Med-Surg: Cardiovascular and Hematology

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, C, D, E B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for coronary artery disease (CAD). - Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage - 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

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 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: During a bone-marrow biopsy, the client will receive local anesthesia and mild sedation and will be awake during the procedure - B: When the iliac crest is the extraction site, the client should be side-lying or prone - D: A bone-marrow biopsy typically takes 5 to 15 minutes

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 The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs. - A: The QRS complexes are much wider than usual in clients who have PVCs - C: The QRS complexes usually demonstrate the opposite polarity of the client's usual QRS complexes for those with PVCs - D: With PVCs, a compensatory pause follows the PVC before the usual rhythm resumes, unless more PVCs follow in immediate succession

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 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: A thick, white coating on the tongue is a manifestation of oral candidiasis rather than pernicious anemia. Instead, the nurse should expect the client to have glossitis, a beefy-red discoloration of the tongue. - B: Tachycardia, not bradycardia, is an expected finding of pernicious anemia - D: Joint pain is a manifestation of sickle cell disease, not pernicious anemia

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, B, D A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom Nausea, vomiting, epigastric distress, diaphoresis (sweating), fatigue, anxiety, and feelings of doom are common manifestations of MI. - C: Chest and left arm pain that subsides with rest is a manifestation of angina, not MI. - E: A diminished or absent pulse is a manifestation of MI due to decreased cardiac output. Tachypnea is an indication of MI due to anxiety and pain.

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'' have to limit the amount of fluid you drink for the first 24 hr

A, B, D 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 - Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30 degrees for 2-6 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 - C: The client will feel a sensation similar to a hot flash when the dye enters the heart - E: Adequate hydration, both IV and oral, is crucial for excreting the contrast medium and reducing the risk of renal toxicity from retaining the dye

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 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 the IV tubing to a set that has a filter

A, C, E 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 the IV tubing to a set that has a filter - 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 - The nurse should administer packed RBCs through IV tubing that has a filter to prevent the administration of aggregates and possible contaminants - B: The nurse should ensure the client has a 20-gauge or larger needle for administration of packed RBCs to prevent the formation of blood clots during the transfusion - D: The nurse should hang a bag of 0.9%NS for administration with the packed RBCs. Lactated ringer's solution is not used because it causes clotting and hemolysis of the blood cells

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, C, E A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference 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 - B: Arterial problems, not venous problems, affect peripheral pulsation - D: The calf usually has warm skin; however, the skin might be cool if the client has an arterial problem

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 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 1c (1.8f) per hour.

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 take? 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 The 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 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 The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation. - B: The nurse should not place the client on bed rest because ambulation can promote venous return and does not increase the risk of pulmonary embolus - C: The nurse should not massage the affected leg, as this increases the risk of dislodging the clot and causing a pulmonary embolus - D: The nurse should not administer aspirin to the client because aspirin can increase the anticoagulant effect of enoxaparin by inhibiting platelet aggregation, increasing the risk of bleeding

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 Elevated ST segments can indicate hyperkalemia and pericarditis - B: Absent P waves can indicate atrial fibrillation and sustained ventricular tachycardia - C: Depressed ST segments can indicate hypokalemia and ventricular hypertrophy - D: Varying PP intervals can indicate an irregular atrial rate and rhythm

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 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 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 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 Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, leathery, and ectopic heartbeats.

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

A. I will not drink coffee 4 hr prior to my test The client should avoid coffee, alcohol, and caffeine on the day of the test. These can affect the client's heart rate and blood pressure during the test. - B: The nurse should instruct the client to have a light meal 2 hours prior to the test - C: The nurse should instruct the client to avoid smoking the day of the test. Smoking is a stimulant and can affect the client's heart rate and BP during the test - D: The nurse should instruct the client to speak with the provider about taking heart medication on the day of the test. Beta blockers or calcium channel blockers are typically withheld on the day of the test to allow the heart rate to increase during the stress portion.

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 The nurse should expect the client to have an increase hematocrit level due to hemoconcentration caused by reduced plasma fluid volume. - B: The nurse should expect the client to have tachycardia to compensate for a decrease in blood pressure, which occurs as a result of reduced plasma fluid volume. - C: The nurse should expect the client to have flat neck veins - D: The nurse should expect the client to have an increased urine specific gravity due to concentrated urine as a result of reduced plasma fluid volume.

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 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 - B: U waves indicate hypokalemia - C: Although absent P waves can reflect other dysrhythmias, they are common with sustained ventricular tachycardia, which hypomagnesemia can cause - D: Ventricular tachycardia often reflects coronary insufficiency, which results in poor oxygenation of the heart

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 hours C. Tell the client to sit with his legs dependent after ambulating D. Instruct the client to wear knee-length socks for 2 weeks after surgery

A. Position the client supine with his legs elevated when in bed The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart. - B: The nurse should encourage the client to ambulate for 5-10 minutes every hour while awake to prevent venous stasis - C: The nurse should discourage the client from sitting or standing for any duration to prevent venous stasis. The feet should be elevated above the heart to prevent venous stasis. - D: The nurse should instruct the client to wear graduated compression stockings for up to 1 week after surgery to promote venous return

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 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. - B: The nurse should review the WBC count if there is a possible infection - C: The nurse should review platelet count following the administration of platelets - D: The nurse should review hematocrit following the administration of packed RBCs

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 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 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 The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery. - B & C: The appearance of Q waves or elevated ST segments indicates infarction, not reperfusion. - D: The recurrence of chest pain can indicate an extension of an acute MI. With reperfusion, chest pain should subside.

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 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. - B: There is no physiological mechanism that stabilizes a clot, although a desired outcome is stabilization and eventual resolution - C: Mobile clots (emboli) are pathological and not an expected resolution of an existing clot - D: Heparin does not dissolve clots. It prevents enlargement of the existing clots and future clot formation. Thrombolytic therapy, not anticoagulant therapy, dissolves clots

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 distention

B, C, E B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distention The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distention due to internal bleeding. - A & D: Bradycardia and flushed, dry skin are not consistent with DIC. DIC is a complex malfunction involving the body's ability to clot. Tachycardia and pallor are manifestations of hemorrhaging.

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, D, E 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 - 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 stream - 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. - The nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as lactated ringer's and dextrose in water can cause clotting or hemolysis of the packed RBCs. - A: The nurse should use an angiocatheter that is 18- to 20-gauge to allow the packed RBCs to flow easily and to prevent occlusion of the catheter. A 23-gauge catheter is too narrow, which can result in a prolonged infusion time and risk for catheter occlusion. - C: The nurse should infuse the packed RBCs slowly over a 2- to 4-hour period to decrease the risk of bacterial contamination

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 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: Absent pedal pulses are a manifestation of peripheral arterial disease rather than venous insufficiency - C: Hair loss of the affected extremity is a manifestation of peripheral arterial disease rather than venous insufficiency - D: Thin, dry, atrophied skin is a manifestation of peripheral arterial disease rather than venous insufficiency

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 Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs. - Options A, C, and D: Peripheral edema, jugular vein distention, and hepatomegaly are manifestations of right-sided heart failure

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. Dysrhythmias According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common causes of death following an MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and read them immediately.

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 Epistaxis (a nosebleed) is a manifestations 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: Vertigo is not a s/s of hypertension. It is a manifestation of several other disorders, including Meniere's disease. - C: Exophthalmos (protrusion of the eyes) is caused by a thyroid disorder, not hypertension - D: Spondylolisthesis is a condition in which a vertebra slips, causing pressure on the nerve root and causing pain in the back and over the buttocks. This condition is not related to hypertension.

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 The expected reference range of Hgb is 14-18 for men and 12-16 for women. Therefore, a client who has an Hgb level of 6.5 has anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallor, dizziness, and tachycardia.

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 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 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 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 back flow of blood from the left. atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion

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 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: Most clients who have thrombocytopenia require 2,000-2,400 mL of fluids per day to decrease the risk of dehydration and to promote regular bowel function - C: The nurse should plan to check the client's IV sites every 2 hours for bleeding - D: The nurse should not plan to administer an enema to a client who has thrombocytopenia due to the increased risk of bleeding

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 A client who received 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: ABO compatibility is required for the transfusion of fresh frozen plasma. A client whose blood type is O, can only receive type O plasma. - C: The nurse should not continue infusing plasma that is not compatible with the client. There is no indication that a repeat type and crossmatch of the client's blood is necessary. - D: The nurse should administer diphenhydramine IV only if the client manifests an allergic transfusion reaction

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 5mL 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, D, E 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 - The nurse should flush the line with 10mL of sterile 0.9%NS 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, the 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: A 5mL syringe generates too much pressure and could rupture the line. The nurse should use a 10mL syringe instead. - B: The nurse should use chlorhexidine for cleansing the insertion site. Chlorhexidine is effective in reducing the incidence of bloodstream infections.

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 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: Pericarditis is usually seen on an ECG as an ST-T spiking. This elevation represents ischemic changes caused by inflammation around the heart. A client who has pericarditis will have tachycardia because of decreased cardiac output and oxygen perfusion. - B: Chest pain associated with pericarditis will increase with deep inspiration due to greater pressure on the pericardial sac - D: Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac.

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 daily B. Continuously wear support hose C. Elevate your legs when sitting D. Use dental floss daily

C. Elevate your legs when sitting Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation. - A: Clients with polycythemia vera should drink at least 3 liters of fluid per day to help lower blood viscosity - B: Clients with polycythemia vera should wear support hose when awake, not continuously - D: Clients with polycythemia vera take anticoagulants. They should not floss between the teeth due to the risk of bleeding. Instead, they should use a soft toothbrush to clean their teeth.

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 A 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: The nurse should expect the client to have hyperkalemia as a result of potassium being leaked from cellular injury. - B: The nurse should expect the client to have hyponatremia once sodium leaks into the interstitial space, causing decreased levels in the blood - D: The nurse should expect the client to have an increased hemoglobin level as blood volume is reduced by vascular dehydration

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 ear more iron-fortified cereal to strengthen my blood

C. I should eliminate uncooked foods from my diet for now The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorganisms that cooking destroys, so the client should avoid raw foods. - A: Although staying active is always a good strategy, clients who have aplastic anemia are not at particular risk for deep-vein thrombosis because a common manifestation of this disorder is a low platelet count. - B: Clients with aplastic anemia should not take aspirin because it can increase bleeding tendencies. - D: Although iron-fortified cereal is a component of a healthy diet, it is a specific recommendation for clients who have iron-deficiency anemia, not aplastic anemia

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 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: The client does not need a provider's prescription to alert airport security when traveling. A card should be given to the client after surgery stating that he has a pacemaker and listing the type of model. The client should carry this card at all times. - B: The client does not need to stand a certain amount of distance away from a microwave. Proper shielding is part of microwave manufacturing. - D: The client can take a bath or shower as long as he gives careful attention to the pacemaker site. The client should not stand directly under the shower or submerge himself in a tub of water.

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 Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

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 To help prevent a recurrence of sickle cell crisis, the client should avoid overextension from especially strenuous activities. - A: The client should drink 3 to 4 L of fluid per day - B: The client should avoid traveling to high altitudes and in airplanes since passenger cabins are non-pressurized - D: The client should avoid recreational activities that require persistent exposure to cold weather

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 Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When an injury occurs to a blood vessel, platelets collect at the edge of the break and adhere to each other to plug the injured area and limit blood loss. - A: Leukocytes, not platelets, help the body fight infection - B: Plasmin is among the many substances that help break down blood clots in the body. Platelets do not perform this function. - D: Red blood cells produce hemoglobin molecules, which transport oxygen throughout the body

A nurse is assessing a client who is receiving a transfusion of packed 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 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: Hypotension due to circulatory shock is an indication of an intravascular hemolytic reaction - B: A fever is an indication of an intravascular hemolytic reaction - D: Tachypnea as a compensatory mechanism due to circulatory shock is an indication of an intravascular hemolytic reaction

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 Variant angina causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium. - A: Variant angina typically occurs with rest - B: Variant angina pain tends to occur at the same time of day - D: Vasospasm, not atherosclerosis, causes variant angina. If the client's cholesterol level is above the expected reference range, attempts should be made to lower it; however, this measure is unlikely to affect variant angina

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 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: Hypotonic 0.45% sodium chloride should not be used for fluid replacement. The solution can cause lysis of red blood cells because it has fewer solutes than the cell, causing osmotic pressure to pull the fluid into the few cells remaining. - B: Dextrose 5% in 0.9% sodium chloride is a hypertonic solution and should not be used for fluid replacement. This solution will diffuse into the cells of the tissue and have no effect on the circulating volume. When the fluid surrounding the cells is hypertonic or has more solutes than the cells, osmotic pressure pulls the fluid from the cells. - C: Dextros 10% in water is a hypertonic solution and should not be used for fluid replacement. Same reason as option B.

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 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 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 The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is 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 A client with unstable angina will have chest pain that lasts 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: A client with unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and a decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina and is caused by an arterial spasm - B: A client with unstable angina will have minimal, if any, relief of chest pain with nitroglycerin - C: A client with unstable angina will report chest pain or discomfort with exertion, which can limit the client's activity

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 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: Decreased capillary refill occurs in clients who have decreased cardiac output resulting from left-sided heart failure - B: When the left side of the heart fails, blood return from the lungs via the pulmonary vein is slowed, causing fluid buildup in the lungs that results in shortness of breath - C: Dizziness occurs in clients who have decreased cardiac output resulting from left-sided heart failure

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 the lower extremities D. Lower back discomfort

D. Lower back discomfort 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: The nurse should assess for mid or lower abdominal pain to the left of the midline because of the enlarged artery mass - B: The nurse should auscultate for a bruit heard over the location of the mass - C: Pitting edema is not expected with an abdominal aortic aneurysm

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 Bleeding is a post-procedure complication of PTCA because 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 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 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. Diabetes mellitus and an increased age also can increase the risk of heart failure.

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 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: A client who has polycythemia vera will have a plethoric (dark and flushed) manifestation of the facial skin and mucous membranes. - B: A client who has pernicious anemia will have glossitis (smooth, beefy-red tongue) and weight loss - C: A client who has sickle cell anemia will have manifestations of jaundice with an enlarged liver and spleen

The 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 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. - A: Ejection fraction is the percentage of blood the ventricles eject during the systolic phase of each heartbeat - B: Stroke volume is the amount of blood the left ventricle pumps during each heartbeat - C: End-diastolic volume is the amount of blood in the left ventricle at the end of diastole (filling)

A nurse observes tachycardia, dyspnea, a cough, and listened neck veins in a client who is receiving a transfusion of packed 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 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 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: Iron deficiency can be a result of blood loss, poor absorption or iron, or poor nutrition in the diet. This condition is called iron-deficiency anemia. - B: Hemolytic blood loss is a result of hemorrhage, not pernicious anemia - C: Folic acid deficiency is caused by poor nutrition related to a lack of green leafy vegetables, citrus fruits, and nuts in the diet. Folic acid 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? (Put the options in the correct order. Use all of the options.) A. Subtract the inspiratory pressure from the expiratory pressure B. Inspect for jugular venous distention and notify the provider C. Identify the first BP sounds audible on expiration and then on inspiration D. Palpate the blood pressure and inflate the cuff above the systolic pressure E. Deflate the cuff slowly and listen for the first audible sounds

1. D 2. E 3. C 4. A 5. B Step 1: The nurse should auscultate the blood pressure to detect paradoxical blood pressure for a client with possible cardiac tamponade by first palpating the blood pressure and inflating the cuff above the systolic BP Step 2: The nurse should deflate the cuff slowly and listen for the first audible sounds Step 3: The nurse should listen for the first BP sounds audible on expiration and on inspiration Step 4: This action should be followed by subtracting the inspiratory pressure from the expiratory pressure to determine pulsus paradoxus. A difference of >10 mmHg can indicate cardiac tamponade. Step 5: The nurse should inspect for jugular venous distention, muffled heart sounds, and decreased cardiac output and notify the provider of the results.

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 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 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 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 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 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 3.6mg of iron.

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 Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea. - A: Hypokalemia causes flattened T waves and cardiac dysrhythmias - C: Hypercalcemia shortens QT intervals - D: Hyperkalemia widens QRS complexes

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 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: Epoetin alfa can be self-administered at home - B: The maximum effect of epoetin alfa will occur in 2-3 months - D: Epoetin alfa is administered to decrease the need for period blood transfusions

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 an acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

C. Substernal chest pain Evidence-based practice indicates that the most common manifestation of an acute MI is substernal chest pain that does not subside with rest or nitroglycerin.

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 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: An implanted access port is surgically placed in the subcutaneous tissue, usually in the upper chest or an upper extremity. These sites do not require a dressing to cover the port site. - B: A special non-coring needle must be used to access implanted ports. These needles have a deflected tip that is specifically designed to penetrate the dense septum without coring small pieces of it. Implanted ports placed in the chest can usually tolerate about 2,000 punctures. The edges of the port should be carefully palpated to identify the septum prior to placement of the needle. It is appropriate for the nurse to use a 22-gauge non-coring needle to access the device. - C: Prior to administering medication through the implanted port, the nurse should always check the site for blood return. If there is no blood return, the nurse should hold the medication until potency can be ensured. Serious extravasation can occur due to the formation of a fibrin sheath over the tip of the catheter causing retrograde subcutaneous leakage.

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 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 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 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 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.

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 In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes (RBCs) in the bone marrow. - A: Venous stasis activates platelets and stimulates blood clotting. It does not affect the production of RBCs. - B: Platelets are essential for blood clotting. A platelet deficiency does not affect the production of RBCs. - C: Inflammation and infection trigger the production of white blood cells, not RBCs.