ATI Standard Quiz- Medical-surgical: Cardiovascular and hematology

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 pound in 1 day B. Pitting edema +1 C. Client report nocturnal cough D. BNP 100pg/mL

A

A nurse is caring for a client who has a Triple A and is scheduled for surgery. The client vitals are BP 160/98, HR 102, Resp. 22. and 02 95>. Which of the following actions should the nurse take? A. Administer antihypertensive medication for blood pressure B. Monitor that urinary output is 20mL/hr C. Withhold pain medication to prepare for surgery D. Take vital signs every 2 horus

A

A nurse is caring for a client who has a myocardial infarction 5 days ago. The client has a sudden onset of SOB and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds the nurse document? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction rub

A

A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following lab values should the nurse to anticipate as the cause of this EKG change? A. Potassium 2.8 B. Digoxin 0.7 C. Hemoglobbin 9.8 D. Calcium 8.0

A

A nurse is caring for a client who is postoperative following vein ligatin and stripping for varicose veins. Which of the following actions should the nurse take? A. Position the client supine with his legs elevated when in bed B. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hours C. Tell the client to sit with his legs dependent after ambulating D. Instruct the client to wear knee-length socks for 2 weeks after surgery

A

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 recongize as health benefit to the client? A. Omega 3 fatty acids B. Antioxidants C. Vitamin A D C D. Beta carotene

A

A nurse is caring for a client who has a demand pacemaker inserted with a rate of 72/min. Which of the following findings should the nurse expect? A. Tele monitor shows QRS complexes occuring at 74/min with no pacing spikes B. THe client is expierncing PVC at 12/min C. Tele monitor shows pacing spikes with no QRS complex D. The client expierncing hiccups

A The nurse should not expect pacer spikes when the clients pulse is greater than set at 72 because the clietns intrisic rate overrides the set of the pacemaker

A nurse is reviewing a clients repeat lab results 4 hr after administering fresh frozen plasma. Which of the following lab results should the nurse review? A. PT time B. WBC C. Platelet D. Hematocrit

A The nurse should review the clients PT time after administertration, which is plasma rich clotting factors. FFP is administer to treat acute clotting disorder.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. WHich of the following manifestations should the nurse expect? SATA A. JVD B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

A B D

A nurse is administering a unit of packed of red blood cells 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 C. Send the blood container and tubing to blood bank D. Obtain a urine sample

B

A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a new Rx for a beta blocker. Which of the following client statements indicates an understanding of teaching? A. I should eat foods in high saturated fats B. Before taking my medication, i will count my radial pulse rate C. I will exercise once per week for a hour at the health club D. I will stop taking my medication when my blood pressure is wihtin normal range

B

A nurse on a tele unity is caring for a client who has a irregulare radial pulse. Which of the following ECG abnormalities should the nurse recongize as atrial flutter? A. P waves occuring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventriculare rate of 82/min D. An irregulare ventriculare rate of 125/min

B

A nurse is transfusing a unit of B positive fresh frozen plasma to a client whose blood type is o negative. 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 corssmatch D. Prepare to administer a dose fo IV diphenhydramine

B A client who receives FFP that is not comptabil can expierence a hemolytic tranfusion reaction. The nurse should stop transfusion and infuse 0.9% sodium chloride and new tubing

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 action 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 clients pain D. Place the bleeding joint in a dependent position

B 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. Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long term loss of rang of motion in repeatedly affected joints

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports SOB on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atria pressure D. Decreased pulmonary artery pressure

B Pulmonary congestion occurs due to right sided heart failure.

A nurse is assessing for cardiac tamponade on a client who had coronanry artery bypass grafts. Which of the following actions should the nurse take? A. Check for HTN B. Auscultate for loud, bouding heart sounds C. Auscultate blood pressure pulses paradoxus D. Check for pulse deficit

C

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? A. Administer ferrous sulfate supplmentation B. Increase dietary intake of folic acid C. Initiate weekly injections of vitamin B12 D. Initiate a blood transfusion

C

A nurse is preparing to transfuse a unit of packed RBC to a client who has anemia. Which of the follwin actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chlrodie with the blood B. Check the clients identification number with the number on the blood C. Witness informed consent D. Obtain pretranfusion vitals

C

A nurse is providing teaching to a client who has anemia and a new Rx for epoetin alfa. Which of the following information should the nurse include in the teaching? A. Hospitilization is reqiured when administering each treatment B. The max effect of medication will occur in 6 months C. HTN is a common adverse effect of this medication D. Blood transfusion are needed with each treatment

C

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 appearacne with desquamation

C A client who has peripheral arterial disease can display dry, scaly, pale or mottled skin with minimal body hair because of narrowing of the artieries in the legs and feet. This causes a decrease in blood flow to the distal extremities which can lead to tissue damage

A nurse is monitoring a client hwo has a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 horus? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhthmias D. Pulmonary emboli

C After an MI, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissues caused by the infarction can also interfere with the normal conduciton patterns.

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D. CHest pain that increase sitting upright

C The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough.

A nurse is assessing a client for manifestations of aplstic anemia. Which of the following findigns shuold the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice with an enlarged liver D. Petechiae and acchymosis

D

A nurse is planning care for a client who is having a PTCA with stent placement. Which of the following actions should the nurse anticipate in the postprocedure plan of care? A. Instruct the client on a longterm cardiac conitioning program B. Administer scheduled doses of acetaminophen C. Check the peak lab markers of myocardial damage D. Monitor for bleeding

D

A nurse is reviewing lab values for an adult client who has sickle cell anemia and history of receiving blood tranfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

D

A nurse is assessing a client who has right sided heart failure. Which of the following findings should the nurse expect? A. Decreased cap refill B. Dyspnea C. Orrthopnea D. Dependent edema

D 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 dependent edema.

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should adminiser which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

D Solutions of 0.9% sodium chloride, as well as lacted ringers solution, are used for fluid volume replacement.

A nurse is completing an assessment for a client who has history of unstable angina. Which of the following fidnings should the nurse expect? A. Chest pain is relieved soon after resting B. Nitro relieves chest pain C. Physical exertion does not precipitate chest pain D. Chest pain lasts longer than 15 min

D The client who has unstable angina will have chest pain lasting longer than 15 min

A nurse is assessing a client who has an abdominal aoritc 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 Triple A involves wdening, stretching, or ballooning of aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots