Evolve Cardiovascular System, Blood, and Lymphatic Systems
Which client should a nurse consider the greatest risk for developing hypernatremia?
63-year-old who has had watery diarrhea since traveling abroad
A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg, the second sound is a swishing sound heard at 130 mm Hg, a tapping sound is heard at 100 mm Hg, a muffled sound is heard at 90 mm Hg, and the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure?
72 mm Hg
When assessing a client with heart failure, the nurse asks when the client most notices an increase in symptoms. Which activity should the nurse expect will cause the client the greatest distress?
Climbing a flight of stairs to the bedroom
When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? (Select all that apply.)
Confusion Poor tissue turgor
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiological effect of nicotine should the nurse explain to the group?
Constriction of the peripheral vessels increases the force of flow
A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take?
Continue to monitor the client
A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? (Select all that apply.)
Coughing Orthopnea Diaphoresis
The occurrence of which condition would warrant the nurse calling the primary health care provider to discontinue the intravenous (IV) fluids?
Crackles in lungs
When assessing a client with the diagnosis of left ventricular failure, the nurse expects to identify:
Dyspnea on exertion
What clinical indicators are the nurse most likely to identify when taking the admission history of a client with right ventricular failure? (Select all that apply.)
Edema Dyspnea
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is:
Elevate the head of the bed and obtain vital signs
The nurse understands that shock associated with a ruptured abdominal aneurysm is called:
Hypovolemic shock
A client who had a myocardial infarction asks the nurse, "What's the chance of me having another heart attack if I watch my diet and stress levels carefully?" The most appropriate initial response by the nurse is to:
Identify the concerns and help the client explore feelings
A client who recently was diagnosed as having myelocytic leukemia discusses the diagnosis by referring to statistics, facts, and figures. The nurse determines that the client is using the defense mechanism known as:
Intellectualization
Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? (Select all that apply.)
Irregular pulse rate Orthostatic hypotension
A blood donor whose blood type is O-negative is known as a "universal donor." What does the nurse consider about O-negative blood that accounts for this classification?
It does not have any of the antigens that can cause a reaction
A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. What is the priority nursing intervention for this client?
Provide pain medication
Digoxin (Lanoxin) and furosemide (Lasix) are prescribed for a client with the diagnosis of pulmonary edema. What client response to digoxin is unrelated to toxicity?
Pulse of 64
A client's blood pressure increases dramatically 6 hours after a femoral-popliteal bypass graft. Which concern motivates the nurse to inform the health care provider?
Rapidly increasing blood pressure may rupture the graft.
After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response?
Reduction in circulating blood volume
A client admitted to the hospital for chest pain is diagnosed with angina. The nurse should teach the client that the most common characteristic of anginal pain is that it is:
Relieved by rest
A client who had a femoropopliteal bypass graft is receiving clopidogrel (Plavix) postoperatively. What should the nurse teach the client related to the medication?
Report multiple bruises on the extremities
A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? (Select all that apply.)
Reports of leg fatigue Tortuous veins in the legs Pain in lower extremities when standing
One week after admission to the cardiac care unit a client displays an outburst of anger and tells the nurse to get out of the room. Which is the most appropriate nursing action?
Return when the client has calmed down
A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness?
Rheumatic fever
A client has an open reduction and internal fixation of a fractured hip. To prevent the most common complication after this type of surgery, the nurse expects the client's postoperative plan of care to include:
Sequential compression stockings
A woman comes to the emergency department reporting signs and symptoms determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? (Select all that apply.)
Severe fatigue Sense of unease
A nurse is providing discharge medication teaching to a client who will be taking furosemide (Lasix), digoxin (Lanoxin), and potassium chloride (K-Dur) after discharge from the hospital. What information is most important for the nurse to include in the teaching plan?
Signs and symptoms of digoxin toxicity
A client who recently started receiving oral corticosteroids for a severe allergic reaction is instructed that the dosage will be reduced gradually until all medication is stopped at the end of two weeks. What reason should the nurse provide for this gradual reduction in dosage?
Slow reduction of the drug will prevent a physiological crisis because the adrenal glands are suppressed
A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? (Select all that apply.)
Slowed neurological responses Forgetfulness about recent events Reduced ability to maintain an erection
A client with heart failure is to receive digoxin (Lanoxin) and asks the nurse why the medication is necessary. The nurse explains that digoxin:
Slows and strengthens cardiac contractions
A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse expect to be listed on the client's plan of care?
Small, frequent intake of juices, broth, or milk
A nurse reviews the plan of care for a client who is recovering from the acute phase of left ventricular failure. The nurse expects which dietary restriction to be included on the plan?
Sodium
A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary?
Spinach salad
A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? (Select all that apply.)
Stupor Paresthesia in affected body parts
A health care provider in the emergency department identifies that a client is in mild hypovolemic shock. Which type of drug should the nurse anticipate will be prescribed?
Sympathomimetic
A client develops internal bleeding after an abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? (Select all that apply.)
Pallor Tachycardia
During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client?
Palpable pulsating abdominal mass
Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? (Select all that apply.)
Palpitations Tachycardia Nervousness
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care?
Perform a neurovascular assessment every two hours
A client develops heart failure. Which response should the nurse expect when assessing the client?
Peripheral edema
A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Recognizing that adherence to a medical regimen improves with understanding, the nurse explains that the salt must be limited to:
Prevent further accumulation of fluid, which increases the workload of the heart.
A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? (Select all that apply.)
Profuse diaphoresis Rapid IV infusion of 5% dextrose in water
Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate?
Protamine sulfate to parenteral heparin
A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?
Verify the pulse by using a Doppler
A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, the nurse explains to the client that the major purpose for catheterization is to:
Visualize the disease process in the coronary arteries
What should the nurse expect the health care provider to prescribe if a client exhibits clinical indicators of warfarin (Coumadin) overdose?
Vitamin K
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? (Select all that apply.)
Vomiting Muscle weakness Irregular heart rate
A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60. The nurse should assess the client for an early sign of decreased arterial pressure which is:
Weak radial pulses
A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? (Select all that apply.)
Weight Smoking
When performing a physical assessment, the nurse identifies bilateral varicose veins. What does the nurse expect the client to report about the legs?
Worsening ankle edema as the day progresses.
A client is hospitalized with chest pain. The client's spouse voices concern about how pale the client is. What is the best response by the nurse?
You must be frightened by this."
A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. The nurse's best response is, "They are caused by:
ncompetent valves of superficial veins.
Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? (Select all that apply.)
nstruct the client to avoid crossing the legs Instruct the client to dorsiflex the feet routinely
A client with arterial insufficiency of both lower extremities is visited by the home health care nurse. An essential nursing intervention is to teach the client to:
Check pulses in the legs regularly
A client with intermittent claudication has been instructed to stop smoking. The nurse explains that the reason that the client should quit smoking is because:
"Cigarette smoking is not suggested for clients like you that have vascular problems."
The nurse provides discharge teaching to a client who has received prescriptions for digoxin (Lanoxin), furosemide (Lasix), and a 2-gram sodium diet. The nurse evaluates that further teaching is needed when the client states:
"I can use a little table salt on my food as long as I do not use it when cooking."
Potassium supplements are prescribed for a client receiving diuretic therapy. What client statement indicates that the teaching about potassium supplements is understood?
"I will report any abdominal distress."
A client requiring surgery because of mitral valve incompetence is admitted to the hospital and states, "I need a new valve, with an oil change, too!" What is the nurse's most therapeutic response?
"I'm sure you have a great deal to ask about your surgery."
A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond?
"This surgery significantly decreases symptoms in most clients."
A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. The behavior that demonstrates an increase in client autonomy is when the client:
1. Actively participates in providing self-care
A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding?
Chemical irritation to the tissues
While obtaining a health history, a nurse expects a client admitted to the hospital with chronic heart failure to report:
A need to use three pillows at night to sleep
An ECG is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. To confirm the presence of hypokalemia, the nurse expects the primary health care provider to prescribe:
A serum electrolyte level
The nurse recognizes that an early finding that indicates that a client is hypertensive is:
A throbbing headache over the left eye when arising in the morning
The spouse of a client who had emergency coronary artery bypass surgery asks why there is a dressing on the client's left leg. The nurse explains that:
A vein in the leg was used to bypass the coronary artery
he person with which type blood is considered a universal blood recipient?
AB
A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? (Select all that apply.)
Absence of hair on the toes Reports of pain associated with exercising
The health care provider prescribes isosorbide dinitrate (Isordil) 10 mg as needed three times a day and a nitroglycerin transdermal disk once a day for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. The nurse's best response is, "The isosorbide dinitrate:
Allows more oxygen to get to heart tissue."
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?
Arteriolar constriction occurs
A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take?
Assess the pulses distal to the dressing
A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. What is an appropriate postoperative nursing intervention on the day after surgery?
Assist the client with walking
A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which parameters should the nurse consider to determine the safe resumption of sexual activity? (Select all that apply.)
At least between 4 and 6 weeks after the myocardial infarction The point at which two flights of stairs can be climbed without dyspnea
To determine the status of a client's carotid pulse, the nurse should palpate:
At the anterior neck, lateral to the trachea
A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk factor for the development of a pulmonary embolus?
Atrial fibrillation
A nurse is teaching a client who had a myocardial infarction about the prescribed 1500-calorie, 2-gram-sodium, weight-reducing diet. Which low-sodium, low-calorie nutrients should the nurse recommend that the client include in the diet? (Select all that apply.)
Baked chicken Mashed potatoes
A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects that a diagnostic finding specific for multiple myeloma is:
Bence Jones protein in the urine
What client response indicates to the nurse that a vasodilator medication is effective?
Blood pressure changes from 154/90 to 126/72
A client who has been taking digoxin (Lanoxin) for 20 years is hospitalized. The client exhibits signs of dehydration and laboratory results identify the presence of hypokalemia. The nurse should monitor the client for which clinical finding indicating digoxin toxicity?
Blurred vision
A nurse expects that a client with right-sided heart failure will exhibit:
Distended neck veins
A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? (Select all that apply.)
Decreased heart rate Decreased bowel sounds
Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? (Select all that apply.)
Decreased urine Hypotension Dry mucous membranes Poor skin turgor
A client with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client?
Decreased white blood cells
A nurse is assessing a middle-aged female client for the presence of risk factors associated with coronary heart disease. Which risk factor carries a greater risk for women than for men?
Diabetes mellitus
Which significant risk factors for coronary heart disease carry a greater risk for women than for men? (Select all that apply.)
Diabetes mellitus Low levels of high-density lipoprotein (HDL) cholesterol
A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?
Feeling of heaviness in both legs
A client develops iron deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased?
Ferritin level
A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial response?
Focus on the client's feelings by exploring the reason why the question was asked.
A client is receiving a 2-gram sodium diet. The family asks whether they can bring snacks from home. The nurse suggests that they bring foods low in sodium such as:
Fresh orange wedges
Which factors should the nurse identify that can precipitate hyponatremia? (Select all that apply.)
Gastrointestinal (GI) suction Diuretic therapy Continuous bladder irrigation
A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the health care provider probably will insert a pacemaker?
Heart block
A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings should alert the nurse to the possible development of the life threatening response of thrombocytopenia? (Select all that apply.)
Hematuria Ecchymosis
A client had a total knee replacement several days ago and has been receiving warfarin sodium (Coumadin) therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the health care provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. The next action the nurse should take is to:
Maintain the client on bed rest until the health care provider reviews the laboratory results
When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse expects that the body initially attempts to compensate by:
Maintaining peripheral vasoconstriction
The nurse evaluates that the client understands the teaching regarding the use of vitamin B12 injections to treat pernicious anemia when the client states, "I must take the drug:
Monthly, for the rest of my life."
A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. What locations on the client's body should the nurse assess? (Select all that apply.)
Nail beds Lining of eyelids Palms of hands
A client with cancer develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. The nurse explains that:
Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs
An older African-American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? (Select all that apply.)
Occasional cocaine use African-American heritage
The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?
Oliguria
A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, the nurse on the medical-surgical unit should monitor the client for:
Tachycardia
A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication?
Tachycardia and petechiae over the chest
Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. The statement by the client that indicates the teaching was effective is, "I should:
Take one tablet before attempting to climb two flights of stairs."
A nurse is caring for a client who had pelvic surgery. The nurse should monitor for which clinical manifestations of thrombophlebitis? (Select all that apply.)
Tender area on the leg Warm area over the calf
A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? (Select all that apply.)
Unusual fatigue Dependent edema Nocturnal dyspnea