Med Surg Cardiovascular, Hematologic, and Lymphatic Systems EAQs

An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? A. Massage extremities B. Obtain rectal temp C. Assess fingers for areas of frostbite D. Determine client's LOC E. Ask for client identification

B, C, D & E A rectal temperature provides the most accurate temperature. Older adults have less subcutaneous fat and inefficient temperature-regulating mechanisms, which makes them vulnerable to extremes in environmental temperature. The extremities are more distal sites of circulation and are at increased risk for frostbite. Hypothermia decreases cerebral perfusion, which will result in confusion and a decreased level of consciousness. Getting client identification will help in learning more about the client's previous health history and aid in contacting family members. Massage is contraindicated because it may injure tissues that have sustained frostbite.

An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its antioxidant effects on the structure of cell walls. I wonder whether it is wise to take it." Which vitamin does the nurse conclude the client is describing? A. K B. B1 C. C D. E

D Vitamin E has antioxidant properties. Vitamin K assists in synthesizing blood clotting factors. Vitamin B 1 is necessary for protein and fat metabolism and for functioning of the nervous system. Vitamin C is used for formation of collagen, which is important for maintaining capillary strength, promoting wound healing, and resisting infection.

The nurse is collecting data from a client with varicose veins who is to have sclerotherapy. Which assessment finding does the nurse expect the client to report? A. Feelings of heaviness in both legs B. Intermittent claudication of legs C. Calf pain on dorsiflexion of foot D. Hematomas of lower extremities

A Impaired venous return causes increased pressure, with subjective symptoms of fatigue and heaviness of the legs. Intermittent claudication, a symptom of cellular hypoxia, is related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot can be indicative of thrombophlebitis. Ecchymosis may occur in some individuals, but there is insufficient bleeding into tissue to cause hematomas.

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session? A. Elevated BP B. Increased blood viscosity C. Fragility of blood cells D. Immaturity of RBCs

B Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation. Hypertension usually is related to narrowing or sclerosing of arteries, not to an increased number of blood cells. The fragility of blood cells does not affect the viscosity of the blood. Erythrocyte immaturity is not related to increased viscosity.

The nurse is caring for a client who is on a cardiac rhythm monitor. The nurse notes that the client's P waves are of normal configuration and that each P wave is followed by a QRS complex. All intervals are normal as well, but the client's heart rate is 112 beats per min. How will the nurse interpret this rhythm? A. Sinus arrhythmia B. Sinus tachycardia C. Junctional tachycardia D. Ventricular tachycardia

B With sinus tachycardia both atrial and ventricular rates are greater than 100 beats per minute, up to 160 beats per minute, but may be as high as 180 beats per minute. Onset is gradual rather than abrupt. Sinus tachycardia is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is less than 0.12 seconds. QT may shorten. P and QRS waves are consistent in shape. P waves are small and rounded. A P wave precedes every QRS complex, which is then followed by a T wave. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone. In junctional tachycardia, P waves may precede the QRS, and may be inverted or upside down, or the P wave may not be visible or may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened less than 0.12 seconds. The rate for junctional tachycardia is greater than 100 beats per minute. The wave of depolarization associated with ventricular tachycardia rarely reaches the atria. Therefore P waves usually are absent. If P waves are present, they have no association with the QRS complex. The QRS is wide and distorted in shape, lasting more than 0.12 second.

The nurse provides discharge teaching for a client with a history of hypertension who had a femoropopliteal bypass graft. Which client statement indicates teaching is effective? A. "I should massage my calves & feet every day" B. "I should keep my foot elevated when I am in bed" C. "I should sit in a hot bath for half an hour twice a day" D. "I should observe the color & pulses of my legs every day"

D Presence of pulses and a normal skin color indicate adequate arterial perfusion and graft viability. Massaging calves and feet every day is contraindicated in peripheral vascular disease because it may traumatize vessels; it can cause a thrombus to become an embolus. Keeping feet elevated when in bed is appropriate for venous, not arterial, problems. The peripheral dilation produced by a hot bath will increase the workload on the heart, which is undesirable in a client with hypertension.

A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding?

"Blood enters the right atrium via the superior & inferior vena cava, flows to the right ventricle & then into the lungs, returns from the lungs to the left atrium & left ventricle & exits out the aorta"

What type of pt is digoxin prescribed for

Pt w/ atrial fibrillation (shown w/ irregular rhythms)

Which symptoms indicate to the nurse that the client has an inadequate fluid volume? A. Decreased urine B. Hypotension C. Dyspnea D. Dry mucous membranes E. Pulmonary edema F. Poor skin turgor

A, B, D & F Lowered urinary output, hypotension, dry mucous membranes, and poor skin turgor are all symptomatic of dehydration. Dyspnea and pulmonary edema may be caused by fluid overload.

How does the human body conserve heat? SELECT ALL THAT APPLY: A. By decreasing muscle activity in the body B. Through peripheral vasodilation in the body C. Through peripheral vasoconstriction in body D. By shunting blood to superficial body tissues E. By shunting blood away from skin surface

A, C & E The human body conserves heat through peripheral vasoconstriction in the body. During peripheral vasoconstriction, the warm blood is shunted away from the skin surface to minimize heat loss from the body. Shunting blood to superficial body tissues would facilitate loss of heat. Increased muscle activity causes heat loss; the body conserves heat through decreased muscle activity. The body conserves heat through peripheral vasoconstriction; vasodilation would cause heat loss.

The primary healthcare provider prescribes warm intravenous fluids for a client with a body temperature of 28 °C. During administration of the fluids, it is important for the nurse to continuously monitor what? A. Client's liver fxn B. Client's cardiac fxn C. Client's RBC count D. Client's blood platelet count

B Body temperature less than 30 °C indicates the need of core rewarming. Core rewarming is done by administering warm intravenous solutions, gastric lavage with warm fluid, peritoneal lavage with warm fluid, and by allowing inhalation of warmed oxygen. Core rewarming may result in cardiac dysrhythmias; therefore, the nurse monitors for cardiac function continuously to ensure safety in the client. Administration of warm intravenous fluids may not disturb liver function; therefore, there is no need to monitor liver function. Core rewarming with warm intravenous fluids may not decrease the red blood cell count and blood platelet count; therefore, there is no need to monitor the blood cell count.

The client is experiencing fatigue, difficulty breathing, and dizziness. Which dysrhythmia does the nurse interpret from the cardiac monitor? A. Atrial flutter B. Sinus tachycardia C. Sinus bradycardia D. Atrial fibrillation

B Sinus tachycardia is regular rhythm but at a rate higher than 100 beats/min. The client may experience shortness of breath, palpitation, fatigue, and dizziness. Atrial flutter (saw-tooth waves) arises from a conduction defect in the atrium resulting in a rapid atrial rate usually between 200 to 350 times/minute. The atrial rate is faster than the atrioventricular (AV) node can conduct so that not all atrial impulses are conducted through to the ventricle. Sinus bradycardia is a regular rhythm but at a rate lower than 60 beats per minute. Atrial fibrillation is an irregular rhythm that is a result of multiple irritable foci firing in the atria and bombarding the AV node with irregular conduction of impulses through the node.

A nurse is preparing medications. Which client's health problem motivates the nurse to question a prescription for a beta blocker? A. Coronary artery disease B. Essential HTN C. Acute HF D. Sinus tachycardia

C Beta blockers reduce cardiac output and must be started slowly, so they are contraindicated for clients with acute heart failure. Beta blockers are used to treat coronary artery disease because they decrease myocardial oxygen demand by reducing peripheral resistance and cardiac contractility. Beta blockers are used to treat essential hypertension because they cause vasodilation and decrease cardiac contractility. Beta blockers lower heart rate.

A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical? A. Edema of feet & ankles B. Reddened & painful areas on calves C. Pain when exercising & thickening of toenails D. Ulcers around ankles & reports of dull ache in legs

C Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these adaptations may be associated with decreased cardiac output related to heart failure.

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? A. Client pushes airway out B. Client has snoring rr C. Client's rr are 16 bbm & shallow D. Client's systolic BP drops from 130 to 90 mmHg

D A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Shallow respirations of 16 breaths per min is a common response to depressant effects of anesthesia.

A client is found unconscious and unresponsive. What should the nurse do first? A. Initiate a code B. Check for radial pulse C. Compress lower sternum D. Give 4 full lung inflations

A Additional help and a cardiac defibrillator must be obtained immediately. The carotid, not radial, pulse is used. Compressing the mid-lower sternum is done after the nurse summons help. The ratio is two lung inflations to 30 chest compressions.

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? SELECT ALL THAT APPLY: A. Canned chili B. Ground beef C. Fresh salmon D. Lunch meat E. Cooked broccoli

A & D Canned chili is high in sodium and should be avoided. Luncheon meats are processed and have high sodium levels to help with their preservation and should be avoided. Beef is lower in sodium than are preserved meats; however, beef is high in saturated fat. Canned salmon is high in sodium, but fresh salmon is not. Broccoli does not have significant sodium levels.

A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? A. Wound drainage B. Diuretic therapy C. GI suction D. Parenteral infusion of 0.9% sodium chloride E. Inappropriate anti-diuretic hormone (ADH) secretion

A, B, C & E Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate anti-diuretic hormone (SIADH), high levels of the anti-diuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia.

Which anatomic changes result in thermodysregulation in elderly people? SELECT ALL THAT APPLY: A. Increased metabolic rate B. Increased shivering response C. Decreased circulation of blood D. Decreased number of sweat glands E. Decreased vasoconstrictive response

C, D & E As aging occurs, body temperature tends to fluctuate because of the body's decreased ability to regulate its temperature. These fluctuations in temperature occur because of decreased blood circulation, decreased number and efficiency of the sweat glands, and decreased vasoconstrictive response. Increased metabolic rate and shivering response do not result in thermodysregulation; they contribute to fluctuations in the body temperature.

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin 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? A. Poached eggs B. Spinach salad C. Sweet potatoes D. Cheese sandwich

B Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.

A client has a low hemoglobin level that is attributed to an iron deficiency. Which foods should the nurse recommend that the client increase in the diet? A. Grapes B. Spinach C. Oranges D. Beef liver E. Cantaloupe

B & D Spinach and beef liver contain high amounts of iron. Grapes, oranges, and cantaloupe are low in iron.

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change? A. Decreased afterload B. Decreased HR C. Increased stroke volume D. Increased intravascular volume

D As fluid is administered intravenously or retained by the kidneys, the intravascular fluid volume increases, resulting in increased preload and afterload, increasing pulmonary artery wedge pressure. Increased, not decreased, afterload will cause an increase in the pulmonary artery wedge pressure. Afterload is the peripheral resistance against which the left ventricle must pump. A decreased heart rate will not increase pulmonary artery wedge pressure. After a pulmonary artery wedge pressure reaches 20 mm Hg, the stroke volume does not increase significantly.

A client is admitted to the intensive care unit in pulmonary edema. What should the nurse expect when performing the admission assessment? A. Weak, rapid pulse B. Decreased BP C. Radiating ant chest pain D. Crackles at base of each lung

D Crackles are the sound of air passing through fluid in the alveolar spaces. With pulmonary edema, fluid moves from the intravascular compartment into the alveoli. With hypervolemia, the pulse is bounding. The blood pressure is increased with hypervolemia. Radiating anterior chest pain will occur with angina or a myocardial infarction.

The nurse is conducting a nutrition class for a group of clients with heart failure (HF). Which information is most important for the nurse to share with the class? A. Restricting fluid intake B. Eating a low caloric diet to reduce weight C. Recognizing which products are high in cholesterol D. Choosing fresh or frozen vegetables instead of canned ones

D The key principle to teach HF clients is the importance of decreasing sodium in their diet and which foods contain sodium. If sodium is decreased, water retention will decrease also. Fresh or frozen vegetables have less sodium than canned ones. If the client is on a low-sodium diet and receiving diuretics but continues to be fluid overloaded, then fluid restriction may be instituted. A low caloric diet is not indicated for all HF clients. Some are very thin because of various factors, including the work of breathing and rapid heart rate. A low cholesterol diet is important for clients with coronary artery disease and for the American population in general but is not specifically related to HF.

The nurse is evaluating the client's cardiac rhythm and measures a PR interval of 0.08 seconds (two small boxes). How should the nurse interpret this finding? A. Normal conduction in the AV node B. End of the P wave to the next deflection C. Delayed conduction in the AV node D. Abnormally fast conduction

D When the PR interval is shorter than normal, the speed of conduction is abnormally fast. The PR interval measures the time it takes for the impulse to depolarize the atria, travel to the AV node, and dwell there briefly before entering the bundle of His. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide. When the PR interval is longer than normal, the speed of conduction is delayed in the AV node. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval.

A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient care analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next? A. Give naloxone intravenous push med (IVP) per protocol B. Assess the client's pain level on a 10-point scale C. Document the findings & reassess in 2 hours D. Call the rapid response team

A A respiratory rate of 10 breaths per min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for postoperative opioid-induced respiratory depression. Pain level also is a part of the PCA documentation protocol. According to protocol, PCA status needs to be documented every 2 hours for the first day and then every 4 hours. The rapid response team might still need to be called, but naloxone must be given first.

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to follow up? A. Whole milk w/ oatmeal B. Garden salad w/ olive oil C. Tuna fish w/ small apple D. Soluble fiber cereal w/ yogurt

A An overall heart healthy diet includes a variety of fruits and vegetables, whole grains, low-fat dairy products, skinless poultry and fish, nuts, legumes and non-tropical vegetable oils. Whole milk is high in saturated fat and should be avoided.

A client comes to the outpatient clinic with a large leg ulcer. Which clinical finding will help the nurse determine that the ulcer is arterial? A. Pain at ulcer site B. Bleeding around ulcer area C. Dependent edema of extremities D. Statis dermatitis on affected extremity

A Arterial ulcers are painful because of their depth and interruption of blood supply. Bleeding around the ulcer area, dependent edema of the extremities, and stasis dermatitis on the affected extremity are characteristic of venous ulcers.

The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? A. Crackles in lungs B. Supple skin turgor C. Urine output of 240 mL over 8 hours D. Increase in BP from 110/76 to 124/68 mmHg

A Crackles in the lungs indicate the client is overloaded with fluids. The nurse should notify the primary healthcare provider to slow or discontinue the IV fluid. Supple skin turgor is a normal finding indicating that the IV fluid is working. A urine output of 240 mL in 8 hours is adequate. Therefore simply having a urine output of 30 mL/hr is not an indication that the IV fluid should be decreased or discontinued; it demonstrates that the kidneys are adequately perfused. An increase in blood pressure is to be expected with administration of fluid.

A nurse is developing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. Which statement from the client indicates the nurse needs to intervene? A. "I will restrict my physical activity" B. "I will take 1 baby aspirin every day" C. "I will continue my smoking cessation program" D. "I will try to lose the extra weight I'm carrying around"

A Physical activity need not be restricted; clients who have had a myocardial infarction have a cardiovascular rehabilitation exercise program prescribed. Exercise should become a part of the client's lifestyle. Taking one baby aspirin every day is desirable because aspirin decreases platelet aggregation. Continuing a smoking cessation program is desirable because cigarette smoking causes arterial constriction. Trying to lose the extra weight the client is carrying around is desirable because obesity increases the body's oxygen demands, which increases the workload of the heart.

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. Which is the priority nursing intervention for this client? A. Provide pain medication B. Transfer to coronary care unit C. Obtain a single ECG D. Have a blood specimen drawn for enzyme studies

A Providing for comfort reduces anxiety and subsequently decreases catecholamine release, indirectly decreasing myocardial oxygen requirements. The client's condition should be stabilized before transfer; relief of pain facilitates stabilization. Obtaining an electrocardiogram is important, but the client should be placed on continuous monitoring, not just receive a reading; therefore pain relief is the priority. The ECG is significant to examine for progressive myocardial changes. Securing blood for enzyme studies is not an emergency intervention, although a blood sample for cardiac enzymes is important for a definitive diagnosis.

A nurse is assessing the ECG rhythm strip. The nurse checks the P wave. Which function of the heart is the nurse assessing? A. Atrial depolarization B. Atrial repolarization C. Ventricular depolarization D. Ventricular repolarization

A The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, visualization of atrial repolarization is obscured by the QRS complex. The T wave represents ventricular repolarization.

A client who had abdominal surgery 24 hours ago reports pain in the left calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do first? A. Elevate both legs B. Keep both legs dependent C. Administer the prescribed analgesic D. Administer prescribed antipyretic

A The clinical findings indicate a possible thrombophlebitis. The legs should be elevated and the healthcare provider notified immediately. A thrombus may progress to a pulmonary embolus. The legs should be kept elevated until the client is evaluated by the healthcare provider. Administering an analgesic for pain may obscure the problem in the calf, place the client in jeopardy, or further delay treatment. Adm

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A. A 65 yr old w/ pulmonary fibrosis B. A 24 yr old w/ uncontrolled type 1 diabetes C. A 45 yr old who has been vomiting for 3 days D. A 54 yr old who takes sodium bicarbonate for indigestion

A The low pH and elevated Pco 2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? A. Oliguria B. Crackles C. Dyspnea D. Bounding pulse

A Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume. Crackles are associated with pulmonary edema, not hypovolemic shock. Dyspnea may be associated with hypervolemia, not hypovolemia, as well as with pulmonary edema and respiratory disorders. Bounding pulse will occur with hypervolemia.

A client is experiencing tachycardia. Which adverse hemodynamic effects will the nurse consider when planning care for this client? SELECT ALL THAT APPLY: A. Decreased ventricular filling time B. Increased coronary artery filling C. Decreased CO D. Increased atrial kick E. Increased CO

A & C Tachycardia is a fast heart rate; the fast heart rhythm may cause a decrease in cardiac output because of the decreased filling time for the ventricles. There is also a decreased, not increased, time for coronary artery filling during diastole. During atrial systole, a bolus of atrial blood is ejected into the ventricles; this step is called the atrial kick, and it contributes more blood to the cardiac output of the ventricles. With fast heart rates, there is less time for the atria to fill, and therefore less blood (atrial kick) to pump.

A client's diet is modified to eliminate foods that act as cardiac stimulants. Which foods will the nurse instruct the client to avoid? SELECT ALL THAT APPLY: A. Iced tea B. Red meat C. Club soda D. Hot cocoa E. Chocolate pudding

A, D & E Tea contains caffeine, which stimulates catecholamine release and acts as a cardiac stimulant; tea should be avoided. Hot cocoa contains chocolate, which contains caffeine; it stimulates catecholamine release and acts as a cardiac stimulant. Cocoa should be avoided. The chocolate in chocolate pudding has a high caffeine content, which may stimulate catecholamine release and act as a cardiac stimulant; chocolate should be avoided. Red meat does not stimulate the myocardium; however, it should be decreased or eliminated if serum cholesterol levels are elevated. Club soda does not contain caffeine and does not stimulate the myocardium; however, most club sodas contain sodium, which promotes fluid retention and should be avoided by a client with a cardiac condition.

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand? A. Plaque from w/in veins is scraped B. The dilated saphenous veins are removed C. Superficial veins are sown together into deep veins D. An umbrella filter is placed in large affected veins

B During a ligation, the saphenous vein is removed. Plaque is an arterial, rather than a venous, problem. Anastomosing (sewing together) superficial veins to deep veins is not done during this surgery; superficial and deep veins usually are attached by communicating veins. An umbrella filter placed in the large affected veins prevents emboli from traveling to the lung; it is not a vein ligation and stripping.

The healthcare provider prescribes a progressive exercise program that includes walking for a client with a history of diminished arterial perfusion to the lower extremities. The nurse explains to the client what to do if leg cramps occur while walking. Which instruction did the nurse give the client? A. Chew 1 aspirin twice a day B. Stop to rest until pain resolves C. Walk more slowly while pain is present D. Take 1 nitroglycerin tabs sublingually

B During an exercise program, the client walks to the point of claudication, stops and rests, and then walks a little farther. Decreasing the demand for oxygen by resting will relieve the pain. Pain will not resolve as long as exercise, thus muscle hypoxia, is continued, regardless of whether aspirin is taken. Walking more slowly while pain is present is appropriate for venous insufficiency, not arterial insufficiency. Sublingual nitroglycerin is not indicated for leg cramps.

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition? A. "I have abnormal platelets" B. "I have abnormal hemoglobin" C. "I have abnormal hematocrit" D. "I have abnormal WBCs"

B The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. While it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? SELECT ALL THAT APPLY: A. Raw carrots B. Boiled spinach C. Dried cranberries D. Brussels sprouts E. Asparagus spears

B & C According to the nutritional table, the food sources highest for Iron is "Liver and muscle meats, dried fruits, legumes, dark green leafy vegetables [which would include spinach], whole-grain and enriched bread and cereals, beans." Although carrots, brussels sprouts, and asparagus spears contain some iron, they are not considered high sources of iron.

A client has second degree atrioventricular (AV) block. Which information will the nurse consider when planning care? A. A temporary pacemaker is the only viable tx B. None of the P waves are conducted to the ventricles C. Some P waves are conducted to the ventricles D. Tx consists of atropine or pacemaker E. Tx consists of a permanent pacemaker

C & D Second degree heart block refers to AV conduction that is intermittently blocked. Therefore, some P waves are conducted, and some are not. The client may require administration of atropine as well as transcutaneous or transvenous pacing for emergent treatment. Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. Treatments include transcutaneous or transvenous pacing and implanting a permanent pacemaker.

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is uniquely related to heart failure? A. "I see sports before my eyes" B. "I am tied at the end of the day" C. "I feel bloated when I eat a large meal" D. "I have trouble breathing when I climb a flight of stairs"

D Dyspnea on exertion occurs with heart failure because of the heart's inability to meet the oxygen needs of the body. Seeing spots before one's eyes, being tired at the end of the day, and feeling bloated are not specific to heart failure.

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? A. Spinal stenosis B. Buerger disease C. Rheumatoid arthritis D. Intermittent claudication

D Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.