NCLEX Cardiovascular, Hematologic, and Lymphatic systems
A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply. A. Pallor B. Polyuria C. Bradypnea D. Tachycardia E. Hypertension
A. Pallor D. Tachycardia
A patient started receiving their first unit of blood at 1000. It is now 1010 and the patient is reporting itching, chills, and a headache. In addition, the patient's temperature is now 99.8'F from 98'F. Your next nursing action is: A. Stop the transfusion B. Notify the physician C. Decrease the rate of the transfusion D. Reassure the patient that this is normal and will resolve in 30 minutes.
A. Stop the transfusion
Before a blood transfusion you educate the patient to immediately report which of the following signs and symptoms during the blood transfusion that could represent a transfusion reaction: A. Sweating B. Chills C. Hives D. Poikilothermia E. Tinnitus F. Headache G. Back pain H. Pruritus I. Paresthesia J. Shortness of Breath K. Nausea
A. Sweating B. Chills C. Hives F. Headache G. Back pain H. Pruritus J. Shortness of Breath K. Nausea
A client is recovering from a myocardial infarction. Which action should the nurse take before developing the client's teaching plan? A. Identify the learning needs of the client. B. Determine the nursing goals for the client. C. Explore the use of group teaching for the client. D. Evaluate the community resources available to the client.
A. Identify the learning needs of the client.
A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply. A. Lack of hair B. Thickened toenails C. Pain at the ulcer site D. Diminished pedal pulse E. Brown skin discoloration
A. Lack of hair B. Thickened toenails C. Pain at the ulcer site D. Diminished pedal pulse
What solution or solutions below are compatible with red blood cells? A. Normal Saline B. Dextrose Solutions C. Any medications with normal saline D. No solutions are compatible with blood
A. Normal Saline
The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first? A. Obtain the other vital signs. B. Recheck the pulse to verify the rate. C. Stay with the client until an ambulance arrives. D. Alert the primary healthcare provider of the client's status.
A. Obtain the other vital signs.
You're providing discharge teaching to a patient about pernicious anemia. Which statement by the patient indicates they did NOT understand the discharge teaching? A. "Pernicious anemia is caused by not consuming enough Vitamin B12." B. "Pernicious anemia causes the red blood cells to appear very large and oval." C. "Treatment for pernicious anemia includes a series of intramuscular injections of Vitamin B12." D. "A red, smooth tongue can be a sign of pernicious anemia."
A. "Pernicious anemia is caused by not consuming enough Vitamin B12."
As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which patient below it is at most RISK for a febrile (non-hemolytic) transfusion reaction? A. A 38 year old male who has received multiple blood transfusions in the past year. B. A 42 year old female who is immunocompromised. C. A 78 year old male who is B+ that just received AB+ blood during a transfusion. D. A 25 year old female who is AB+ and just received B+ blood.
A. A 38 year old male who has received multiple blood transfusions in the past year.
Select the patient below who is at MOST risk for pernicious anemia: A. A 75 year old male who recently had surgery on the ileum. B. A 25 year old female who reports craving ice and clay. C. A 66 year old male whose peripheral blood smear showed hypochromic red blood cells. D. All the patients above are at risk for pernicious anemia.
A. A 75 year old male who recently had surgery on the ileum.
A patient needs 2 units of packed red blood cells. The patient is typed and crossmatched. The patient has B+ blood. As the nurse you know the patient can receive what type of blood? Select all that apply: A. B- B. A+ C. O- D. B+ E. O+ F. A- G. AB+ H. AB-
A. B- C. O- D. B+ E. O+
A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit, the client's vital signs remained stable for 1 hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first? A. Check the dressing on the incision B. Increase the intravenous flow rate C. Elevate the head of the client's bed D. Continue monitoring the client's vital signs
A. Check the dressing on the incision
A client is seen in the clinic with sickle cell anemia. The primary healthcare provider has prescribed an iron supplement to treat the client's anemia. What is the nurse's primary concern in regard to giving the supplement? A. Giving iron with this condition is contraindicated. B. Finding a straw is necessary to prevent staining of teeth. C. When giving iron, orange juice is needed to improve absorption. D. Warning about stools changing to black will prevent undue stress.
A. Giving iron with this condition is contraindicated.
A client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a screening session at a health fair asks the nurse what to do in light of this result. How should the nurse respond? A. "Your cholesterol is high, and you may need medication." B. "This is within the acceptable range, and no action is required." C. "Your level is low; you should eat more foods that contain cholesterol." D. "Your cholesterol is elevated slightly. A diet low in saturated fats should be followed."
D. "Your cholesterol is elevated slightly. A diet low in saturated fats should be followed."
Red blood cells are very vital for survival. Which statement below is NOT correct about red blood cells? A. "Red blood cells help carry oxygen throughout the body with the help of the protein hemoglobin." B. "Extreme loss of red blood cells can lead to a suppressed immune system and clotting problems." C. "Red blood cells help remove carbon dioxide from the body." D. "Red blood cells are suspended in the blood's plasma."
B. "Extreme loss of red blood cells can lead to a suppressed immune system and clotting problems."
A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? A. "I must touch the shunt several times a day to feel for the bruit." B. "I have to take his blood pressure every day in the arm with the fistula." C. "He will have to be very careful at night not to lie on the arm with the fistula." D. "We really should check the fistula every day for signs of redness and swelling."
B. "I have to take his blood pressure every day in the arm with the fistula."
A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? A. "The cause is abnormal configurations of the veins." B. "The cause is incompetent valves of superficial veins." C. "The cause is decreased pressure within the deep veins." D. "The cause is atherosclerotic plaque formation in the veins."
B. "The cause is incompetent valves of superficial veins."
According to the American Association of Blood Banks, what is the recommended hemoglobin level for a blood transfusion? A. 5-7 g/dL B. 7-8 g/dL C. 4-7 g/dL D. 9-10 g/dL
B. 7-8 g/dL
A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume
B. A failure of the circulatory pump
What is the priority nursing action when caring for a client with disseminated intravascular coagulation? A. Monitor for Homans sign. B. Avoid giving intramuscular injections. C. Take temperatures via the rectal route. D. Apply sequential compression stockings.
B. Avoid giving intramuscular injections.
Within 4 to 6 hours after a client has a myocardial infarction, the nurse expects which blood level to increase? A. Lactate dehydrogenase (LDH-1) B. Creatine kinase-MB band (CK-MB) C. Erythrocyte sedimentation rate (ESR) D. Serum aspartate aminotransferase (AST)
B. Creatine kinase-MB band (CK-MB)
Your patient is having a transfusion reaction. You immediately stop the transfusion. Next you will: A. Notify the physician. B. Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%. C. Collect urine sample. D. Send the blood tubing and bag to the blood bank.
B. Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%.
A nurse is assessing a client who has had a carotid endarterectomy. Which response does the nurse consider evidence of a complication of the surgery? A. Decreased appetite B. Impaired swallowing C. Change in bowel habits D. Slight edema of the neck
B. Impaired swallowing
A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home? A. No further drainage from the incisions B. Increased edema in the leg that provided the donor graft C. Mild incisional pain and tenderness for three to four weeks D. Extreme fatigue and a mild fever occurring for several weeks
B. Increased edema in the leg that provided the donor graft
Select ALL the signs and symptoms that can present in pernicious anemia: A. Erythema B. Paresthesia of hands and feet C. Racing thoughts D. Extreme hunger E. Depression F. Unsteady gait G. Shortness of breath with activity
B. Paresthesia of hands and feet E. Depression F. Unsteady gait G. Shortness of breath with activity
A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan? A. Basic principles of hygiene B. Techniques to reduce stress C. Measures to improve nutrition D. Signs of an impending exacerbation
B. Techniques to reduce stress
A nurse is working with a cardiologist for a client needing temporary pacing. Which methods are examples that the cardiologist with the assistance of the nurse might use? Select all that apply. A. Implantable cardioverter defibrillators (ICDs) B. Transcutaneous pacing C. Transvenous pacing D. Biventricular pacing E. Epicardial pacing
B. Transcutaneous pacing C. Transvenous pacing E. Epicardial pacing
When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, what should the nurse caution the client to avoid? A. Applying a hot water bottle to the abdomen B. Using a heating pad to warm the extremities C. Drinking a warm cup of tea when feeling chilly D. Turning the room thermostat above 72° F (23.3° C)
B. Using a heating pad to warm the extremities
Before starting a blood transfusion the nurse will perform a verification process with __________. This will include? A. any available personnel; physician's order, patient's identification, blood bank's information, expiration date of blood B. licensed personnel only (another RN); physician's order, patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, assess the bag of blood for damage or abnormal substances C. blood bank; patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, bag of blood for damage or abnormal substances D. licensed personnel only (another RN); blood compatibility, physician order, expiration date
B. licensed personnel only (another RN); physician's order, patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, assess the bag of blood for damage or abnormal substances
A patient is ordered to receive 2 units of packed red blood cells. The first unit was started at 1400 and ended at 1800. You send for the other bag of red blood cells. As the nurse you know it is priority to: A. obtain signed informed consent for the second unit of blood from the patient B. obtain a new y-tubing set for this unit of blood C. type and crossmatch the patient D. hang a new bag of dextrose to transfuse with the blood
B. obtain a new y-tubing set for this unit of blood
A patient who needs a unit of packed red blood cells is ordered by the physician to be premeditated with oral diphenhydramine and acetaminophen. You will administer these medications? A. 15 minutes before starting the transfusion B. Immediately after starting the transfusion C. Right before starting the transfusion D. 30 minutes before starting the transfusion
D. 30 minutes before starting the transfusion
Your patient needs 1 unit of packed red blood cells. You've completed all the prep and the blood bank notifies you the patient's unit of blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know that you must start transfusing the blood within _________. A. 5 minutes B. 15 minutes C. 30 minutes D. 1 hour
C. 30 minutes
A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic? A. International normalized ratio (INR) is between 2 and 3 B. Prothrombin time (PT) is 2.5 times the control value C. Activated partial thromboplastin time (APTT) is double the control value D. Activated clotting time (ACT) is in the range of 70 to 120
C. Activated partial thromboplastin time (APTT) is double the control value
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 hypertension C. Acute heart failure D. Sinus tachycardia
C. Acute heart failure
You're providing care to a 36 year old male. The patient experienced abdominal trauma and recently received 2 units of packed red blood cells. You're assessing the patient's morning lab results. Which lab result below demonstrates that the blood transfusion was successful? A. Hemoglobin level 7 g/dL B. Platelets 300,000 µl C. Hemoglobin level 15 g/dL D. Prothrombin Time 12.5 seconds
C. Hemoglobin level 15 g/dL
A patient with O+ blood received A+ blood. The patient is at risk for? A. Febrile transfusion reaction B. None: O+ and A+ are compatible blood types C. Hemolytic transfusion reaction D. Allergic transfusion reaction
C. Hemolytic transfusion reaction
A doctor suspects pernicious anemia in a patient presenting with a beefy red tongue. The patient reports feeling extremely fatigued and numbness and tingling in the hands. The doctor orders a peripheral blood smear. From your nursing knowledge, how will the red blood cells appear in the peripheral blood smear if pernicious anemia is present? A. Round-shaped and hypochromic B. Oval-shaped and hyperchromic C. Large and oval-shaped D. Small and hyperchromic
C. Large and oval-shaped
Before initiating the blood transfusion, you obtain the patient's baseline vital signs, which are: heart rate 100, blood pressure 115/72, respiratory rate 18, and temperature 100.8'F. Your next action is to: A. Administer the blood transfusion as ordered. B. Hold the blood transfusion and reassess vital signs in 1 hour. C. Notify the physician before starting the transfusion. D. Administer 200 mL of the blood and then reassess the patient's vital signs.
C. Notify the physician before starting the transfusion.
In pernicious anemia, intrinsic factor is not being secreted by the _______ cells which are found in the gastric mucosa. A. Visceral B. Langerhan C. Parietal D. Chief
C. Parietal
A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action should the nurse take to prepare for the arrival of the client? A. Reserve an operating room. B. Organize equipment for a tracheotomy. C. Prepare equipment for chest tube insertion. D. Arrange for a portable chest x-ray examination.
C. Prepare equipment for chest tube insertion.
The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. What teaching will be included? A. The client will be ambulated shortly after being transferred to the inpatient room after the procedure. B. The client will be given a general anesthetic and therefore will be asleep during the procedure. C. The client will need to stay In the supine position with the affected leg extended for several hours after the procedure. D. The client will be allowed only clear liquids for the remainder of the procedure day.
C. The client will need to stay In the supine position with the affected leg extended for several hours after the procedure.
What blood type is known as the "universal recipient"? A. Type A B. Type B C. Type AB D. Type O
C. Type AB
Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching? A. "I'll get pillows for you. I want you to be as rested as possible." B. "It's not a good idea, but you do look uncomfortable. I'll get one." C. "We don't allow pillows under the legs because you will get too warm." D. "A pillow under the knees can result in clot formation because it slows blood flow."
D. "A pillow under the knees can result in clot formation because it slows blood flow."
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? A. "Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." B. "Blood enters the heart from the inferior vena cava; it then flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." C. "Blood enters the heart from the aorta, flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricle, and finally exits through the superior vena cava." D. "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."
D. "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."
A client with a dysrhythmia is admitted to telemetry for observation. In the morning the client asks for a cup of coffee. What is the nurse's best response? A. "Hot drinks such as coffee are not good for your heart." B. "Coffee is not permitted on the diet that was prescribed for you." C. "You cannot have coffee. I can bring you a cup of tea if you like." D. "Coffee has caffeine that can affect your heart. It should be avoided."
D. "Coffee has caffeine that can affect your heart. It should be avoided."
It is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. The client expresses concern about having an increased risk of accidental electrocution. How should the nurse respond? A. "No one has been electrocuted yet by a pacemaker." B. "New technology prevents electrocution from occurring." C. "The pacemaker is pretested for safety before it is inserted." D. "The voltage emitted is not strong enough to electrocute."
D. "The voltage emitted is not strong enough to electrocute."
A donor has AB- blood. Which patient or patients below can receive this type of blood safely? A. A patient with O- blood. B. A patient with A- blood. C. A patient with B- blood. D. A patient with AB- blood.
D. A patient with AB- blood.
A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will: A. Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood transfusion. B. Administer the IV antibiotic via secondary tubing into the blood transfusion's y-tubing. C. Hold the antibiotic until the blood transfusion is done. D. Administer the IV antibiotic as scheduled in a second IV access site.
D. Administer the IV antibiotic as scheduled in a second IV access site.
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram? A. Elevate the foot of the bed. B. Encourage the client to void. C. Maintain the high-Fowler position. D. Assess the client's affected extremity.
D. Assess the client's affected extremity.
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 the airway out. B. Client has snoring respirations. C. Client's respirations are 16 breaths per minute and unlabored. D. Client's systolic blood pressure drops from 130 to 90 mm Hg.
D. Client's systolic blood pressure drops from 130 to 90 mm Hg.
A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation? A. Sickle cell anemia is a random condition with no known cause. B. If one parent is a carrier and one is negative for the gene, the child will get the disease. C. If both parents are carriers, all of their offspring will probably get this disease, and they should consider sterilization. D. If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.
D. If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.
A patient with pernicious anemia is ordered to receive supplementary Vitamin B12. What is the best route to administer this medication for patients with this disorder? A. Intravenous B. Orally C. Through a central line D. Intramuscular
D. Intramuscular
A home care nurse makes an initial visit to a 60-year-old client with heart failure. The client lives with her daughter, who is addicted to drugs and a single parent of seven children. When the nurse enters the home, the client is feeding a 6-month-old granddaughter and preparing dinner for the rest of the family. A 14-year-old grandson, disabled and in a wheelchair, states that his mother is sleeping. What should the nurse do? A. Sit down with the client and exchange identifying data. B. Accept coffee when offered by the client and socialize for a few minutes. C. Ask the client whether it is all right to look around the apartment and evaluate environmental conditions. D. Question the client to determine whether there is a private place to take a health history and perform an examination.
D. Question the client to determine whether there is a private place to take a health history and perform an examination.
A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client? A. Warm, flushed skin B. Increased pulse pressure C. Lethargy with confusion D. Reduced peripheral pulses
D. Reduced peripheral pulses
A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? A. Fever and chest pain B. Positive Homans sign C. Loss of sensation in the operative leg D. Tachycardia and petechiae over the chest
D. Tachycardia and petechiae over the chest
A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction? A. This prevents an increase in blood pressure from tissue edema. B. This reduces the circulating blood volume by a diuretic effect. C. This reduces the amount of edema, which interferes with heart action. D. This prevents further fluid accumulation, which increases the workload of the heart.
D. This prevents further fluid accumulation, which increases the workload of the heart.
What blood type is known as the "universal donor"? A. Type A B. Type B C. Type AB D. Type O
D. Type O
You're gathering supplies to start a blood transfusion. You will gather? A. PVC free tubing and dextrose B. Polyethylene-line tubing and 0.9% Normal Saline C. Y-tubing with in-line filter and dextrose D. Y-tubing with in-line and 0.9% Normal Saline
D. Y-tubing with in-line and 0.9% Normal Saline
You've started the first unit of packed red blood cells on a patient. You stay with the patient during the first 15 minutes and: A. run the blood at 100 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. B. run the blood at 20 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. C. run the blood at 200 mL/min and then decrease the rate after 15 minutes, if tolerated by the patient. D. run the blood at 2 mL/min and then increase the rate after 15 minutes, if tolerated by the patient.
D. run the blood at 2 mL/min and then increase the rate after 15 minutes, if tolerated by the patient.
True or False: Intrinsic factor is a protein that plays a role in how the body absorbs Vitamin B12.
True