COTAC CARDIAC ATI PREP

What diagnostics would be ordered to help diagnose infectious and inflammatory disorders of the heart?

-Blood cultures -Blood count -Cardiac Enzymes -ESR/CRP (inflammatory markers, but can't tell you where the inflammation is) -EKG -Echo -Strep -Chest Xray

What are the frequently seen clincial manifestions of a MI (heart attack)?

-Chest pain -Left arm pain -Shortness of breathe -Nausea/Indigestion -Cool pale moist skin -Increased RR + HR -Anxiety

Pharmalogical management of valve disorders may include which classes of medications?

-Diuretics -Afterload reducing agents (BP meds) -Positive Inotropic Agents (Digoxin) -Anticoagulants -Antiarrythmics

What are interventions to help with hypervolemia (fluid overload)?

-Fluid restrictions -Low sodium diet -Monitor Is/Os -DiureticsWhat can

What are 5 modifiable risk factors for CAD?

-Smoking-Hypertension -Cholesterol (LDL) -Diabetes Mellitus -Obesity -Activity

The pathway of electricity of the Heart

1. SA Node 2. AV Node 3. Bundle of His 4. L & R Bundle Branches 5. Pukinji Fibers 6. Myocardium

What's the pathway of the heart?

1. Superior Vena Cava 2. Pulmonary Artery 3. Right Atrium 4. Right Ventricle 5. Pulmonary arteries 6. Pulmonary Veins 7. Left Atrium 8. Left Ventricle 9. Aorta

What is normal venous pressure?

2-6

We check troponin levels every _____ hours

4 (This is done to see what the trend is, we want the levels to trend down to know the cardiac event has passed)

The average Cardiac Output in a resting adult

4 to 6L/min

Average resting stroke volume

60 - 130 mL

Three types of percutaneous coronary interventions (PIC)

Artherectomy Stent Balloon

A nurse is providing teaching about lifestyle changes to a client who experienced a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? A."I should eat foods that are high in saturated fat." B. "Before taking my medication, I will count my 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."

B. "Before taking my medication, I will count my radial pulse rate." (Rationale: A beta blocker will induce bradycardia. The client should take the pulse rate for 1 minute before self-administration.)

These are frequently seen clinical manifestations of a MI

CP left arm pain SOB nausea/indigestion cool pale moist skin increased HR and RR anxiety

What is Cardiac Depolarization ?

Cardiac depolarization is a reversal of charges at a cell membrane so that the inside of the cell becomes positive in relation to the outside; the opposite of the cells resting state in which the inside of the cell is negative in relations to the outside.

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

D. Superior vena cava (Rationale: The nurse should identify that the superior and inferior vena cava carry deoxygenated blood to the right atrium.)

When occluded, I am known as the widow-maker

Left Anterior Descending Artery

Clinical manifestations of what condition include hypotension, muffled heart sounds, JVD, and paradoxical pulse?

Pericardial Tamponade

What type of chest pain exhibits pain that is experiencing sharp, severe substernal or epigastric pain. The pain can radiate to neck arms and back. Associated symptoms may be fever malaise, dyspnea, cough, nausea, dizziness and palpitations.

Pericarditis

What are the differences between a right and left heart catheter?

Right --In a vein -Can be left in -Biopsy Left --In an artery -Cannot left in -Biospy is possible -Looks at coronary vessels

Cough, crackles, restlessness, and dyspnea on excertion are what?

Symptoms of left-sided heart failure

What type of chest pain exhibits pain or discomfort ranges from mild to severe. Associated with shortness of breath diaphoresis, palpitations, unusual fatigue and nausea or vomiting.

Unstable Angina

What is Cardiac Repolarization ?

When the ions return to their resting state after depolarization

What is unstable angina ?

chest pain not relieved by rest or nitrolgycerin

What is stable angina ?

chest pain relieved with rest or nitroglycerin

Symptoms of Left Sided Heart Failure

cough crackles dyspnea on exertion restlessness

unstable angina

unstable chest pain that does not go away

What are nursing interventions for a patient with heart failure?

-Low sodium diet -Fluid restrictions -Monitoring vital signs -Bed rest + energy conservation -Lung assessments -Is + Os-Monitor Labs

What are the risk factors for infective endocarditis?

-Structural malformities (any congenital heart defect)-Implanted cardiac devices-Prosthetic heart valves-IV drug use-Immunosuppression (always at risk for infection)-Dental procedures (over 30 minutes)-Copper IUD (Anything implanted, especially metal increases the risk of infective endocarditis)

What would you expect to see with hypervolemia?

-Weight Gain-Edema-Crackles in the lungs-JVD (jugular vein distension)

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A."I should check my heart rate at the same time each day." B."I don't have to take my antihypertensive medications now that I have a pacemaker." C. "I should keep a pressure dressing over the generator until the incision is healed." D."I cannot stand in front of our new microwave oven when it is on."

A. "I should check my heart rate at the same time each day." (Rationale: The nurse should instruct the client to check the heart rate at the same time each day and to document the rate in a log for reporting to the provider.)

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.) A. Assess and document the client's vital signs B. Restart the IV with a 22-gauge needle C. Verify with another nurse the blood type and Rh of the packed RBCs D. Hang a bag of lactated Ringer's IV solution E. Change IV tubing to a set that has a filter

A. Assess and document the client's vital signs C. Verify with another nurse the blood type and Rh of the packed RBCs E. Change IV tubing to a set that has a filter (Rationale: The nurse should assess and document the client's vital signs prior to initiating 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 determine whether the client is tolerating the volume of the prescribed blood product. The nurse should verify the blood type and Rh of the packed RBCs with another RN and compare these data with the client's information for compatibility. This action decreases the risk of an ABO incompatibility reaction. The nurse should administer packed RBCs through IV tubing that has a filter to prevent the administration of aggregates and possible contaminants.)

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

A. Elevate the affected leg (Rationale: The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.)

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 intervals

A. Elevated ST segments (Rationale: Elevated ST segments can indicate hyperkalemia and pericarditis.)

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of 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

A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom (Rationale Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI.:)

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor 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.

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

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 of 1 kg (2.2 lb) in 1 day B. Pitting edema +1 C. Client report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

A. Weight gain of 1 kg (2.2 lb) in 1 day (Rationale: A weight gain of 1 kg (2.2 lb) in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's heart failure is worsening.)

Why would you do cardiac enzymes?

After an MI, we commonly see pericarditis

What can Coronary Artery Disease cause?

Angina (ischemic chest pain), Myocardial Infaction (Heart Attack), Cardiac Arrest

What type of chest pain exhibits uncomfortable pressure, squeezing or fullness in sub-sternal chest area, it can radiate across the chest to the medical aspect of one or both arms and hands, jaws, shoulders, upper back or epigastrium. Radiation to arms and hands described as numbness or tingling.

Angina Pectoris

Initially, aortic valve problems cause disturbances on what cardiac structure?

Aortic-ventricular (Hypertrophy + dysrhythmias)

A nurse is assessing 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

B. Crackles in the lung bases (Rationale: Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs.)

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes

B. Prolonged QT intervals (Rationale: Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.)

this type of cardiac valve replacement lasts 7-10 years and 3 months of anticoagulants

Biological valves

These diagnostics would be ordered to help diagnose infectious & inflammatory disorders of the heart

Blood cultures blood count cardiac enzymes ESR/CRP EKG echo strep

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

C. Grilled chicken salad with fresh tomatoes (Rationale: Sodium reduction helps control blood pressure. Grilled chicken salad and fresh tomatoes are free of preservatives and, therefore, are likely to be low in sodium. However, it is essential to make sure the food preparer has not added salt generously to the chicken and the salad.)

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 an MI? A. Headache B. Hemoptysis C. Nausea D. Diarrhea

C. Nausea (Rationale: Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.)

A nurse is preparing to transfuse 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. Compare the client's identification number with the number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs

C. Witness the informed consent document (Rationale: The nurse should apply the least invasive priority-setting framework, which assigns priority to nursing interventions that are the least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, since witnessing the informed consent is the least invasive action, it should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion for a client.)

Stable angina

Chest pain is relived with nitro or rest

Can cause angina, MI or cardiac arrest

Coronary artery disease

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

D. Chest pain lasts for longer than 15 min. (Rationale: A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.)

A nurse is preparing an in-service presentation about the basics of hematology. Which of the following factors provides a stimulus for the production of RBCs? A. Venous stasis B. Thrombocytopenia C. Inflammation D. Tissue hypoxia

D. Tissue hypoxia (Rationale: In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes (RBCs) in the bone marrow.)

Troponin tells us what?

Damage to the cardiac tissue Onset: 3-4 hours Peak: 1 day Duration: 7-10 days

Pharmacological management of valve disorders may include which classes of medications?

Diuretics, afterload reducing agents (BP) positive inotropic agents (dig), anticoagulants antiarrhytmics

What's a parodoxial pulse?

Drop in systolic pressure when holding breath or inhalingThis can only be measured with an arterial line

Primary functions is to evaluate cardiac structures

Echocardigram

One of the primary functions of this test is to evaluate cardiac structures.

Echocardiogram (Helps us see how the pump heart is working as a whole)

Potassium dumping diuretics

Furosemide

What diuretics spare potassium, and which ones hold onto them?

Furosemide - dumps potassium Spironalactone - potassium sparing

What is the only cause of rheumatic endocarditis?

Group A Beta Hemolytic Strep (Causes strep throat)

Cause of Rheumatic endocarditis

Group A Beta-Hemolytic Strep

All valve issues if left untreated will lead to what?

Heart Failure

Elevated troponin indicates what?

Heart damage (most likely from a Myocardial infarction/ heart attack)

If venous pressure is too low (under 2), what's the problem?

Hypovolemia

What is pericarditis? What causes it?

Inflammation of pericardium commonly follows a respiratory infection, can be due to an MI

What is myocarditis? What causes it?

Inflammation of the myocardium Caused by viral, bacterial or fungal infection, crohns or cardiomegaly

What is used to evaluate coronary patency?

Left Heart Catheter

When occluded, what is known as "the window maker"?

Left anterior descending artery (The most commonly occluded coronary vessel and one of the most dangerous)

5 interventions or modifications for heart failure

Low NA diet fluid restrictions monitoring VS bed rest and energy conservation lung assessments I&O's monitor labs patient education

What education would you give to a patient with heart failure?

Low sodium Low fat Know about which diuretic they're on to determine potassium intake

this type of cardiac valves replacement lasts a life time but will need lifelong INR checks

Mechanical valves

What is infective endocarditis? What causes it?

Microbial infection of the endothelial surface of the heart. Typically caused by IV drug use, structural cardiac malformations, prothetic heart valves and splinter hemorrhages

Often caused by mitral valve prolapse

Mitral Reguritation

What is mitral valve regurgitation?

Mitral valve does not close completely- blood backs up into L atrium. The atrium stretches as a result.

What is often caused by mitral valve prolapse?

Mitral valve regurgitation

Initially mitral problems cause disturbances in this cardiac structure and aortic valve problems cause disturbances on this one

Mitral-atrial(hypertrophy and dysrhythmias) Aortic-ventricular(hypertrophy and dysrhythmias)

Initially, mitral valve problems cause disturbances on what cardiac structure?

Mitrial-atrial (Hypertrophy and dysrhythmias)

Unstable angina is a precurser to what?

Myocardial Infarction (Heart attack; NSTEMI or STEMI) which can lead to heart failure

What's the onset, peak, and duration of troponin?

Onset: 3-4 hours Peak: 1 day Duration: 7-10 days

Symptoms of pulmonary edema

Pink frothy sputum; cyanosis, tachycardia, JVD, coughing, anxiety, confusion

What type of chest pain exhibits pain that is sharp or severe substernal or epigastric pain arising from inferior portion of pleura. Patient may be able to localize pain.

Pulmonary Disorders, Pneumonia and pulmonary embolism

Pink frothy sputum is an indication of what complication?

Pulmonary Edema

What type of heart catheterization can be left in for hemodynamic monitoring?

Right heart catheter

Also known as cor pulmonale, symptoms may include JVD, dependent edema, ascites, and fatigue

Right sided heart failure

What's another name for Cor Pulmonale?

Right-sided heart failure

JVD (jugular venous distension), dependant edema, ascites (excess abdominal fluid), and fatigue are all signs of what?

Right-sided heart failure (also known as Cor Pulmonale)

Potassium sparing diuretics

Spironalactone

Diseases that are caused by hardening or thickening of the cardiac valve leaves

Stenosis

What disorders are caused by hardening and thickening of the valve leaves?

Stenosis Think that STenosis STiffens

What are the 3 types of percutaneous coronary interventions?

Stent Arthectomy - Removal of plaquePerc. Transluminal Coronary Angioplasty - put balloon in, squish plaque against the walls, and insert a stentRemember SAP!

Stroke Volume (SV)

The amount of blood ejected from one of the ventricles per heartbeat.

Cardiac Output (CO)

The total amount of liters of blood ejected by one of the ventricles per minute.

What Lab is used to diagnose a MI

Troponin

What is the lab used to diagnose a Myocaridal Infarction (heart attack)?

Troponin

What would be a concerning troponin level?

Troponin over 0.03

These medications are commonly used in treatment of infectious and inflammatory diseases of the heart

antibiotics antipyretics anti-inflammatories antifungals antivirals pain medication

If venous pressure is too high (over 6), what's the problem?

hypervolemia - we see this with heart failure

Signs and Symptoms of Cardiac Tamponade

hypotension muffled heart sounds JVD paradoxical pulse

I evaluate coronary artery patency

left heart cath

Cardiac Contractility

refers to the force generated by the contracting myocardium

Which type of heart catheterization can be left in for hemodynamic monitoring

right heart cath

Risk factors for infective endocarditis

structural malformations cardiac implants or devices prothetic heart valves IV drug use immunosupression

Cardiac Preload

the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole

Cardiac Ejection Fraction

the percentage of the end-diastolic blood volume that is ejected with each heartbeat.

Cardiac Afterload

the resistance to ejection of blood from the ventricle, and is the second determinant of stroke volume.

What caused Rheumatic Endocarditis?

untreated strep throat

A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home? A. "I'll stick with soft foods for now." B. "My family will be bringing me fresh flowers today." C. "I'll use a new disposable razor each day." D. "I'll blow my nose more often to avoid nosebleeds."

A. "I'll stick with soft foods for now." (Rationale: Thrombocytopenia (a low platelet count) is common after a bone marrow transplant. To prevent bleeding until the client's platelet count improves, the client should avoid hard foods that could cause mouth trauma.)

A nurse is 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 hr for bleeding D. Administer an enema as needed for constipation

B. Measure the client's abdominal girth daily (Rationale: The nurse should 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 of bleeding due to delayed clotting.)

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? 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."

A. "I can snack on fresh fruit." (Rationale: 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 preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give 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 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 hr."

A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure." (Rationale: Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° 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 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 fibrinolysis 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 other clots from forming."

A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." (Rationale: Fibrinolysis is a process that breaks down a clot over time in the body. This process is a treatment option for clots that are not immediately life-threatening.)

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

A. Beef liver (Rationale: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 teaching about a low-cholesterol diet to 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

A. Chicken breast and corn on the cob (Rationale: 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. Coarse crackles B. Wheezes C. Rhonchi D. Friction rub

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

A nurse is assessing 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

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference (Rationale: Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.)

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

A. Hyperkalemia (Rationale: 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 assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia (Rationale: Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.)

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

A. Increased hematocrit level (Rationale: The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume.)

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 distension B. Moist crackles D. Increased heart rate (Rationale: The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses.)

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 alterations? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency

A. Necrosis (Rationale: ST-segment 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 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 (Rationale: 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 caring for a client who is postoperative following 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. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr 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. Position the client supine with his legs elevated when in bed (Rationale: 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 with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 9.8 g/dL D. Calcium 8.0 mg

A. Potassium 2.8 mEq/L (Rationale: A flattened T wave or the development of U waves is indicative of a low potassium level.)

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit

A. Prothrombin time (Rationale: The nurse should review the client's 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 a set rate of 72/min. Which of the following findings should the nurse expect? A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes B. Premature ventricular complexes at 12/min C. Telemetry monitoring showing pacing spikes with no QRS complexes D. Hiccups

A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes (Rationale: 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 reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch 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

A. Turkey on whole-wheat bread (Rationale: 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 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

A. Ventricular dysrhythmias (Rationale: The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.)

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2 g sodium diet. Which of the following statements by the client indicates an understanding 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."

B. "I can have yogurt as a dessert." (Rationale: The client understands the teaching when he selects yogurt as a dessert. Yogurt is low in fat and sodium and is a good source of calcium and protein.)

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

B. Ankle swelling (Rationale: 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/mm^3. 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 5 min C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol

B. Apply pressure to the catheter removal site for 5 min (Rationale:A platelet count below 100,000/mm^3 indicates thrombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure to the site for at least 5 minutes, the nurse promotes coagulation and prevents additional blood loss.)

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS pattern

B. Atrial rate of 300/min with QRS complex of 80/min (Rationale: The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.)

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-hr period D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride

B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride (Rationale: The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the blood steam. In addition, the nurse should ask another nurse to check the packed RBCs label against the medical record for safety verification. The nurse should ensure that the client's complete name and identification number match and that the blood group name and number are correct. If there is any type of discrepancy, the nurse should not infuse the blood and should notify the blood bank. Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs.)

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B.Dysrhythmias C. Heart failure D.Pulmonary edema

B. Dysrhyrhmias (Rationale: According to evidence-based practice, 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 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 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 (Rationale: A client who receives FFP 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 red blood cells (RBCs) to a client who is postoperative. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? A. Maintain 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 (Rationale: Using the urgent vs. non-urgent priority-setting framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.)

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates 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."

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

A nurse is providing discharge teaching for 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. "Keep your cell phone 6 inches away from your pacemaker when making a call." D. "Avoid showering for the first 2 weeks following surgery."

C. "Keep your cell phone 6 inches away from your pacemaker when making a call." (Rationale: The nurse should instruct the client to keep a cell phone 6 inches away from the pacemaker when making a call to avoid interfering with the function of the generator inside the client's pacemaker.)

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates 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."

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

A nurse is assessing a client who had coronary artery bypass grafts 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 pulsus paradoxus D. Check for a pulse deficit

C. Auscultate blood pressure for pulsus paradoxus (Rationale: The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.)

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. 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 135 mg

C. Elevated LDL levels (Rationale: An elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL.)

A nurse is providing teaching to 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.

C. Hypertension is a common adverse effect of this medication. (Rationale: A common adverse effect of epoetin alfa is hypertension 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 red blood cell level.)

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 supplementation B. Increase dietary intake of folic acid C. Initiate weekly injections of vitamin B12 D. Initiate a blood transfusion

C. Initiate weekly injections of vitamin B12 (Rationale: The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia and then decrease the injections to a monthly schedule. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.)

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

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

A nurse is assessing 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

C. Report of sudden, severe back pain (Rationale: An aortic aneurysm is a weak spot in the wall of the aorta (the primary artery that carries blood from the heart to the head and extremities) that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.)

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 the nose every 5 min B.Instruct the client to sit with his head hyperextended C.Apply ice compresses to the back of the client's neck D.Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min (Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.)

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

D. Apply the defibrillator pads to the client's chest (Rationale:After obtaining the AED, the nurse should first 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 the 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 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 (Rationale: Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema.)

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

D. Encourage increased fluid intake (Rationale: The nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can aggravate sickling and client discomfort.)

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 (Rationale: An abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.)

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? A. Instruct the client about a long-term cardiac conditioning program B. Administer scheduled doses of acetaminophen C. Check for peak laboratory markers of myocardial damage D. Monitor for bleeding

D. Monitor for bleeding (Rationale: Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis is assured.)

A nurse is assessing a client for 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

D. Petechiae and ecchymosis (Rationale: A client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all 3 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 is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion

D. Stop the medication infusion (Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.)

A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? A. Warm the unit of blood to room temperature before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate (Rationale: These are the manifestations of a hypervolemic reaction due to circulatory overload, which likely occurs when the blood transfusion is too rapid for the client's size or status. To prevent this problem with future transfusions, the nurse should use a transfusion pump to regulate the transfusion at a slower rate.)

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

D. Vitamin B12 deficiency (Rationale: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 checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps? Identify the first BP sounds audible on expiration and then on inspiration. Deflate the cuff slowly and listen for the first audible sounds. Subtract the inspiratory pressure from the expiratory pressure. Inspect for jugular venous distention and notify the provider. Palpate the blood pressure and inflate the cuff above the systolic pressure.

Palpate the blood pressure and inflate the cuff above the systolic pressure. Deflate the cuff slowly and listen for the first audible sounds. Identify the first BP sounds audible on expiration and then on inspiration. Subtract the inspiratory pressure from the expiratory pressure. Inspect for 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 hr. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

10 (Rationale: To solve using ratio and proportion and "desired over have" methods: Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the volume the nurse should infuse? 250 mL Step 3: What is the total infusion time? 4 hr Step 4: Should the nurse convert the units of measurement? Yes (hr does not equal min) 1 hr/60 min = 4 hr/X min X = 240 min Step 5: Set up an equation and solve for X. Volume (mL)/Time (min) x drop factor (gtt/mL) = X gtt/min 250 mL/240 min x 10 gtt/mL = X gtt/min X = 10.4 gtt/min Step 6: Round if necessary. 10.4 gtt/min = 10 gtt/min Step 7: Reassess to determine whether the amount to administer makes sense. If the prescription is for packed RBCs (250 mL) X 10 gtt/mL infused over 240 min, the nurse should set the manual IV infusion to deliver packed cells (250 mL) to infuse at 10 gtt/min. To solve using dimensional analysis: Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the quantity of the drop factor that is available? 10 gtt/mL Step 3: What is the total infusion time? 4 hr Step 4: What is the volume the nurse should infuse? 250 mL Step 5: Should the nurse convert the units of measurement? Yes (hr does not equal min) 1 hr/60 min Step 6: Set up an equation and solve for X. X gtt/min = Quantity/1 mL x Conversion (hr)/Conversion (min) x Volume (mL)/Time (min) X gtt/min = 10 gtt/1 mL x 1 hr/60 min x 250 mL/240 min X = 10.4 gtt/min Step 7: Round if necessary. 10.4 gtt/min = 10 gtt/min)

A nurse is teaching a client with heart disease about a low-cholesterol diet. 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 preparing meals." D. "I can use whole milk in my oatmeal."

A. "I should remove the skin from poultry before eating it." (Rationale: The nurse should identify the client understands the teaching when he states he will remove the skin from poultry before eating, as the skin contains the greatest amount of fat.)

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates 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?"

A. "I would never have believed I could get used to enjoying my food without salt." (Rationale: This statement implies that the client has stopped adding salt to food. Sodium restriction is a single aspect of the treatment plan, but it does indicate dietary adherence by the client.)

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. Exophthalmos D. Spondylolisthesis

B. Epistaxis (Rationale: Epistaxis (a nosebleed) 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 completing an assessment on 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

B.Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking (Rationale: A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for coronary artery disease (CAD). Hypertension and hyperlipidemia 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 recommendations. Cholesterol levels, such as total HDL and LDL levels, should be monitored since elevated total serum cholesterol levels increase the risk of a myocardial infarction. Finally, 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 caring for a client who reports calf pain. What 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

C. Check the affected extremity for warmth and redness (Rationale:The first action the nurse should take using the nursing process is to assess the client's calf for swelling, redness, and warmth. These findings can indicate a deep vein thrombophlebitis.)

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 (Rationale: 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 caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (Select all that apply.) A. Use a 5 mL syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use

C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use (Rationale : The nurse should flush the line with 10 mL of sterile 0.9% sodium chloride solution before and after administering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger. PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line.)

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 hr prior to my test." B. "I can eat a light meal 1 hr prior to the test." C. "I can have a cigarette up to 30 min prior to the test." D. "I will take my heart medication on the day of the test."

"I will not drink coffee 4 hr prior to my test." (Rationale: 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 rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade

A. Acidosis (Rationale: Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1°C (1.8°F) per hour.)

A nurse is caring for a client who has 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 antihypertensive medication for blood pressure B. Monitor to ensure the client's urinary output is 20 mL/hr C. Withhold pain medication to prepare the client for surgery D. Take the client's vital signs every 2 hr

A. Administer antihypertensive medication for blood pressure (Rationale: The nurse should administer antihypertensive medication for elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.)

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

A. Avoid IM injections (Rationale: This client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding.)

A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? (Click on "Exhibit NCLEX 3" under Resources on the right-hand side for additional information about the client) A. BNP of 200 pg/mL B. Bradycardia C. Fluid restriction of 3 L per day D. 4 g sodium diet

A. BNP of 200 pg/mL (Rationale: 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 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

A. Decreased albumin (Rationale: A decrease in the 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 teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Eggs B. Squash C. Kale D. Tofu

A. Eggs (Rationale: The nurse should encourage the client to increase consumption of foods rich in vitamin B12, such as dairy products, animal protein, poultry, shellfish, and eggs.)

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

A. Erythropoietin (Rationale: Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.)

While participating in a community health fair, a nurse is providing information to a client who has a blood pressure of 150/90 mmHg during 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

A. Give the client a written record of his BP to bring to his provider (Rationale: Since this client has an elevated BP reading from a hypertension screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider.)

A nurse is teaching 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

A. Lentils (Rationale: 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 providing discharge teaching to an adult female 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 ask my provider to change my contraception to an intrauterine device." B. "I will notify my doctor before I have dental procedures." C. "I will avoid using antiseptic mouthwash for oral care." D. "I will wear a mask when I go out in public."

B. "I will notify my doctor before I have dental procedures." (Rationale: 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 invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection.)

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

B. A client who is a vegetarian D. A client who is pregnant E. A toddler who is overweight (Rationale: A client who is a vegetarian might require additional iron because the availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for iron-deficiency anemia.)

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

B. Hgb 6.5 g/dL (Rationale: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, pallor, dizziness, and tachycardia.)

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

B. Increased pulmonary congestion (Rationale: Pulmonary congestion is a manifestation of mitral valve stenosis. Because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilates. The increased pressure results in a backflow of blood from the left atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion.)

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 than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm

B. Much greater amplitude than the usual QRS complexes (Rationale:The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs.)

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 (Rationale: 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, which can result in a long-term loss of range of motion in repeatedly affected joints.)

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 the chest and arms D. Flushed, dry skin E. Abdominal distension

B.Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension (Rationale: 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, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distension due to internal bleeding.)

A nurse is teaching 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."

C. "Elevate your legs when sitting." (Rationale: Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation.)

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 plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen."

C. "Platelets plug breaks in blood vessels." (Rationale: The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.)

A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with 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."

C. "Variant angina can cause changes on your electrocardiogram." (Rationale: Variant angina causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium.)

A nurse is preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in preoperative teaching? 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."

C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow." (Rationale: The nurse should prepare the client to expect a painful, pulling sensation when the provider aspirates the marrow as well as some discomfort from the rotation of the needle into the bone.)

A nurse is assessing 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

C. Absence of hair on the legs (Rationale: A 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 has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST-segment depression B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D. Chest pain that increases when sitting upright

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

C. Elevated Hct (Rationale: The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration.)

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

C. Substernal chest pain (Rationale:Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.)

A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temperature C. Sudden oliguria D. Decreased respirations

C. Sudden oliguria (Rationale: The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs.)

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

C. Ventricular dysrhythmias (Rationale: 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 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

C. Vitamin B12 (Rationale: The nurse should expect the client's provider to prescribe vitamin B12 for pernicious anemia.)

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

C. Vitamin C (Rationale: Vitamin C deficiency produces symptoms of scurvy such as delayed wound healing and capillary fragility.)

A nurse is teaching a 70-year-old client about risk factors for heart 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 will not increase my risk of heart failure." B. "My asthma makes it more likely for me to have heart failure." C. "My age does not increase my risk of heart failure." D. "My coronary artery disease is a risk factor for heart failure."

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

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should 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

D. 0.9% sodium chloride (Rationale: Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride (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 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

D. Impaired circulation (Rationale: Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's toes. Severe arterial disease is identified through an assessment of the quality of the client's posterior tibial pulses by comparing the pulses in both feet.)

A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A. A dressing is not applied to the port site after use. B. A 22-gauge non-coring needle is used to access the port. C. Blood return is noted prior to administering the medication. D. A solution of 5 mL heparin 1,000 units/mL has been prepared.

D. A solution of 5 mL heparin 1,000 units/mL has been prepared. (Rationale: Implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing." It is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action requires intervention by the charge nurse.)

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

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

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

D. Ample hydration (Rationale: A client who is in sickle cell crisis needs ample hydration (either IV, oral, or both) to shorten the duration of painful episodes. The nurse should plan to offer the client water, juice, or a favorite beverage that does not contain caffeine.)

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

D. Iron toxicity (Rationale: A client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as in sickle cell anemia.)

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 from the client B. Apply pneumatic compression boots to the client C. Request a referral for a speech-language pathologist D. Keep the client NPO

D. Keep the client NPO (Rationale: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 has been completed. A client who has experienced a cerebrovascular accident is at risk for dysphagia, which increases the change of life-threating aspiration.)

A nurse is assessing 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. Paresthesia C. Hypertension D. Low back pain

D. Low back pain (Rationale:Low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include a headache, chest pain, tachypnea, tachycardia, and dark urine.)

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? A. The percentage of blood the ventricles pump during each beat B. The amount of blood the left ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume

D. The heart rate times the stroke volume (Rationale: Cardiac output is the product of the client's heart rate and stroke volume (the amount of blood the left ventricle pumps with each contraction). In systolic heart failure, the heart cannot pump enough oxygenated blood into the circulation, causing cardiac output to decrease.)