cardiovascular Unit#2(Ch.30-31)
The nurse is inspecting the tonsils of a client that complaints of a sore throat for six and appearance. What is the appropriate documentation for n observation of tonsils that touch the uvula?
3
The nurse is assisting the physician to control the bleeding for a client who has had an insertion of a vascular access. What can the nurse obtain for the physician to use to control the bleeding?
A fibrin sponge
A client with end stage renal disease has a decreased red blood cell production. What medication can the nurse administer with physician's order that will increase the production of erythrocytes?
Epoetin alfa (Epogen)
When obtaining vital signs from a client who has reduced erythrocyte production and a hemoglobin level of 8.2 g/dL, what results would be indicative of these lab studies?
Heart rate of 120 beats/minute
A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?
Iron
The nurse is caring for a client who is having a side cell crisis. Which order for analgesic should the nurse consult with the physician?
Meperedine (Demerol)
Undifferentiated cells that migrate to the thymus gland develop into which of the following?``
T lymphocytes
A client is volunteering to donate blood for the second time and was mailed a letter telling him that he is type AB blood. If the client requires a blood trans fusion in the future, what type of blood use he receive?
They can receive blood from persons with any type of blood if the RH factor is compatible.
Macrophages attack and destroy foreign substances to the body. Where does this action occur?
at the site of trauma
Why would it be important for the nurse to obtain information regarding dietary history client with possible abnormality of the hematopoietic or lymphatic system?
compromised nutrition interferes with production of blood cell and hemoglobin
The nurse observes that a client who had an arterial blood gas performed 30 minutes still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood clot?
platelets
A client is expecting chromes hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find this client when collecting objective data?
postural hypotension
You are assisting your client with multiple myeloma to ambulate. What is the most important nursing diagnosis too let prevent fractures in this client?
safety
A patient's family member asks what hematopoiesis is. What should the nurse tell the family member?
the manufacture and development of blood cells
A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?
the spleen is lymphatic structure and assists with phagocytosis
The nurse is discussing vitamin replacement with a client in the clinic. Which vitamin would the nurse discuss with the client in order to increase the absorption of folic acid and iron?
vitamin C
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time. and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron deficiency anemia?
erythrocytes that are microcytic and hypo chromic
A client is taking a medication that has the side effect of depressing the hematopoietic system. What signs of leukopenia should the nurse monitor for while the client is taking this drug?
five, sore throat, and chills
A 15 year old client with hemophilia sustains a leg laceration after falling off of his skateboard and is brought to the emergency department. The laceration is bleeding profusely even direct pressure to the site. What does the nurse anticipate will be ordered for administration to continue bleeding?
fresh frozen plasma
The LPN is following a plan of care fo a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assess vital signs and O2 saturation and observes saturation at 89% for 3 minutes. What should the first action by the nurse be?
give oxygen per nasal cannula
Albumin is a protein in the plasma portion of the. blood. Under normal conditions, albumin cannot pass through the wall of capillary. What significance is this for the vascular compartment?
helps retain fluid in the vascular compartment
A client has laboratory studies that determine he is deficient in copper. What does the nurse understand is the importance of copper in the body?
involved in the transfer of iron from storage plasma
A client was admitted to the hospital with pathologic pelvic fracture. The client informs nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on the symptoms?
multiple myeloma
A client with diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate?
neurologic involvement
A client is being treated I the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
notify the physician
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?
observe stools for blood
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?
obtain the pain medication and delay the bath and position change until the medication reaches its peak
The nurse is caring for an older adult client with hemolytic anemia. What does the nurse understand about the reason this client is most susceptible to this disorder?
older adult clients often take more medications than younger people
The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest. What would be the best position for the nurse to place the client in for the test?
on the side opposite the aspiration site
You are caring for a client with multiple myeloma. Why would it be important to assess the client for fractures?
osteoclasts breakdown bone cells so pathologic fractures occur
The nurse will be assisting the physician with a bone marrow aspiration.Where should the nurse cleanse, clip hair, and drape he skin prior to the procedure?
over the posterior superior iliac crest
The nurse is caring for a client who is developing hypovolemic shock fro ma duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?
place the client in a modified trendelenburg position
The nursing instructor is teaching her clinical group about laboratory blood tests. What is the major function of erythrocytes ?
transportation of O@ to the tissues and removal of CO@ from the tissues
The nurse caring for an older adult with diagnosis of leukemia would encourage the client to use an elector razor. why?
trauma and micro abrasions may contribute to anemia
A client is in the hospital with bleeding gastric ulcer and requires a blood transfusion.He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client ?
type O
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?
urine output of 15 mL/hour
A client diagnosed with polycythemia vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. What complication would you suspect this client ?
congestive heart failure
A client is seen in the emergency department with sever pain related to a sickle cell crisis.What does the nurse understand is occurring with this client?
vascular occlusion in small vessels decreasing blood and oxygen to the tissues
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such s contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?
contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart?
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron deficiency anemia. What should the nurse include in the instructions?
dilute the liquid preparation with another liquid such as Mylanta
A client informs the nurse that he is having a difficult time coping with seasonal allergies and have taken over the counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies?
elevated eosinophils
A client is seeing the physician at the clinic and tells the nurse he is fatigued and short of breath with minimal exertion. What lab study may reflect a decrease in transport of oxygen?
erythrocyte count
The nurse is caring for four clients on the medical surgical unit of the hospital. What client mostly likely to be receiving treatment for sickle cell crisis?
a 19 year old African American male
The nurse is assisting the physician with obtaining a sample to determine the status of blood cell formation. What type of procedure will the nurse hav prepared the client for?
a bone marrow aspiration
A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client?
acute chest syndrome
A client is scheduled for a bone marrow aspiration and is extremely apprehensive about having the procedure done. The nurse explains. hat there may be a feeling of pressure or discomfort when puncturing the bone. What intervention can the nurse provide to assist with this concern?
assist the client with focused imagery to avoid focusing on the procedure and any discomfort associated with it.
You are caring for an 87 year old female who has been admitted to your unit with anemia. What would you suspect?
blood loss from the gastrointestinal or genitourinary tract
The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin?
bronze of the skin
You are caring for three clients who have the following blood count values: Client A had 24,500/mm3 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm3 platelet count. Which statement correctly describes the condition of each client?
client A had a higher WBC count than normal, client B has a normal hemoglobin, and client C has a normal platelet count.
The nursing instructor is talking with her clinical group about coagulopathies. How should the instructor define coagulopathies?
coagulopathies are bleeding disorders that involve platelets or clotting factors
