Med-Surg imp from ATI adaptive
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? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Inspect for jugular venous distention and notify the provider. B. Identify the first BP sounds audible on expiration and then on inspiration. C. Palpate the blood pressure and inflate the cuff above the systolic pressure. D. Deflate the cuff slowly and listen for the first audible sounds. E. Subtract the inspiratory pressure from the expiratory pressure.
Correct Answer: Palpate the blood pressure and inflate the cuff above the systolic pressure. Deflate the cuff slowly and listen for the first audible sounds. Identify the first BP sounds audible on expiration and then on inspiration. Subtract the inspiratory pressure from the expiratory pressure. Inspect for jugular venous distention and notify the provider. 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 pressure. 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 performing discharge teaching about ostomy care while at home for a client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? A. "Empty your ostomy pouch when it becomes half full." B. "Place an aspirin in the ostomy pouch to eliminate odor." C. "Change the ostomy appliance every week." D. "Cleanse the site around the stoma with hydrogen peroxide and water."
Correct answer: (A) "Empty your ostomy pouch when it becomes half full." The nurse should instruct the client to empty the ostomy pouch when it is one-third to one-half full. This prevents the ostomy from becoming too full of stool and gas and exploding. Incorrect Answers:B. The nurse should instruct the client to avoid placing an aspirin in the ostomy pouch to eliminate odor. This can cause irritation of the skin and ulceration of the stoma. Instead, a breath mint can be placed in the ostomy pouch to assist with the odor. C. The nurse should instruct the client to change the ostomy appliance every 2 weeks. Changing it too frequently can irritate the client's skin. D. The nurse should instruct the client to cleanse the site around the stoma with mild soap and water prior to placing the appliance.
A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? "I need to lie still in bed during my brachytherapy treatment." "I will have an implant placed once a month during my brachytherapy treatment." "I must stay at least 3 feet away from others between brachytherapy treatments." "I should expect some blood in my urine after each brachytherapy treatment."
Correct answer: (A) "I need to lie still in bed during my brachytherapy treatment." The nurse should confirm that the client understands the need to remain on bed rest with limited movement while the radioactive implant is in place to prevent dislodgment. Incorrect Answers: B. The nurse should explain that the provider often prescribes brachytherapy treatments 1 to 2 times per week. C. The nurse should explain that the client does not emit any radiation between treatments; therefore, there are no restrictions regarding contact with others. D. The nurse should explain that blood in the urine is not expected after brachytherapy treatment. The client should notify the provider immediately if she develops this manifestation.
A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching? A. "You can suck on popsicles to numb your mouth." B. "Season food with spices instead of salt." C. "Avoid the use of a straw to drink liquids." D. "Eat foods at hot temperatures."
Correct answer: (A) "You can suck on popsicles to numb your mouth." The nurse should instruct the client to suck on popsicles or ice chips, which can numb the mouth. Incorrect Answers:B. The client should avoid spices, acidic foods, and salt, which can irritate and burn the mouth. C. The client should instruct the client that using a straw can decrease the comfort when drinking liquids. D. The client should consume foods that are cold or at room temperature. Hot foods can be irritating or possibly burn the mouth.
A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. Assign the client to a private room with negative-pressure airflow. B. Add contact precautions to the client's plan of care. C. Wear an N95 respirator when entering the client's room. D. Ensure the client's environment provides 4 exchanges of fresh air per minute. E. Institute protective environment precautions as soon as the client arrives on the unit.
Correct answer: (A) (C) This client's history and present status suggest tuberculosis, a communicable infection that mandates a private room with negative-pressure airflow. Airborne precautions will be required, including wearing an N95 respirator when entering the client's room. Incorrect Answers:B. Tuberculosis is a communicable infection that mandates a different type of transmission-based precautions in addition to standard precautions. D. Tuberculosis mandates the provision of a well-ventilated room with 6-12 exchanges of fresh air per minute. E. Protective environment precautions are for immunocompromised clients who are at high risk of infection (e.g. clients who had chemotherapy).
A nurse in an emergency department is caring for 4 clients. Which of the following findings requires the nurse to act as a mandatory reporter? A. A child who was left unsupervised for several hours at home and is being treated for a fractured leg B. A client who was admitted for pneumonia and reports having no heat or running water at home C. A client who has depression and a self-inflicted wrist laceration D. A public official who is admitted with alcohol withdrawal and delirium tremens
Correct answer: (A) A child who was left unsupervised for several hours at home and is being treated for a fractured leg. This child exhibits findings of neglect and endangerment. The nurse is a mandatory reporter for any client situation in which children or older adult clients are being abused or neglected. Incorrect Answers: B. This client would benefit from a referral to social services for assistance with living conditions. Mandatory reporting of this situation to legal authorities is not indicated. C. None of the information given indicates that this client is a danger to others. This client will likely be placed on suicide precautions, but disclosure to a legal authority is not indicated. D. Sharing this information outside the care team for this client is a violation of HIPAA regulations. Disclosure to a legal authority is not indicated.
A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? A. Ask the client to empty his bladder before the procedure B. Place the client leaning forward over the bedside table for the procedure C. Inform the client he will be sedated during the procedure D. Instruct the client to fast for 6 hr prior to the procedure
Correct answer: (A) Ask the client to empty his bladder before the procedure. The nurse should ask the client to empty his bladder before the procedure to prevent injury to the bladder. Incorrect Answers:B. The client should lean forward over the bedside table for a thoracentesis to be performed. This gives the provider complete access to the client's chest and back and expands the spaces between the client's ribs where the pleural fluid has accumulated. C. The client will be fully awake during the procedure; sedation is not required. D. The client can eat or drink up until the procedure; fasting is not required.
A nurse is providing dietary teaching a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet? A. Calcium B. Phosphorous C. Potassium D. Sodium
Correct answer: (A) Calcium. A client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. The client should supplement dietary calcium. Incorrect Answers:B. A client who has CKD can develop hyperphosphatemia because excretion of phosphorous by the kidneys is reduced. C. A client who has CKD can develop hyperkalemia because excretion of potassium by the kidneys is reduced. D. A client who has CKD can develop hypernatremia because excretion of sodium by the kidneys is reduced.
A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider? Show Explanation44% of exam takers got this question correct. A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations
Correct answer: (A) Increased coughing. The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing. Incorrect Answers:B. Diaphragmatic breathing is the act of inhaling deeply by flexing the diaphragm. It is not a manifestation of tracheal stenosis. C. Coughing up blood, otherwise known as hemoptysis, is an abnormal finding following endotracheal extubation that should be reported to the provider. However, it is not a manifestation of tracheal stenosis. D. Kussmaul respirations are a deep and labored breathing pattern that is most often seen in clients who have metabolic acidosis. It is not a manifestation of tracheal stenosis.
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? . A. Offering the client a diet high in fluid and fiber B. Encouraging active range of motion of the affected leg C. Removing the weights prior to repositioning the client D. Inspecting pin sites every 24 hr for drainage
Correct answer: (A) Offering the client a diet high in fluid and fiber. A client who is immobile is at risk of constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function. Incorrect Answers:B. Active range of motion of the unaffected limbs is encouraged to prevent muscle wasting; however, active range of motion of a limb in traction is not feasible, as the traction apparatus limits mobility. C. Once the weights are in place, the nurse should not remove them. D. The nurse should plan to inspect the client's pin sites at least every 8 to 12 hours due to the risk of infection.
A nurse is teaching a client with Barrett's esophagus who is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."
Correct answer: (B) "This procedure can determine how well the lower part of your esophagus works." An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures. Incorrect Answers:A. A pH probe study, which involves the insertion of a specially designed probe into the distal esophagus, is performed to monitor for the presence of acid in the normally alkaline esophagus. C. An EGD is performed while the client receives moderate sedation. D. A colonoscopy is performed to detect colon cancer.
A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. "You can expect your vision to return immediately after the procedure." B. "You should avoid reading for 1 week." C. "You can remove eye shields when you're sleeping." D. "You should not lift objects that weigh more than 25 lb."
Correct answer: (B) "You should avoid reading for 1 week." The client should avoid reading and any activity that can cause rapid movement of the eye due to the risk of detachment of the retina. Incorrect Answers: A. The client's vision will not be restored immediately after the procedure because of swelling of the eye and the dilating effects of eye drops. The client's vision should return gradually over several weeks. C. The client should wear eye shields for 2 to 6 weeks after surgery when sleeping to protect the eye from injury. D. The client should not lift objects that weigh more than 20 pounds to prevent an increase in intraocular pressure.
A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? A. An assistive device when the client is ambulating B. Heat paraffin therapy applied to the client's joints C. Gentle massage of the client's hands D. Active range-of-motion exercises on the client's affected joints
Correct answer: (B) Heat paraffin therapy applied to the client's joints. The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacological intervention. An elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relieves the stiffness of the client's joints and provides comfort. Incorrect Answers:A. Clients who have rheumatoid arthritis do not need assistive devices. An assistive device is only needed when severe loss of range-of-motion occurs. C. Massage can aggravate inflammation. Most clients have a tendency to rub inflamed, aching joints but should be taught instead to massage over surrounding muscles, not joints. D. During exacerbations of rheumatoid arthritis, active range-of-joint motion exercises should not be performed; only passive or isometric exercises are indicated.
A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37°C (98°F)
Correct answer: (B) Instilling 50 mL of fluid with each irrigation. When irrigating a client's ear, the nurse should use no more than 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness. The nurse should stop irrigating if the client experiences pain, nausea, vomiting, or dizziness. Incorrect Answers:A. The nurse should use an otoscope to check the location of the impacted cerumen and verify the eardrum is intact before beginning the irrigation. In order to visualize the ear, the nurse should select a speculum that fits comfortably in the client's ear. C. After the client tilts the head slightly toward the unaffected ear, the nurse should gently pull the auricle of the affected ear upward and backward. During irrigation, the nurse should apply gentle but firm continuous pressure, allowing the water to flow against the top of the ear canal. D. Warming the irrigation fluid to 37°C (98°F) will reduce the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness.
A nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? A. Monitor visitors for manifestations of infection B. Remind the client to use an electric razor C. Encourage frequent rest periods D. Instruct the client to rinse mouth daily with normal saline
Correct answer: (B) Remind the client to use electric razor. Thrombocytopenia is a decrease in the client's blood platelet count, which places the client at an increased risk of bleeding due to the blood's inability to clot. Therefore, the nurse should institute bleeding precautions, including the use of an electric razor. Incorrect Answers:A. The client has thrombocytopenia, not neutropenia. Neutropenia, which involves a decreased WBC count, places a client at risk of infection; the nurse should monitor for visitors who are ill. C. The client has thrombocytopenia, not iron-deficiency anemia. Iron-deficiency anemia necessitates the encouragement of frequent rest periods secondary to fatigue. D. Stomatitis, an inflammation of the mucous membranes of the mouth, is not a manifestation of thrombocytopenia. A client who has stomatitis should use bland rinses and avoid commercial mouthwashes that contain alcohol, which might cause a further breakdown of the oral tissue.
A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? A. "I can keep my dentures in during the procedure." B. "I am allowed only clear liquids prior to the procedure." C. "A tissue sample might be obtained during the procedure." D. "A signed consent form is not required for this procedure."
Correct answer: (C) "A tissue sample might be obtained during the procedure." The nurse should inform the client that a tissue sample might be obtained during the procedure for biopsy testing. Incorrect Answers:A. The client needs to remove dentures, glasses, or contacts so they can be stored safely until after the procedure is completed. B. The client should ingest nothing by mouth for 6 hours prior to the procedure to reduce the risk of aspiration. D. A signed consent form is required prior to a bronchoscopy because it requires sedation, and risk is involved. By signing the consent form, the client is demonstrating an understanding of the procedure and the risks.
A nurse is teaching a client who tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen through which of the following statements? A. "I will begin vacuuming once a week." B. "Carpeting the entire house will be very expensive, but it will be worth it." C. "I will put a mattress cover on my bed." D. "Installing curtains on the windows will help control the dust in my house."
Correct answer: (C) "I will put a mattress cover on my bed." The nurse should instruct the client to apply a hypoallergenic mattress cover that can be zipped over her bed to control the amount of dust. The client should remove and machine-wash the mattress cover periodically. Incorrect Answers:A. The client should vacuum daily to decrease the amount of dust in the client's environment. B. Carpeting should be removed from as many rooms as possible, especially from the bedroom or any other common areas where the client spends time. Carpet accumulates large amounts of dust in the client's environment. D. The client should remove curtains in the house and replace them with pull shades. Pull shades accumulate less dust than curtains and can be easier to clean.
A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following client statements indicates the need for additional teaching? A. "I will empty my bladder every 4 hours." B. "I will drink 2 L of fluids per day." C. "I will use a vaginal douche daily." D. "I will wear cotton underwear."
Correct answer: (C) "I will use a vaginal douche daily." The client should avoid vaginal douches, bubble baths, and any substances that can increase the risk of UTIs. The client should use mild soap and water to wash the perineal area. Incorrect Answers:A. The client should empty her bladder every 4 hours to prevent urinary stasis, which can cause UTIs. B. The client should maintain a daily fluid intake of 2 to 3 L to flush the kidneys and prevent urinary stasis. D. The client should wear loose-fitting cotton (not nylon) underwear to prevent irritation.
A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? A. "You will be NPO for 8 hr following the procedure." B. "An allergy to shellfish is a contraindication to this procedure." C. "You will need to be on bed rest following the procedure." D. "A creatinine clearance is needed prior to the procedure."
Correct answer: (C) "You will need to be on bed rest following the procedure." A renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the kidney. The client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hours following the procedure to reduce the risk of bleeding. The nurse can elevate the head of the bed. Incorrect Answers:A. The client will be NPO for 4 to 8 hours prior to the procedure; however, food and fluids can resume following the procedure. B. An allergy to shellfish is not a contraindication to this procedure because contrast media is not used. D. Because of the risk for post-procedural bleeding, preliminary lab tests include coagulation studies such as platelet count and prothrombin time. Tests for anemia are also done to evaluate whether a pre-procedural blood transfusion is needed. Creatinine clearance is not required.
A nurse is monitoring a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect? A. Polyuria B. Dehydration C. Hyponatremia D. Hyperthermia
Correct answer: (C) Hyponatremia. A client who has SIADH will have hyponatremia caused by the excessive release of antidiuretic hormone (ADH). As a result of the excess ADH, the client retains water, which causes dilutional hyponatremia. Incorrect Answers:A. A client who has SIADH will retain free water and have decreased urine output with increased urine osmolarity. B. A client who has SIADH will retain free water in the circulatory system, which is due to excess antidiuretic hormone. The client will not have dehydration. D. A client who has SIADH will have hypothermia resulting from a disturbance in the central nervous system.
A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? A. Remain NPO 6 to 8 hr prior to the EEG B. Take a sedative the night prior to the EEG C. Thoroughly shampoo her hair prior to the EEG D. Sleep for at least 8 hr during the night prior to the test
Correct answer: (C) Thoroughly shampoo her hair prior to the EEG. The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG. Incorrect Answers:A. The nurse should instruct the client to eat regularly scheduled meals prior to the EEG because a low blood glucose level resulting from NPO status can alter EEG results. B. A sedative is not administered the night before a standard EEG because a sedative depresses CNS functioning and can alter EEG results. D. The nurse should instruct the client to be sleep-deprived prior to the EEG to increase the likelihood of recording seizure activity. The nurse should instruct the client to awaken at 0200 to 0300 on the morning of the EEG.
A nurse is obtaining a client's health history who has cancer of the cervix. Which of the following manifestations should the nurse expect? A. Weight gain B. Oliguria C. Vaginal bleeding D. Back pain
Correct answer: (C) Vaginal bleeding. The most common manifestation of cancer of the cervix is painless vaginal bleeding. Incorrect Answers:A. Unexplained weight loss is a manifestation of cancer of the cervix. B. Dysuria is a manifestation of cancer of the cervix. D. Pelvic pain and chest pain are manifestations of cancer of the cervix.
A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? A. Ferrous sulfate B. Epoetin alfa C. Vitamin B12 D. Folic acid
Correct answer: (C) Vitamin B12. The nurse should expect the client's provider to prescribe vitamin B12 for pernicious anemia. Incorrect Answers:A. The nurse should expect a prescription for ferrous sulfate for a client who has iron-deficiency anemia. B. The nurse should expect a prescription for epoetin alfa for a client who has anemia secondary to chemotherapy. D. The nurse should expect a prescription for folic acid for a client who has anemia due to a folic acid 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? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D
Correct answer: (C) Vitamin C. Vitamin C deficiency produces symptoms of scurvy such as delayed wound healing and capillary fragility. Incorrect Answers:A. A deficiency in vitamin A produces manifestations of night blindness and immunodeficiency. It is not associated with scurvy. B. A deficiency in vitamin B3 produces manifestations of pellagra, which include a scaly rash on sun-exposed skin, confusion, paranoia, and diarrhea. D. A deficiency in vitamin D produces manifestations of rickets and osteomalacia, which include bowed legs, fractures, and malformed teeth.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back discomfort
Correct answer: (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. Incorrect Answers: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 a manifestation of heart failure. This is not an assessment expected with an abdominal aortic aneurysm.
A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? A. Blood urea nitrogen (BUN) B. Blood glucose C. Urine ketones D. Specific gravity
Correct answer: (D) Specific gravity. Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, an infection, or a tumor. In this condition, an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus. Incorrect Answers:A. BUN measures the ability of a client's kidney to excrete urea nitrogen and is not used to assess DI. B. Blood glucose is used to monitor a client who has diabetes mellitus and is not used to assess DI. C. Urine ketones are used to measure diabetic ketoacidosis and are not used to assess DI.
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)
Correct answer: (D) Temperature of 39.1°C (102.4°F). An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms. Incorrect Answers:A. Significant edema is expected when fluid shifts after a burn injury. B. Superficial partial-thickness and deep partial-thickness burns are painful throughout burn therapy. C. A urinary output of 30 mL/hr is within the expected reference range. A decrease in urine output is expected with edema and fluid shifts around the fourth day following a major burn injury.
A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? A. The percentage of blood the ventricles pump during each beat B. The amount of blood the left ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume
Correct answer: (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. Incorrect Answers: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).
Adult-Medical Surgical A nurse is caring for a client who has pernicious anemia. Which of the following factors is associated with this condition? A. Iron deficiency B. Hemolytic blood loss C, Folic acid deficiency D. Vitamin B12 deficiency
Correct answer: (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. Incorrect Answers: A. Iron deficiency can be a result of blood loss, poor absorption of iron, or poor nutrition. This condition is called iron-deficiency anemia and is not related to pernicious 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.
