrill c) Pitting edema in lower extremities d) Lower back discomfort
d) Lower back discomfort Abdominal aortic aneurysm involves a widening, stretching or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
