ATI_AQ_MED-SURG_Cardiovascular_and_Hematology

A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following pieces of information should the nurse include in the teaching? A. "Avoid lifting both arms above your head when dressing." B. "Use your cell phone on the same ear as the pacemaker site is located." C. "Do not travel by airplane." D. "Hiccups are an expected outcome of having a pacemaker."

"Avoid lifting both arms above your head when dressing." *The client should avoid lifting the arm or shoulder or the side of the pacemaker because dislodgment of the pacer leads can occur

A nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and just received a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? A. "I should eat foods high in saturated fat." B. "Before taking my medication, I will check my blood pressure and radial pulse rate." C. "I will exercise once a week for an hour at the health club." D. "I will stop taking my medication when my blood pressure is within a normal range."

"Before taking my medication, I will check my blood pressure and radial pulse rate." *A beta blocker will induce bradycardia. The client should take her pulse rate for 1 minute before self-administration

A nurse is reinforcing teaching with a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? A. "Drink at least 1 liter of fluid each day." B. "Continuously wear support hose." C. "Elevate your legs when sitting." D. "Use dental floss daily."

"Elevate your legs when sitting." *Clients who hace polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation.

A nurse is reinforcing dietary teaching with a client who has heart failure and is on a 2 g sodium diet. Which of the following statements by the client indicates an understading of the teaching? A. "I should use salt sparingly while cooking." B. "I can have yogurt as a dessert." C. "I should use baking soda when I bake." D. "I should use canned vegetables instead of frozen."

"I can have yogurt as a dessert." *Salt should be eliminated from the client's diet. Spices or vinegar can be used to season the client's food. Baking soda is high in sodium and should be eliminated from the client's diet. Canned vegetables are high in sodium and should be eliminated from the client's diet. Frozen or fresh vegetables, which are low in sodium, should be incorporated into the client's diet

A nurse is reinforcing teaching with a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following client statements indicates the teaching has been understood? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option for me."

"I can snack on fresh fruit." *The nurse should identify that fresh fruits contain little to no sodium and are a good snack for a client who has hypertension

A nurse is reinforcing discharge teaching with a client who has a new permanant pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. "I should check my heart rate each day." B. "I don't have to take my antihypertensive medications now that I have a pacemaker." C. "I should stretch my arms above my head every 4 hours." D. "I cannot stand in front of our newmicrowave oven when it is on."

"I should check my heart rate each day." *The nurse should instruct the client to check his heart rate each day and to document the rate in a log to support future discussions with the provider. The nurse should instruct the client to notify the provider if the heart rate is below the prescribed parameters

A nurse is reinforcing discharge teaching with a client who has aplastic anemia. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I need to stay active to prevent blood clots in my legs." B. "If I have a bad headache, I can take aspirin to get rid of it." C. "I should eliminate uncooked foods from my diet for now." D. "I should eat more iron-fortified cereal to strengthen my blood."

"I should eliminate uncooked foods from my diet for now." *The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorganisms that cooking would destroy, so the client should avoid raw foods

A nurse us reinforcing dietary teaching about a low-cholesterol diet with a client who has heart disease. Which of the following client statements indicates the teaching was effective? A. "I should remove the skin from poultry before eating it." B. "I will eat seafood once per week." C. "I should use margarine when premaring meals." D. "I can use whole milk on my oatmeal."

"I should remove the skin from poultry before eating it." *The client should remove the skin from poulty before eating because the skin contains the greatest amount of fat

A nurse is reinforcing teaching about measures to increase comfort and promote circulation with a client who has been admitted to the hospital with a deep-vein thrombosis (DVT) of the left leg. Which of the following statements by the client indicates an understanding of the teaching? A. "I will wear compression stockings on my legs when I plan to take a walk." B. "I will apply cool compresses to my leg." C. "I will massage my leg when it hurts." D. "I will keep my legs elevated when I'm in bed."

"I will keep my legs elevated when I'm in bed." *The client should keep the legs elevated while in bed to promote venous return to the heart and prevent venous pooling

A nurse is providing information to a client who is scheduled for an exercise electrocardiography test. Which of the following client statements indicates an understanding of the teaching? A. "I will not drink coffee 4 hours prior to my test." B. "I can eat a light meal 1 hour prior to the test." C. "I can have a cigarette up to 30 minutes prior to the test." D. "I will take my heart medication on the day of the test."

"I will not drink coffee 4 hours prior to my test." *The client should avoid coffee, alcohol, and caffeine on the day of the test. These can affect the client's heart rate and blood pressure during the test

A nurse is reinforcing discharge teaching with a client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching? A. "I will reschedule any body piercings if I have a fever." B. "I will notify before I have dental procedures." C. "I will floss my teeth twice a day as part of my oral care." D. "I will wear a mask when I go out in public."

"I will notify before I have dental procedures." *The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to undergoing invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements should the nurse identify as an indication that the client is adhering to the treatment plan? A. "I would never have believed I could get used to enjoying my food without salt." B. "My blood pressure device at home usually shows about 156 over 98 or so." C. "I make sure I take my blood pressure medicine when I have headaches." D. "My blood pressure pills are very expensive. Could I take a cheaper medication?"

"I would never have believed I could get used to enjoying my food without salt." *This statement implies that the client has most likely stopped adding salt to food. Sodium restriction is an aspect of the treatment plan and indicates dietary adherence by the client

A nurse is reinforcing teaching with a 70-year-old client about risk factors for heat failure. The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? A. "My diabetes increases my risk for heart failure." B. "My asthma makes it more likely for me to have heart failure." C. "My age does not increase my risk for heart failure." D. "My coronary artery disease is a risk for heart failure."

"My coronary artery disease is a risk for heart failure." *Coronary artery disease is a primary risk factor for the development of heart failure. Other risk factors for heart failure include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism

A nurse is reinforcing discharge teaching with a client who had sickle cell crisis. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I should try to drink at least 2 liters of fluid per day." B. "I can still fly out to visit my sister in Colorado for a while." C. "Physical activity is good for me, but I need to avoid overexertion." D. "I can still go skiing during the cold winter months."

"Physical activity is good for me, but I need to avoid overexertion." *To help prevent a recurrence of sickle cell crisis, the client should avoid overexertion from especially strenuous activities

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection." B. "Platelets help break down clots in the body." C. "Platelets help plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen."

"Platelets help plug breaks in blood vessels." *Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When a blood vessel is injured, platelets collect at the edge of the break and, by adhering to each other, plug the injured area and limit blood loss.

A nurse is reinforcing discharge teaching with a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? A. "Request a provider's prescription when traveling to alert airport security." B. "Stand at least 3 feet away while using a microwave." C. "Use a cellular phone on the opposite ear from the pacemaker." D. "Avoid showering for the first 2 weeks following surgery."

"Use a cellular phone on the opposite ear from the pacemaker." *The nurse should instruct the client to use and hold a cellular phone to the opposite ear from the pacemaker. This will avoid interference of the generator inside the pacemaker

A client who has just learned that he has variant (Prinzmetal's) angina asks the nurse how this condition compares to stable angina. Which of the following replies should the nurse make? A. "Exertion often brings on pain." B. "Variant angina occurs randomly at various times." C. "Variant angina can cause changes on your electrocardiogram." D. "Reducing your cholesterol can help you experience less pain."

"Variant angina can cause changes on your electrocardiogram." *Variant or Prinzmetal's angina causes ECG changes that reflect coronary artery spasms, resulting in less oxygen supplying the myocardium

A nurse is assisting with preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in the preoperative instructions? A. "You'll receive heavy sedation, so you might even sleep during the procedure." B. "You'll have to lie on your back throughout the procedure." C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow." D. "Expect the procedure to take about an hour."

"You'll feel a painful, pulling sensation when the doctor withdraws the marrow." *The nurse should prepare the client to expect a painful, pulling sensation when the provider aspirates the marrow and some discomfort from the rotation of the needle into the bone

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibronolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your bloodstream." D. "Treatment with heparin will dissolve the clot and keep the other clots from forming."

"Your body has a process called fibrinolysis that will eventually dissolve the clot." *Fibrinolysis is a process that breaks a clot over time in the body. It is a treatment option for cloths that are not immediately life-threatening.

A nurse is assisting an RN who is preparing to administer packed RBCs using a Y-tubing blood transfusion administration set for a client who is hypovolemic from blood loss. Which of the following should the nurse identify as the IV solution to administer with the blood product? A. Lactated Ringer's Injection, USP B. 5% Dextrose Injection, USP C. 10 mEq Potassium Chloride D. 0.9% Sodium Chloride Injection, USP

0.9% Sodium Chloride Injection, USP *Only Normal saline is compatible with a blood transfusion because it does not cause clotting or hemolysis of the blood cells

A nurse is assisting with the care of a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

0.9% sodium chloride *Solutions of 0.9% sodium chloride, as well as lactated ringer's solution, are used for fluid-volume replacement. Sodium chloridem a crystalloid, is a physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse reinforce with the client before the procedure? (select all that apply) A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." C. "You'll feel a very cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hours."

1. "You'll have to lie flat for several hours after the procedure." 2. "You'll receive medication to relax you before the procedure." 3. "You'll have to keep your leg straight after the procedure." *Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30 degrees for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure

A nurse in a provider's office is reviewing the medical records of a group of clients. The nurse should identify that which of the following clients are at risk for iron-deficiency? (select all that apply) A. A client who is postmenopausal B. A client who is vegetarian C. A middle aged adult male client D. A client who is pregnant E. A toddler who is overweight

1. A client who is vegetarian 2. A client who is pregnant 3. A toddler who is overweight *A client who is vegetarian might require additional iron because of the limited availability of iron in vegetable sources. *During pregnancy, maternal blood volume increases, and the fetus requires iron. therefore, teh RDA of iron for clients who are pregnant is increased to 27 mg/day. *Toddlers who are overweight might get most of their calories from milk and from foods that are not considered healthy, which places toddlers at risk of iron-deficiency anemia.

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (select all that apply) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on chest and arms D. Flushed, dry skin E. Abdominal distention

1. Bleeding at the venipuncture site 2. Petechiae on chest and arms 3. Abdominal distention *The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur as manifested by bleeding at the venipuncture site, petchiae on the arms and chest, and abdominal distention due to internal bleeding

A nurse is assisting with the care of a client who is scheduled to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply) A. Check and document the client's vital signs B. Ensure the client's IV site uses a 22-gauge needle C. Make sure the blood type and Rh of the packed RBCs are checked by 2 nurses D. Obtain a bag of lactated Ringer's IV solution E. Provide the RN with IV tubing that has a filter

1. Check and document the client's vital signs 2. Make sure the blood type and Rh of the packed RBCs are checked by 2 nurses 3. Provide the RN with IV tubing that has a filter *The nurse should check and document the client's vital signs prior to a blood transfusion to obtain a baseline for comparison. Monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and identify if the client is tolerating the volume of the prescribed blood product. Additionally, 2 nurses should check the blood type and Rh of the packed RBCs and compare these items with the client's information for compatibility. This action decreases the risk of an ABO incompatibility reaction. Finally, the nurse should provide the RN with IV tubing that has a filter to prevent the administration of aggregates and possible contaminants

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply) A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6-hour period D. Seek verification from 2 RNs to compare the packed RBCs label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride

1. Check to determine the packed RBCs are less than 1 week old 2. Seek verification from 2 RNs to compare the packed RBCs label against the medical record 3. Prime the transfusion tubing with 0.9% sodium chloride *The nurse should check to determine that the RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the bloodstream. *The nurse should seek verification from 2 RNs before the packed RBCs are hung by the RN. Verification involces comparing the packed RBCs label against the medical record, against the client's complete name and identification number, and against the blood group name and number. If there is any discrepancy, the nurse should not infuse the blood and should notify the blood bank. *The nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions sych as Ringer's Lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs

A nurse is collecting data from a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (select all that apply) A. Hardening along the blood vessel B. Absence of a peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumference

1. Hardening along the blood vessel 2. Tenderness in the calf 3. Increased leg circumference *Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins. Additionally, deep-vein thrombosis causes pain or tenderness in the calf and an increased circumference of the leg due to swelling

A nurse is collecting data from a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (select all that apply) A. Hypothyroidism B. Hypertension C. Diabetes Mellitus D. Hyperlipidemia E. Tobacco smoking

1. Hypertension 2. Diabetes Mellitus 3. Hyperlipidemia 4. Tobacco smoking *Hypertension can be controlled by diet and exercise, along with medication if needed *Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage. Diabetes mellitus can be managed by monitoring glucose levels and implementing diet and exercise *Hyperlipidemia can be controlled with diet and exercise, along with medication if needed *Cholesterol levels (total, HDL, and LDL) should be monitored, as elevated total serum cholesterol levels increase the risk of myocardial infarction. *Smoking accelerates the rate of the narrowing of the coronary arteries and increases the risk of clot formation. Smoking cessation classes or other forms of treatment can be offered to help the client quit smoking

A nurse is collecting data from a client who has fluid volume overload resulting from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (select all that apply) A. Jugular vein distention B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

1. Jugular vein distention 2. Moist crackles 3. Increased heart rate *The increased venous pressure to excessive circulating blood volume results in neck vein distention. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment that results in an increased heart rate and bounding pulses

A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and a myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of an MI? (Select all that apply) A. Nausea and Vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea

1. Nausea and Vomiting 2. Diaphoresis and dizziness 3. Anxiety and feelings of doom *Nausea, vomiting, and epigastric distress are common manifestations of MI, as well as diaphoresis (sweating), dizziness, fatigue, and anxiety and feelings of doom and fear

A nurse is checking for paradoxical blood pressure in a client who has a possible cardiac tamponade. In what sequence should the nurse take the following steps? A. Identify the first BP sounds audible on expiration and then on inspiration B. Subtract the inspiratory pressure from the expiratory pressure C. Deflate the cuff slowly and listen for the first audible sounds D. Inspect the jugular venous distention and notify the provider E. Palpate the blood pressure and inflate the cuff above the systolic pressure

1. Palpate the blood pressure and inflate the cuff above the systolic pressure 2. Deflate the cuff slowly and listen for the first audible sounds 3. Identify the first BP sounds audible on expiration and then on inspiration 4. Subtract the inspiratory pressure from the expiratory pressure 5. Inspect the jugular venous distention and notify the provider

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hours. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the blood transfusion to deliver how many gtt/min?

10

A nurse is collecting data about the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? A. Pallor B. Jaundice C. Absence of hair on the legs D. Poor nailbed capillary refill

Absence of hair on the legs *Progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. the nurse should look for further indications of arterial insufficiency and report these findings to the provider

A nurse is assessing a client who is 85 years old. Which of the findings should the nurse identify as a manifestation of a myocardial infarction? A. Sudden hemoptysis B. Acute diarrhea C. Frontal headache D. Acute confusion

Acute confusion *Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestation can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue

A nurse is assisting in the care of a client who as an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? A. Administer an antihypertensive medication for blood pressure B. Monitor for a urinary output of 20 mL/hr C. Withhold pain medication to prepare for surgery D. Take vital signs every 2 hours

Administer an antihypertensive medication for blood pressure *The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of teh aneurysm due to pressure on the arterial wall

A nurse is contributing to the plan of care during a sickle cell crisis. Which of the following interventions should the nurse recommend? A. Ambulate the client every hour B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Administer oxygen via nasal cannula

Administer oxygen via nasal cannula *The nurse should administer oxygen to the client during a sickle cell crisis. Hypoxia increases sickling and client discomfort

A nurse is assisting with the admission of a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse suggest to include in the client's plan of care? A. Flexion of the extremities B. Therapeutic hypothermia C. Upright positioning D. Ample hydration

Ample hydration *A client who is in sickle cell crisis needs ample hydration (IV, oral, or both) to shorten the duration of painful episodes. The nurse should plan to offer the client water, juice, or the client's favorite beverage, as long as it does not contain caffeine

A nurse is collecting data from a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

Ankle swelling *The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis

A nurse is caring for a client who has a platelet count of 50,000/mm3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 10 minutes C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol

Apply pressure to the catheter removal site for 10 minutes *A platelet count below 100,000/mm3 indicates thrombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure tot he site for 10 minutes, the nurse promotes coagulation and prevents additional blood loss

A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first? A. Press the analyze button on the machine B. Stop CPR and move away from the client C. Push the charge button to prepare to shock D. Apply the defibrillator pads to the client's chest

Apply the defibrillator pads to the client's chest *After obtaining the AED, the nurse should apply 2 large adhesive defibrillator pads on the client's anterior chest wall to enable the machine to analyze the rhythm and deliver the shock appropriately if indicated. One pad should be applied to the upper right chest area above the client's nipple and to the right of the sternum, and second pad should be applied to the left lower chest area below the client's nipple and pectoral muscle. The pads should be applied without interrupting CPR

A nurse is checking a client who has pericarditis for cardiac tamponade. 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 pulse paradoxus D. Check for a pulse deficit

Auscultate blood pressure for pulse paradoxus *The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg highter on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles

A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? History & Physical: Diabetes mellitus, Bradycardia, Hypertension Diagnostic results: Sodium 138 mEq/L; Potassium 4.0 mEq/L; Creatinine 1.1 ng; BNP 200 pg/mL Nurses' notes: Client is admitted with heart failure and reports shortness of breath and weight gain; Diet: 4 g sodium; Fluid restriction of 3 L per day A. BNP of 200 pg/mL B. Bradycardia C. Fluid restriction of 3 L per day D. 4 g sodium

BNP of 200 pg/mL *The nurse should identify that a client who has heart failure will have an elevated human B-type natriuretic peptide (BNP) level of >100 pg/mL. Endogenous BNP is released into the client's bloodstream due to decreased cardiac output, a process called natriuresis

A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Beef liver B. Oranges C. Turnips D. Whole milk

Beef liver *The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, and poultry. A 3 oz serving of beef liver contains 4.17 mg of iron

A nurse is caring for a client who reports calf pain. Which of the following is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin

Check the affected extremity for warmth and redness *The first action the nurse should take using the nursing process is to collect data about the client's calf to check for swelling, redness, and warmth that can indicate deep-vein thrombophlebitis

A nurse is reinforcing teaching about a low-cholesterol diet with a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions

Chicken breast and corn on the cob *The nurse should identify that chicken breast is low in cholesterol and all vegetables, including corn, are cholesterol-free; therefore, this food selection by the client indicates an understanding of the teaching

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

Coarse crackles *A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by the movement of air through airways partially or intermittently occluded with fluid. These sounds are associated with heart failure and frothy sputum, are heard at the end of inspiration, and are not cleared by coughing

A nurse in a clinic is collecting data from a client who has a history of peripheral arterial disease. Which of the following findings on the client's lower extremities should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation C. Cool, pale skin with minimal body hair D. Sunburned appearance with desquamation

Cool, 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 the lower legs, and weakened pulses

A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting, peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly

Crackles in the lung bases *Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs. The others are manifestations of right-sided heart failure

A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

Decreased albumin *A decreased albumin level can be an indication of long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Dizziness D. Dependent edema

Dependent edema *Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent venous backup leads to the development of dependent edema.

A nurse is collecting data from 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 D. Chest pain that increase when sitting upright

Dyspnea *The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade

A nurse is assisting with the preparation of an in-service presentation about the management of myocardial infarction (MI). The nurse should identify that death following MI is most often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema

Dysrhythmias *According to evidence-based practice, the nurse should identify that dysrhythmias, specifically ventricular fibrillation, are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately

A nurse is reinforcing teaching with a client who has pernicious anemia. The nurse should encourage the client to increase his consumption of which of the following foods? A. Eggs B. Squash C. Kale D. Tofu

Eggs *The nurse should encourage the client to increase consumption of foods rich in vitamin B12 such as dairy products, animal proteins, poultry, shellfish, and eggs

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort

Elevate the affected leg *The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid and electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Hct D. Decreased Hgb

Elevated Hct *The nurse should expect a client who is experiencing third spacing resulting from a majr burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration

A nurse is caring for a male client who is undergoing screening tests for athersclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? A. Cholesterol level 195 mg/dL B. Elevated HDL levels C. Elevated LDL levels D. Triglyceride level of 135 mg

Elevated LDL levels *An elevated LDL level increases a client's risk for atherosclerosis. The client's desirable LDL level is below 130 mg/dL

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP interventals

Elevated ST segments *Elevated ST segments can indicate hyperkalenia and pericarditis

A nurse is checking laboratory values for an adult client who has sickle cell anemia and is in crisis. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Elevated bilirubin

Elevated bilirubin *The client who has sickle cell anemia and is in crisis will have an elevated bilirubin because hymolysis of the abnormal red blood cells occurs

A nurse is caring for a client who has advanced heart failure. Which of the following actions should the nurse take? A. Place the client in a low-Fowler's position B. Assist the client to use the incentive spirometer every 4 hours C. Weight the client every other day D. Enforce fluid restrictions

Enforce fluid restrictions *The nurse should enforce fluid restrictions to help reduce fluid retention in the lungs and lower extremities

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? A. Vertigo B. Epistaxis C. Exopthalmos D. Spondylosthesis

Epistaxis *Epistaxis is a manifestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches, dizziness, facial flushing, and fainting

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

Erythropoietin *Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure

A nurse participating in a community health fair is providing information to a client who has a reading of 150/90 mmHg during a blood pressure (BP) screening. Which of the following actions should the nurse take? A. Give the client a written record of his BP to bring to his provider B. Encourage the client to go to the nearest emergency department C. Instruct the client to follow up with a provider within 6 months D. Explain to the client that he is not at risk unless he has manifestations of hypertension

Give the client a written record of his BP to bring to his provider *When a client has an elevated reading at a hypertension screening, the nurse should encourage teh client to see the provider for further evaluation within 2 months. To help facilitate this process, the nurse should give the client a written record of the BP at the screening to share with the provider

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower QRS complexes B. Greater amplitude QRS complexes C. Same polarity QRS complexes D. Immediate resumption of the usual rhythm

Greater amplitude QRS complexes *The QRS complexes are of unusually great amplitude in height and depth for clients who have PVCs

A nurse is reinforcing teaching with a client about dietary modifications to help control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instruction? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes D. Chicken bouillon and crackers

Grilled chicken salad with fresh tomatoes *Sodium reduction helps control blood pressure. Grilled chicken salad and fresh tomatoes are fresh food items that are likely to be low in sodium. However, the client should make sure the food preparer has not added salt generously to the meal

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? A. Magnesium 2.0 mEq/L B. Hgb 6.5 g/dL C. WBC count 9.6/mm3 D. Creatinine 0.8 mg/dL

Hgb 6.5 g/dL *The expected reference range of Hgb is 14 to 18 g/dL for men and 12 to 16 g/dL for women. Therefore, a client who has an HgB level of 6.5 g/dL has anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallow, dizziness, and tachycardia

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

Hyperkalemia *The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid

A nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of 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

Hypertension is a common adverse effect of this medication *A common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythocytes and other blood cell types. Epoetin alfa is a synthetic version of human erthropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level

A nurse is collecting data from a client who has heart failure and is taking furosemide. The client's apical pulse is weak and irregular. This client has manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

Hypokalemia *The nurse should identify that furosemide can cause a loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation

Impaired circulation *The nurse should identify that prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations of the client's toes. Severe arterial disease is identified through assessment of the quality of the client's posterior tibial pulses by comparing the pulses on both feet

A nurse is collecting data from a client who has isotonic dehydration. Which of the following findings should the nurse expect? A. Increased hematocrit B. Bradycardia C. Distending neck veins D. Decreased urine specific gravity

Increased hematocrit *The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume

A nurse is assisting in the plan of care for a client who us having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postoperative plan of care? A. Reinforce teaching with the client about a long-term conditioning program B. Administer scheduled doses of acetaminophen C. Check for peak laboratory markers of myocardial damage D. Initiate an aspirin regimen

Initiate an aspirin regimen *The nurse should plan to initiate an aspirin regimen or another antiplatelet agent. The antiplatelet medication maintains the patency of the stent by reducing platelet aggregation

A nurse is contributing to the plan of care for a client who has pernicious anemia. Which of the following interventions should the nurse recommend? A. Adminsiter ferrous sulfate supplementation B. Increase dietary intake of folic acid C. Initiate weekly injections of vitamin B12 D. Initiate a blood transfusion

Initiate weekly injections of vitamin B12 *Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the GI tract. The nurse should recommend weekly injections of vitamin B12 for a client who has pernicious anemia. These may be decreased to monthly

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation laboratory studies B. Apply pneumatic compression boots C. Request a referral for a speech-language pathologist D. Keep the client NPO

Keep the client NPO *The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this as been completed. A client who has experienced a cerebrovascular accident is at risk of dysphagia, which increases the risk of life-threatening aspiration

A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

Lentils *The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, poultry, and dried beans and peas. A 1-cup serving of lentils contains 3.6 mg of iron

A nurse is collecting data from a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? A. Bradycardia B. Parethesia C. Hypertension D. Low back pain

Low back pain *The nurse should identify that low back pain is a manifestation of a hemolytic tranfusion reaction. Other manifestations include headaches, chest pain, tachypnea, tachycardia, and dark urine

A nurse is collecting data from a client who has 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

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

A nurse is assisting with planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluids to 1,000 mL per day B. Measure the client's abdominal girth daily C. Check IV sites every 4 hours for bleeding D. Administer an enema as needed for constipation

Measure the client's abdominal girth daily *The nurse should plan to measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk for bleeding due to delayed clotting

A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take? A. Weight the client weekly B. Monitor the client for ototoxicity C. Place the client on a 24-hour urine collection analysis D. Monitor for hypoglycemia

Monitor the client for ototoxicity *The nurse should monitor the client for ototoxicity, and the client should report any manifestations of hearing impairment while on the loop diuretic. the nurse should use caution when a loop diuretic is used in conjunction with other ototoxic medications such as aminoglyceride antibiotics

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of MI? A. Headache B. Hemoptysis C. Nausea D. Diarrhea

Nausea *The nurse should identify that nausea is an associated manifestation of an MI. Manifestations of an MI include chest pain and pain in the jar, shoulder, or abdomen. Anxiety, dizziness, dyspnea, dysrhythmias, fatigue, and palpitations

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alteration? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency

Necrosis *ST0segmented elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery

A nurse is collecting data from a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognizer as a health benefit to the client? A. Omega-3 fatty acids B. Antioxidants C. Vitamins A, D, and C D. Beta-carotene

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 collecting data from a client who has pernicious anemia. Which of the following findings should the nurse expect? A. Thick, white coating on the tongue B. Decreased pulse rate C. Paresthesias in the hands and feet D. Joint pain in extremities

Paresthesias in the hands and feet *The nurse should identify that paresthesias (tingling sensation) in the hands and feet is an expected finding of pernicious anemia. Other manifestations include weight loss and fatigue

A nurse is caring for an older adult client who has had an acute myocardial infarction (MI). When collecting data from this client, the nurse should identify that older adults are prone to complications of MI in tissue perfusion because of which of the following age-related factors? A. Peripheral vascular resistance increases B. The sensitivity of blood pressure-adjusting baroreceptors increases C. Blood is hypercoagulable and clots more quickly D. Cardiac medications are less effective

Peripheral vascular resistance increases *Older adult clients are more prone to complications from poor tissue perfusion following acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels

A nurse is collecting data from a client who has manifestations of aplastic anemia. Which of the following findings should the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice with an enlarged liver D. Petechiae and ecchymosis

Petechiae and ecchymosis *The client who has aplastic anemia will have manifestation of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? A. Have the client gently blow clots from his nose every 5 minutes B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the client's neck D. Pinch the soft portion of the client's nose for 10 minutes

Pinch the soft portion of the client's nose for 10 minutes *The nurse should apply direct pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions

A nurse is contributig to the plan of care for a client who has thrombophlebitis. Which of the following actions should the nurse recommend for the plan of care? A. Place compression stockings on the lower extremities B. Apply cold compresses to the affected extremity C. Gently massage the area every 4 hours D. Inform the client that heparin is prescribed to dissolve the thrombus

Place compression stockings on the lower extremities *The nurse should apply compression stockings on the client's lower extremities to promote blood returb and decrease venous stasis

A nurse is caring for a client who is postoperative following a vein ligation 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. Encourages the client to ambulate for 15 minutes every while awake for the first 24 hours C. tell the client to sit with his legs dependent after ambulating D. Recommend wearing knee-length socks for 2 weeks after surgery

Position the client supine with his legs elevated when in bed *The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart

A nurse is caring for a client who has heart failure and is lethargic with muscle weakness. The client's telemetry reading displays dysrhythmias. Which of the following laborator results should the nurse anticipate? A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 11.5 g/dL D. Calcium 8.0 mg

Potassium 2.8 mEq/L *Manifestation of hypokalemia include muscle weakness and cramps, confusion, and drowsiness. Hypokalemia can also result in life-threatening dysrhythmias

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

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 evaluating a client's repeat laboratory result 4 hours after administering fresh frozen plasma (FFB). Which of the following alboratory values should the nurse review? A. WBC count B. Prothrombin time C. Platelet count D. Hematocrit

Prothrombin time *The nurse should review the client's prothrombin time after the administration of FFP, whichis 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 collecting data from a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular-vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

Report of sudden, severe back pain *An aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden, increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction? A. Prepare emergency medications B. Monitor vital signs every 5 minutes C. Stop the infusion D. Send the blood container and tubing to the laboratory

Stop the infusion *For this client, a life-threatening event such as circulatory collapse is possible. Therefore, the nurse should stop the infusion to prevent any further administration of blood

A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. The client reports itching and has hives 30 minutes after the infusion begins. Which of the following actions should the nurse take first? A. Maintaing 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

Stop the infusion of blood *The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction

A nurse is assisting with the preparation of an in-service presentation about collecting data from client who are having acute myocardial infarction (MI). The nurse should identify that the most common finding of acute MI is which of the following? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

Substernal chest pain *Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does subside with rest of with nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation

A nurse is showing a client who has right-sided heart failure an illustration of the heart. The nurse should identify the blood vessels that carry deoxygenated blood to the right atrium as which of the following? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

Superior vena cava *The superior and inferior vena carry deoxygenated blood to the right atrium

A nurse is assisting with data collection from a client who has a history of unstable angina. Which of the following findings should the nurse expect? A. The client reports chest pain when at rest B. Nitroglycerin relieves chest pain C. Physical exertion does not precipitate chest pain D. Chest pain lasts for under 5 minutes

The client reports chest pain when at rest *A client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina, caused by an artery spasm

A nurse is collecting data from a client who has arteriovenous (AV) fistula for hemodialysis. Where should the nurse listen for a bruit?

The nurse should identify that an AV fistula is commonly located in the client's forearm. It is the surgical connection of an artery and vein to provide access for hemodialysis. The nurse should assess the client's formarm by listening for a bruit over the vascular access site

A nurse is assisting with preparing an in-service presentation about the basics of hematology. The nurse should suggest explaining that which of the following factors provides a stimulus for the production of RBCs? A. Venous stasis B. Thrombocytopenia C. Inflammation D. Tissue hypoxia

Tissue hypoxia *In response to tissue hypoxia, the kidneys release erythropoietin, which stimulate the production of erythrocytes (RBCs) in the bone marrow

A nurse is reviewing the menu selections of a client who has heart failure and anticipates being discharged home from the following day. Which of the following lunch menu choices should the nurse identify as an indication that the client understands his dietary instructions? A. Turkey on whole wheat bread B. Hamburger and french fries C. Frankfurter on a white roll D. Macaroni and cheese

Turkey on whole wheat bread *The primary dietary alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole wheat bread has a relatively low sodium content

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

Ventricular dysrhythmias *After a myocardial infarction, 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 heart's electrical system

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

Ventricular dysrhythmias *The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery

A nurse is assisting with developing the plan of care for an older client who is to receive a unit of packed red blood cells (RBCs). Which of the following actions should the nurse recommend? A. Verify the information on the packed RBCs with another nurse B. Administer the packed RBCs through an 18-gauge IV catheter C. Infuse the packed RBCs over 2 hr D. Allow the packed RBCs to warm at room temperature for 1 hr before starting the transfusion

Verify the information on the packed RBCs with another nurse *The nurse should verify the information on the label of the packed RBCs with another nurse. The nurse should also verify the information on the label with the provider's order, the blood administration form form the blood bank, and the client armband and blood bracelet

A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? A. Ferrous sulfate B. Epoetin alfa C. Vitamin B12 D. Folic acid

Vitamin B12 *The nurses should expect the client's provider to prescribe vitamin B12 to a client who has pernicious anemia

A nurse is caring for a client who has pernicious anemia. Which of the following factors is associated with this condition? A. Iron deficiency B. Hemoytic blood loss C. Folic acid deficiency D. Vitamin B12 deficiency

Vitamin B12 deficiency *A client who has pernicious anemia is deficient in vitamin B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12

A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D

Vitamin C *Vitamin C deficiency produces signs and symptoms of scurvy, such as delayed wound healing and capillary fragility

A nurse is caring for 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 of 1 kg (2.2 lb) in 1 day B. Pitting edema +1 C. Report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

Weight gain of 1 kg (2.2 lb) in 1 day *A weight gain of 1 kg in 1 day alerts the nurse that the client might be 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 assisting in the preparation of a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Check the client's identification number with the number on the blood C. Witness the informed consent D. Prepare the blood with a Y-type infusion set

Witness the informed consent *Since witnessing the informed conesnt is the least invasive action, it should be performed first. Unless the situation is an emergency, informed consent shouble be obtained prior to initiating a blood transfusion for a client

Sinus Rhythm P Wave *PICTURE OF EKG

the normal (optimal) heart rhythm arising from the sinoatrial node