Med-Surg II (ATI) Cardiovascular and Hematology
A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following pieces of information should the nurse include in the teaching
"Avoid lifting both arms above your head when dressing."
A nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and just received a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching
"Before taking my medication, I will check my blood pressure and radial pulse rate."
A nurse is reinforcing teaching with a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include
"Elevate your legs when sitting."
A nurse is reinforcing dietary teaching with a client who has heart failure and is on a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching
"I can have yogurt as a dessert."
A nurse is reinforcing teaching with a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following client statements indicates the teaching has been understood
"I can snack on fresh fruit."
A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching
"I should check my heart rate each day."
A nurse is reinforcing discharge teaching with a client who has aplastic anemia. Which of the following statements should the nurse identify as an indication that the client understands the instructions
"I should eliminate uncooked foods from my diet for now.
A nurse is reinforcing dietary teaching about a low-cholesterol diet with a client who has heart disease. Which of the following client statements indicates the teaching was effective
"I should remove the skin from poultry before eating it."
A nurse is reinforcing teaching about measures to increase comfort and promote circulation with a client who has been admitted to the hospital with a deep-vein thrombosis (DVT) of the left leg. Which of the following statements by the client indicates an understanding of the teaching
"I will keep my legs elevated when I'm in bed."
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
"I will not drink coffee 4 hours prior to my test."
A nurse is reinforcing discharge teaching with a client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching
"I will notify my doctor before I have dental procedures."
A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements should the nurse identify as an indication that the client is adhering to the treatment plan
"I would never have believed I could get used to enjoying my food without salt."
A nurse is reinforcing teaching with 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
"My coronary artery disease is a risk factor for heart failure."
A nurse is reinforcing discharge teaching with a client who had a sickle cell crisis. Which of the following statements should the nurse identify as an indication that the client understands the instructions
"Physical activity is good for me, but I need to avoid overexertion."
A nurse is reinforcing discharge teaching with a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching
"Use a cellular phone on the opposite ear from the pacemaker."
A client who has just learned that he has variant (Prinzmetal's) angina asks the nurse how this condition compares to stable angina. Which of the following replies should the nurse make
"Variant angina can cause changes on your electrocardiogram."
A nurse is assisting with preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in the preoperative instructions
"You'll feel a painful, pulling sensation when the doctor withdraws the marrow."
A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse reinforce with the client before the procedure
"You'll have to lie flat for several hours after the procedure." "You'll receive medication to relax you before the procedure." "You'll have to keep your leg straight after the procedure."
A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make
"Your body has a process called fibrinolysis that will eventually dissolve the clot."
A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect
(Click on "Exhibit NCLEX 3" under Resources on the right-hand side for additional information about the client) BNP of 200 pg/mL
A nurse is checking for paradoxical blood pressure in a client who has a possible cardiac tamponade. In what sequence should the nurse take the following steps
(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A nurse is assisting an RN who is preparing to administer packed RBCs using a Y-tubing blood transfusion administration set for a client who is hypovolemic from blood loss. Which of the following images should the nurse identify as the IV solution to administer with the blood product
0.9% Sodium Chloride Injection, USP
A nurse is assisting with the care of a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions
0.9% sodium chloride
A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hours. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
10
A nurse is assisting with the care of a client who is receiving continuous cardiac monitoring. To determine if the client is in sinus rhythm, which of the following waveforms should the nurse observe
A - the short rhythm
A nurse in a provider's office is reviewing the medical records of a group of clients. The nurse should identify that which of the following clients are at risk for iron deficiency. (Select all that apply.)
A client who is a Vegetarian A client who is pregnant A toddler who is overweight
A nurse is collecting data about the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder
Absence of hair on the legs
A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of a myocardial infarction
Acute confusion
A nurse is assisting in the care of a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take
Administer an antihypertensive medication for blood pressure
A nurse is assisting with the admission of a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse suggest to include in the client's plan of care
Ample hydration
A nurse is caring for a client who has a platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take
Apply pressure to the catheter removal site for 10 minutes
A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first
Apply the defibrillator pads to the client's chest
A nurse is checking a client who has pericarditis for cardiac tamponade. Which of the following actions should the nurse take
Auscultate blood pressure for pulsus paradoxus
A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods
Beef liver
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.)
Bleeding at the venipuncture site Petechiae on chest and arms Abdominal distension
A nurse is assisting with the care of a client who is scheduled to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take (Select all that apply.)
Check and document the client's vital signs Make sure the blood type and Rh of the packed RBCs are checked by 2 nurses Provide the RN with IV tubing that has a filter
A nurse is caring for a client who reports calf pain. Which of the following is the first action the nurse should take
Check the affected extremity for warmth and redness
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.)
Check to determine the packed RBCs are less than 1 week old Seek verification from 2 RNs to compare the packed RBCs label against the medical record Prime the transfusion tubing with 0.9% sodium chloride
A nurse is reinforcing teaching about a low-cholesterol diet with a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching
Chicken breast and corn on the cob
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document
Coarse crackles
A nurse in a clinic is collecting data from a client who has a history of peripheral arterial disease. Which of the following findings on the client's lower extremities should the nurse expect
Cool, pale skin with minimal body hair
A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect
Crackles in the lung bases
A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect
Decreased albumin
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect
Dependent edema
A nurse is collecting data from a client who has pericarditis. Which of the following manifestations should the nurse expect
Dyspnea
A nurse is assisting with the preparation of an in-service presentation about the management of myocardial infarction (MI). The nurse should identify that death following MI is most often a result of which of the following complications
Dysrhythmias
A nurse is reinforcing teaching with a client who has pernicious anemia. The nurse should encourage the client to increase his consumption of which of the following foods
Eggs
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
Elevate the affected leg
A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid and electrolyte imbalances should the nurse expect
Elevated Hct
A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect
Elevated ST segments
A nurse is caring for a client who has advanced heart failure. Which of the following actions should the nurse take
Enforce fluid restrictions
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
Epistaxis
A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin is 8 g/dL. The nurse should expect a prescription for which of the following medications
Erythropoietin
A nurse participating in a community health fair is providing information to a client who has a reading of 150/90 mmHg during a blood pressure (BP) screening. Which of the following actions should the nurse take
Give the client a written record of his BP to bring to his provider
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
Greater amplitude QRS complexes
A nurse is reinforcing teaching with a client about dietary modifications to help control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions
Grilled chicken salad with fresh tomatoes
A nurse is collecting data from 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.)
Hardening along the blood vessel Tenderness in the calf Increased leg circumference
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
Hgb 6.5 g/dL
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
Hyperkalemia
A nurse is collecting data from a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease (Select all that apply.)
Hypertension Diabetes mellitus Hyperlipidemia Tobacco smoking
A nurse is reinforcing teaching with 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
Hypertension is a common adverse effect of this medication.
A nurse is collecting data from a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. This client has manifestations of which of the following electrolyte imbalances
Hypokalemia
A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities
Impaired circulation
A nurse is collecting data from a client who has isotonic dehydration. Which of the following findings should the nurse expect
Increased hematocrit
A nurse is assisting in the plan of 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 postoperative plan of care
Initiate an aspirin regimen
A nurse is contributing to the plan of care for a client who has pernicious anemia. Which of the following interventions should the nurse recommend
Initiate weekly injections of vitamin B12
A nurse is collecting data from a client who has fluid volume overload resulting from a cardiovascular disorder. Which of the following manifestations should the nurse expect (Select all that apply.)
Jugular vein distension Moist crackles Increased heart rate
A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first
Keep the client NPO
A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods
Lentils
A nurse is collecting data from a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction
Low back pain
A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect
Lower back discomfort
A nurse is assisting with planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care
Measure the client's abdominal girth daily
A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take
Monitor the client for ototoxicity
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 MI
Nausea
A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and a myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of an MI (Select all that apply.)
Nausea and vomiting Diaphoresis and dizziness Anxiety and feelings of doom
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
Necrosis
A nurse is collecting data from a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client
Omega-3 fatty acids
A nurse is collecting data from a client who has pernicious anemia. Which of the following findings should the nurse expect
Paresthesias in the hands and feet
A nurse is caring for an older adult client who has had an acute myocardial infarction (MI). When collecting data from this client, the nurse should identify that older adults are prone to complications of MI in tissue perfusion because of which of the following age-related factors
Peripheral vascular resistance increases.
A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take
Pinch the soft portion of the client's nose for 10 minutes
A nurse is contributing to the plan of care for a client who has thrombophlebitis. Which of the following actions should the nurse recommend for the plan of care
Place compression stockings on the lower extremities
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
Position the client supine with his legs elevated when in bed
A nurse is caring for a client who has heart failure and is lethargic with muscle weakness. The client's telemetry reading displays dysrhythmias. Which of the following laboratory results should the nurse anticipate
Potassium 2.8 mEq/L
A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take
Prepare for replacement of the missing clotting factor
A nurse is evaluating a client's repeat laboratory results 4 hours after administering fresh frozen plasma (FFP). Which of the following laboratory values should the nurse review
Prothrombin time
A nurse is collecting data from a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding
Report of sudden, severe back pain
A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction
Stop the infusion
A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. The client reports itching and has hives 30 minutes after the infusion begins. Which of the following actions should the nurse take first
Stop the infusion of blood
A nurse is assisting with the preparation of an in-service presentation about collecting data from clients who are having acute myocardial infarction (MI). The nurse should identify that the most common finding of acute MI is which of the following
Substernal chest pain
A nurse is showing a client who has right-sided heart failure an illustration of the heart. The nurse should identify the blood vessels that carry deoxygenated blood to the right atrium as which of the following
Superior vena cava
A nurse is assisting with preparing an in-service presentation about the basics of hematology. The nurse should suggest explaining that which of the following factors provides a stimulus for the production of RBCs
Tissue hypoxia
A nurse is reviewing the menu selections of a client who has heart failure and anticipates being discharged home the following day. Which of the following lunch menu choices should the nurse identify as an indication that the client understands his dietary instructions
Turkey on whole wheat bread
A nurse is assisting in monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hours
Ventricular dysrhythmias
A nurse is caring for a client who has pernicious anemia. Which of the following factors is associated with this condition
Vitamin B12 deficiency
A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease
Vitamin C
A nurse is caring for a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect
Weight gain of 1 kg (2.2 lb) in 1 day
A nurse is assisting in the preparation of a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first
Witness the informed consent
A nurse is collecting data from a client who has an arteriovenous (AV) fistula for hemodialysis. At which of the following locations should the nurse listen for a bruit (Using the hot spots in the artwork, select only the area that corresponds to the answer.)
radial
A nurse is assisting with developing the plan of care for an older adult client who is to receive a unit of packed red blood cells (RBCs). Which of the following actions should the nurse recommend
verify the information on the packed RBCs with another nurse
